Tuesday, March 30, 2004

Trent McBride over at The Proximal Tubule has started a serial debate over paternalism in medicine. While I was going to wait until he got to something related to procedures and informed consent I have been moved to comment on his post about the requirement to obtain a doctor's prescription to obtain certain medications.
I'm too tired after a hard day seeing patients at the Acme Surgical Corp to debate the main point, mainly should prescriptions be required for certain medications. I will however throw in my two cents worth about some medications that should not be sold over the counter. My take on this is different than say, DB, who prescribes many different medications, since the main prescriptions I write (antibiotics and narcotics) have already been addressed.
Tamoxifen: This is a medication that has a wide variety of side effects such as thromboembolism, endometrial cancer, and cataracts. One use of Tamoxifen is the prevention of breast cancer in selected high-risk women. A woman who was not at high risk may have such a fear of cancer that she may take the medication if offered over the counter, needlessly exposing herself to risks.
Coumadin: A medicine that is hard even for experienced physicians to manage. The therapeutic range is narrow and can be affected my so many variables (diet, other drugs) . A patient may be going on a plane trip and wants to avoid "economy class syndrome" and takes some OTC Coumadin. Suppose this patient has protein C or S deficiency?
Thyroid hormone: With the recent ban on ephedra, patients could achieve the same results with OTC Synthroid.
But according to Mr. McBride the potential for misuse is a secondary concern:

If somebody was stupid enough to buy and take very toxic drugs without physician supervision, I still don't think that takes away from the point that they should still have that right.

What of "first do no harm"? Is paternalism the same as protectionism?

Monday, March 29, 2004

My partner and I spent our lunch hour operating on a 19 year old who had been running from the police and seems to have made the mistake of pointing a weapon toward them. They took offense to this and shot this individual with a .40 caliber weapon. The entry wound was at the right midaxilliary line with the projectile in the subcutaneous tissue at the midline. Off to the OR we go. After a right chest tube was placed the exploration began....
Large amount of blood found within the abdomen, most in the right upper quadrant. Performed a Pringle maneuver to control the hemorrhage. The hollow-point bullet tore a 5cm wide and 2cm deep laceration along the anterior surface of the liver. Needless to say the damage was extensive. Multiple portal and hepatic venous branches along with hepatic artery branches were injured. Titanium clips and silk suture were used. Avatine and packing were applied to the raw surface to try to gain hemostasis with little effect. Fibrin glue was applied (home-made, since the only Tisseel carried at big hospital was in the 1cc amounts. We then were faced with the unfortunate situation of the triad of hypotension, hypothermia, and coagulopathy. The decision was then made to leave the packs in and pursue a damage control laparotomy plan. Packs were left in and a 3-liter irrigation bag was cut and autoclaved. Using a modification of the Bogota bag one-half of the bag was placed over the bowel with a towel. A VAC sponge was placed over the bag and the rest of the bag was placed over the sponge. The sponge was connected to suction which helps with the "cleanliness" of the wound. The patient received multiple units of packed cells and plasma. The utility of this approach is to allow for correction of coagulopathy and hypothermia with planned return to the OR.
Apparently the police force has great confidence in us as they say that while the patient is in "critical condition" (you think?) he is expected to "recover fully". At least he has the advantage of youth.

Sunday, March 28, 2004

About the only good thing that can be said about dialysis access surgery is that one can perform the operation while sitting down. HD access, for good or ill, makes up a large portion of our practice at Acme Surgical Corp. These patients can be a challenge to manage, both from a technical and physiologic standpoint. The National Kidney Foundation has as one of their projects something called the Kidney Disease Outcome Quality Initiative (KDOQI). Part of the KDOQI is a set of practice guidelines. (You may draw your own conclusions about Amgen's sponsorship of guidelines that advocate use of a great deal of Epoetin.) One set of these guidelines sets out recommendations for HD access. The guidelines are extensive. Their main point is that arterio-venous fistulas should be the access of choice due to their better long-term patentcy rates. The goal of these programs is to increase the rate of fistula creation to 50 percent as a first access, and to 40 percent as a secondary access. The rates in the US now are 20-30 percent with Canada, Europe, and Japan having fistula rates between 70-90 percent. What role the HD populations in those countries (and the more widespread use of HD in the US) play in that figure is not addressed in the Fistula First material.
There is a great deal of emphasis on preoperative evaluation of the inflow and outflow vessels, including vein mapping and arterial duplex studies (to ensure an outflow vein >2.5mm in diameter and an artery diameter >2mm). If at all possible I construct fistulas but given the limitations described above, not all patients qualify. As with most things surgical, each procedures have their advantages and disadvantages. Fistulas have greater long-term patentcy (I have seen fistulas that have been working for over ten years), are associated with lower long-term costs due to their patentcy, and, particularly with radio-cephalic wrist fistulas, easier to construct. On the other hand fistulas take longer to mature, actually have poorer early patentcy rates than grafts, may fail to mature, and have few surgical options when they do thrombose. Grafts mature earlier, allow for larger areas for cannulation, are easier to cannulate, allow for a more "customized" route of access, and are very amenable to surgical correction (declotting and revision) should problems arise. The problem with grafts are their durability. About fifty percent will fail and require revision in two years. Obviously this is a problem given the costs associated with graft failure. The KDOQI program is a sound strategy for managing dialysis access with strong emphasis on quality and evidence-based methods...except for this.
The weak point in their emphasis on fistula creation lies with what is one of the foundations of the system, outcome improvement. Much is made of patentcy rates of grafts over time, but when it comes to monitoring fistulas:


Primary Access Failure–Native AV Fistulae

No guideline for primary access failure is recommended. (Opinion)

Rationale To achieve the proposed goal of attaining native AV fistulae in at least 40% of patients requiring dialysis access (see Guideline 29: Goals of Access Placement–Maximizing Primary AV Fistulae), the Work Group recommends that the primary failure rate of AV fistulae not be used as an indicator of quality. To do otherwise might discourage native fistulae construction in patients with more complex vascular anatomy (ie, in patients who are at a higher risk for failure). Nevertheless, primary failure of native AV fistulae should be examined in dialysis centers as part of their QA/CQI vascular access programs.......


Cumulative Patency Rate of Primary AV Fistulae

No guideline for cumulative access patency is recommended. (Opinion)

Rationale To achieve the proposed goal of attaining native AV fistulae in at least 40% of patients requiring dialysis access, the Work Group recommends that the cumulative patency rate of AV fistulae not be used as an indicator of quality. To do otherwise might discourage native fistulae construction in patients with more complex vascular anatomy who may be at a higher risk for failure. Nevertheless, cumulative patency rates should be examined in dialysis centers as part of their QA/CQI vascular access programs.
(emphasis mine)

So what this says to me is that their goal of a higher fistua rate is so important that they would rather have a surgeon place a fistula in a patient that they know by experience has a high possibility of failure than have a surgeon place a primary graft. I am sure that as more surgeons move toward more aggressive placement of fistulas that the patency rates will decline. But doesn't that indicate the need for qualified fellowship-trained vascular surgeons to be the only ones doing dialysis access? It would be, but HD access is the "red-headed stepchild" of vascular surgery. Even among vascular surgery patients dialysis patients are considered difficult and somewhat unsatisfying to take care of. They aren't like carotid or AA patients where you perform an operation and they get better, they are more like a severe peripheral disease patient that requires multiple operations. The vascular surgeons calling for their own board rarely mention HD access as a motivator.
Anyway I have to return to work tomorrow,oh well....

Thursday, March 25, 2004

Thanks to Trent McBride of The Proximal Tubule for alerting me to the fact that I can now do trackback with Blogger.
Needless to say I fattened the bottom line at many of Las Vegas' finest (and not so fine) casinos while finding time to make the meeting. It was fun and educational. We learned of trauma applications for such hemostatic agents as QuickClot, Chitosan, and the bane of hospital and pharmacy administrators, recombinant factor VIIa. We learned that if you have 24/7 operating room capability with immediate access and in-house surgeons, you can manage abdominal gunshot wounds non-operatively. Of course not everyone works under those circumstances, and those rules don't apply to the intoxicated, head-injured, or those requiring general anesthesia for other purposes. As this limits the eligible patient population, your results may vary. It was nice to hear how the "big dogs" of academic trauma handle things during the case discussions. Discussions of EMTALA were lively with the opinion of the speaker echoing my thoughts (posted here) about how smaller hospitals won't be required to provide specialty (read neurosurgery and orthopedics) coverage. This will place additional burdens on the larger trauma centers.

Plenty of discussion was about the lack of interest in trauma as a career among current surgical residents. The reasons, as discussed before, include lousy hours, poor reimbursement, largely inappreciative patients, high litigation risk, and the increasing move of trauma surgery from an operative practice to a resuscitative one. Many academic trauma surgeons are also taking over the "emergency surgery" (after-hours appendectomies) duties in addition to trauma surgery. In fact it seemed that many of the speakers would go to great extremes to avoid operating on trauma patients. The impression I received was the growing desire of the "trauma establishment" to bring in the community trauma surgeon, a move long overdue in my opinion.

On the last day, half of the morning was spent on discussions of "ethical issues" the most interesting one was related to the presence of family members in the trauma bay during resuscitation. Objections included the lack of space in the ED, having family members "fall out" during a resuscitation, family member interference and criticism (that's not how Dr. Carter did it on ER last night!) and of course, fear of litigation if things don't go well. Those that support the presence of family members during resuscitation cite reports (mainly related to ICU codes) that state the emotional benefits and "closure" that having family members present provides. The speaker polled the audience asking who would want their family member to see them with all of the accessories that go along with a complicated trauma resuscitation, very few said yes. I think that the presence of families in the trauma bay can only be a hindrance.

Anyway, it's good to be back home.

Sunday, March 21, 2004

Off today to Las Vegas for the annual Trauma and Critical Care meeting. Maybe I can win enough at the $5 blackjack table to retire. Posting to resume Thursday.

The tort refrom issue has claimed its' first political victim in Georgia, House Judiciary Chairman Tom Bordeaux...

House Speaker Terry Coleman abruptly removed the chairman of a powerful committee Thursday in a rare public show of political force.

Rep. Tom Bordeaux (D-Savannah) blamed his removal as chairman of the House Judiciary Committee on disagreements with Coleman on several pending tort bills.

"Under this Gold Dome, politics is a contact sport," Bordeaux said. "When you stand up for those who are abused by the powerful, you can expect to be knocked down."

Coleman would say only that he ousted Bordeaux because of "philosophical differences." Coleman appointed Rep. Mary Margaret Oliver (D-Decatur) to the Judiciary chair.

Replacing a committee chairman in the midst of a legislative session is rare. Twenty years ago, then-Lt. Gov. Zell Miller fired Sen. Nathan Dean as head of the Senate Rules Committee after a political disagreement.

Bordeaux believes his reluctance to move forward on several tort bills in his committee contributed to his demise. "He told me I'd become a lightning rod on the issue and I assume he meant tort reform," said Bordeaux, who is a trial lawyer

And of course the Vast Medical Wing Conspiracy was to blame:

There's very little legislatively we can do to truly help the doctors," Bordeaux said. "There's a lot the Legislature can do to change the laws to make doctors immune from being responsible for their mistakes. That's what doctors want. I don't think, personally, that's fair."

In the background of all this is the recent redistricting map handed down by a three-judge federal panel, which is expected to give republicans control of the state house for the first time in 140 years. This would seem to give tort reform a easier road to passage.

Even more from the Journal-Constituion's political insider:

Wednesday's decapitation of Tom Bordeaux, the powerful House Judiciary chairman, was indeed about tort reform.


It was also a very public message sent to the more liberal side of a seriously split House Democratic caucus, to close ranks with the conservative members who lead it.

To that extent, the future of the man who wielded the ax -- House Speaker Terry Coleman -- now depends on how his 108 Democratic colleagues absorb the disciplinary measure.

"It's always effective to shoot a general now and then. I don't know that I'd have shot this one," said one relatively influential Democrat.

In the main, this sacking of a top House chairman was more about occupational loyalty than party loyalty.

The Legislature has 36 lawmakers who list their livelihood as "attorney." Eight of them attended the news conference held by Bordeaux, a Savannah lawyer.

Elsewhere in the Capitol, some 54 lawmakers include the word "business" in their job descriptions. One of them is the House speaker.

As much the 2002 election of Gov. Sonny Perdue, the rise of Coleman as House speaker 14 months ago led Georgia business leaders to launch an unprecedented campaign to limit the filing of liability lawsuits -- which they say is driving away business in general and medical practitioners in particular.

The Holy Grail is a $250,000 cap on the noneconomic worth of a human being.

Earlier this session, Bordeaux's counterpart in the Senate -- Charles Tanksley of Cobb County, another attorney -- bucked his Republican leadership when they tried to route tort reform legislation around his committee. He successfully forced the bills back to his committee, where they remain. Tanksley may yet lose his chairmanship over the episode.

In the House, Bordeaux moved no more quickly. And now has been removed.

The speaker chose state Rep. Mary Margaret Oliver (D-Decatur) to replace him as judiciary chairman. She's an attorney, too, but has a history of flexibility on the tort reform issue -- in the Senate, she teamed up with colleague Sonny Perdue to pass a tort reform bill.

Have to go pack. Have a good week.

Saturday, March 20, 2004

As feared this past week Georgia Medicaid briefly ran out of money:

Georgia's health care program for the poor has run out of money, but that fact didn't bring legislative leaders to an agreement Thursday on a plan to bail out Medicaid.

The program's money dried up late Wednesday afternoon, stopping payments to doctors, hospitals and other medical providers who care for the 1.4 million Georgians on Medicaid. Payments for PeachCare, which covers uninsured children, also were suspended.

Doctors and other medical providers were frustrated, saying the holdup will persuade more physicians to limit the number of Medicaid patients they see --- or drop them altogether.

"Even if this is fixed, physicians will look at whether they will continue to provide Medicaid services," said Dr. Michael Greene, a family physician in Macon who is president of the Medical Association of Georgia.

Steve Barber, chief financial officer of Royston-based Ty Cobb Healthcare System, said: "It's incredible to me they let it get this far. It's not as if they didn't see it coming."

And the finger-pointing is proceeding at a rapid pace:

It's the House's fault," said Senate Majority Leader Bill Stephens, R-Canton. "They're picking politics over people."

House Speaker Pro Tem DuBose Porter, D-Dublin, laid the blame on the Senate. "Obviously, the Medicaid payments do not matter to the Senate," he said.

This isn't like Blue Cross running late on some payments. Physicians who have a high number of Medicaid patients in their practice cannot withstand a prolonged freeze on payments. Anything past a few days and there will be a problem meeting payroll. Nursing homes could also be hard hit:

It will pose "an immediate danger to the patients and the employees of Georgia's nursing homes," said Fred Watson, president of the association. "Many facilities will be trying to make payrolls tomorrow and next Friday. Some will have to make loans, and we suggest the state borrow short-term funds to get us through this crisis."

And while the money was found yesterday to fund the program, the pork projects that had been holding things up got passed as well:

Gov. Sonny Perdue and legislative leaders moved Friday to get the state's massive health care program for the poor and elderly back in business. Perdue released $57 million to Medicaid to allow the Department of Community Affairs to process health care claims over the weekend. The program, which provides health care to 1.4 million Georgians, ran out of money to pay claims late Wednesday.

The governor announced the transfer of money from the Department of Human Resources to Medicaid just after House and Senate leaders agreed on a mid-year budget adjustment that will provide an extra $171 million to the program. The spending plan, which also would provide more than $100 million in additional funding for fast-growing schools, will go to the full House and Senate for a vote Monday......Perdue blamed the budget roadblock on "silly, partisan political differences."

"A child needing insulin doesn't really care who's fault it is," the governor said. "A lot of this revolved around the trade-off for special projects and trying to take home pork to our districts when we didn't want to provide medicine for those who can't afford it. That's what offends me so much about this."

The mid-year plan approved Friday includes about $40 million in local projects using bond money from a West Georgia reservoir that was never built. The House and Senate split the money.

Among the projects are a park/museum in the hometown of Senate President Pro Tem Eric Johnson (R-Savannah), a golf course in the district of Senate Appropriations Chairman Jack Hill (R-Reidsville), and a dam project in the district of Sen. Don Cheeks (D-Augusta), one of the budget negotiators. Another $15 million would go for a land conservation program being pushed by Perdue.

This is one of the things about a state-sponsored single-payer system that concerns me. Do the physicians out there want their reimbursements conditional upon whether a legislator gets a golf course or dam in their district? Would anyone want the funds for their healthcare be the subject to political whim? Your representative displeases the party in power, and now the health budget in your district is cut, is this what we want?

Wednesday, March 17, 2004

Lifesaving Defibrillators Are Absent From Most Gyms

Stephen P. James was playing racquetball at a Bethesda health club on Feb. 3, 2002, when someone urgently called him to help a player on a nearby court who had collapsed in cardiac arrest. James, a physician, gave the man cardiopulmonary resuscitation for more than 20 minutes with the help of two other people. By the time an ambulance arrived and the man's heart was shocked, he was dead.

Afterward, James, who works at the National Institutes of Health, suggested the club get an automated external defibrillator (AED), a device someone with little or no training can use to deliver a lifesaving jolt of electricity to someone in cardiac arrest. Nothing came of the request.

On the Saturday after last Thanksgiving, it happened again. James, 56, was at the club when he received another urgent summons to tend to a man who had collapsed on the basketball court. He and a few others, including a club employee, performed CPR for about 10 minutes.

This time they were luckier. After a shock from the paramedics' AED, the victim's heart started beating again and he began to breathe. He is alive today.

I think I would join a new gym. Anyway, the article comments on the benefits that having AED's in such places as airports, casinos and stadiums. It seems that gyms would be a logical place for AED's to be, given the number of people who ignore the advice to "consult a physician before beginning an exercise program"..

What sets health clubs apart is that they are places where a person's risk of sudden death is certifiably above average. While regular exercise decreases the lifetime risk of heart disease, the stress of exercise can trigger cardiac arrest.

Information collected on 22,000 male doctors enrolled in the Physicians' Health Study run by Harvard Medical School found that risk of dying during (or right after) exercise was 17 times higher than at times of no exertion. Another study, which looked at the two-year experience of a chain of 320 health clubs in the United States, recorded one death in every 2.6 million workouts. Most victims were people in their mid-fifties who exercised sporadically.

"Men come in and throw caution to the wind, turn the treadmill on at 6 miles an hour and go to it," said Barry A. Franklin of William Beaumont Hospital near Detroit, who conducted the health club study.

The concerns over liability have been a large hurdle in the acquisition of the devices, but the only suits that have materialized so far have been involving facilities without AED's. You can purchase an AED here for less money than quoted in the article. I will investigate the AED situation at my gym today.
From this: 1000 styles of Rumsfeld to this...
Rumsfeld Hosts No-Holds-Barred Martial Arts Tounament At Remote Island Fortress

U.S. Secretary of Defense Donald Rumsfeld has opened his fortified island headquarters to participants in his second no-holds-barred martial arts tournament, the enigmatic mastermind announced Monday.

"Warriors of the world, hear me," said Rumsfeld, seated on the onyx throne overlooking the fighting arena at the island's central volcano, surrounded by a phalanx of exotic but murderous beauties and his seven-foot-tall guard Omarra. "I declare the Eagle Fist all-styles, hand-to-hand combat world championship open once more. For the next 10 days, the world's mightiest fighters will come together here at Fang Island to compete for a prize of $1 million and the post of Associate Secretary Of Full-Contact Defense!"

Rumsfeld then declared the tournament open by symbolically shattering a block of obsidian with his prosthetic dragon's claw—the powerful weapon grafted onto his right wrist after 2003 champion Li severed his hand with manji butterfly swords.

Snatch the pebble from my hand....

Monday, March 15, 2004

That, gentle readers, is the sound of Dr. Parker beating the dead horse named DoctorsKnow. The beating was inspired by a recent comment posted on the Medrants site. The commenter, named "arf", asks if the database contained only information on frivolous suits, would it be ethical to use it? But the more salient point IMHO comes next:

A medical business magazine identified some neurosurgeons in Southern Illinois who have closed their practices because of the malpractice climate. The article states that neurosurgeons in Illinois are sued an average of once every nine months.

The hospital offered to make them employees and take over their malpractice costs, but that was not good enough for them, and they chose to leave. Now there are no neurosurgeons in the lower third of Illinois. This will result in this hospital sending patients an hour to Kentucky or two hours to St. Louis.

So, instead of a physician denying medical services to an INDIVIDUAL because of a perceived high litigation risk, these doctors are denying medical services to an entire REGION because of a perceived high litigation risk in the entire area.

Is this "ethical"? I can imagine one's answer, but why is it a problem when a physician declines to put his neck in the noose in one situation but not another?

The reports of departures among Illinois neurosurgeons, Mississippi neurosugeons and Nevada obstetricians don't seem to produce the visceral reaction that the DoctorsKnow site did. The closure of the trauma center in Las Vegas and a walkout of surgeons in West Virginia did evoke some media outrage, but again not to the level of recent events. It seems that the loss of medical services to a region, perhaps permanently, evokes a yawn while more "pro-active" efforts causes the populace to run for their torches and pitchforks. Why? Why is the story of someone who supposedly can't find a physician to treat a non-emergent condition of a family member so compelling to as to warrant an appearance on Good Morning America but the wider problem of physician access can't generate the same amount of attention? To paraphrase Uncle Joe: "One patient's denial of medical care is a tragedy, but the denial of thousands is a statistic"

Sunday, March 14, 2004

Will fall on Wednesday (sorry,Thursday actually, eds.)this year. Not St. Patrick's day (the most important day of the year for some) but the annual day of medical student anxiety, where some will laugh and some will cry, many will get intoxicated for reasons good and bad, I am referring of course to Match Day. Match day at my medical school was a grand affair with all of the class assembling in the main lecture hall with the Dean of Students solemnly calling our names in alphabetical order. At least we didn't have to open the envelopes and read it out in front of everybody as had been done in the past, and is still done at some schools, I have heard. Of course the rumors had been floating around about who had gotten a call from the Dean's office on Black Monday, and sent Tuesday in the Scramble.
This will be the second year that the Match has been conducted while the NRMP has been fighting a lawsuit alleging that the Match violates anti-trust laws and artificially holds down the wages of residents. The NRMP has, of course, denied this and the suit has been going on for about two years now. Db posted on this a few months ago, and I thought it would be a good thing to revisit the issue given the proximity of Match Day.
Both the NRMP and the plaintiffs in the Match lawsuit have websites up which makes for interesting reading..
The NRMP has their "Save the Match" site which lays out their case for keeping the match as it is. The section of the site describing the bad old days before the match give the picture of a chaotic system under which applicants and programs were not well served. The NRMP claims that their program is fair and free of bias. I will give them credit for bringing order to a disorganized system and eliminating the abuses that had some medical students accepting internship positions as early as their second year. The claim that the match eliminates the "old boy's network" I find difficult to accept, as far as surgery goes. I had faculty of my school make phone calls for me and others would say, "Dr. So-and-so called me from State U., how did your interview go?"
The plaintiff's site RESIDENT PHYSICIANS' ANTI-TRUST CLASS-ACTION in my opinion does not do as good of a job at making their case. They allege that the current system artificially depresses wages and enforces dangerous work-hour requirements (a moot point with the new work-hour restrictions in place). The plaintiffs also allege that the Match is discriminatory against minorities and women. They blame this on bias felt to be in the computer system itself, as well as the fact, to quote:

The NRMP was designed and implemented during an era in which large segments of society were not only insensitive to racial issues but intent on preserving racial divides. The NRMP predates even the true awakening of racial issues in the 1960's. It is not unreasonable to believe that the designers of the match were not cognizant of how it
might impede the opportunity of minorities in medicine.

They opine that these circumstances are ongoing today because the programs are able to hide their discrimination by claiming "the machines did it":

The match provides a ready-made excuse for such hospitals and specialties to conceal discrimination; they can blame the distorted ethnic composition of their incoming residents on vagaries of a computer assignment and absolve themselves of responsibility.

They also view the Match as an impediment to a remedy for discrimination since programs cannot hire minority candidates outside the Match. Given that women now outnumber men in medical school classes, the sexism argument may no longer apply. I am very wary of any attempt to promulgate social engineering through medical residency slots. The plaintiffs put forth a system they call the Voluntary Match in which programs may split their slots between Match and non-match. I can understand their point about the pressure on applicants to hedge their bets and apply to many programs because of the nature of the Match. This can be an expensive endeavor for students who embark on multiple interviews (1/03). But a return to the "free agent" market could lead to more "corruption" today than existed in the pre-match era. The heavy Medicare funding in graduate medical education today, that did not exist in 1952 would create a strong financial incentive to ensure their program filled. This could lead to programs to ignore any voluntary deadlines and limitations in effect.
I welcome your comments and your own match experiences.

Saturday, March 13, 2004

Cost analyst: Ordered to skew Medicare figures

The nation's top Medicare cost analyst confirmed Friday that his former boss, Thomas Scully, ordered him to withhold from lawmakers unfavorable cost estimates about the Medicare prescription drug bill. He said the estimates exceeded what Congress seemed willing to accept by more than $100 billion.

Richard Foster, the chief actuary at the Centers for Medicare and Medicaid Services, said Friday night that he received a handwritten note from Scully, then the centers' administrator, in early June ordering him to ignore information requests from members of Congress who were drafting the drug bill.

Mr Foster apparently was threatened by the loss of his job if he responded to requests by members of congress:

Foster said Scully insisted upon a pattern of withholding of information.

"Estimates that were supportive of the legislation were generally released and estimates that could be used to criticize the legislation were generally not released," Foster said.

Give the figures that have come out since the bills passage, Mr. Foster's cost estimates were accurate:

Knight Ridder reported Friday that Foster's Office of the Actuary suggested that the drug benefit would cost at least $100 billion more than the $395 billion estimated by the Congressional Budget Office, whose job it is to project costs of legislation. One projection prepared in early June by Foster's office and obtained by Knight Ridder concluded that a Senate version of the bill might cost as much as $551 billion.......When Bush signed the bill in December the drug benefit bore a $395 billion price tag. In January, the president's budget director, Joshua Bolten, upped the estimate by $139 billion.

Congress now seems ready to leap into action:

In a grim-faced floor speech Friday, Daschle called for reopening the vote on the drug benefit. He also called for an investigation into the firing threat and assertions that the administration had withheld its cost estimates from Congress.

"Whether this is criminal or not is a matter we will certainly want to clarify," Daschle said. "But if not criminal, it was certainly unethical. And I think we need to know the facts."

A group of House Democrats concurred, asking that the Health and Human Services Department's inspector general investigate the matter.

I don't think that Congress would take the drug benefit away during an election year. It will be interesting to see how this plays out. Some, myself included, want to know "What did the President know, and when did he know it?"

Foster said he believed higher-ranking members of the administration than Scully knew of the higher cost estimates that his office had computed.

"Did the president know? Did (Health and Human Services) Secretary Tommy Thompson know? I don't know," Foster said.

Friday, March 12, 2004

Glazed diet? Krispy Kreme plans low-sugar doughnut

Hot. Now. Healthy?
Krispy Kreme Doughnuts (KKD), long known for its high-calorie treats, says it plans to offer a low-sugar doughnut to attract dieters and diabetics.

Exactly how low the sugar content would be was unclear. Krispy Kreme spokeswoman Amy Hughes said the new doughnut is still in the early stages of development. It is set to debut before the end of 2004.

One of Krispy Kreme's Hot Original Glazed doughnuts has 10 grams of sugar and 200 calories. More than half those calories come from fat, 12 grams of it.

Krispy Kreme lover Nathan Painter said he would give one of the newfangled doughnuts a try. Still, he found the whole idea strange.

"It just seems odd they're trying to be healthy," he said.

What next, low fat all the way dogs at The Varsity?

Wednesday, March 10, 2004

UCLA suspends its Willed Body Program

Top officials at UCLA Tuesday voluntarily suspended the university's Willed Body Program after accusations that its director and others sold body parts for profit, a lawyer for the school said.

The announcement came as a Los Angeles Superior Court judge issued a temporary restraining order to halt the program.

The order was issued one day after a class-action lawsuit was filed by families of donors who allege parts of their loved ones' remains were illegally sold for profit.

Louis Marlin, an attorney for UCLA, said the university's decision to suspend the program was effective immediately, and hinted that it's possible the program won't be restarted.

This has the potential to severly harm medical education throughout the country. Medical schools are dependent on the generosity of individuals to donate their bodies for education and research. Many schools are getting away from the use of cadavers for anatomy instruction, and using computer simulations. I think that medical education suffers from the diminished use cadavers for two reasons, first of all a computer simulation cannot duplicate the "feel" of human tissue and the use of cadavers instills the medical student with the responsibility that accompanies being a physician.
It is inevitable that people will think twice about donating their bodies now.

More at Blogborygmi
Seems like the DoctorsKnow folks couldn't take the heat:

DoctorsKnow.Us has permanently ceased operations as of 3/9/04. The controversy this site has ignited was unanticipated and has polarized opinions regarding the medical malpractice crisis. Our hope is that this controversy will spark a serious discussion that results in changes that are equitable to both patients and physicians. All charges that have been collected will be returned to members and trial members.

Doctors.Know.Us, L.L.C.

Sure was fun while it lasted.
I had not planned on posting anything today with the resident service, a lunchtime trauma talk, and trying to come up with a QA plan for the use of FAST exams at big hospital. But when I saw what Mr. Holt had on his site today my "day of blogging rest" went right out the window.
Posted today on THCB is an email sent to Mr. Holt by a reader known as "Industry Veteran". "Industry Veteran" has had a few other things posted on Mr. Holt's blog in the past, usually about pharma issues. While DB and Dr. Rangel can understand the frustration that can lead to a site such as DoctorsKnow, they make principled arguments, which I understand, that the site as currently promulgated, is more hurtful than helpful, the "Industry Veteran" feels the need to, shall I say, make it personal. Since Mr. Holt does not have open comments on his site I feel the need to respond here.

I was sorry to see your statement that you "take the doctors' side" in their battle against the malpractice lawyers. Among those who deserve blame for the shortcomings and inequities in this country's two-tier healthcare system, organized medicine is at least as blameworthy as hospitals, Big Pharma and insurance companies. Although you back away from this ill-considered partisanship in subsequent sentences, your initial sentiment reveals a reflexive simpatico that you should try to eradicate.....All the participants have historically sought to dip their beaks in the public's blood and, in the case of healthcare, the providers have enacted the Tony Soprano role to an extent equalling that of manufacturers and payers.

So while Mr.Lambe of Texas Watch describes physicians as engaging in"pure thuggery", the "Industry Veteran" compares physicians to a fictional Mafia kingpin who cheats on his wife. Moving along.....

Paul Starr's Social Transformation of American Medicine and other monographs have described the tactics that organized medicine used to elevate medical practice from a middling, lower-middle class occupation at the start of the 20th century (when the requirement for admission to Harvard's medical school consisted of the ability to read and write) into the significant holder of gross domestic product that it is today. "In the physicians' view," according to Starr, "the competitive market represented a threat not only to their incomes, but also to their status and autonomy...and threatened to turn them into mere employees."

I have not read Mr. Starr's book (but I plan to) and cannot comment on that particular part of the paragraph above. But I wonder if the "Industry Veteran" would like to be treated by a physician whose main qualification was that they were literate? So much of medicine and medical education has changed since that time due to such things as technology and the Flexner report. In those days the hospital was not where you went for treatment, but went to die.

While increasing a profession's exposure to tort liability is rarely the sole means of reforming public policy, I believe that in this case malpractice actions do help to advance the process. Dragging physicians into the dock furthers the demystification and dissipates the profession's unchallenged self-judgment, both of which permit physicians to insert economic bottlenecks into healthcare while making the provider sector a two-caste system.

How do malpractice actions advance that process? Most of the "economic bottlenecks" I come into contact with from day-to-day are manufactured by the insurance companies and the government.

Other positive functions of malpractice activity include making medicine less attractive to the spoiled princes (and, increasingly, princesses) of American society

How? Other than to provide incentive for the children of current physicians not to go into medicine. I certainly was not a "spoiled prince". Neither of my parents graduated from college, my father was a small business owner and my mother was a part-time realtor. Medical school and the practice of medicine is to hard work for a "spoiled" individual to stick with it very long. If you want to make easy money, medicine is not the place to do it. I can't think of another profession were its practicioners are expected to render service without any promise of compensation, where every customer is a potential litigant, and attempts to secure payment for services rendered is viewed as unseemly when compared to other similar professions. (lawyers, for example)

Certainly I agree with your contention that the necessary process of knocking physicians from their pedestal can be abetted by the increased use of physician extenders (I prefer the term used by labor historians: "de-skilling") and the enforcement of evidence-based logarithms to constrain self-indulgent, self-dealing, cost escalating "autonomy." Despite the nervous handwringing from some of your fellow bloggers, I also want to advance the feminization (more accurately, the "mom-ification") of medicine to deter avaricious ambition from the profession (keep the Jeff Skillings and the Billy Tauzins in business and politics where they belong) while making it more hospitable to the needs of 9-5, live-and-let-live employees

I wish to point out to "Industry Veteran" that you get what you pay for, and I don't mean from a monetary standpoint. Apparently "Industry Veteran" wishes to live in a world where physicians are cookbook following, time-card punching automatons who have been largely supplanted by "physician extenders". Would "Industry Veteran" want themselves or a family member treated by a 9-to-5 physician? "Oh sorry you're having chest pain, but its five o'clock you know, time to punch out." This line of reasoning is much the same as those who want the practice of medicine to be treated like any other job, but recoil in horror when physicians themselves want to go along with that worldview. Then they wail, "You can't do that, health care is different from everything else....everyone has a right to medical care.....if you don't then you will be a thuggish violator of your Hippocratic Oath!" Physicians as people are many things, but stupid usually isn't one of them. The practice of medicine is still special to me and most other physicians, if it loses that luster, many of the best and brightest will move on to something else.

And lastly from "Industry Veteran":

I think we can proceed through a long, tedious dialogue on this issue, and we'd probably conclude with more agreement than disagreement. I don't wish to engage in such a colloquoy, and would instead urge a way for you to expunge your reflexive sympathy for physicians. Instead of maintaining the preconscious image of a workaday British physician such as your father, think instead of the two-dollar whores who demand that the pharmaceutical companies entice them to breach fiduciary responsibilities to patients.

I have just given a long, tedious monologue on this issue. Most of the surgeons I know are workaday (and workanight) physicians and are not, "two-dollar whores". I'm not that cheap of a date. While I disagree with the positions that "Industry Veteran" takes on these issues, many others agree with them. However, most of those individuals are able to express those opinions and debate them without resorting to describing physicians as Mafiosi, spoiled princes, or prostitutes. Is there a corollary of Godwin's Law that would apply? Got to go.

Tuesday, March 09, 2004


Lead editorial and reply in today's paper. More of the same from both sides, I'm afraid:

Fans of tort reform try deception

Supposedly, doctors across Georgia are quitting in droves because of skyrocketing malpractice insurance rates resulting from jury awards in the gazillions. The alleged exodus is so great that women can't even find obstetricians to deliver their babies.

The solution, according to the state's medical associations, is to limit how much juries can award victims of serious malpractice for their pain and suffering. A Republican-backed bill in the Senate would impose a $250,000 cap on such awards as a way to bring down the soaring insurance premiums and allow doctors to stay in business.

It's a persuasive argument, until you look beyond anecdotes and study the facts.

For example, tort-reform advocates claim a growing shortage of obstetricians and gynecologists in the state. But the American Medical Association says that in 2000 there were 1,256 ob-gyns in the state. By 2002, that number had grown to 1,312.

Last year, 18,134 physicians were practicing in Georgia, according to the Federation of State Medical Boards. In 2000, 17,151 doctors practiced in Georgia. So over three years' time, the number of doctors practicing in Georgia increased by nearly 1,000.

How many of those OB/GYN's are still delivering babies? I have tried to find the numbers cited above on the FSMB site but cannot find them. Do the numbers reflect physicians who are actively practicing medicine, or are they the number of licensed physicians who may or may not be working? Moving along:

No one denies that medical malpractice costs are climbing, but the evidence does not suggest that profligate juries are to blame. Between 1998 and 2001, the amount of money paid out by malpractice insurers nationwide rose 8.2 percent. Yes, that increase could justify a bump in insurance rates, but it clearly can't explain the stratospheric hikes in premiums that doctors describe.

It can if you realize that insurers must not only plan to pay off today's claim, but must set aside funds for tomorrow's as well. MAG Mutual (PDF) has noted that their awards greater than $ 1 million have risen from 11 in 2001 to 20 in 2003. The "stock market bubble" is blamed as a cause of the premium increases, which is not allowed under Georgia law.

Now for the counter-punch....Insurance costs put health care in jeopardy :

Access to quality health care is the issue. Soon it may be access to any health care. Consider the following: 40 percent of all radiologists no longer interpret mammograms, and nearly one half of all pathologists no longer read Pap smears due to the inherent limitation in the accuracy of the tests. Result? Your access to quality health care is limited.

Emergency trauma coverage by neurosurgeons is no longer available 24 hours a day, seven days a week at the majority of hospitals in metro Atlanta because of increased liability premiums. Result? Your access to quality health care is limited.

No certified insurer is writing any new insurance for hospitals in our state, because of increased risks. Twelve percent of ob-gyn doctors in Georgia have stopped delivering babies in the last year -- due primarily to increased liability premiums. Six-hundred physicians in Georgia will retire or leave the state in the next year -- primarily because of increased liability premiums.

The solution according to State Sen. Tom Price (R-Roswell):

A coalition of groups -- medical and otherwise -- has proposed responsible solutions that would not limit one dollar of economic (real) damages an aggrieved party may recover. Reason would be restored to a system by keeping lawyers from shopping for the most favorable jury; requiring that expert testimony be taken only from a true expert, not a hired gun; and allowing juries to determine a percentage of responsibility for both plaintiffs and defendants to end gold-digging for a deep pocket.

Here is what I wish he had added:

Despite what the plaintiff's bar may tell you, medical malpractice litigation today is not about protecting patients. It is a lottery. Many patients with legitimate claims are turned away by attorneys because they don't think they will get a large enough award to make it worth their while. Meanwhile physicians are faced with large jury awards where there was no negligence on their part. The medical liability system is unpredictable and affordably underwriting insurance in an unpredictable market is difficult if not impossible. Georgia should take the lead in making the medical liability structure reliable, predictable, and fair. Physicians who practice bad medicine and attorneys who abuse the system should be held accountable. Only then will health care be secure for all of Georgia's residents throughout the state, now and for years to come.

Let the congregation say Amen!
I wish I could write 1/10th as well as Lileks does..

People were hungry for the food we had prepared, but more so, hungry for John’s message of hope.

Which goes great with a béarnaise sauce, I hear. Chow down! Look, people, it’s one thing to drink the Kool-Aid, but it’s another to pee it into Dixie Cups and pass it around. I can understand people getting passionate about Howard Dean – when you’re in your 20s and aflame with Justice and Revolution, your cockles are stoked by someone who seems to mirror your own enthusiasm. But Kerry? It reminds me of the cover in ’84 after the Democrat convention: it had a picture of Dukakis, looking confident and secure. The cover said “THE DUKE.” It played right to the emotions of his supporters: we are not entirely unenthusiastic of his candidacy, Reagan is insane, and our guy has a great nickname that makes us feel cool when we say it! Landslide loss.

As The Professor says. "Heh, indeed."

Monday, March 08, 2004

On call today so not a great deal of time to post something big. I found this on the Medical Economics site and thought it would add some more grist for the mill: How plaintiffs' lawyers pick their targets

Two top malpractice attorneys explain why some physicians are more likely to get sued. Basically, it's a business decision, but some personal factors—like a doctor's arrogance or poor bedside manner—can also weigh heavily......

Allen: Even before we request records, Alice and I will sit down and evaluate the case. The first thing we need to assess is the dollar value of the damage. If there's no damage, then there's no case for us, no matter how badly the doctor may have screwed up. I could be more compassionate about it, but that's the real basis for our decision: You establish the damage first, then the liability.

Burkin: Because of our time investment and costs, we really can't consider a case unless we can expect a payoff of at least $200,000 in damages, and even that's really not enough. If we end up taking the case to trial, we're probably going to spend $20,000 to $30,000 or more. So we have to make a business decision: Are the potential damages worth the time and expense we'll have to invest to win?

Sorry Mr. Smith, since you have Georgia Medicaid the measly reimbursement I would receive would not be worth the time and office expense I would have to invest in treating you.

Doesn't quite roll off the tongue as easily, does it?

Sunday, March 07, 2004

A point-counterpoint the Atlanta Journal-Constitution on Saturday:
First, a patient's story, 'Winning' lawsuit does nothing to ease pain :

I am speaking for my son Haiden, as I am the only voice he has left.

Haiden was 16 months old. He could walk and talk and he could feed himself. Haiden loved cookies. In fact, I could get him to eat almost anything by telling him it was a cookie. Haiden had an amazing laugh, too. However, all of that is gone now.

Christmas morning, Haiden was very sick. Haiden's pediatrician had already diagnosed him with an ear infection. But Haiden was unconscious and vomiting when I rushed him to the emergency room. We waited for hours and when we were finally seen by a doctor, he looked in Haiden's left ear and said, "Oh, yeah, that's a bad one."

After that, I was chastised for "overreacting to the flu." The emergency room doctor breached several national standards of care, including not taking one set of vitals and not performing one test.

I was not given any discharge instructions. Phenergan, which causes drowsiness, was prescribed to an already lethargic baby, making it impossible for me to tell if Haiden was doing better.

The next day, I took Haiden to his pediatrician, who, at first sight, ordered me to meet him at the ER for a spinal tap. Within the hour, it came back positive for bacterial meningitis........

Unless it is your son or your daughter, you cannot understand what happens after a "successful" lawsuit. I never ended up "winning" anything. We recovered a specific amount of money. However, I will never "recover."........I agree there is a problem with frivolous lawsuits, and I am afraid that this bill will be passed partly because bogus lawsuits are the only ones that make the headlines. The truly valid lawsuits are settled and come attached with confidentiality agreements so they can't make headlines.

A very sad story to say the least. As with most of these accounts the details of the actual case are lacking. That is a problem with the debate over tort refrom, emotion sometimes overcomes reason. The best point is the feelling that nothing was "won" despite the jury award.

The "counter-point" to the story above: Impose legal limits to preserve freedoms by former Attorney General Griffin Bell and former Senator Alan Simpson (R-WY):

Legal reform is bogged down in the clear perception that what's at stake is only a battle between special interests -- tort reformers (mainly corporations and doctors) against trial lawyers.

What's really at stake is far more important -- the health and vitality of common institutions such as schools and hospitals and, ultimately, the fabric of a free society. When anyone can sue for almost anything, the effect is to diminish everyone's freedom. Justice is not supposed to be "democracy in action," where every case is decided by a jury plebiscite, tolerating wildly inconsistent verdicts for the same conduct. Justice is intended to be rendered by the rule of law, which requires judicial rulings that citizens can rely upon as guides for action. The principal role of the jury in a civil case is to decide disputed issues of fact, such as who is telling the truth.

Congress appears to labor under the misperception that limiting any claim is always an infringement of freedom, and only in extreme circumstances should it limit someone's so-called right to sue.....When legal disputes rise to a level of national importance, such as how to compensate the victims of asbestos or restoring order to health care, it is the responsibility of Congress to make the judgments of who can sue for what. By not making deliberate choices on matters affecting the broad public interest, Congress is clearly leaving that choice to self-interested people........The harm caused by America's unreliable legal system is not just industry-ruining class action lawsuits or occasional bizarre verdicts in personal injury cases. The main harm is that Americans no longer trust our system of justice. They go through the day looking over their shoulders instead of doing what they know is right.

Doctors squander billions in unnecessary tests. Jungle gyms and other athletic equipment are removed from playgrounds. Even seesaws have disappeared. Teachers, worn down by legal threats, don't dare hug a child and have almost given up trying to maintain order in the classroom.

It is the responsibility of Congress to restore order to what is now a free-for-all.

While not limited to medical liability reform, a good synposis of the overall problem.
Now in today's paper is this little piece about the worth of a human life: Life — hard to know what price is right

How much are we worth? That delicate and esoteric question permeates the tort reform debate in the Legislature.
Broken down to basic chemical elements, a human body is worth maybe $5. But isolated into fluids, DNA and tissues, our bodies could theoretically fetch $45 million in the medical and scientific fields, according to an analysis by Wired Magazine. The 1,000 grams of bone marrow — if harvested and sold at the maximum price of $23,000 per gram — could be worth $23 million alone.

Doctors and insurance companies argue that juries are tagging them with unreasonable verdicts and want to cap "noneconomic" damages — for a victim's pain and suffering — at $250,000.

The problem is, life has no "replacement cost," no book value.

So does this mean that since life is priceless, no one should get a jury award, or should the awards be of lottery caliber? The story goes on to review many methods of determining what a life is "worth", including the mother of all compensation scales, the 9/11 Victims Compensation Fund:

The fund's compensation grid starts at $250,000 and maxes out at about $7 million; the average payout has been about $1.8 million.

The fund's Web site describes actual cases: The survivors of a 36-year-old project manager with one dependent and a $221,000 salary received $3.5 million after $940,000 in other benefits and insurance were deducted. And survivors of a married business official, 38, with a $65,000 salary received $985,000, after $588,000 in "collateral offsets."

Determining how much a life is worth, being largely a subjective exercise, can be influenced by emotion. A bad thing according to my insurance agent:

Such verdicts are often an emotional response rather than a realistic one, argues Tom Gose, president of MAG Mutual, which insures most of Georgia's doctors. He says jurors' sense of sympathy can tack zeroes onto a verdict.

"That emotion, while normal, has gotten to the point of unaffordable," Gose said. "No one is worth $47 million, because the system can't afford it. It's all about balance."....He and others say huge malpractice verdicts are chasing doctors out of business, which ultimately hurts more people. And damage awards tend to be larger when a plaintiff survives some terrible injury or ordeal.

Emotion always seems to trump fact in these circumstances. The system is broken and I am afraid it will take some politician or their family member dying after showing up in an ER without a physician available due to liability concerns to really get something done.

Oh, and SB 432 is befrore the Senate Judiciary Comittee this week, keeping my fingers crossed.

Saturday, March 06, 2004

Concerning a few items making their way through the medical blogosphere....
First off the debate surrounding the DoctorsKnow website and the controversy it has set in motion. The story has been reported in the New York Times and The Wall Street Journal. Dr Smith has shared her thoughts as well as DB with the usual lively debate in his comments section.
I can see the problems on both sides of this issue. Some malpractice litigation is legitimate and some patients have suffered due to negligence (as the examples in both stories point out). The database apparently does not provide many details of the litigation, so it may be difficult to separate the wheat from the chaff as it were.
On the other hand the data that is available to patients about physicians can be impressive. While the National Practicioner Data Bank is not available to the general public, some states publish the claims history of physicians in their state. Several commercial physician research sites exist to provide patients information about the physicians that they are seeing. This database may be a way of leveling the playing field:

"There's no question that physicians are totally frustrated by the relentless assault on the medical profession by trial lawyers," said Dr. William G. Plested, chairman of the A.M.A.'s board of trustees and a cardiovascular surgeon in Santa Monica, Calif. Dr. Plested said the government already maintained a database of doctors who had been sued, for use by medical professionals.
"Is it fair to come to me if you've sued the last 10 physicians you've seen and never collected?" he asked. "Is it fair for me not to know that?"

The articles used such tried-and-true phrases such as "blacklist" and "chilling effect" to describe the effect the database may have on patients who have previously sued and try to find a physician.
Texas Watch a self-described " non-partisan advocacy organization working to improve consumer and insurance protections for Texas families" has this reply via the New York Times:

Dan Lambe, executive director of Texas Watch, said the site is attempting to scare patients.
``This type of blacklisting runs counter to the Hippocratic Oath to the ethical and moral goals and obligations of medical professionals,'' Lambe said.

Mr. Lambe, however was not as eloquent in his press release:

"This contemptuous disregard for the public health and the Hippocratic Oath is moral malpractice," said Dan Lambe, Executive Director of Texas Watch. "It is pure thuggery intended to blacklist patients who have already suffered tremendous harm and loss by medical malpractice."
This new website is the latest in a growing movement among extremist doctors across the nation who are denying medical treatment and ignoring their duty to patients simply because they have turned to the courts for justice in the past. Texas Watch has noted stories of doctors in Florida, Georgia and Texas denying or threatening to deny care to patients or patient advocates as well as communication between New Jersey medical professionals advocating that doctors inconvenience patients and delay care in order to highlight the medical malpractice issue.

As seen in their report on courts in Texas from their 501(c)(3) organization, Texas Watch is no friend of physicians.

I would find the claims of moral outrage from the trial lawyers and others more plausible if the decision making process by an attorney in a medical liability claim was based only on "Was this patient harmed by medical negligence?" and not by "Can I get an award from a jury to make this worth my time?" As I posted earlier, in battles such as these physicians will always have a hand tied behind their back because of the basic responsibility that physicians feel to care for their patients. On a more practical level, it is often forgotten that physicians, except for emergencies, may refuse to provide treatment for anyone they see fit.

The other story, brought to my attention by GruntDoc, about the ordeal a physician went through over a false claim of sexual assault. I agree that this physician went through hell over this and is entitled to ask, as former Secretary of Labor Ray Donovan did, "Where do I go to get my reputation back?" If only he had a chaperone at his side, this could have been avoided. IMHO, he should have dismissed the patient from his practice after he declined to testify in his civil suit.

I think the problem is going to get worse before it gets better.

Friday, March 05, 2004

Why have some asthma medications no longer available in MDI form? Are the diskus devices cheaper? Are the propellants in MDI's eating away at the ozone? Does their use increase compliance? I would appreciate some guidance from my primary care readers.

Thursday, March 04, 2004


The Onion
Deaths Go Unexamined and the Living Pay the Price from The New York Times.

Dr. Gregory Davis hunched over an autopsy table last Thursday morning and cut into the lifeless body of a 52-year-old man.

Days earlier, the man, who had no real health problems other than a smoking habit, had been found dead in his apartment, the victim of a heart attack, a coroner determined.

But Dr. Davis, a forensic pathologist at the University of Kentucky, opened him up and found something startling. The actual cause of death was bacterial meningitis, a severe infection that could have spread to others before the man died......

Autopsies were once routine, performed in more than half of hospital deaths and, in some parts of the country, in a majority of deaths that occurred elsewhere. But over the last few decades, the number of such procedures in the United States and several other countries has sharply dropped.

Hospitals, afraid of being sued over mistaken diagnoses, increasingly forgo autopsies, experts say. The advent of sophisticated imaging techniques like C.T. scans and M.R.I.'s have created an illusion among doctors that the procedure is unnecessary. Grieving relatives, too, are often unwilling to shoulder the cost or wait for autopsies to be completed.

The decline, researchers say, may be gradually eroding the quality of care. A growing number of missed or mistaken diagnoses are going unchecked, depriving doctors of a learning tool. And studies, including one published last week, find that autopsies uncover missed or incorrect diagnoses in up to 25 percent of hospital deaths.

The story goes on to describe the theory that the fall in autopsy rate has adversely affected the quality of care and allows mistakes to go undected:

Another factor, some experts said, is the risk of malpractice suits if a mistake or a missed diagnosis is exposed. In most wrongful-death cases against a hospital or physician, an autopsy is critical to establishing negligence, said Wayne Grant, a lawyer in Atlanta who has won many malpractice suits over 25 years.

"Of the potential death cases that we have turned down, well over 50 percent are cases in which there has not been an autopsy," Mr. Grant said. "When a patient dies and there's no autopsy, the doctor can bury his mistakes along with the patient."

My, My...well, moving along. DB has already ranted on this follow-up editorial:

Autopsies have dwindled for a number of reasons. Hospitals were once required to perform them to be accredited, but that requirement ended in 1971. Insurance companies do not pay for autopsies. But the problem really lies in our attitude toward them. In recent years, families have become increasingly reluctant to authorize autopsies, and doctors too often believe that modern diagnostic tools like CAT scans and M.R.I.'s have made them obsolete. Yet underlying these reasons is another, more pervasive one: the risk of malpractice suits. An autopsy that uncovers an error in treatment also uncovers the potential for litigation. Never mind that it may improve subsequent diagnoses.

An overwhelming amount of what we know about the human body and its diseases was discovered by means of autopsies. X-rays and M.R.I.'s may create the illusion that the human body is now, somehow, translucent, more open to the scientific eye, but the fact remains that in many ways, we are still as opaque as we ever were. Hospitals can discover how well they're doing not only by the number of people they cure, but also by closely examining a reasonable percentage of those they don't cure. To assume that a patient has died of a diagnosed disease is, too often, to assume too much.

I agree wholeheartedly with DB that this is over the top. I have only twice had a family member agree to an autopsy after an unexpected death. I have only been asked to order one once, and complied. The autopsy is a unique learning experience and one that medical students today rarely experience. When I did path my second year one of the requirements was to observe an autopsy. About 1/4 of the class had to view one simultaneously because of the low numbers. I took a autopsy elective my fourth year. They were so rare I was able to greatly improve my golf game. I think the real reason that autopsy rates have gone down is an economic one, the survivors don't want to pay for it.
But what of the growing industry of private autopsy services? According to this California entrepreneur business is booming:

Autopsy companies say they are benefiting from publicity about shocking cases of medical malpractice.

"We can almost time it," said Sebastian of Northwest Autopsies. "I'll see a story on the 7 a.m. news about the number of people being killed by hospitals, and our phones light up."
In one recent case in Los Angeles, an elderly woman felt strange after undergoing heart surgery. The woman died after ordering her daughter to have an autopsy done if she passed away.
A pathologist from 1-800-AUTOPSY found a piece of gauze left in the woman's heart. "I'm sure (the daughter) has a case, but she doesn't have her mother. Money isn't everything," said Herrera's wife and business partner, Vicki.

Even some university medical centers offer private autopsy services, including the University of Kentucky pathology services provided by Dr. Gregory Davis. The private autopsy services offered by Dr. Davis, which can be quite lucrative, somehow did not make it into the first story linked above. I wonder why?

Anyway all this pathology/autopsy stuff reminded me of a medical/science-fiction story I read when I was in grade school titled Star Surgeon. In this tale the intergalactic medical corps had red uniforms for internists, green ones for surgeons, and was run by the black-uniformed pathologists. Interesting concept to say the least.

Wednesday, March 03, 2004

The misdeeds of the Harricks laid bare.

Harrick Jr. made up the 425-point grading system for the PE course he taught in which Cole, Daniels and Wright received grades of "A" though they didn't attend class nor take the final exam. Daniels told Howard: "He contacted us and he said that, you know, you all are probably going to be questioned about the class, but, you know, just in case you are, just tell them it was a point system scheduling, and that's how it was."

This in addition to buying televisions for players and giving them money.

The final exam for the class described above may be found here.

Tuesday, March 02, 2004

Blogborygmi a blog written by a medical student with a rather clever title as Shazam points out:

For those of you who don't know what the title means, it's a play on the medical term "Bourborygmi" which is a fancy term for the noise your stomach makes when it grumbles.

If someone could come up with a clever blog name involving tenesmus I would be very impressed.
We have a beauty contest in Georgia today:
Flag Georgia flag 2003


Flag Georgia flag 2001

In addition to the presidential primary, voters will participate in a nonbinding referendum on the state flag, choosing between the blue banner adopted in 2001 or the red, white and blue flag passed last year. The 1956 flag with the Confederate battle emblem is not an option.

The non-binding nature of the referendum and the exclusion of the 1956 flag has angered some, but their enthusiasm has cooled somewhat in recent weeks. But politicians would be wise to heed the lesson of Roy Barnes and the price he paid for altering the flag.

As evident from my sidebar, I support the 2003 flag.
Mr. Hawkins links to this New York Times article on Charles Cullen. What kept Mr. Cullen working and killing may be summed up thusly:

Ms. Beckert refused to say how extensively Liberty had inquired into Mr. Cullen's past before hiring him. Two hospitals that say they called Liberty for references on him, though, say it did not pass along its concerns.

Liberty's apparent reticence was no anomaly. Mr. Cullen's case has exposed a fundamental weakness in health care: the difficulty of prospective employers to learn of someone's past troubles.

Employers frequently refuse to pass on negative information, even about people they have fired, for fear of being sued for slander by the former employee. And state and federal systems for warning employers of bad doctors and nurses are widely regarded as weak. The reporting requirements are so narrowly drawn that it is not clear they would ever have applied to someone like Mr. Cullen. And there are few penalties for hospitals that flout reporting rules.

"There needs to be some kind of safe harbor that would allow past employers who've taken adverse actions to share that, and to describe the associated facts, without fear of legal action," said Dr. Arnold Milstein, a health care consultant and one of the founders of the Leapfrog Group, a national business alliance dedicated to improving health care.

Several of the hospitals where Mr. Cullen worked said their policy was not to say anything about a former employer, good or bad. When someone calls for a reference, they give only the person's job title and dates of employment. So Mr. Cullen's career, which now looks so horrific, could have seemed unremarkable to hospitals hiring him.

So we have the lawyers saying on the one hand if we will just clean our own house and get rid of the bad apples, the medical liability problem will take care of itself. But when such efforts are made, the lawyers try to put a stop to it.

As an example: A physician is removed from the medical staff from a hospital, after extensive due process, for multiple patient care issues. They promise, not threaten, to sue if not reinstated. The physician's national specialty society is asked to come in and review the case, they agree. Physician promises to sue said specialty society if they become involved. Specialty society then withdraws their agreement. This sends the message that it is easier for hospitals, specialty societies, and even state boards of medicine to go along and hope that these physicians/nurses/EMT's don't hurt anybody else than to draw a line in the sand and say "No more".

Explain the logic in this to me, please.

Monday, March 01, 2004

The bills that were passed out of the Judiciary Committee on Friday were:
HB 1399, HB 1396, and HB 1400. The Medical Association of Georgia had these comments:

On Friday, the House Judiciary passed three tort reform related bills out of committee. The following legislation was considered and passed:

HB 1399 is an inadequate attempt to deal with the expert witness issue. It contains numerous loopholes and does not apply to the pre-filing affidavit rule currently in effect in Georgia. As a result, this legislation will not have a meaningful impact on preventing frivolous lawsuits from entering the judicial system.

HB 1396, the Committee's so-called emergency room bill, deals solely with the issue of vicarious liability. That is, hospitals are insulated from liability for the acts of physicians who provide services as independent contractors. This bill does not do anything to address the crisis in providing coverage in the emergency department and our state's diminishing trauma care.

HB 1400 was an attempt to deal with frivolous lawsuits. The legislation passed out of committee provides some sanctions for lawyers who engage in frivolous activity after a case has been filed. However, the bill does not attempt to prevent frivolous lawsuits from entering the judicial system.

None of these bills will provide relief for the rapidly growing crisis in Georgia.

This legislation is expected to come back to the House combined as a single bill. When re-introduced, a vote will be taken to engross this bill. Engrossment means that the bill cannot be amended in any way. If these bills are re-introduced in their current form, the Medical Association will oppose engrossment.

So maybe it's less than half a loaf.

I've been busy on call today, more posting tomorrow.
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