Soaring Medicare costs will soon make the recent economic troubles look like a drop in the bucket.

Maggie Mahar tries her best to address this in a recent paper, summarizing many themes from her blog. Suggestions include instituting a comparative effectiveness agency and increasing funding for primary care, as well as left-leaning suggestions like eliminating the bonus payments to Medicare Advantage and negotiation of drug prices with pharmaceuticals.

I would have liked to see her use some conservative ideas as part of the solution, such as whether health savings accounts can play a role, or addressing defensive medicine - which liberal wonks tend to ignore or discount - responsible for $210 billion of wasteful medical spending annually.

The bottom line is that a solution will have to blend ideas from both sides in order to have a chance of realistically passing.

In the Clinic - Dr. Mark Batshaw, MD, discusses an unusual cause of seizure in newborns

Hospitals are doing away with them.

No wonder, as medical care becomes more fractionated with specialists and sub-specialists, and the pressure increases to see more patients, there's less downtime to spend in the lounge.

It's a shame, since it makes it difficult to know your colleagues, let alone put a face to the specialist you are consulting.

There are some Internet social networking options, like Sermo, that try to pick up the slack. Obviously, it doesn't have a local flavor, and certainly isn't the same as chatting with your colleagues in person.

I've almost finished watching the first season of Californication - great show by the way - and started thinking if David Duchovny's recent tribulations could somehow be related to Hank Moody, the sex-obsessed character he plays on the show.

How real is sex addiction? Well, the WSJ has a column (via the WSJ Health Blog) on the topic today, and apparently, it's quite controversial within the psychology community:

One camp thinks the very notion of "sex addiction" implies a narrow, moralistic view of what's acceptable. "There are millions of people stuck in unhappy relationships who go to massage parlors or the Internet and to demonize their sexuality is terribly unfair," says Marty Klein, a licensed marriage and family therapist and certified sex therapist in Palo Alto, Calif. He says people who are unhappy with their sexual choices may be depressed or bipolar or need to face the fact that their relationships have failed, but the problem isn't necessarily sex.

I wonder how effective the treatments are. Unlike alcohol, drugs , gambling and other addictions, is sex really something you can abstain from?

Normally antagonistic to physicians, here's a nice change from the NY Times detailing the crisis that is affecting primary care and cognitive medicine. It even takes a jab against one of it's pet themes, universal coverage:

There is a crisis in medicine today, and it will not be fixed by any candidate’s proposal to provide health insurance for the 45 million Americans now without it. In fact, an increase in insured Americans could make it worse.

Of course, that's nothing new to regular readers here.

One interesting point made is that the best, most humanitarian, doctors are leaving the system for cash-only or concierge practices.

What does that imply about the doctors who are left? That they're happy with the 5-minute visits? That they're at the lower end of the humanitarian spectrum?

Some patients find Internet-based health information empowering, others find it overwhelming.

Either way, it's here to stay and patients are going to have to get used to the growing amount of medical information available to them.

The NY Times has a nice article giving patients suggestions as they navigate through the web:

The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.

Physicians need to accept the fact that more patients are coming to them more informed about their disease. It's up to us to help them interpret the information and to use their newfound empowerment to guide them to a mutually agreeable treatment and diagnostic course.

Many doctors are reluctant to do this. I'm saying there soon isn't going to be a choice, we better get used to it.

Tired of waiting months for patients to receive a dermatology consult? Kaiser has a novel way to solve this. Enter the roving dermatologist, who takes consults over the cell phone and drives to the requesting physician's office for an evaluation or biopsy:

The roving dermatologists can provide same-day assessments and biopsies of skin lesions, saving patients the month-long wait it can otherwise take to get an appointment with a dermatologist.

Although convenient, I can only see this working with dermatology. Don't expect to see any roving cardiologists or surgeons anytime soon.

The primary care physician shortage has been well-documented.

Now general surgeons are becoming scarce, with medical students pursuing specialty surgery for increased income and a better lifestyle.

I can see this eventually happening to medical specialties. For instance, there may soon be a general cardiologist shortage as more sub-specialize into interventional cardiology or electrophysiology.

Again, no surprise when you consider the incentives.

Pfizer, who once ruled the cardiac drug scene with Lipitor and Norvasc, is pulling out of heart medications to focus on more profitable areas like oncology and Alzheimer's disease.

They got burned pretty badly with the HDL-raising drug torcetrapib, and their combo statin-hypertension medication Caduet is having anemic sales.

Profits obviously dictate where innovation should lie. The same thing happened to antibiotics where there hasn't been a breakthrough drug in years.

Medicaid payments to doctors will likely be targeted next year as an effort to save costs:

"No states like to cut provider payments," Dr. Smith said. "But it is perhaps one of the first places states would turn to because it is a real savings."

Idiocy. As always, the wonks take the short-sighted approach that will do nothing to save money.

Medicaid rates are already so low, it's essentially charity care. As patients can tell you, finding doctors that take Medicaid is already an exercise in futility.

Cutting payments will lead to more physicians dropping Medicaid, forcing patients to go without care or to the emergency room.

That can only further raise, not lower, health care costs.

Well, that can happen if this family physician gets his way.

I often talk about PSA screening for prostate cancer. The USPSTF recently did not recommend screening men age 75 or older.

PSAs have not been shown to improve mortality, and can lead to a slew of unnecessary biopsies and anxiety.

Predictably, urologists do not agree, as more PSA screenings lead to more revenue-generating workups.

The unnecessary testing brigade over at Dartmouth, summarizes the arguments for and against testing in a Boston Globe op-ed.

It rebukes the rampant, uncritical, publicity that the media and celebrities give to prostate cancer screening.

I'm not saying don't do it, but go in with your eyes open and realize it isn't a black and white issue:

Prostate screening has been heavily marketed to the public for years in ways that have exaggerated the risk of cancer and the benefit and safety of screening.

To really help men, we need to help them understand the risks they face and which ones can be reduced with interventions of proven benefit.

CRNA salaries are rising and slowly eclipsing those of decreasing primary care physician wages.

The Happy Hospitalist notes that nurse-anesthetists have the overwhelming advantage in today's payment environment, that many medical students are finding out to their dismay.

During last week's Presidential debate, Senator McCain pointed out the height difference between North and South Koreans.

This is likely due to malnutrition and poor living conditions:

Studies of escapees from North Korea show that those born after the partitioning of the Korean Peninsula in the North were consistently about two inches shorter than their counterparts in the South.

Tara Parker-Pope considers this fact, as well as an interesting observation of a growing height gap between Americans and Europeans.

Apparently height itself is a form of "biological shorthand" that can be extrapolated to measure a society's well-being.

The increasing amount of letters after the signature signifies the fragmentation of physician into hundreds of professional societies, effectively "neuter[ing] us as effective voices in healthcare reform."

CEOs of the Mayo Clinic and Johns Hopkins write an op-ed suggesting some common sense ideas to dealing with the runaway Medicare train.

Among the suggestions are comparative effectiveness, removing Congress from coverage decisions, and eliminating price controls.

All good ideas, will the government listen?

A doctor thinks back to a story where he successfully resuscitated an 89-year old. This left a lasting impression:

From that point on, I no longer considered a patient's age as a determinant of the care they should receive.

A great story to be sure, but consider that happy endings like these are a statistical rarity.

Better to focus on patients having an appropriate advance directive than to highlight a successful long shot.

David Kibbe with an analogy between rising health care spending and the banking bailout.

He says that unless doctors and hospitals get a grip on unnecessary testing, a future health care bailout would vilify the medical profession in the same light as Wall Street CEOs.

Which may be true, since much of the testing performed is wasteful and contributes to the revenue of the hospitals.

One factor Kibbe neglects to mention is that the malpractice system has to be reformed as well, since that is a primary factor motivating unnecessary testing, as I mentioned yesterday.

Unhappy that he wasn't paid, a dentist in Germany takes matters into his own hands:

According to police, the dentist form Bavarian town of Neu-Ulm barged into the womans house, tied her up, forced her mouth open and yanked out the two dental bridges that he had previously put in.

The Gone Wild series continues.

This New Jersey doctor talks about the demise of primary care in New Jersey, which is endemic nationwide.

Here's the extent that some of his primary care colleagues go through to stay afloat:

"Renting out space to specialists and by venturing into cosmetic surgery and other cash businesses. The primary care portion of his practice loses money each year."

"I bought property and made investments that enable me to survive without continuing to make a big salary."

Boy, does that sound appealing to today's medical students.

ER Stories compiles a list of record high or low lab values, or "numbers that are often not compatible with life."

Indeed.

Richard Reece writes about how primary care is powerless and impotent in every facet of health care, from medical school to the health insurers to the legal system.

Our health care system is shaped by what is valued, and the lack of importance placed on primary care will only hasten its demise.

Perhaps then primary care will stop being kicked around.

Will it make "your life is hell for the next year?"

The answer is yes. It takes about 6-12 months for electronic records to fully manifest into the patient workflow, and for doctors to feel totally comfortable with the system.

It demonstrates how poorly designed many of the programs are, evidenced by the lack any kind of physician input in the user interface.

Our favorite politician Pete Stark has introduced legislation giving bonuses for physicians who transfer over to a federally-approved electronic record system. The total payment is $40,000 over five years per physician, with penalties for late adopters.

Considering it costs up to $30,000 for each physician to implement computerized records, this surprisingly seems like an appropriate sum of money.

In the Clinic - Dr. Jennifer Temel, MD, Massachusetts General Hospital, discusses the importance of imaging in early detection of lung cancer

The following op-ed was published on April 23rd, 2008 in the USA Today.

A recent analysis by PricewaterhouseCoopers concluded that more than half the dollars in our $2.2 trillion health care system are wasted.

Medical errors, inefficient use of information technology and poorly managed chronic diseases were all cited as factors. Dwarfing these reasons is a phenomenon in which doctors order tests to avoid the threat of a malpractice lawsuit. This is known as "defensive medicine."

At $210 billion annually, defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, MRIs, cardiac testing and hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93% of doctors reported practicing defensive medicine.

When you consider that rampant testing is a major driver of escalating health care dollars, addressing defensive medicine should be a primary goal of cost containment.

Testing to protect the doctor

Why do doctors order these unnecessary tests? The simple reason is that every physician wants to avoid being sued. Win or lose, the ordeal of a malpractice trial is a devastating experience. The American Academy of Family Physicians, citing a study that interviewed doctors who had fought medical liability cases, said 90% "suffered significant mental effects from the lawsuits" and, disturbingly, 10% contemplated suicide.

In an optimal system, every case tried should involve clear medical malpractice — wrong-site surgery or performing an incorrect procedure, for instance. But the reality is far from that. Poor medical outcomes occasionally occur despite textbook medical care.

A landmark study from The New England Journal of Medicine analyzed more than 1,400 malpractice claims and found that in almost 40% of cases, no medical error was involved. Facing such an unpredictable malpractice climate, a physician's instinct is to increase testing. When facing jurors and trying to explain a medical catastrophe, who wants to tell them why a specific test wasn't ordered?

In my experience, patients don't seem to mind the extra testing, and they often equate defensive medicine with "more thorough" care. After all, if one test is good, wouldn't more be better?

More harm than good

Not necessarily. Every test has the risk of a "false positive," which is a positive test in the absence of disease. Doctors generally act on every abnormal result, so a simple X-ray finding could lead to further tests, such as an advanced imaging scan or biopsy. When you consider that a CT scan can expose patients to radiation equivalent to several hundred X-rays, and a biopsy might have serious complications such as bleeding or infection,there comes a point where increasing the frequency and degree of diagnostic studies could lead to harm.

This is what studies have found. Pioneering work by researchers at the Dartmouth Atlas Project concluded that higher intensity medical services have led to worse outcomes, higher costs and an increased number of medical errors.

How do we tackle this problem?

Whenever a test is performed, there has to be a willing patient. Know that more tests might not always be better medicine. Before undergoing a scan or procedure, understand why it is being ordered. This includes a thorough discussion of the risks as well as a sense of what the physician is looking for. Patients tend to decline tests of questionable benefit when appropriately informed of possible complications. Don't be afraid to ask questions.

For physicians, remove the incentives to order defensive tests. Specifically, the malpractice system needs to do a better job to not try doctors who experience poor medical outcomes despite practicing the appropriate standard of care. Although the majority of physicians win malpractice cases, remember that the trial itself is emotionally scarring and that the statistics do not reflect the vast number of cases settled out of court.

Until the system is perceived as being fairer, physicians will do all they can to avoid being sued. That involves ordering unnecessary tests, which is a shame, because those billions of dollars can be put to much better use.

More from the Laryngospasms.

Here are last week's most visited posts at Kevin, M.D.

Grand Rounds 5:1 - In Your Own Words
Welcome to the historic, 5th year anniversary of Grand Rounds, the weekly summary of the best of the medical blogosphere.

Breathe
A little riff by the Laryngospasms, a singing group of CRNAs.

Melamine, China and milk
There is one hypothesis suggesting that melamine was added to Chinese powered milk formulas to fool government quality tests when the makers fraudulently added water to the formula.

Patient handoffs
A major downside to capping resident work-hours is increasing the number of patient handoffs between doctors.

Did John McCain have a stroke?
Watching partisans engaging in Fristian-style video doctoring to score political points leaves me to question the motivation, and thus the credibility, of Shadowfax's analysis in this case.

This time it's falsifying records. Anesthesiologists were writing their medical notes in advance, even sometimes before the actual procedure.

The institution has been hit with a variety of scandals recently:

They had to shut down their transplant program when Medicare funding was withdrawn after 32 people died awaiting livers in 2004-05. Their doctors turned down organs that were successfully transplanted elsewhere.

They came under fire when the director of the University's Willed Body Program sold parts of cadavers and did unauthorized autopsies.

In 1995 the fertility doctors were accused of stealing patient's eggs and embryos and implanting them in other patients without permission. That program was also shut down.

I'm not sure how they're running things over there, but there seems to be serious management problems.

Continuing plastic surgery analysis of the country's political figures over at In Your Face. (via Tony Youn)

The verdict? A definite maybe:

If she's had any surgery, the only thing I would speculate is an upper blepharoplasty, or upper eyelid lift. Other than that, maybe a touch of Botox, but I doubt it.

The latest fad is for people to come together and have genetic testing "parties":

Debra Netschert, a financial analyst, was sitting next to her husband, K. C. Dustin, an equities salesman, and spitting into a test tube at a party last week in Chelsea to promote a DNA testing company.

As the ACP Internist Blog points out, whole-body CT scans are yesterday's news. Genomic spit parties are in.

This is another example of how companies are profiting off the public's appetite for screening tests.

Not publicized are the implications for the results of these genetic tests. Without proper counseling and interpretation, it can do more harm than good:

“People think if you have money to spend on this, why not buy a test instead of a model train for Christmas,” said Dr. Alan Guttmacher, acting director of the National Human Genome Research Institute of the National Institutes of Health. “It can be neat and fun, but it can also have deep psychological implications, both for how you view yourself and how others view you, depending on who else has access to the information.”

Most primary care physicians are not educated in interpreting results of these genetic tests.

Ideally, these tests should be done only in conjunction with genetic counseling follow-up. I don't think that's happening.

In the Clinic - Professor Chung-mau Lo, University of Hong Kong, discusses the importance of live donor liver transplantation

A recent study in Canada discloses that there are safety implications when patients "act aggressively or refuse to believe the doctor's diagnosis."

Among the problems are patients who self-diagnose via the Internet and those who don't disclose taking alternative medications. Often times, interactions between "natural" and prescription medications can be significant.

Sub-optimal trust and open communication lines only impedes appropriate diagnosis and treatment, and in some cases, can jeopardize patient safety.

And this is how it ends.

The common perception is that e-mailing your physician and becoming better informed via reading Internet information leads to improved health outcomes.

A recent study suggests otherwise, showing that increased consumerism leads to lower perceived quality:

Consumerist patients place additional demands on their doctors’ time, thus imposing a negative externality on other patients . . . Data from a large national survey of physicians shows that high levels of consumerism are associated with lower perceived quality.

In other words, the time spent to answer questions garnered from the Internet leads to less time for other patients.

Of course, it doesn't have to be that way. Doctors are only paid for patients seen in the office. Re-aligning incentives to include spending time with the patient, or communicating via e-mail, would benefit everybody involved.

Clot-busters for acute stroke is one of the more controversial interventions. Normally, the recommendation is for a 3-hour window between drug and onset of symptoms.

A recent study suggests that this can be lengthened to 4 1/2 hours.

There is no mortality benefit to using thrombolytics.

The downside is the not insignificant risk of bleeding leading to neurological complications, which malpractice attorneys are taking advantage of. It was 2.4 percent in the reported study.

It is because of the risk of being sued that emergency physicians are gun-shy about using the drug.

One answer? WhiteCoat suggests immunity:

If an emergency physician gets a CT report from a radiologist that says “no bleed,” the patient meets the criteria for thrombolytic therapy and doesn’t have any exclusion criteria, then the emergency personnel cannot be held liable for any bad outcomes for giving thrombolytics.

That's an extreme measure, and unlikely to happen. However, if the public demands increased clot-busting use in stroke, that's what it may take to convince some doctors to use them.

It's better to emphasize to patients about the very real risks of thrombolytics for only potentially marginal benefits that do not impact mortality.

Let the patients decide.

What's wrong with health care, and how to fix it, on one page. (via Our Own System)

Left-leaning Shadowfax openly wonders, after watching some video.

This is one instance where I'm going to call this oft-respectable blogger out for it.

As I mentioned before, I'm undecided and McCain certainly has his shortcomings. However, watching partisans engaging in Fristian-style video doctoring to score political points leaves me to question the motivation, and thus the credibility, of Shadowfax's analysis in this case.

Update:
Orac and Dr. RW also comment on the issue, both suggesting that Shadowfax's medical view of McCain may have been clouded by a partisan lens:

Well, if I present to an ER with Bell’s Palsy please don’t anybody give me tPA.

Ouch.

topics: mccain, stroke

If I Had - A Thyroid Nodule - Dr. Douglas Van Nostrand, MD, Washington Hospital Center & Georgetown University

It's the standard warning for every erectile dysfunction medication.

Here's a look at what happens after someone really makes that call.

One point of contention that rose from the recent study on physician empathy is that expressing the emotion takes an inordinate amount of time. Something that is in very short supply these days for doctors.

Surgeon Pauline Chen says that empathy shouldn't be left to the end of the visit. In fact, expressing empathy throughout the visit shouldn't make visits any longer, and patients appreciate the care that much more.

In other words, too little empathy, or empathy expressed too late in an encounter, may actually result in longer visits.

When the doctors did respond in a way that explicitly recognized patient emotions, patient responses were not long, as some of us might imagine. Instead, patients usually responded with one or two words, or a single sentence.

Update:
Health Beat has a nice piece today on the whether medical school beats the empathy out of prospective doctors, and what some institutions are doing about it.

This letter is causing a firestorm over at MedPolitics.

An anesthesiologist unloads on the obstetrics profession, where he feels that they take patient rights too far.

The source is a .PDF file, so the letter is re-printed in it's entirety:

If the tone of this epistle is less cordial than you’re used to, well then so be it. I’m feeling a bit surly.

It is 0230 again. We could have done this case nine hours ago. The sun was still up, and she’d been stuck at 6 cm longer than the life cycle of some butterflies. We should have done this case nine hours ago, but the patient “really wanted” to delivery vaginally. Apparently becoming a mother just wasn’t enough, and the actual avenue of the child’s arrival had some bearing that I, as a sleep-deprived and callous male, just couldn’t grasp.

She had been told that the baby was too big and that a primary C-section was indicated, not what she wanted to hear. She doctor-shopped until she found one who agreed with her diagnosis.

It doesn’t always happen this way, but this time we got a meconium-stained, cone-headed, floppy baby that required resuscitation. I guess that balances with the patient’s need to labor and attempt an ill-advised vaginal delivery. Or not.

No other specialty has allowed itself to deteriorate to the state of patient control that obstetrics has. We are all concerned about patient rights. We have to be. But come on. Let’s say you have a kidney stone and you present at the urologist’s office wincing with pain but holding in your hand a seven-page stone-retrieval plan and a list of dates that are satisfactory to your social calendar (and as a bonus would make the stone a Libra) – the urologist would and should inform you that his afternoon was booked but that his esteemed colleague from across town would (he’s sure) be happy to see you.

Patients don’t always know best. I’m not suggesting that doctors always know best. I am suggesting, however, that we can make an expensively educated guess and be right enough of the time to eclipse the records of Jean Dixon, Nostradamus or the average meteorologist.

Good medicine should not infringe on the patient’s rights. I’m afraid our brethren in OB have let patient’s rights infringe upon their medicine.

A recent survey asked physicians what they thought about the potential universal health care coverage.

The big conclusion is that almost 20 percent of the country's physician workforce will stop practicing medicine if the United States were to adopt universal coverage.

Delving deeper into the study, you can see the differences split between specialist/generalist, partisan, and gender lines.

Essentially, there are two physician worldviews:

Further segmentation of LocumTenens.com's physician survey respondents divides them into two distinct clusters - one skeptical about physicians' ability to make a decent living under universal health care (44 percent of respondents) and the second more concerned about ensuring that people who need access to health care get it, so they tend to embrace universal health care (56% of responding physicians).

Those who support the "decent living" view tend to be men, Republican, and procedural specialists.

Those who "embrace universal healthcare" tend to be women, Democrat, and generalists.

And now you see why significant health reform will be very difficult to come to fruition with such polarizing views within the physician community.

The situation is looking dire in Connecticut, and patients are going to have to endure longer wait times. 17 days for instance, to see an internist.

Going to the ED isn't the answer, as they're already overcrowded and will not be able to provide adequate follow-up care.

The Hartford Courant wants you jettison physician stereotypes about the affluent doctor:

Lest you are tempted to dismiss these results as the whinings of a privileged class of affluent people, it is time to jettison doctor stereotypes. The average primary care physician, gatekeeper for most health plans, makes $72,000 per year. Medical students begin practice with an average debt of $170,000.

As I wrote in the USA Today last month, government efforts to target physician pay is a notoriously poor way to control health care costs. It will simply make a desperate situation worse.

When doctors or their family members receive medical care, should you reveal that you're a physician?

I normally don't, although sometimes it can't be helped within the smallish city I live in.

A piece in Salon talks about a case where care was unacceptable until the patient's son revealed his medical background:

The fact that I was a doctor helped my mother in other ways during the difficult days of her hospitalization. Her surgeon showed me her CT scan to back up his judgment about the need for surgery (which required a little explanation to the radiologist, given most doctors don't show up to see scans in a T-shirt, shorts and sandals). I saw a sea change in her internist, who suddenly felt comfortable communicating with me in our common clinical language. He knew, I suppose, that I would be able to save him time and translate his assessment into plainer English for my parents.

It's an unfortunate reality that physicians and their families often receive better communication within the medical system.

Maybe it's there's an increased level of comfort talking between colleagues, not having to explain medical jargon.

Or perhaps the providing physician tends to opens up knowing that there is mutual understanding of the difficulties navigating the medical system.

Whatever the reason, and I certainly don't think it's a conscious effort for doctors to preferentially provide better care to their medical brethren.

Nice list that The Efficient MD compiled on surviving a night of call.

For me, the first tip is the most important. You cannot underestimate how much staying hydrated helps you stay awake and alert in the middle of the night.

A man undergoes what seems like a routine circumcision.

The urologist suspects cancer, and subsequently removed the penis. Tests later confirmed the malignancy.

Despite that, I can't imagine why there wasn't a discussion prior to the more invasive procedure.

Thanks Shadowfax for bring this to my attention - not sure how I missed this either.

Nothing new that hasn't been discussed here, but it's well worth reading. I'll leave you with the money (so to speak) quote:

In short, we doctors do what we get paid to do and we get trained to do what we get paid to do. Therefore, if the system of reimbursement changes to value the work of primary care doctors as much as sub-specialists, then this trend can be reversed—if leaders at the highest levels of government make this a priority.

How close is John McCain really to death?

Despite the partisan attacks invoking his melanoma and his overall health, it would help if left-leaning bloggers get their scientific facts straight.

You may not like or vote for him, but please at least get the medicine right.

It's so much more than just a DNR. Rural Doctor does it right.

If you think the financial markets are in trouble, you ain't seen nothing yet. The upcoming Medicare crisis will dwarf what we're going through now:

Whereas the newly-burst mortgage bubble has left us with an unfunded liability of merely (we think) something less than $2 trillion, our unfunded liability for Medicare alone, over the next several decades, is estimated to be between $25 trillion and $55 trillion. Considering the fatal damage our current, relatively trivial financial crisis apparently came within a few hours of triggering, this sounds like a lot of money.

I wonder how the government will bail us out of that one?

Well, they can't. As DrRich points out, health care rationing will come one way or another. Saying "no" to tests and treatments will soon be forced upon all of us, whether we like it or not.

I suggest that our leaders try to soften the blow in the coming years by first reining in unnecessary testing.

Answer is, he couldn't.

Brilliant. (via WhiteCoat Rants)

What a way to control costs.

Imagine if doctors stopped treating certain diseases to slow down health care spending.

Uh, don't think that's going to fly.

How's this for a rural remedy:

Slather “grease” of some kind (I imagined Crisco…but I’m sure it’s often something closer to the barnyard for people who actually do this) onto a bandanna Then pour turpentine onto the grease and fold the bandanna on itself until it is approximately the width of the child’s throat. Put the folded bandanna into the oven and heat that baby up until the grease melts into the bandanna. Then put it on the child’s throat (once it’s cooled down a bit, of course).

Safe to say, I've never tried that before.

A Washington Post editor has a case of sore throat, stridor and high fever.

Find out how a rural emergency department dealt with the situation, and how close she came to dying. The insight of the on-call physician helped lead to the correct diagnosis.

Epiglotittis is no joke. Although typically afflicting children, adult cases are no less serious. It is rare in developed countries where the Hib vaccine is mandatory, protecting against the most common bacteria responsible for the disease.

However, with the anti-vaccine crusade becoming more popular, will we see more frequent cases of this disease?

Controversial comments in Europe, suggesting that people with dementia have a "duty to die":

"If you're demented, you're wasting people's lives -- your family's lives -- and you're wasting the resources of the National Health Service."

Extreme views to be sure, but any attempt to provoke discussion of futile care should be welcomed.

There is certainly no "duty" for the elderly and demented to die. However, we currently are on the opposite end of the spectrum, spending what we can to keep them alive.

A solution, like most things, lies somewhere in the middle.

Dr. A interviews Jeffrey Parks, otherwise known as Buckeye Surgeon, on the show tonight.

Here's how to listen.

Wouldn't it be nice to have a government run single-payer system where everyone was covered, health care would be "free", and no one would die in the emergency department waiting ro . . . oh, never mind.

The NEJM has always been the medical journal equivalent of the NY Times.

Several early release articles are available critiquing the Presidential candidate's health reform proposals again show their stripes.

They have a somewhat balanced analysis of the Obama plan, but to have an overt Obama supporter criticizing the McCain approach is hardly impartial analysis.

As I mentioned before, I don't think either plan will work, but the NEJM continues to show an obvious liberal bias that spits in the face of objectivity.

If I Knew Then - Dr. Niall Galloway, MD, FRCS, Emory University, Discusses Respect for Patients and their Families

Well, this is pretty obvious:

Figures released Thursday show seniors are more likely to ask their pharmacist for generic medications when they are paying, but choose the more expensive originals when the government is covering the costs.

Perhaps it's time to invoke P.J. O'Rourke.

It's not as rare as you think. And when it does happens, the results are horrifying.

This complication is entirely preventable, so what are hospitals doing about it?

The NY Times with an interesting piece on the controversy surrounding color coded bracelets for patient conditions.

There is conflict between clarity and patient privacy, like those who wear bracelets signifying a DNR status:

The nation’s leading hospital-accreditation agency, known as the Joint Commission, has expressed caution about the new system, citing concerns about branding patients by their end-of-life choices, or inadvertently broadcasting those choices to family and friends who have not been consulted.

A bigger problem is that the colors are not standardized, as there is significant variation in hospitals across the country:

A survey by the Greater New York Hospital Association last year found nine different colors used to denote patients with D.N.R. orders, five to indicate allergies and nine to highlight risks of falling.

That's frankly ridiculous. Unless they can come up with a nationwide, uniform standard, the colored bracelet system has the potential to cause more harm than good.

Pharmacists are allowed to dispense prescription medications in the UK. A recent study suggests however, that they are not very stringent with the required screening questions:

Imigran Recovery [Imitrex in the US] should only be dispensed following a series of questions set by the Medicines and Healthcare Products Regulatory Agency, but Which? ranked 13 out of 35 visits as "unsatisfactory".

In 40% of the 13, the pharmacy assistant did not even alert the pharmacist before handing over the drug.

This does not lend very much confidence to the pharmacists on Alberta, Canada, who are also seeking authority to prescribe medications.

An Indian urologist on a diuretic tries to use the restroom in-flight. He couldn't because the pilot was using it, and subsequently was arrested and jailed overnight.

He had to pay a $2500 fine and plead guilty for a quick resolution.

To rub salt in the wounds, he has yet to receive an apology from Southwest.

Did race play a role?

A major downside to capping resident work-hours is increasing the number of patient handoffs between doctors.

Further decreasing allowable work-hours to 56 hours per week will only exacerbate the problem.

A survey of MGH residents suggested that this practice led to significant patient harm, almost as serious as medication-related events:

More than half of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs. About one in nine said the harm that resulted was significant.

No road to happiness here. An anesthesiologist gets called at 4am to the ED for angioedemia. WhiteCoat describes the sphincter-tightening tale.

(via MedGadget)

The latest fad is for medical institutions to be the "official hospital" of professional sports teams.

In the case of the St. Louis Rams, doctors from their official hospital actually do not provide care to the players.

Roy Poses wonders if this marketing ploy crosses the line into deception.

So I got to try the da Vinci surgical robot last night.

As an internist, it's probably my first and only time I'll get a chance to use the system. It has certainly drawn controversy as a reason contributing to the hospital arms race raising the cost of health care.

That being said, it's quite impressive and I can see how many surgeons enthused about the technology. It's very intuitive, and after about 30 seconds, it pretty much become an extension of my hands.

It turns surgery into a very expensive video game.

I'd be curious to see what the urologist and gynecologist bloggers think of the system.

More backlash against the very small VA doctor empathy study being popularized by mainstream media. It was noted yesterday that only 20 transcripts were studied, and the results were based on VA care.

Not that there's anything wrong with VA care, but anecdotally, there may be a difference with physician satisfaction, attitudes, and care when compared to private practice.

Doug Farrago says the study conveniently fits into the media narrative that so eagerly condones bashing against the physician establishment.

The pre-med scene has always been cutthroat. Some would say medical school is as well. It seems to have gotten nastier, with worsening stories of academic guerrilla warfare.

TIME Magazine reports stories of students sabotaging others, and generally being unhelpful and misleading to their fellow classmates. Not the best traits for our future physicians:

In some cases, the competition turns into sabotage. Students take important books out of the school library and keep them so long that no one else can use them; a few have gone so far as to tear out crucial pages, making the books useless to other students. Pre-meds are also not above doctoring each other's laboratory work, adding extra ingredients to a classmate's chemistry experiments, or coughing in somebody else's culture dishes—thus starting unwanted bacteria colonies that ruin experiments.

Update:
This article was from 1974 (!) - didn't realize they archived that far back. I wonder if much has changed in 34 years.

I'm honored to co-guest-host this week's Grand Rounds. Without further ado, here's Dr. Val Jones.

Welcome to the historic, 5th year anniversary of Grand Rounds, the weekly summary of the best of the medical blogosphere. As the proud new co-leader of Grand Rounds, I am committed to expanding its reach, promoting the Grand Rounds “brand,” and making sure contributors’ voices are heard by healthcare’s movers and shakers.

This day happens to be historic for me as well, since I have just taken the leap into blogging independence. I’m excited that “Dr. Val and the Voice of Reason” lives on at the Getting Better Blog. I am committed to integrity, transparency, and medical accuracy – presented in a warm, and down-to-earth manner. Unfortunately, my new site is not live yet, so KevinMD and Kim from Emergiblog have graciously allowed me to crash guest blog at their sites for this edition of Grand Rounds.

I’ve chosen to present the submissions in their authors’ own words – the purest form of expression. I selected my favorite quote from each blog post, and organized them topically with an introductory cartoon of my own. The order in which they appear reflects the order in which they were submitted. Asterisks denote exceptional story-writing (IMHO).

Thank you for reading – and please consider supporting Grand Rounds by featuring its new button on your blog or website. Health bloggers have a collective voice – it is Grand Rounds!



The Healthcare “System”

Dr. Wes, Our Healthcare Hindenberg: “I wonder how any health care system, much like the foregone housing market, can sustain itself with our current similar mindset of universal, limitless healthcare for all… Like the 12-step program for Gambler's Anonymous, we must first acknowledge we have a problem and ar