Thursday, March 31, 2005

Hospital Credentials

It is interesting to watch the discussions on mail-lists and blogs regarding credentialing in hospitals.

When I was a FP resident, we took for granted that we would be allowed to perform the procedures for which we where training. I trained in the Navy and all of the Navy FP programs at that time were at community hospitals and were the only residency training programs in those hospitals. We did endoscopies, treadmills, fracture care and a full spectrum of OB care, included instrumented and operative deliveries. I left my program credentialled to do flex-sigs, treadmills, appendectomies, adult circumcisions, vasectomies and vacuum-assist and forceps deliveries.

My first hospital as a full-fledged FP was also in a Navy hospital, where I was granted all the credentials I left my residency with.

What a surprise it was at the first civilian hospital I went to. Initially, it seemed the Credentials Committee just rubber stamped my application, without reviewing it, because I was given all the credentials for which I applied, including instrumented deliveries. I did not apply for c-sxn or appy privileges.

However, I soon found out that anything I tried to do that was "not the norm" for the other FP's in the hospital was either scrutinized with a microscope or simply refused. Especially if it seemed it might take money away from a more established physician in the hospital.

For example, treadmills. I had done about fifty as a resident and more at my first hospital. I was current in my procedure list. The norm at this hospital was that the internists did all the treadmills. I asked around and found out how to schedule my own patients for me to do. The routine at that hospital was for the docs in town to refer to a general scheduling list and these would be assigned to the docs who did treadmills (at the time, the two internists in town.) I asked to be part of that rotation. I asked to be allowed to read and bill for my own inpatient EKG's and to be added to the reading rotation. After all, I was trained and credentialled to do these activities. I soon got a visit from the head of the respiratory department who informed me that I was not allowed to do treadmills or bill for EKG's, that this was the purview of the internists and the "FP's don't know how to do these. After all, all the other FP's in town refer to the internists."

The next issue was flex-sigs. One of the internists in town had done part of a GI fellowship. I am unclear why he didn't finish it. Anyway, he dominated the GI lab. One of the general surgeons (of two in town) fought to get one start time a week for her colonoscopies and she was soon pressured to leave, and did. I asked for one day every other month to do my own patients and got a visit from the hospital administrator. He told me that my credentials to do flex-sigs were cancelled. I argued that he didn't have the authority to pull my credentials, only to suspend them on an emergency basis and that he had to have cause and that I should be formally notified and have access to due process.

Well, what do you know? I was successful in that argument. He replied that my credentials were intact, but that the nurse who ran the GI lab worked for him and would be instructed not to schedule any more of my procedures. And, oh by the way, the director of the treadmill lab won't be scheduling any of those for you either.

I wasn't allowed to bill for my EKG's or to be on the unassigned call list for pediatrics in the ER or from the newborn nursery either.

The position of the American Academy of Family Practice (see Tips for Avoiding Privileging Disputes) is that credentials should be based on the demonstrated compentency of the individual and not generally on the residency completed. In other words, if you require an FP to have done 15 supervised flex-sigs with at least 5 of those at your institution, you should require the same of an internist. You should not grant an internist blanket credentials for a procedure and then require additional documentation of compentency from an FP.

On the AAFP website, there is a document titled, Procedural Privileges Legal Opinion which should be helpful to any physician, regardless of specialty, who is in a credentialing dispute. The section on The Grant or Denial of Privileges notes:
Accrediting organizations and professional associations uniformly acknowledge that credentialing decisions must be based on the demonstrated competency and experience of the physician in question. Decisions which are based upon competitive factors, personal biases, or other similar grounds are not consistent with the obligations of hospitals and physicians involved in the peer review process.
This same page quotes JCAHO:
The mutual objective of both the governing board and the medical staff is to improve the quality and efficiency of patient care in the hospital. Decisions regarding hospital privileges should be based upon the training, experience and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital and especially patients. Personal friendships, antagonisms, jurisdictional disputes or fear of competition should be disregarded in making these decisions. Physicians who are involved in the granting, denying or termination of hospital privileges have an ethical responsibility to be guided primarily by concern for the welfare and best interests of patients in discharging this responsibility.

and a joint statement of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. The AAFP-ACOG Joint Statement on Cooperative Practice and Hospital Privileges provides in part:

The assignment of hospital privileges is a local responsibility and privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to assure the provision of high-quality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies.

The standard of training should allow any physician who receives training in cognitive or surgical skill to meet the criteria for privileges in that area of practice.
Also from this page:
Courts prefer credentialing decisions to be made primarily on the basis of competency and quality of care. The courts have frequently invalidated restrictions on privileges when the restrictions were based upon factors other than the demonstrated capabilities of the physician in question. See, e.g., Desai v. St. Barnabas Medical Center, 510 A.2d 662 (N.J. 1986) (restriction based upon years of practice invalidated); Berman v. Valley Hospital, 510 A.2d 673 (N.J. 1986) (restriction based upon years of practice invalidated); Berman v. Valley Hospital, 510 A.2d 673 (N.J. 1986) (restriction based upon affiliation with another physician invalidated) Armstrong v. Board of Directors of Fayette County General Hospital, 553 S.W.2d 77 (Tenn. Ct. App. 1976) (restriction based upon specialty certification found unreasonable).
As you can infer from the list of my jobs above, I am no longer in practice at this hospital. I did contact an attorney, but he advised that, although I would likely win a lawsuit, I would spend a lot of money to do it and the actual financial damages were small. I mean, heck, I was only asking to do about 20 or so procedures a year. The internist who stirred up this trouble was doing about 20 colonoscopies a week! And there was no way I would have wanted to work in this community after a lawsuit.

I am much happier where I am now, anyway. But hopefully this info can help someone out there.


Welcome Grand Rounds readers. Please feel free to browse here. Some of it is actually interesting.

Monday, March 28, 2005

More on Power of Attorney

Much, Much more, at The Medical Insurance Guru. Read this and GET YOURS DONE NOW!

Thursday, March 24, 2005

Durable Power of Attorney for Health Care

HospiceBlog writes about the various versions of a power of attorney.

The word "durable" in the title of a Durable Power of Attorney for Health Care means that the power won't expire when the assigner of the power becomes incompetent to continue to verify it. If not "durable," the power may expire.

As HospiceBlog notes, this is the PoA that specifically designates who you want to make medical decisions for you if you can't. This, obviously, is very important.

A frustrating situation for me, as an ER doc, is when there is no family member, or other, named as DPoAHC, or when the power is not local and I have local family members in the ER badgering me and I can't get the power on the phone.

Folks, get your DPoAHC named. Make sure the document is where EMS can find it when they come to your house to get you. Put a copy of your Living Will and your DPoAHC in a clear bag on your bedside table or in your medicine cabinet. These are places where EMS will look. If you primarily use one hospital, ask if you can put a copy of these documents on file with that hospital.

If you really want to be careful, put contact info for your DPoAHC in the packet.

Go here for and select your state for info and copies of documents.

Bad Instapundit

I generally agree with Instapundit. However, I'm very disappointed with his writing about Terri Schiavo.

Here, he said:
VARIOUS PEOPLE seem to think I should have an opinion of the Terry Schiavo case. I've tried, but I really just don't. I think I'll let Randall Terry and James Wolcott fight this one out without me. If you want more, Sissy Willis seems to be providing some pretty balanced coverage.

UPDATE: Reader Harvey Schneider emails: "You have no opinion on Terri Shiavo!!! Good, because neither do I. Other than it sounds complicated, tragic…and really none of my business."

Yeah, that's pretty much how I feel.
My problem with his approach is, although he claims to have no opinion, all of his quotes have been from those who espouse that TS is in a persistent vegetative state and that the federal government should have stayed out of it. He has ignored Ann Althouse, someone to whom he frequently links, and her arguments that this is not a federalism issue and that the federal government was within its right, although not right, to get involved. She wrote:
Whether one agrees with the conception of rights reflected in Congress's Schiavo law, one should not deny that Congress has an important, well-established role enforcing the rights of the individual and displacing choices made at the state level.
Why, Glenn? Why haven't you linked to any of the bloggers who are presenting the family's side of the story and the statements from the many doctors and nurses who disagree with the courts findings? Aren't you aware that the primary doctor saying that TS is in a persistent vegetative state admitted on Hannity and Colmes that he only examined her for 45 minutes? If you don't have an opinion, why don't you stay out of it, or at least present both sides?

Instapundit even selectively quoted James Taranto. The quote he pulled made it look like BOTW agreed that TS was in PVS. However, if you "read the whole thing," you find out just the opposite.

This is what Instapundit quoted:
Reading over the report on Schiavo prepared in 2003 by guardian ad litem Jay Wolfson (link in PDF) helps make clear why this last effort will not succeed. Many physicians have backed the PVS diagnosis, and the courts are unlikely to give much weight to an eighth or ninth opinion at this late stage.

The 38-page report is by and large a persuasive document, showing that the Florida courts did not lightly reach the conclusion that Mrs. Schiavo should die.
However, the second paragraph is actually the first sentence of this paragraph:
The 38-page report is by and large a persuasive document, showing that the Florida courts did not lightly reach the conclusion that Mrs. Schiavo should die. But it does raise some troubling questions: Why does Florida law allow the admission of hearsay evidence (in this case, from Mr. Schiavo, his brother and his sister-in-law, who testified that Mrs. Schiavo had once said she wouldn't want to be kept alive in such circumstances) when human life is at stake? And why didn't the court at some point reconsider Mr. Schiavo's guardianship of his wife in light of his having remarried all but in name? A real de novo review in federal court might have cast some light on these matters.
This may not be a true Dowdification, because Instapundit didn't use any ellipse, but by leaving off the last of the paragraph he definitely gives the wrong impression about what BOTW was saying.

Now, one of the reasons I got into blogging in the first place was because I sympathized with the bloggers who complained about getting e-mails that said, "Why don't you write about this or that?" or vociferously and rudely disagreed. The standard answer was that we all have the opportunity to start our own blog. Glenn, you inspired me, but here you disappoint me. You state you don't have an opinion, but your selective blogging reveals your bias. I don't suggest that you shouldn't have a bias. By all means, it's your blog, not mine or anyone elses. Any blogger has a right to an opinion and a bias, but don't deny one and then selectively blog.

Another Terri Schiavo post

DB has today's TS rant up.

I want to share my opinion about some of the "rule of law" topics.

First of all, the courts don't make law, nor do they have the sole responsibility for the interpretation and imposition of the law. The President swore an oath to uphold the Constitution. The 5th ammendment protects citizens from loss of life without due process. The 14th ammendment protects citizens from state laws that seek to deprive them of this due process. The federal courts review state court actions everyday. Remember, death penalty cases make it to federal courts all the time. The Supreme Court of the US has the ultimate authority to review state cases.

The Congress of the United States has the authority, granted by the Constitution, Article 3, I believe, to direct the jurisdiction of the federal courts. It is perfectly legal for the Congress to direct a federal court to review a state action.

The law passed by Congress required the federal court to perform a de novo review of this case. This is where the "rule of law" was flouted! The reviewing judge did not perform a de novo review, without deference to the state judges rulings, but simply reviewed the procedures and said there was no procedural reason to believe the family would prevail and refused to act. The judges responsibility was to review the facts of the case and render findings of fact, with regard to the opinions and findings of the state judge.

Another example of flouting the rule of law was when the state judge disregarded a Congressional subpoena. No judge has the authority to ignore a Congressional subpoena.

There is considerable disagreement among the nurses and doctors who have had contact with TS. There are numerous affidavits from those nurses and doctors that have been ignored by the courts. Numerous people have offered testimony that MS was interested only in getting rid of TS.

What's wrong with performing a PET scan or an MRI to look at TS's brain? Why won't MS allow this?

Read this by CodeBlueBlog.

Ann Coulter addressed this same issue better than I, in her usual irreverent manner:
As a practical matter, courts will generally have the last word in interpreting the law because courts decide cases. But that's a pragmatic point. There is nothing in the law, the Constitution or the concept of "federalism" that mandates giving courts the last word. Other public officials, including governors and presidents, are sworn to uphold the law, too.
As I've said before, you should read anything Thomas Sowell writes. Here, he said:
Terri Schiavo is being killed because she is inconvenient to her husband and because she is inconvenient to those who do not want the idea of the sanctity of life to be strengthened and become an impediment to abortion. Nor do they want the supremacy of judges to be challenged, when judges are the liberals' last refuge.

Guilty by videotape

This is a great post from Pundit Guy. He discusses the limitation of videocameras in the delivery room.

Years ago, when I was still doing deliveries, I was an active sonographer. I didn't do the "Level 3" or complete fetal survey types of ultrasounds, but I could look for the sex of the baby, measure amniotic fluid, see the heartbeat, verify 4 chambers. The basics. I would print out pictures of the babies face, etc.

I never videotaped any of my ultrasounds. Only once was I asked and I said no. I was concerned that something would show up on the tape that I didn't notice. Not that I necessarily should have, as this wasn't my skill level. I never claimed to be able to do an anatomic survey, but I was concerned that was the standard to which I would be held.

Interestingly, there were sono techs out in town who moonlighted doing videotapes. They would have the woman sign a release, but we know what those are good for, don't we?

I wonder if those sono techs got sued. They weren't physicians and I don't know what their liability would have been.

How we contribute to our patient's bankruptcy

I know that the medical bills/bankruptcy issue has been discussed frequently and recently in the MedBlog world but I want to offer a little different take.

It makes sense that someone who becomes significantly ill will incur a large amount of expense, even if they have medical insurance. According to this study, the journal Health Affairs says that most (75.7%) of the people who declared bankruptcy after a medical illness had health insurance at the onset of their illness. But one-third of those had lost their insurance by the time they filed for bankruptcy.

Why did they lose their insurance?

As one who reviews disability applications, I frequently see doctors decide that their patients can't work. The doctors may or may not list specific restrictions and limitations (see my previous posts on this subject here, here and here) but will often add "can't work" or will indicate that they have not released their patient to return to work.

How many of us have had specific vocational training? How do we know whether our patient can work or not? Do you realize that when you write this down, not only does your patient now believe that they cannot work, but, frequently, the employer will not let the patient work, even if the patient wants to do so. This applies even if the employer wants to accomodate any specific restrictions described.

The bankruptcy and loss of health insurance enters the picture if the disability claim is denied. Often, having been "taken out of work" by the doctor, the employee will not attempt to return to work, or the employer will refuse to allow the employee to return without a release from the physician. In the absence of a finding of disability, the employee will often lose the job. This means losing insurance coverage, unless the employee can purchase continued coverage through COBRA; something they can rarely afford.

The resulting loss of insurance causes debt and, as we have all seen, a patient who cannot afford the care we think they need.

Remember, the patient may not describe their job accurately to you or may be unaware of accomodations the employer may be willing to make.

I recommend you list, as specifically as possibly, what you think you patient can or cannot do, without specific regard to the job they have, and defer an opinion about ability to work to the vocational experts. Don't be afraid to request a Functional Capacity Examination or a vocational analysis by an expert. When asked to give an opinion on ability to work, to quote the lady in red, "Just say no."

We all want to be patient advocates. Sometimes, advocating in favor of our patient's desire not to go to work is not the best for the patient. We are advocates for our children, but don't give them everything they want, do we?

For those readers who will be the patients in this scenario, don't let your doctor write that you can't work. If your condition actually is such that you cannot do your job, and your employer can't/won't accomodate, you will get your benefits even if your doctor doesn't specifically write no work. However, if she does write that, you won't be able to work even if you want to and even if your employer will accomodate.


Welcome, COTV readers. Please click here to read more. Trust me, it is not all as serious as this.

Wednesday, March 23, 2005

Odd question with reasonable answer

Seen on a VA Hospital questionnaire:

Q: Have you donated your body to science?

A: No, I'm still using it.

Tuesday, March 22, 2005

I have insisted for years that the patient's relationship with their insurance is just that, the patient's relationship. I left private practice because I got tired of the insurance hassle. I was constricted in my ability to refer to specialists because the patients were always asking me, "Does this doctor take my insurance?" Well, gee, how the &*(^% was I supposed to know? I wasn't even sure if I took their insurance!

I got tired of choosing what drug to prescribe based on one of the fifty formulary books on the shelf. Instead of spending time teaching my patient, I was flipping through a book to see what "was covered."

One doctor has done what I would love to see become much more prevalent in the community. Here is his story.

Another clinic has developed a unique capitation plan to help indigent, uninsured patients in their community. It would be cool if this could catch on.

My two cents worth on Terri Schiavo

I am striving to resist the temptation to blog on Terri Schiavo. The reason: I just don't know enough about it. However, I am finding myself agreeing with Ann Althouse's opinions regarding the federalism issues. And I agree that Congress' recent actions were a bad idea, even if legal and constitutional.

In addition you should read this by Thomas Sowell. Actually, you should read anything Thomas Sowell writes.

Keep in mind that her family is arguing that she is not unconscious nor is she in a persistent vegetative state. This changes the whole thing. The press has consistently presented that she is irreversible. This seems to be disputed.

This is an interesting video.


As I learn more, you will see me blogging more.

Keeping a business in the black

I am watching The Incredibles with my daughter right now. I just saw the part where Mr. Incredible's boss yelled at him for authorizing payment on a claim where someone's house was burglarized. He yelled, "Tell me how you're keeping Insuracare in the black. Tell me how that's possible..." The idea being that the only way for an insurance company to make money is to deny all the claims.

Well, tell me, would you buy insurance from a company that never pays any claims?

Don't you think that the best way for an insurance company to stay in the black is to sell reasonable policies and give good service and pay valid claims?

Life Sentence Sought for Va. Pain Doctor

Read this article in the Washington Post.
The government accused Hurwitz of prescribing excessive amounts of dangerous drugs -- in one instance 1,600 pills a day -- to addicts and others, some of whom then sold the medication on a lucrative black market.


Patient advocates have portrayed Hurwitz as a heroic figure who helped patients nobody else would treat. Advocates reacted with shock to the government's call for a life sentence.


Prosecutors quoted from letters sent to the judge by relatives of Hurwitz's victims. One was from Mary Meyer, mother of Linda Lalmond, who died of a drug overdose in Fairfax County in 2000 shortly after meeting Hurwitz. She wrote that her daughter "left home hopeful and smiling, had 2 visits with Dr. Hurwitz and was returned home in a container."

"I request that Dr. Hurwitz be sentenced to the fullest extent of the law," Meyer wrote.

The Association of American Physicians and Surgeons (AAPS) has written a letter to the judge:
We write to express in the strongest terms possible how unjust we think it would be to punish the caring and devoted Dr. Hurwitz with a lengthy incarceration. This man, whom we have known for nearly ten years, is a colleague dedicated to helping his patients in every way. He devoted himself in his 24/7 availability and tireless research to aid his patients, and the United States of America should not punish him with a virtual life sentence.

I can't argue that Dr. Hurwitz was not dedicated to his patients or that he didn't devoted "himself in his 24/7 availability and tireless research," but I am aware of one case where the care, IMHO, was incredibly inappopriate and one in which I cannot see how Dr. Hurwitz could have reasonably conceived that the patient was actually using all of the drugs he prescribed. I counted the prescriptions and the acetaminophen content would have killed the patient if she had been taking the drugs as prescribed. Not to mention that the narcotic doses were so high that I don't see how the patient could have been awake long enough to take all the drugs that were prescribed.

I don't know the particulars of this legal case, but I was not unhappy to see Dr. Hurwitz close his clinic.

Drug News

The very rich battle the phenomenally rich!

Fake drugs, an important topic for so many reasons.

"The FDA approved the Symlin injection to be used in conjunction with insulin to treat diabetes. The drug is targeted toward diabetic patients who don't achieve glucose control despite insulin treatments."

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Sunday, March 20, 2005


Please read this by The Cheerful Oncologist before reading this epilogue:
A young research assistant walked into the meeting with an odd shaped shield. He described his concern that the weapons used by the scientists were so indiscriminant and focused on characteristics of the enemy that were shared by so many of the townspeople.

He proposed that a weapon that focused on a trait of the enemy that was present on very few, if any, of the townspeople would do the trick. He described his theory and the use of his shield.

Persuaded by his youthful excitement and the novelty of his shield, the scientists agreed to attempt his technique.

When the volunteer in the town cried, "Positive Biopsy Spotted!" the young assistant and his crew sprung into action.

With a wagon full of the fancy new shields, the assistant set up a sales stall in the afflicted township. He had made the price of the new shields attractive to the invaders, but not attractive in the least to the townspeople. Soon, almost all of the invaders were carrying one of the new shields, only to find that they were unable to put them down. Permanently bonded, one might say. Only a rare townsperson was carrying one, and found that they could discard them whenever they wished.

After giving the assistant time to distribute the shields, the scientists instituted therapy the attack.

The shields began to heat up. They seemed to be absorbing the effect of the new weapon system without any effect on any of the other elements of the township.

However, as the shields continued to heat up, the invaders carrying them began to become uncomfortable. Eventually, the shields became so hot that the invaders began to be affected and were dying. As the invaders died and dropped their shields, the town's custodial staff simply swept them into the disposal system, breaking the shields down.

Very little damage occurred to the townspeople. Almost none of them were affected by the new weapon.

Interest in the assistant's ideas began to grow.

Friday, March 18, 2005

Paul was an enterprising platelet. He didn't want to be just another cell sticking around. He wanted to be a special cell. After all, wasn't he the offspring of the same progenitor megakaryocyte as Benjamin, the platelet who started the clot that closed off that bleeder in the lesser curvature last month? After all, the host would have died if not for that.

Realizing that he only had a week to work, he found a convenient rough spot on one of the leaflets of the aortic valve. What better place to set up business than a nice comfortable little vegetation?

"RIDE THE TURBULENCE!" the first sign said. Being very safety conscious, and not wanted to endanger any immature thrombocytes, he also put up a sign that read, "You must be at least this adherent to ride this ride."

Alright, in business! The other platelets were coming along for the ride. Everybody wanted to be the first piece of thrombus to embolize and "ride the turbulence." The first embolus ripped off and roared around the curve, heading down the descending aorta.

What a rush! How exciting to be a part of the clot!

"OH MY GOSH!" The humanity!! Those cursed natural defenses!

Tissue plasminogen and it's activators!

Hundreds of thousands of perfectly good thrombocytes, minding their own business, just out for a little fun and trashed like this!

But Paul is determined to have an effect in this world body. Laying down another platform of platelet chemotactic attractants, he soon has another thrombus waiting to embolize.

This new embolus "Rides The Curve" like the one before it, shooting off down the "Big Tube" for one of the best thrill rides ever. Wedging into the superior mesenteric artery and setting up a new base for thrombus! Every little platelet's dream realized.

High on success, and only 1 day from senescense, Paul joins the next embolus to go. Being an experienced guide, Paul manages to steer this one into the brachiocephalic. What a coup! None of the other outfitters have ever been able to steer into this side. They usually shoot for the easier route into the left side.

Rocketing cephalic, the embolus flips into the right common carotid. The crowd goes wild! This one may make the big time.

Knowing this body manager's proclivity for bacon and processed fats, Paul is concerned that he may not make it out of the carotid. Cursed Stenosis!

What's this, only 50% stenosis? We may make it!

Deftly guiding this raft through the opening, Paul manages to navigate into the internal carotid and from there into the middle cerebral artery. As this is the most popular ride in the body, this is not a small embolus.

End of the ride. Now wedged in the atherosclerotic MCA, Paul organizes his fellow thrombocytes to recruit the clotting pathway. Now, was this intrinsic or extrinsic? Do I ask for Factor XII or Factor VII? Whatever, let's clot!

Eventually finding his way into the common clotting pathway, Paul calls for cleavage!

No, not that kind, cleavage of fibrinogen to fibrin monomer. Now get in there and coalesce fibrin monomer to fibrin polymer. Or whatever.

With a lifespan of 7 days, what does Paul care about hemiparesis, faciobrachial paresis, athetosis, chorea and dystonia?

Let's just have a good time!

A platelet's gotta do what a platelet's gotta do!

Anabolic Steroids

This article, Steroid Medical Realities Outweigh Steroid Myths, argues that physicians need to do a better job recognizing when our patients are using anabolic steroids. Some clues:
"Physicians need to recognize the signs and symptoms of steroid abuse," says Gary Wadler, MD, an associate professor of clinical medicine at New York University, and a member of the World Anti-Doping Agency. "It has to go into their differential diagnoses. I particularly emphasize this for pediatricians."

Signs and symptoms of anabolic steroid use may include:

  • Behavioral and psychological changes - including aggression, impulsiveness, and depression
  • Breast enlargement (men)
  • Breast shrinkage (women)
  • Body hair (women)
  • Deepening of voice (women)
  • Male-pattern baldness (men and women)
  • Acne
  • Striae in axilla
  • Testicle shrinkage
  • Menstrual abnormalities
  • Abnormal cholesterol distribution marked by very low levels of HDL
  • Dramatic changes in muscularity and athletic performance
  • And, finally, "The look," as Dr. Roberts calls it - "a little too buff, a little too much muscle and a little too enhanced."

The evidence regarding the adverse effects of steroid use is sometimes conflicting:
Here's a rundown on what is known -- and what is not.

  • Cardiovascular. Experts list heart and stroke risks as among their biggest worries. Steroids reduce HDL cholesterol, raise LDL, impair glucose tolerance, and increase levels of triglycerides, clotting factors, C-reactive protein, and insulin. Case reports and cohort series have linked steroids to hypertrophic cardiomyopathy, myocardial infarction, sudden cardiac death, and thrombotic events, but so far it's difficult to prove a direct causal connection.
    "The data are scant," says Dr. Wadler, "But from looking at case reports I have been convinced that (anabolic steroid use) represents a cardiovascular risk." Others agree.

  • Hepatic. "Oral anabolic agents are hepatotoxic," says Dr. Yesalis. They lead to cholestatic jaundice, peliosis hepatis (a condition in which microscopic pools of blood are present throughout the liver parenchyma, which may lead to congestion and necrosis), and hepatocellular hyperplasia and adenomas -- problems that are mostly reversible when steroid use ends.
    Although some allege a steroid connection to liver cancer, "that hasn't been established," says Dr. Yesalis. But even benign tumors pose a risk. "If a benign tumor ruptures, you hemorrhage to death," says Dr. Yesalis, as at least two case studies have documented.

  • Masculinization of females. A number of hormonal changes occur when females use the primary male sex hormone. "Permanent masculinization can take place," says Dr. Yesalis.

  • Male reproductive abnormalities. These include testicular shrinkage, and a reduction in endogenous testosterone, sperm count, and sperm motility.

  • Growth plates. Ironically, to become more muscular, some steroid users may be giving up stature because androgens hasten epiphyseal closure. "High doses can shut down their growth plates," says Dr. Yesalis.

  • Erythrocytosis. Erythrocytosis is a common side effect of pharmacologic doses of all androgens, probably due largely to direct androgen stimulation of erythropoiesis.

  • Musculoskeletal injuries. Case studies have attributed tendon injuries and neuropathies to steroids. Researchers haven't yet established a cause-effect link.

  • Prostatic cancer. Case reports, but evidence lacking.

  • Compromised immune function. Evidence lacking.

Thursday, March 17, 2005

A Libertarian Utopia?

I find it interesting that a libertarian wants to dictate what goes into a corporate document.
Change corporate governing documents to put the environment, community, and employees on an equal footing with shareholders.

Perhaps I don't understand libertarianism, but what's wrong with removing interference and letting the marketplace govern corporate behavior?

A corporation exists as a business to maximize return to the shareholders. I know there are those who don't think this should be the case, but it is.

Maximizing return to the shareholders means pleasing the customers. If the customers don't want your product, whether services or goods, you don't sell anything or bring in any revenue. If the customers' abhorrence of your corporate behavior is more significant to them than the product you make available, they won't purchase your product.

So, there will be a balance between the corporation's behavior and the relative importance of that behavior to the customer, and by extension, to the shareholder. After all, what is important to the customer is important to the shareholder. And the collective will of the shareholders establishes the priorities of the corporation.

If the portion of customers who want a particular behavior are significant to the corporate bottom line, the corporation with behavior consistent with that desire. For example, when Target decided to prohibit the Salvation Army bell ringers. They heard quickly from their customers and corporate behavior changed. This didn't have to be dicated in a corporate document.

Likewise, the corporation will be sensitive to environmental issues if these issues are of signficant importance to their customers. If not, why should you, me or some other minority try to dicate it?

Health Courts

The Doctor's Court?, an article on LegalAffairs discusses the use of a specialty court, a health court, to adjudicate malpractice claims:
Health courts could begin to solve these problems by providing consistent expert rulings on standards of care. Health courts could work in a number of ways, but we believe the general ingredients would include the following:
  1. full-time judges assisted by medical staff, who would make written rulings;
  2. neutral experts hired by the court;
  3. a liberalized standard of recovery, so that liability is automatic where there is a clear mistake;
  4. scheduled limits on non-economic damages, varying according to the nature of the injury.

Sounds like a good idea to me.

Thanks to MedRants.

Get rid of Cultures?

From Texas A&M Researchers Develop Nanotechnology To Detect Bacteria
A group of Texas A&M University researchers have developed a novel nanotechnology to rapidly detect and identify bacteria.

The researchers call their technique SEnsing of Phage-Triggered Ion Cascade, or SEPTIC. Using a nanowell device with two antenna-like electrodes, the scientists can detect the electric-field fluctuations that result when a type of virus called a bacteriophage infects a specific bacterium, and then identify the bacterium present. The researchers tested their technology on strains of E. coli and experienced a 100 percent success rate in detecting and identifying the bacteria quickly and accurately.

Expand your horizons!

The Carnival of the Vanities, the longest running blogging carnival, is up at Bird's Eye View.
Doctor, I appreciate the prescription, but Ultram has never worked for me. Can I have tramadol instead?

On time for appointments

I feel for the staff in this office, as described by Dreaming Again.

When I was in private practice, I strived to be on time. I began to get the impression that my patients thought I wasn't concerned about them. I felt like I was spending more time watching the clock than I was attending to my patient.

I took an informal survey and found that my patients were more concerned that they and my other patients were getting the time they needed than they were about my being on time.

My patients told me that they would be upset if I were running behind because I was goofing off (or blogging I presume) but not if they thought I was giving extra time to patients that needed it. They felt confident that they would get the extra time when they needed it.

Hat tip to MedPundit.

On time for appointments

I feel for the staff in this office, as described by Dreaming Again.

When I was in private practice, I strived to be on time. I began to get the impression that my patients thought I wasn't concerned about them. I felt like I was spending more time watching the clock than I was attending to my patient.

I took an informal survey and found that my patients were more concerned that they and my other patients were getting the time they needed than they were about my being on time.

My patients told me that they would be upset if I were running behind because I was goofing off (or blogging I presume) but not if they thought I was giving extra time to patients that needed it. They felt confident that they would get the extra time when they needed it.

Tuesday, March 15, 2005

Detecting cancer at ONE CELL!

My estimate of 2030 may be overly optimistic for nano-robots of the type I described, but this is here today:

Nanomedicine: Treating cancer at molecular level

Current applications of nanomedicine

This article in the Washington Post gives some good examples of current research uses of nanotechnology. Nanotechnology doesn't necessarily mean nano-machines (as in my story earlier) but simply refers to the use of very small technology. The difference between what is considered nanotechnology and technology involving other very small things (such as microprocessors) is more than a matter of scale, however. Nanotechnology is used to describe the situation that exists when the very small size imparts unique properties on the particles.

Such as with qdots. As the size of the qdot changes, the color changes, even if the material is the same. We are used to the color remaining the same between a 1 inch dot of paint and a 1 yard dot of paint. By utilizing the change in color that is associated with the change in size, these very small qdots can be put to medical use:
Scientists are already using quantum dots as research tools to help them understand how proteins, DNA and other biological molecules catch rides on the various transportation systems inside cells. First they coat some qdots with a material that makes the dots attach specifically to the molecule they want to track, then they inject those coated dots into cells growing in laboratory dishes. Once the dots grab their targets, researchers simply watch the trails of colored light to see where they go.
We are all familiar with the imaging techniques that utilize immunologic properties to attach a radio-tracer to the desired target. For example, tagged red cell bleeding studies, or even the now everyday use of radio-immune assays for various diagnostic tests.

This is a very similar process. However, instead of attaching a radio-tracer, you attach a qdot. These qdots simply diffuse throughout the sample into which they are placed and attach according to the qualities of the proteins or other substance being investigated.
There are scores of proteins and other substances in the body that are early indicators of disease but which are difficult to detect with current technologies. While qdots and other nano-materials have not been proved safe for use in the body, they are clearly capable of spotting diseases in blood or tissue specimens. Qdots that bind to proteins unique to cancer cells, for example, can literally bring tumors to light.
Another example in this article is the use of tiny carbon nanotubes. When charged with electrons and exposed to infrared light, these nanotubes glow, a property unique to the physics at this nano-scale. The more the charge, the more the glow. So, with a spectrometer, you can measure the intensity of the glow and calculate the intensity of the charge. When the electrons are created by the presence of glucose, as in this example, these properties can be used to measure glucose concentrations, as in diabetics.

Read the whole thing for very practical applications of todays nano-technology.


This article describes the area inhabited by nanoparticles, between molecules and atoms described by quantum physics and larger particles described by Newtonian physics:
A nanoparticle, an object with a width between a few nanometres and a few hundred, contains tens to thousands of atoms and exists in a realm that straddles the quantum and the Newtonian.

At those sizes "everything, regardless of what it is, has new properties," says Dr Chad A Mirkin, a director of Northwestern University’s Institute for Nanotechnology in Illinois. That, he adds, is "where a lot of the scientific interest is".

This in-between realm gives rise to an unusual physics where the properties of a material change depending on its size.

At the quantum level, one gold atom acts like any other gold atom, and a nugget of gold large enough to see or hold has the same chemical and electrical properties as any other nugget. But two nanoparticles, both made of pure gold, can exhibit markedly different behaviour - different melting temperature, different electrical conductivity, different colour - if one is larger than the other.

Time for a new job?

Grand Rounds

Monday, March 14, 2005

Good News

Drugs in the news

Will Meridia be around much longer? Weight Loss Drug Meridia from Abbott Laboratories Awaits FDA NOD

Is anyone still using Crestor? Pressure on Crestor Mounts with FDA's Second Warning

So maybe we actually should be eating fruit! Apples May Combat Bad Cholesterol

This is good news. More is better. FDA Panel Backs Bristol-Myers Hepatitis Drug

Sunday, March 13, 2005

Medicine in 2030

Charlie is an 83 year old man who presents with chest pain and dyspnea. His pain is sharp, pleuritic and right sided, primarily in the right infra-axillary area. The chest pain has been present for several months, gradually worsening, and has now reached the point where he can't take a satisfying breath. Charlie has no history of pulmonary or cardiac disease. He has lost 30 pounds in the last several months.

He has used OTC analgesics with moderate relief.

His past medical history is significant for Type 2 diabetes mellitus, cured 5 years PTA with nano-treatments.

He smoked for 40 pack years, quitting in 2010.

He is married and his wife, 80 years old, is in excellent health. Charlie has 2 sons in their 60's, both healthy status post cure of hypertension. They are on no medications and have not received any recent nano-treatments.

His review of systems is negative except as mentioned in the history of present illness.

The physical exam revealed a man in NAD, comfortable appearing except for an occasional wince with respiration. Lungs were mostly clear to auscultation except for fine rales in the right axilla. The balance of the physical exam was normal.

For diagnostics, Charlie's physician injected him with one milliliter of a milky white fluid. Immediately, millions of tiny molecular computers fanned out through Charlie's body, interrogating each cell's DNA. The particles, many times smaller than the nuclei of each cell, crawl along the DNA of each cell, looking for errors. Others measure the concentration of every chemical and cellular element in Charlie's blood.

When Charlie returned the next day, a technician inserted a sample of his blood into the Diagnostic TX210 analyzer. Thirty minutes later, Dr. Milton was counseling Charlie about potential treatment for his lung cancer.

Later that day, Charlie received another injection. This time, the nano-computers in the milky fluid were controlling nano-sized molecular repair machines. Directed to the right location, the repair machines quickly penetrated the membranes of the malignancy.

Each nano-computer controlled crawlers that analyzed the DNA atom by atom and compared it to a known normal. This normal was determined by reading strands of DNA in Charlie's millions of cells. Each strand may contain a small error, but by reading millions of strands, the computers were able to determine the correct structure for Charlie.

As each error is found, the crawlers called for repair machinery. As the machine attached to the DNA molecule, arms reached for the error and grasped on either side. Another arm came in with a molecular cutter and removed the mistake. Yet another arm reached into a container of repair atoms and inserted the correction. The crawler moved on down the strand.

Some of the cells were simply deconstructed. As the machinery broke the cells down to the basic chemicals, these were supplied to building machinery that performed repair and new construction. Based on the known structure of Charlie's bronchial tree, the repair progressed from the molecular to the cellular to the functional elements of Charlie's airways and vasculature.

Waste products that were not necessary for repair were excreted by the kidneys, transported there by special nano-machinery.

Three days later, Charlie was pain free and without dyspnea. He was again injected with the milky white diagnostic fluid. The next day the message was completed cure.

The future is coming.


For those interested in more info on nanotechnology and nanomedicine, I recommend this book, Engines of Creation by Eric Drexler or this site by Robert Freitas.

Saturday, March 12, 2005

Cat Blogging

Kitty Rat:

Wednesday, March 09, 2005

Hospital EMR and med admin times

See this by MedPundit:
Nurses are required to record (chart) administration of medications contemporaneously. However, contemporaneous charting requires time when there is little time available. Computerized physician order entry systems compound this challenge considerably. To chart drug administrations, nurses must stop administering medications, find a terminal, log on, locate that patient’s record, and individually enter each medication’s administration time. If medications are not administered (eg, patient was out of the room), nurses must scroll through several additional screens to record the reason(s) for nonadministration.
Why not use barcodes and scanners? I have seen wireless systems with terminals on rollers (the company called them "Nurse on a stick") like IV poles. Put one of these on a med cart with a scanner, scan the barcode on the med and the one on the patient's wrist and the system automatically records the drug administration in the computerized MAR. Likewise, vital signs can be entered into the system by the machine taking them, just scan the patient's bar code.

Of course, an advantage to paper records or post hoc entry into the computerized system is the ability to "adjust" the time things are done (or at least the time something is recorded as having been done.)

Tuesday, March 08, 2005

Hospitalist hours today

I had fun this morning. I am augmenting our usual hospitalist staff while the census is high. It's nice that I don't do it full time. Actually, I have so many jobs that I don't get tired of any of them, although I do get tired of the whole thing some times.

But this morning I think I actually did some good things. One of my patients was hospitalized for pneumonia and will be discharged to a skilled nursing facility. The signout I got was just to write nursing home orders and make sure she got out the door. When I went to see her, I noticed she had a sling on her left arm and asked why. She (and her sister) answered that she had fallen and broken her arm on 12/26. I then remembered why she looked so familiar. I had taken care of her in the ER that day! Anyway, I asked her how much longer she was going to have to wear the sling. She remarked that she had an appointment with the orthopedist on 3/11. I didn't see any reason to have to haul her out of the nursing home to the ortho office in 3 days (and pay for the ambulance) so I ordered the appropriate x-rays and called the orthopedist who saw her today before she left. How cool to make something like this easier for her.

Another patient was a curmudgeon (I hope I spelled this right, I usually use ***hole) who was in line to go to a very good rehab center but wanted to go home and do outpatient physical therapy. Nothing against the PT program locally, but I would certainly want my family member in the rehab center. He expected the same response from me that he received from several others--argument and active resistance to his decision. I sat down and said, "OK, let's talk about it." I reassured him that he was in charge of his health-care decisions and that I was not going to handcuff him to a gurney (besides, my cuffs were outside in my SWAT bag and it was raining out there) and force him to go the rehab center. I asked him about his concerns about the center and his hopes for recovery. I told him I would write the order for the outpatient PT if that was his insistence, but that I didn't think it was a good decision. I pointed out that his chances of being admitted to the rehab center if he missed this opportunity were very slim. Finally, he teared up slightly and asked, "Doc, am I going to get use of my legs back?" I answered, "I don't know, but your chances are much better if you take advantage of this opportunity." He decided to go with the rehab center, convinced that I cared more about him than my "plan."

What a great day!

Grand Rounds

Is up at Hospice Guy. Read, Read, Read. Of course, it's your choice.

Monday, March 07, 2005

Long hours in residency

Megan McArdle has posted twice recently on this subject. Here and Here. The comments were many and interesting and reflected quite a bit of animosity and perhaps some jealousy.

Several comments that I didn't want lost in the shuffle.
  • Many of the comments, and indeed, the main post, discussed the impairment sleep deprivation causes. What wasn't discussed was the possibility that med school and residency are designed to screen for those who could, or screen out those who couldn't, function acceptably well despite this. Perhaps those who couldn't function well in this environment dropped out, or went into medical specialties that didn't require this kind of tolerance. Does anyone out there have any studies about this?
    The comments about Navy Seals touched on this. When I was in the Navy, I knew many Seals, Seal washouts, and saw BUDS students (Seal training) in the hospital. Those who couldn't function after 40 hours awake stood a good chance of washing out.
  • Why do so many people think that there is some mysterious conspiracy at the AMA or in medicine to control access to this field? Do you really think we are that afraid of competition? Twenty percent more docs in a few years isn't going to affect my income at all. Most of the areas I have worked were so underserved that an extra 20% would just be swallowed up and not even noticed. This is just paranoia, IMHO.
  • If you think docs aren't smart now, just wait. As medicine becomes more and more regulated, price controls will reduce the attractiveness of the field. In the words of one of my attendings, in our lifetime we will see double digit IQ's in medical school. Trust me, if it wasn't hard, everyone would do it. If you think we make so much money, why aren't you in this field? Or is it like the comedian's line, "I could have been a doctor. It was just that science stuff that was so hard."
I'm sorry for venting, but I just get tired of people dumping all over doctors. I don't know a single one of my colleagues with a "GOD" complex. That seems to be one of the most common criticisms and observations. We are just people with families who want to earn a living and help some people.

We are not greedy A**holes who are just in it for the money. I know very few doctors who think the money is worth it. There are lots easier ways, less threatening ways, to earn a living.

I really feel sorry for those people who have had such bad experiences that they hate doctors so much. Perhaps they went into the relationship with unrealistic expectations (GOD) and were disappointed when the person caring for them or their loved one turned out to be simply an everyday person, with all the attendant foilables.


I have yet to talk to a physician who wants to limit med school enrollment or read a post on a medblog recommending limits. This, at DB's Medical Rants, is much more typical.

Bankruptcy legislation

Instapundit has been blogging about bankruptcy legislation, specifically about credit card debt and abuses by the credit card companies.
Perhaps the real problem isn't bankruptcy as such, but unaddressed abuses by the credit-card industry. And perhaps those should be looked at regardless of what happens with this legislation. I don't actually think that credit card companies are evil -- the expansion of consumer credit is a good thing -- but their marketing practices are dishonest, and their complaints that their loans to poor risks aren't panning out leave me unmoved.
Come on, Glenn, don't be taken in. We all know that bankruptcies are caused by disability and medical bills!

Maybe it's both. I know of a woman who has financed, with credit cards, over $10,000 worth of cosmetic surgery in a two month period. She estimates it will take her 5 years to pay this off.


Megan McArdle writes about medical bills and bankruptcy:
Her academic work has the same sort of sizeable omissions that bias the results. She's the author of the recently famous study showing that 50% of all bankruptcies were caused by medical bills. You should read the Zywicki post I linked above, but to summarise here, this "finding" was generated by attributing any bankruptcy in which the filer had more than $1,000 in out-of-pocket expenses in the last 12 months to medical bills. That's ridiculously lax, and indeed, only 28% of the respondants attributed their trouble to medical problems. Given that medical bills are by far the most attractive reason to claim for your bankruptcy (compared to other major causes like divorce, compulsive gambling, and total financial irresponsibility), it seems unlikely that there's a special "hidden" kind of medical bankruptcy so subtle that the people filing don't realise that medical woes were the source of their problems. Furthermore, the study seems to have implied that medical bills were the main problem, when loss of income due to illness plays at least as great a role.

Sunday, March 06, 2005

Animal experiments

OracKnows comments on Bill Maher:
For someone who bills himself as being so rational and skeptical, proudly trumpeting his atheism and claiming that religious people have a "neurologic disorder" because of their belief in things that can't be proven, Maher certainly seems to be rather credulous about other things that fit into his own world-view. Certainly, his close affiliation with PETA and his rather uncritical acceptance of its claims argues for this. Money quote from an interview from a few years ago:

To those people who say, "My father is alive because of animal experimentation," I say "Yeah, well, good for you. This dog died so your father could live." Sorry, but I am just not behind that kind of trade off.
I went to med school at the University of Mississippi in Jackson, MS. Class of 89. The chairman of the Department of Physiology at the time was Arthur Guyton. Ring any bells? Many of you may know that Dr. Guyton had polio when he was a resident and could only walk or stand with crutches.

Now, the medical school, as was the case with most, used dogs in expirements and education. The school would buy the dogs from the local pound for $25, if I remember correctly. These were animals that were slated to be put down and not those that just arrived. The local animal rights advocates managed to persuade the city council to prohibit the sale of these animals to the school. This meant the school had to get animals from a breeding kennel in LA, at a substantially higher cost. I suppose no one told the taxpayers about that part.

Dr. Guyton, being a very smart man, went to a city council meeting to try to get the ordinance repealed. When offered a seat, he declined. The visual was surely persuasive. He told them, "The reason your children won't look like me is because of animal research."

The ordinance was repealed that day.

Disabled or simply impaired?

Mudfud offered this insight in a difficult situation:
I've been in conversations where a medical professional has basically said that their patient will never succeed in getting a job, or holding a job, or being successful because of their disease. Yes, obviously, someone who is severely depressed will be likely to have some problems in the job department. But, if they are compliant with treatment, then they do have a real chance of being successful.
In my job reviewing medical records for disability claims, I am often disappointed when I see doctors recommend "disability retirement" or that the patient "go on disability" as part of the treatment for a disease that has resulted in an impairment.

I've seen letters from employers who are trying to use disability to get rid of "problem" employees. After all, isn't it easier to have an able bodied employee who never misses work for medical appointments and doesn't need any accomodations to do their job. Why put out the effort to help someone who could "just go on disability."

A patient may be impaired by a medical process, but may be able to do their job if properly treated or if the doctor helped the patient explore reasonable accomodations. Unfortunately, it is often easier to recommend that the patient avoid the difficult situation rather than to be an enabler of capacity and help the patient discover new ways to do things or to maximize treatment.

MudFud described that people assumed (and some still do) that she would be unable to do what she wanted based on an impairment. However, she is proving them wrong by maximizing his abilities and minimizing impairment.

Bravo to those who persevere in light of impairment and deny disability an opportunity to grip their lives.

This is not to suggest, of course, that those who are unable to continue despite maximum effort are no less heroes.

Dream Job?

If you like the Dukes of Hazard, check this out:
Want to throw your cowboy hat into the ring to become the Vice President, CMT Dukes of Hazzard Institute? Well, slap on your "Daisy Dukes" -- or tight-fittin' jeans -- practice your Yeeee Hahhhh and apply for the ultimate dream job: getting paid $100,000* to watch The Dukes of Hazzard on CMT.

CMT celebrates the return of one the most beloved pop culture hit series, of all time, The Dukes of Hazzard. A six-figure income is being offered to a Dukes of Hazzard enthusiast to be the new Vice President, CMT Dukes of Hazzard Institute.

The job responsibilities for the Vice President, CMT Dukes of Hazzard Institute are:

* watch The Dukes of Hazzard every weeknight on CMT;
* know the words to The Dukes of Hazzard theme song, "Good Ol' Boys," written and performed on the series by the legendary Waylon Jennings;
* serve as media expert on The Dukes of Hazzard for the CMT Dukes of Hazzard Institute: must be available for TV, radio and newspaper interviews to share passion for The Dukes of Hazzard on CMT;
* write the CMT Dukes of Hazzard Institute online blog for;
* be passionate about The Dukes of Hazzard on CMT;
* make appearances at special events such as Dukesfest 2005 in Bristol, Tenn., (June 4-5, 2005).

Saturday, March 05, 2005

Hi Speed At Last

I live out in the sticks where we are lucky to have running water. Come to think of it, we don't actually have running water, we have a well.

Anyway, we don't have cable or DSL. We have been relying on dial-up. Years ago, I had Direcway satellite, but I didn't like it very much. First of all, it only worked on Windows OS and I have been a Mac man since 1989. It was very buggy, conflicted with a lot of other software, and crashed/lost connection frequently.

We have basically had to rely on dial-up. I know, cry for me.

I rechecked on the Direcway and it is now available for any operating system! The old Direcway had the software residing on the computer, now it resides in the modem.

I plugged the ethernet cable from the modem into an Airport Express and now my house is a HotSpot!

Costs of malpractice

Megan McArdle writes:
People who oppose reforming the medical malpractice laws often like to point out that most medmal cases are resolved in favour of the defendant. "See!" they cry triumphantly. "No crisis!"

But this is hardly a good sign. If the overwhelming majority are resolved in favour of the defendant, that means that a lot of weak cases are being brough to trial. Such cases are no less expensive to defend than cases in which the doctor is at fault. This represents an enormous cost to the system.

Assuming that attorneys are rational actors, and that on net the expected value of all verdicts in malpractice cases in a given year should not be less than zero (or a lot of medmal attorneys would go out of business), then this means that medmal attorneys are in effect playing the lottery: buying a lot of "tickets" that are unlikely to hit, in the hopes of a big payout.

Reducing the payoff of the cases that "hit", particularly the lucrative punitive and pain&suffering damages, should cause the number of weak cases to fall, until the expected value of all payouts is once again something just high enough above zero to produce a living wage in contingency fees. Ideally, we would like to see payouts occur in 50% of the cases, since this would mean that the cases going to court are the ones where there is a likelihood of guilt, but the circumstances are sufficiently murky to make settlement unobvious.

(This presumes, of course, that whether a case pays off is directly related to doctor culpability, rather than essentially random. But if the latter is true, then we need medmal reform more than ever).

Medmal cases have, of course, other costs than just dollars wasted on attorney's fees in frivolous cases. You have doctors wasting time in court, rather than using their expensively acquired, and socially valuable skills. You have "defensive medicine" -- unnecessary tests and consults just for CYA purposes. In a medical system that is already strained, how can one justify imposing these costs when a majority of the cases lack merit?

I agree that there are definitely economic costs to be considered as a result of malpractice, but what about the costs that can't be measured with a financial calculator?

A physician suffers an immediate and substantial blow to her confidence when sued for malpractice. Even if you are sure you didn't do anything wrong, it can take years before you don't question every decision you make in light of the accusation against you. I remember a study from years ago that showed that it takes two years for an ER doc to return to pre-lawsuit levels of operating confidence.

Imagine starting every shift with thoughts of the suit, questioning every disposition through the lens of the suit. How many extra tests will you order and admissions you recommend because of that lack of confidence, in addition to the extra defensiveness?

What about the damage to reputation, even when acquitted?

Another cost to the physician that is rarely discussed is the personal cost. A physician sued for malpractice is consumed by the suit, both professionally and personally. How many divorces result from malpractice lawsuits? How many physicians enter therapy after a lawsuit? How many suicides?

Friday, March 04, 2005


Paper and a pen
Power of the physician
Prescribing healing


If I hadn't seen it with my own eyes, I would never believe that Depends makes a thong.


Knives, wrecks, broken glass
Lacerations, tears and cuts
Staples, sutures, glue

Interesting patients

A young woman was in car wreck and hit her face on the dash. She had a through and through laceration of her lower lip all the way down to the chin. She left the ER without repair at about 0430 saying that her plastic surgeon was waiting for her and that she didn't want to have a scar. What a sight she was leaving with that lac.

A 41 year old man presented with global weakness. He was unable to extend his wrists past neutral and unable to move against resistance with any extremity. Turns out his potassium was 2.8 and his phosphorus was 0.6. When these were replaced, his exam was normal. But why were they this low? Especially as his hypertension was treated with an ACE inhibitor and triamterene.

We have a lot of Bartter's syndrome in East Tennessee, but these hypokalemic people are usually asymptomatic at 2.8.


When you see someone with syringes and needles in her pocket, she's either a drug abuser or an ER nurse.

Thursday, March 03, 2005

Grand Rounds 23

Please check the menu at intueri.

Nothing wrong with her!

What a horrible way for this girl to have lived her life:
From the time Tilly Merrell was a year old, doctors told her family she would never have a normal life -- or even a normal meal.

British doctors found that the food she swallowed went into her lungs instead of her stomach, causing devastating lung infections. They said she had isolated bulbar palsy, and their solution was to feed her through a stomach tube. Forever.

But having a backpack with a food pump wired to her stomach wasn't much of a life for a girl whose favorite smell is bacon frying -- a girl who once broke through a locked kitchen door in an effort to sneak some cheese. So her family got help from their community of Warndon, about 120 miles north of London, raising enough money to take Tilly, now 8, on a 5,000-mile journey they hoped might change her life, a journey to Lucile Salter Packard Children's Hospital at Stanford University.

Doctors at Packard were intrigued that she had no neurological symptoms often associated with the palsy. In all other ways, she was a normal child with a mischievous smile and a truckload of energy. After seeing her Feb. 7, they ran three tests and found out what was wrong with her.



Floating in the air
Small droplets sweetly inhaled...
Breathing, Breathing, Joy

Government vs Science

We do not want the government budget determining our health care recommendations. See this at Code Blue.

Advisor or dictator of care?

This post by Kevin,MD was interesting, but the comments are off the wall.

I don't like the paternalistic attitude of some physicians, but I don't think we are here to provide everything the patient wants. We are not just merchants. I often see the "Walmart" philosophy in the ER. Patients think, "I came here for an X-ray" and get upset if they don't get one. A major part of my job is to figure out what the patient came here for so I can address it, one way or the other. I have found that if I explain the uselessness of a nasal bone xray, the patient will usually make the choice to avoid it.

I truly see myself as an advisor or teacher. I get most of my enjoyment from teaching a patient about her disease process and seeing the light go on with understanding. When a patient with asthma or diabetes is educated, not only are you empowering the patient but you are not going to get those phone calls.

It doesn't matter what I want the patient to do, it matters what the patient decides to do. I'm not going to her house to place the pills in her mouth, I have to educate her to the point where she makes the decision for herself to do it.

In the case cited by Kevin,MD, perhaps the patient should be offered the less medically acceptable alternative. The physician might describe the choices, orchiectomy, biopsy, or do nothing and help the patient understand the risks/benefits of each. If he were my patient, I don't think I would do a biopsy without a concurring second opinion and very careful documentation regarding informed consent and my specific, forceful opinion that the patient's decision was wrong. I don't know that I would refuse to do it, but my documentation would be extensive. I do know that I wouldn't just go along with it simply because that is what the patient wanted.

Wednesday, March 02, 2005

Routine for us, not for them

I appreciate the lengths that Orac went through to treat this patient. I especially appreciate his comment:
Thinking about this case, it occurs to me that we doctors too often become rather blasé about cancer. As mysterious and implacable a foe it is to us, we nonetheless treat it as fairly routine. We have to, particularly if it's our business to treat it. However, to the patient it is most definitely not routine.
I often have to remind myself that this is also true of my ER patients. I suppose it applies to all of our patients. When we are faced with disease, death and dying, we remind ourselves that "the patient is the one with the disease." I know that I will go home OK at the end of my shift.

But for the patient, the experience is unique. I have worked so many hours in this ER that I am familiar with every routine, every corner and every sound. For my patients, every sight and sound is new and potentially frightening.

Ordering a lab test, for me, is a matter of circling something on a form. For the patient, it usually involves a needle stick and some degree of discomfort. Add to this the uncertainty regarding what is being ordered and for what reason. The patient must wonder what is going to happen to them (not for them, as I would think) as a result of that test.

We will occasionally get a complaint from a patient regarding laughter at the nurses station. We get defensive and say, "Just because they are miserable, why do they expect that we should work in a restrictive environment. They should realize that this is our workplace and our comrades, and we may laugh as they may at their wrokplace with their comrades." However, there are few workplaces where the customer is as depersonalized as in this one.

We strip the patient naked, place them in an uncomfortable bed, poke them with needles; strangers come in and look at personal places that even family members haven't seen; we take them down halls to other departments without adequate explanations.

Thank you, Orac, for reminding me of the scared PERSON who I am treating, instead of the PATIENT who I all too often depersonalize.

ER blogging

On the night shift.

Why do patients so often lie to medical folks? I saw a patient a little while ago who was somnolent and had slurred speech. Her chief complaint, as described by her and her boyfriend, was hematemesis. Large amounts for two days. No history of melena, actually no history of bowel movements at all. I was concerned about her mental status and wondered about her volume status and how low her hemoglobin was going to be. She and her boyfriend denied narcotic use. She was on Xanax (bad drug, bad drug) but was only using one a day.

On physical exam, I saw two squares of dirts on her right lower anterior chest wall. They were caused by the adhesive from two patches. She said she had been using nicotine patches there.

Wondering about narcotic use, I gave her some Narcan with a UDS pending. Wow, acute narcotic withdrawal! She and her boyfriend continued to deny narcotic use. They weren't fooling anyone.

Her agitation was so bad I finally had to remedicate her with morphine to calm her down. Her boyfriend finally admitted the squares were from Duragesic.

I saw no evidence of hematemesis in the ER. Her rectal (which I did think to do before the Narcan, was mildly heme positive. Her hemoglobin was normal.

Now she's sleeping peacefully somewhere else in the hospital. BTW, the drug screen was positive for benzos and THC. It doesn't indicate legitimate opiates, even in supratherapeutic levels.

If she had told me up front about chronic narcotic use, I would not have used the Narcan and she would have been spared the discomfort.