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The consequences of making medicine a business

Business principles are applied to American medicine to an extent found in no other country in the world.

Every procedure, office visit, or hospitalization is assigned a quantitative work value, known as relative value units, that is used to base revenue and salary decisions on.

Harvard physicians Pamela Hartzband and Jerome Groopman looks at how such a fiscal-based system affects medical decision making. The results are …

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Would you undergo a colonoscopy without sedation?

Colonoscopies are routinely performed without sedation in Europe and Asia.

With health care costs rising, and staffing become scarce, a study suggests that a no-sedation colonoscopy can help on both fronts. Of 145 patients who elected to undergo a colonoscopy without sedation, 112 completed the procedure.

As a gastroenterologist shortage is looming, a no-sedation colonoscopy may become an option for some patients.

Additionally, patients do …

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Are there too many hospitals?

Should hospitals be run more like fire departments?

“Each neighborhood has its own firehouse,” says #1 Dinosaur, adding that “because the training is generally similar from one company to another, you don’t have huge, expensive advertising campaigns touting the superiority of the Main Street Fire Company over the one on Church Street.”

Calling it “the ultimate in capitation,” he envisions hospitals to be funded like police and …

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Physician assistants and nurse practitioners are staffing rural ERs full time

The physician shortage is forcing rural ERs to use mid-levels exclusively to staff their emergency departments.

Local doctors are the backup, available by phone and able to go the hospital within minutes for emergencies.

Some hospitals have no choice, since the alternative would be to shut the ER down due to the lack of available physicians.

There is a marked difference in the amount of training an …

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Providing universal care, should patients be held accountable?

Should there be preconditions for patients in order for universal care to be enacted?

Chris Rangel weighs the “practical interest in keeping the workforce healthy and reducing the economic burdens from people who become sick and disabled as a result of unhealthy or risky lifestyles” versus the “undue burdens on beneficiaries” that can “lead to decreased participation.”

Dr. Rangel points out that under any reform plan that increases …

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Does a checklist before surgery really save lives?

A simple tool can potentially yield huge beneficial results.

As reported by MedPage Today, Atul Gawande led a team that studied whether surgical teams who completed one-page procedural checklist in the operating room affected patient care.

The results, published in the NEJM, were stark. In eight hospitals in eight different countries, both 30-day death rates from non-cardiac surgery and inpatient complications were significantly lowered.

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When was the last time you actually saw a doctor?

Ever schedule an appointment with a physician only to see a mid-level provider instead?

Patients better get used to it, as the doctor shortage, especially in primary care, is leading hospitals and practices to staff mid-level providers like nurse practitioners and physician assistants instead.

A retired doctor reminisces about the old days, and notes that “it is really all about economics,” and that the doctors patients really …

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What should you have in your medicine cabinet?

Here’s what an emergency physician would recommend.

In addition to everyday things like gauze, alcohol wipes, bandages, and select over the counter medications, some of the non-traditional items include hemostats and trauma shears (both available online), as well as Krazy Glue.

Why Krazy Glue? Dermabond, liquid bandage that’s often used in the emergency department, has the same active ingredient that’s found in Krazy Glue.

The data argues against an annual physical, but is it still needed?

I’ve written in the past that the routine physical exam does not have data to back up its efficacy.

Family physician Ben Brewer (via the WSJ Health Blog) has a different take, saying that it provides time to build relationships, which can have “a beneficial impact on health quality, costs and outcomes that goes way beyond disease detection and health screening.”

There are some variables that …

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Banning balace billing is tantamount to single-payer

California doctors are going to lose a lot of money.

Emergency physician Shadowfax analyzes the recent California decision that bans balance billing. Calling it “a disaster in the making,” he writes that removing the option to directly bills patients removes the leverage physicians have when negotiating with insurance companies. Namely, the option to stop accepting insurance.

Without this option, doctors “have to accept whatever pittance …

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Teaching medical procedures to interns and residents

The traditional method of learning medical procedures may need to be revamped.

Procedures, like inserting a central line, can be technically difficult and fraught with complications. The traditional way of teaching was to do one, have a medical resident watch, and then supervise the physician-in-training’s first attempt. Today’s focus on patient safety doesn’t lend itself to medical trainees practicing on live patients.

Indeed, the teaching …

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If physician salaries were lowered, would people still want to become doctors?

Are the rewards of medicine itself enough to entice the best students to become doctors?

Edwin Leap reminds us that at one time, the rewards of medicine outweighed the financial benefits associated with the profession. Medical students and young doctors today may not be as altruistic, and indeed, seem to place greater priority on lifestyle. This is especially true in the current era of restricted work-hours …

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When your office manager steals, a doctor learns the hard way

The office manager of a physician practice plays a vital role, and is trusted with a tremendous amount of private and financial information.

One doctor learns how her office manager has been routinely stealing from the practice, to the tune of almost $50,000.

“I had read countless times about victims of office embezzling, but that was always in large medical groups,” writes Dr. Miriam Griggs, the victimized physician. …

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Should you stop taking Vytorin if you’re already on the drug?

There has been some controversy surrounding the combination cholesterol medication.

Vytorin, a combination of simvastatin and ezetimibe, was found to lower LDL cholesterol, but did not measurably decrease atherosclerotic plaque. Despite this, MedPage Today reports that the FDA recommended that those already on the medication may continue taking it.

As always, internist Matthew Mintz provides further insightful analysis of the situation. The question that the FDA …

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Should patients be advised that better care is available elsewhere?

Doctors may have an ethical obligation to do so.

An article cited by the NY Times says that especially in the cases of cancer treatment, “doctors have an ethical obligation to tell patients if they are more likely to survive, be cured, live longer or avoid complications by going to Hospital A instead of Hospital B. And that obligation holds even if the doctor happens to work at …

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"You’re going to be an interesting clinical case"

Those are words no patient wants to hear.

Hospitalist Jonathan Roylance talks about his aortic valve replacement, embolic stroke, and ascending aortic aneurysm, all dealt with as he was going through medical training.

Would he have received the same care if he wasn’t a medical “insider?”

“My ordeal taught me the value of responsibility, hard work, and compassion,” writes Dr. Roylance, and points out “I was blessed …

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Is the physician shortage expanding to gastroenterology?

The numbers are pointing to a shortage of gastroenterologists.

However given the source of the data, I’d be a little dubious. Olympus Corporation of the Americas, a company that manufactures endoscopes, commissioned the study. It certainly would be in their best interest to have more gastroenterologists trained, and use their scopes.

That being said, a recent NEJM study, which showed that colonoscopies aren’t as …

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The waning effect of direct to consumer drug advertising

Patients have finally become wary of drug advertising they see on TV or read in a newspaper.

MedPage Today reports a study that showed that in only 3.5 percent of encounters did a patient ask about a specific new prescription medication, down from almost 16 percent five years ago.

Recent scandals and negative publicity have placed the reputation of the pharmaceutical industry only slightly higher than that …

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Would you rather have Gregory House or Marcus Welby as your doctor?

Most would prefer Dr. House.

According to a survey, the acid-tongued master diagnostician of Fox’s television series (via Dr. RW) was the preference of 20 percent of respondents. The good-manned Dr. Welby was second at 13 percent.

Ironically, the 95 percent of the same respondents said bedside manner was the most important trait they looked for in a doctor, something Dr. House is definitely not known …

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Hospital scrubs and lab coats are dirty, infested with germs, and can kill

Ever see medical personnel wear their scrubs in public?

Well, they shouldn’t. In a WSJ op-ed, Betsy McCaughey warns about how contaminated scrubs and lab coats can be.

65 percent of medical providers change their lab coats less than once per week, and even more disturbing, 15 percent less than once per month.

Bugs like drug-resistant C. Difficile contaminate nearly every surface, and invariably find …

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