Friday, July 29, 2005

Seen in a disability claim file:
It is my opinion that my patient is temporarily totally disabled and that this will be permanent.

Wednesday, July 27, 2005

I am looking at Home Design CAD software for Macintosh OS X. Any ideas?
I'm one of those who believes that gun control means using two hands. I have read to many articles about the inverse relationship between private gun ownership and crime rates to believe that honest people shouldn't have guns.

We don't need more gun laws to prevent gun crimes, just prosecute the crimes that were committed. Likewise, the crimes are committed by whom? Anyone? Anyone? Criminals, that's who. And does anyone seriously think that making another law against guns will keep them from using guns in their crimes? Hey, they're CRIMINALS, remember?

I liked this article, from Opinion Journal.

Tuesday, July 26, 2005

Doctors ask court to uphold limits on lawyer's fees
Unhappy that lawyers have figured out a way to get around voter-approved limits on how much they can collect in medical malpractice cases, the Florida Medical Association is asking the state's high court to deliver what it hopes will be the knockout punch.
Hospitals study when to apologize to patients
Harvard Medical School's major teaching hospitals are considering adopting a sweeping disclosure policy that would establish detailed procedures for physicians to openly acknowledge medical errors and other bad results to their patients, and provide for training in apologizing.

A group of physicians, patients, and executives from the hospitals, led by Dr. Lucian Leape, a national specialist on patient safety, began drafting the policy last year. In recent months, the group circulated a 50-page first draft among hospital leaders, who responded favorably to its broad goals but have suggested numerous revisions, which the group is now implementing.

If Harvard's largest teaching hospitals -- Massachusetts General Hospital, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Dana-Farber Cancer Institute, and Children's Hospital Boston -- adopt the policy, it would create a uniform response across the Harvard system to some of medicine's most difficult situations. The Harvard hospitals also would join a growing number of US medical centers and malpractice insurers that are embracing immediate and open disclosure and apology to patients when medical care goes wrong.
TennCare To Phase In New Prescription Restrictions Soon
For the people who will continue to be covered by TennCare, more changes are coming. TennCare will phase in its new prescription drug restrictions by the end of the week.

The State says it will only be able to afford a certain number of prescriptions for each enrollee.

Joseph Phillips is one of the people TennCare will still cover, but the 47 year-old's kidney problems are expensive, especially when it comes to the long list of prescription drugs he's on.

All remaining enrollees on TennCare, except children and institutionalized adults, will have big changes to their coverage. Beginning August 1st, next Monday, there will be new restrictions on how many prescription drugs TennCare will pay for.

Right now, TennCare covers an unlimited number of prescription drugs in any given month. So, if you have eight prescriptions, when the healthcare benefit changes go into effect, TennCare will only cover five of those prescriptions.

Of the five prescription drugs filled each month, only two can be brand name drugs. The other three have to be generic. The new co-pay for brand name drugs will be $3.00.

If you are on a certain drug regimen, for something like cancer, each medication on your treatment won't necessarily count towards your five prescriptions per month limit.

Some of your medicines will cost more than others. TennCare advises you to go over some of the pricing with your doctor and make sure he or she prescribes the most expensive ones first, because TennCare is only going to cover the first five prescriptions.

For those who've lost their TennCare coverage and are not being picked up under Medicaid, there's a number you can call.

The Health Options hotline based out of Memphis is taking about 400 calls a day.

The hotline is connecting people with low cost services in their county. You can also get more information on prescription - assistance programs.

The Health Options hotline number is 1-888-486-9355.
Disability Activists Blast PBS for ADA Anniversary Promotion of Better Dead than Disabled Film
In an all-too-common feat of cultural insensitivity, PBS has chosen July 26th, the anniversary of the signing of the Americans with Disabilities Act (ADA), to air “POV: The Self-Made Man.” The documentary features the videotaped statements of Bob Stern, an elderly man deciding to commit suicide rather than face possible disability, medical uncertainly or complications.
Abortion Drug Deaths in California Subject of Federal CDC Review
The Centers for Disease Control is looking into why four women, all from California, have died after taking the abortion drug in the last three years. While five women have died overall since the FDA approved sales of RU 486, four lived in the Golden State, including one unnamed woman who died recently.
Not to mention the dead babies.
I was never much of a union fan. When I was in high school, I got a job as a cashier at Krogers, a union shop. When I refused to have union dues taken out of my check, I was fired. Didn't seem right then, doesn't seem right now.

From the OpinionJournal:
Without such a new vision, Big Labor will only continue its slide. All the more so given new Labor Department rules, recently upheld in court after an AFL-CIO challenge, requiring that unions disclose more details about how they spend hard-earned member dues. Some of the nation's largest unions will now have to disclose their spending by specific categories, such as political donations, grievance proceedings, or organizing. This sunshine will expose just how much labor money is being wasted on political activities that have little to do with improving workers' lives.

Union leaders seem genuinely to believe that their glory days will return if only they can defeat President Bush, or oust Tom DeLay as House Majority Leader. But their real obstacle is the reality of the modern global economy. Until they offer workers something more than class warfare, circa 1955, they will continue to decline.
Grand Rounds is up at Pharyngula. Go there, read it, and come back.

Monday, July 25, 2005

Hi, my name is Fred. OK, it is actually KB304692l. But you can call me Fred. I am one of a family of programmable nanobots. Let me introduce you to my sister, Eunice.

Eunice can be programmed to recognize specific proteins expressed on the surface of cells. Any cells, actually, but she is usually directed at cancer cells. What is interesting about Eunice is that when she binds to the protein in question, her conformation shifts and she "injects" RNA into the cell. This RNA codes for a protein that poisons the mitochondria of the cell. The mitochondria is the powerhouse of the cell and the cell cannot function without it. Actually, I have billions of sisters named Eunice. When injected into the bloodstream of a cancer patient, she can effectively cure the cancer. She can only inject the RNA after she is bound to the protein. By programming her to bind only to proteins expressed on the surface of the cancer cell, she only affects cancer cells.

Eunice is usually used in combination with Alice. Alice basically does the same thing, but is programmed to recognize a different protein in the same cancer cells. She injects protein that irreversibly binds to the nuclear DNA material, preventing transcription.

Eunice and Alice are used together to prevent the survival of any cells that don't manifest one or the other proteins. Unlikely, but why take chances?

Frieda, another sister, is the golden child. Seriously, she carries nanoshells. These are miniscule beads coated with gold. These can be designed to absorb specific wavelengths of light, including near-infrared light, which can easily penetrate several centimeters of human tissue. The absorption of light by the Frieda creates an intense heat that is lethal to cells.

Did I mention Milton? He is my brother. Milton is one of my favorites. He is sort of like a "bone-glue." When injected into the fracture hematoma, he and his millions of "twins" bind together forming a lattice between the fracture fragments. Within hours, the lattice approximates natural bone strength, allowing full use. Over time, the osteoclasts fill in the lattice.

But my absolute favorite is my little brother Lester. He is a respirocyte. He is a bloodborne spherical 1-micron diamondoid 1000-atm pressure vessel with active pumping powered by endogenous serum glucose, able to deliver 236 times more oxygen to the tissues than natural red cells and to manage carbonic acidity. Release of oxygen is managed by an onboard nanocomputer and numerous chemical and pressure sensors. Obviously, he would function well as a transfusable blood substitute. Imagine, someone with Lester onboard could run full speed for 15 minutes without breathing, or sit on the bottom of a pool for hours.

Maria, another sister, is a silicon-based microcapsule containing pancreatic islet cells. Now most people who receive a pancreas transplant have to be on multiple immune suppressive drugs, with all the attendant complications. Maria is a way around this. She has multiple "nanopores." Now small molecules such as oxygen and glucose can enter, and insulin can exit, but larger molecules such as immune complexes cannot enter. Millions of Marias are implanted beneath the skin of the diabetic patient, allowing natural glucose control functioning without the need for immune suppression.

I am relatively simple, myself. I am used to treat hemachromatosis, or iron overload. I am injected into the bloodstream and I bind iron. After binding, my structure shifts, allowing me to be filtered by the kidneys, taking with the iron. I have numerous relatives that are used as therapy for various toxic ingestions. An emergency room keeps these programmable nanobots handy and programs them for whatever toxic ingestion presents. No more of that nasty n-acetyl cysteine!

The first step to discovering/inventing something is to imagine it and believe that it is possible. This is often the most difficult step, but can be the most fun.

Sunday, July 24, 2005

I just switched to using Haloscan for comments. I used the automatic install. Guess what? It seems that many of the custom changes I made to the template are now gone. No more link bar. I guess I'll have to start over. All of my comments are gone. Bummer.

Thursday, July 21, 2005

Pilots Arrested for Disability Payments
Forty pilots were arrested after an investigation found they were licensed to fly but were receiving Social Security disability payments for a variety of illnesses, federal officials said.

The pilots, who include commercial and transport pilots, claimed to be medically fit to fly airplanes. However, they may have been flying with debilitating illnesses that should have kept them grounded, ranging from schizophrenia and bipolar disorder to drug and alcohol addiction and heart conditions, said Marlon Cobar, a prosecutor with the U.S. Attorney's office in Fresno.
I am aware of a case where a doctor completed paperwork for an insurance company stating that his patient was completely incapable of working. On review of the medical records, it was noted that, on the same day, the doctor had completed a DOT physical so the patient could maintain his commercial driver's license (CDL.) When the reviewer got a copy of the CDL physical, it described a completely healthy individual without any restrictions.

Obviously, there was fraud; either on the disability paperwork or on the CDL paperwork.

RU-486 stuff

FDA Issues Warning About Abortion Pill

Abortion Drug Company Boasts That 460,000 American Babies Were Killed in Five Years

Do you think the state of CA will require the Catholic church to provide insurance coverage for this pill, as they did for OCP's?
Doctor pursues hospital post
Faison said the state needs surgeons with two good eyes.

"It's just nutty to have a surgeon without depth perception," he said. "You're just asking for serious problems. We shouldn't have surgeons who are blind in one eye. Let them go be psychiatrists, or attorneys."
You don't have to be blind in one eye to be without depth peception. How many surgeons out there have been tested for depth perception problems? There probably are surgeons in NC and every other state that lack depth perception.
Pharmaceutical company attacks meth bills
Days before legislators are scheduled to vote on a bill that aims to reduce methamphetamine abuse in the state, the pharmaceutical company that makes Claritin has started running radio ads in opposition to the proposal.

"If that bill is passed, the days of just going to the store for these trusted and effective products is over. You would have to go to your doctor first," the radio ad says, referring to over-the-counter products containing pseudoephedrine, a key ingredient of methamphetamine.

Under the bill, such products would require a prescription.
Site requires free registration.

Here in TN, we have to show ID and sign for pseudoephedrine at the pharmacy counter. The law limits how much you can buy at one time. It's a pain, but imagine how much worse it would be if you had to have a prescription.

Hey, if the state makes it a prescription drug, will insurance start paying for it?
Pharmaceutical Company Methods Drawing More Scrutiny
Until the late 1990s, physicians were virtually the only members of the public who heard drug companies' pitches. But in 1997 the FDA, which regulates the claims that can be made about prescription drugs, issued new, more relaxed guidelines for advertisements aimed at the public. Suddenly a new form of commercial appeal -- the direct-toconsumer drug ad -- became the fastest-growing segment of the advertising business and a staple of daytime TV, talk radio and glossy magazines.

Wednesday, July 20, 2005


Wiring the Brain at the Nanoscale
Already, the researchers note, physicians routinely use arterial pathways to guide much larger catheter tubes to specific points in the body. This technique is frequently used to study blood flow around the heart, for example.
Following the same logic, the researchers envision connecting an entire array of nanowires to a catheter tube that could then be guided through the circulatory system to the brain. Once there, the wires would spread into a "bouquet," branching out into tinier and tinier blood vessels until they reached specific locations. Each nanowire would then be used to record the electrical activity of a single nerve cell or small groups of them.

Tuesday, July 19, 2005

Answering (and writing) consults

I remember the best education I received about writing and answering consults. I was a fourth year med student, doing a rotation in the Surgery Department at the Naval Hospital in Bethesda. I was on a vascular service and received a consult from an internist on a patient with suspected peripheral vascular disease. He requested a specific test. I don't remember what it was, but it wasn't the right test for this patient. I did the right test and wrote up the consult. My resident and staff approved it and it was sent to the internist.

A few days later I received a message to call Colonel Internist, MD, USAF. Now I was just a measly Ensign, medical student, and was, of course, terrified.

However, he was very nice. He asked me why I hadn't done the test he requested. When I told him, he agreed that it was the wrong test, but suggested that, because he had asked a specific question about a specific test, that I should have answered the question. I should have explained why I wasn't doing the test he ordered and why the test I did was preferable.

He went on to spend a fair bit of time with me about the need to ask specific questions of consultants and the need to give specific answers when I was the consultant.

A very useful interaction.
I know I have read her blog before, but you know how it is with trying to keep up every day. However, I went to her via Grand Rounds today and I don't know why I haven't been reading every day. I added Maria to my sidebar today and you should, also.


This post by Maria at Intueri prompted me to post about someone I saw in the ER last night.

A 23 year old woman was transported by EMS to the ER. According to her, her neighbors found her somnolent and difficult to arouse. After awakening her, they asked her why she was so sleepy and she replied that she had taken some pills. I think they did the right thing by calling EMS, as this woman had some psychiatric history. She reported that she had taken pills about a year earlier and that was a suicide attempt. Her mother strongly felt that this was a suicide attempt, although she couldn't tell us why. There was no note or comments by the patient.

However, as with Maria's patient, she denied suicidal intent or ideations. She stated that she was "stressed out" and that she just wanted to get some sleep. She reported that she took a 10mg Hydrocodone (she didn't say Hydro) and 5 Vicoprofens. This was fairly consistent with the meds remaining in her prescription bottles.

There were plenty of pills left in her bottles that she could have taken if genuinely suicidal.

She had a low potassium, don't ask me why, and needed to be admitted. All other labs, including acetominophen levels, were normal. In our hospital, most suicide precaution patients go to the ICU because the nurses don't feel they can watch them closely on the floor. So, if she had been admitted without suicide precautions, she could have gone to the floor.

What do you think? Do you believe her story? Or the story of Maria's patient? In our community, if this patient's potassium had been normal, I would have consulted Crisis Response and they would have come to see her. When they see a patient with this type of story, specifically denying suicidality, they will usually send them home with a no harm contract and scheduled follow-up.

Of course, if you wanted to commit suicide, and knew that if you admitted it you would be locked away where you couldn't kill yourself, wouldn't you lie and sign the no harm contract?

Monday, July 18, 2005

Robin Hoods or Legal Hoods?
"Without notes he launched into a brief history of the American tort system and how crucial it was in protecting the masses from the greed and corruption of big corporations that make dangerous products. And, while he was at it, he didn't like insurance companies and banks and multinationals and Republicans, either."

- John Grisham, "The King of Torts"

THREE months ago, William S. Lerach, the powerful class-action attorney both feared and loathed in executive suites across the country, received a disturbing call from his lawyer. Federal prosecutors, Mr. Lerach was told, wanted more time to build a criminal case against him.

Until then, a three-year investigation into whether Mr. Lerach and his former New York law firm, Milberg Weiss Bershad & Schulman, had used illegal tactics in shareholder lawsuits that made him and the firm rich and famous had appeared to be dormant. The phone call meant that the inquiry had suddenly gained traction.

Abusing the system--TennCare fraud stories

The Blackmail Worked

Or is it extortion?
The Food and Drug Administration will decide by Sept. 1 whether a morning-after contraceptive pill can be sold without a doctor's prescription.

The long-awaited deadline was unveiled in a letter sent by Michael Leavitt, secretary for the Health and Human Services Department, to high-ranking senators. The news prompted two Democratic senators -- Patty Murray of Washington and Hillary Rodham Clinton of New York -- to announce Friday they would allow a vote on the confirmation of Lester Crawford as FDA commissioner.

The two had placed a hold on the nomination because of the lack of a decision on the pill, also called Plan B.
I don't think a senator should be able to put this type of hold on a nomination. This is extortion, plain and simple. What do you want to be that they won't allow the vote until after the decision? Plainly as an effor to say to Mr. Crawford that they will only vote for him if he decides his way.

Friday, July 15, 2005

Giving birth drunk

Whither responsibility? Good post by RedStateMoron.
Police: Coach Told Player to Injure Disabled Teammate, 8
A youth baseball coach paid one of his players to hurt an 8-year-old mentally disabled teammate so the boy wouldn't be able to play in a game, state police said Friday.
No Fizz in Soda Scare
The food police filed a petition this week with the federal government to require that regular (non-diet) soft drinks carry health warning labels. But scientific data, including a new study published this week, expose such soda scaremongering for what it is — junk science-fueled nanny-ism.

Saying I'm Sorry

Doctors Should Say They're Sorry, Avoid Malpractice Suits
"The majority of people who file medical lawsuits file out of anger, not greed," says Sorry Works! founder Doug Wojcieszak. "That anger is driven by lack of communication, being abandoned by doctors and no one taking responsibility for his mistakes. Apologizing and offering some up-front compensation reduces this anger."

Seventeen states have enacted apology laws; some make remorseful words inadmissible in court if uttered soon after mishaps occur. U.S. Sens. Max Baucus, D-Mont., and Michael Enzi, R-Wyo., introduced the Reliable Medical Justice Act on June 29 to provide federal funding for apology projects around the nation. While the need for federal grants here is a mystery, Washington should encourage this concept without reflexively whipping out the checkbook. Implementing it in VA hospitals would be a solid start.

This terrific idea should sweep the nation. To cure medical-malpractice lawsuits, "sorry" shouldn't be the hardest word.
A court substitutes its judgement for that of the elected officials in the legislature.
The Supreme Court found no rational basis for the cap, which is now roughly $433,000. It rejected the argument that the limit cuts medical costs.
It argued that the cap violated the equal protection clause of the constitution. I am no constitutional scholar, but would a "rational basis" have changed this. The court substituted its brief review of this issue for the judgement of months/years of consideration by the legislature. If the real issue was equal protection, what does the rational basis arguement have to do with it?
SneezingPO is like an RSS feed of good stuff from medblogs. You should check this site for things you missed on others.

Thursday, July 14, 2005

An excellent post on peer review, by Dr. Rangel.

I haven't had experience with being targeted by peer review malignantly, as Dr. Rangel described, but I was by a hospital administrator.

I have had a couple of interesting interactions with peer review, however. These, I think, were just sloppy, not malignant.

A companion of a patient I saw in the middle of the night complained about me. Now, these don't usually make it to peer review, but the allegations were significant enough that the medical services personnel forwarded it to peer review. The companion accused me of touching the patient, inappropriately, after she asked me to leave the room and of refusing to leave the room when requested and that the nursing supervisor had to be called to escort me out of the room. Now, none of this was true.

However, I didn't receive any request from the peer review to tell my side of this interaction. The first I knew that there was a complaint was a letter from the chairman of the peer review committee that they had reviewed the complaint and found that my behavior was inappropriate and that it should not be repeated.

I wrote to the commmittee chairman and expressed my disappointment that I was not allowed to provide any input to the committee. I also asked for an audience with the committee. I asked him what witnesses they had interviewed.

He answered that they had interviewed no witnesses. He said that the accusations were significant enough to warrant a warning to me and they didn't feel they need to investigate. I replied that the accusations were significant enough that, if true, they warranted disciplinary actions and, possibly, referral for criminal prosecution.

It would have been easy enough, I argued, simply to ask the nursing supervisor whether she had been called to escort me from the patient's room or to ask the nurse who was in the room with me whether I had touched the patient inappropriately.

After further investigation, I received a letter that stated that the committee had decided there was no support for the complaints. However, to avoid disturbing the complaintant, they never sent her a letter.

The other situation was when I used IM ketamine in a child in the ER without starting an IV first. I received a letter from the peer review that I had violated standard of care and that it was a level 3 occurrence. Of course, no one had asked my opinion before rendering this decision. My medical director had graded this a level 3 occurrence.

When I presented the chairman of the peer review committee with the abudance of literature that supported my use of ketamine, he referred me to my medical director. His comment was that I had violated the nursing policies and procedures for conscious sedation, but he agreed with my opinion regarding standard of care.

There is a huge difference between violating a nursing policy and a level 3 occurrence, violating standard of care. I received another letter of correction. However, the original letters censuring me remain in my peer review file. So the complaints could be "trended." If you trend bullshit, you get bullshit.
Hush Money for Malpractice Settlements?
In California, plaintiffs who win malpractice lawsuit settlements often must promise not to notify state authorities. But in cases of true wrongdoing, critics say such agreements amount to hush money.
So what if it is hush money? Since when has it been illegal to require silence as a condition of a settlement of a civil case? We've seen plenty of cases that could be construed as criminal where the plaintiffs/witnesses/victims are required not to go to the authorities as a condition of the settlement (see Michael Jackson).
The pain and suffering this man went through just about brings you to tears. I don't blame him for his anger.

When I am in the room with a patient who isn't doesn't seem to be participating in the discussion, either from decreased level of consciousness or from dementia, I will remind myself to direct some comments to the patient. I will greet the patient as I enter the room.

I try to remember that the patient may be hearing and assimilating all or much of what I am saying. Telling someone that the patient "will never" do something is basically stupid, as we don't know for certain. There are two many tales about apparently hopeless cases that awaken and walk.
This, described and discussed by Dr. Andy, is very exciting.

As he says, not yet developed or proven. And resistance could still develop to the phage.

Obviously, the phage would have to recognize the pathologic bacteria, enter it, and then induce some fatal change. From an immunological standpoint, the bacteria could become resistant by changing whatever surface marker the phage is programmed to recognize. Then the phage would be worthless, as it wouldn't be able to recognize the target.

Remember, the changes that provide immunity are not deliberate. They result from random mutation, not from intelligent design (got that, Orac?) and, if the phage could recognize more than one surface marker there would be less chance that the bacteria could survive. Considering the odds against even one surface marker changing by random mutation sufficient to provide resistance, by targeting multiple surface markers, the odds against resistance become astronomical.

Your thoughts?
Very interesting case, at Cut to Cure
Commercial applications of nanotechnology:
Hitachi Home & Life Solutions Inc. has released new washing machine models that can deodorize clothes without using water or detergent.

The Beat Wash models are equipped with a filter incorporating as a catalyst titanium particles with an average diameter of 5 nanometers, 200 times smaller than conventional catalyst particles. A nanometer is a billionth of a meter.

The Hitachi Ltd. subsidiary says the nano-titanium catalyst filter can catch odor molecules that pass through a conventional catalyst filter.

If users smell cigarette odor on their clothes, for example, they can eliminate it by running the clothes in the drum in the deodorizing mode without water for 10 minutes. Allergenic pollen can be also removed.
So it gets the cigarette odor out, but what about the lipstick on the collar?

Wednesday, July 13, 2005

Way Cool!

Researcher Fashions DNA to Further Advances in Nanotechnology
While other efforts in recent years have focused on learning how to build DNA-based nanostructures, Yan's work is novel because it makes it feasible to attach any desired biomolecule onto DNA nanostructures. Such work is an important step and can serve as a future foundation for biocatalytic networks, drug discovery or ultrasensitive detection systems.
Nanotechnology Conference To Cover Top Six Beneficial Nano Uses:
The Foresight Nanotechnology Challenges are:

    Meeting global energy needs with clean solutions
    Providing abundant clean water globally
    Increasing the health and longevity of human life
    Maximizing the productivity of agriculture
    Making powerful information technology available everywhere
    Enabling the development of space


This lady can do everything!

Rice lands top spot in nanotechnology ranking
I don't think we can afford not to be the leaders:

U.S. Leadership Position in Nanotechnology Is Under Threat
Lux Research, the world's leading nanotechnology research and advisory firm, has released a report which served as the basis of Vice President of Research Matthew M. Nordan's testimony before the Research Subcommittee of the House Science Committee's hearing on nanotechnology earlier today.

Based on Lux Research's proprietary analysis frameworks, "Nanotechnology: Where Does the U.S. Stand?" assesses how U.S. research and business activities in nanotech measure up to those of international competitors. The report finds that the U.S. is still ahead of the rest of the world in nanotech by almost every standard, from funding and investment to patents and publications, but cautions that several significant trends threaten that status.

"The U.S. leads the world in nanotechnology today, but its position is tenuous," said Nordan. "To maintain global leadership, U.S. policy makers must grow federal funding for nanotech research; eliminate regulatory uncertainty surrounding environmental, health, and safety issues; and do a better job of retaining foreign Ph.D. students. In addition, the U.S. must create financial incentives aligned with desirable applications and approach export controls sensibly."

The report notes that although the U.S. puts more government funding to work on nanotech research than any other country on an absolute basis, it has already fallen behind Asian competitors on a relative basis: When spending levels are corrected for purchasing-power parity, the U.S. invested $5.42 per capita in government spending on nanotechnology in 2004, exceeded by South Korea at $5.62, Japan at $6.30, and Taiwan at $9.40 -- nearly twice the level of the U.S. In addition, other nations lead the U.S. in many promising nanotech applications, like using carbon nanotubes for displays, where even the U.S. Patent and Trademark Offices catalogues far more patents from Japan and South Korea than from the U.S.

Falling Deficit

Instapundit wrote about the falling trade deficit. One might wonder why. I have the answer:

Rice heading to China this weekend

Of course, President Bush deserves the credit, wouldn't you say?

Bredesen for President?

I try to follow Governor Bredesen and TennCare. Here is an interesting editorial from the Opinion Journal about President Bush, Medicare and Bredesen:
Mr. Bredesen is the other Tennessean, the one Mr. Bush didn't tap, and who is worth listening to on health-care issues. I met him in Washington recently. He was to deliver a powerful speech on Medicaid at the National Press Club the following morning and I wanted to know how the government might restrain a program that is sucking up more tax dollars every year. I was drinking tea and he was largely leaving his coffee untouched as he delved deep into his thinking about how to control costs. But this was no policy-wonk session, laboriously meandering through mundane details. What Mr. Bredesen was laying out was a broad governing philosophy of the sort we don't normally hear inside Washington.

Irag-al Qaeda connection?

From the Opinion Journal:
The difficulty lies in piecing together the picture, which is indeed murky (that being part of the aim in covert dealings between tyrants and terrorist groups)--but rich enough in depth and documented detail so that the basic shape is clear. By the time Mr. Hayes is done tabulating the cross-connections, meetings, Iraqi Intelligence memos unearthed after the fall of Saddam, and information obtained from detained terrorist suspects, you have to believe there was significant collaboration between Iraq and al Qaeda. Or you have to inhabit a universe in which there will never be a demonstrable connection between any of the terrorist attacks the world has suffered over the past dozen years, or any tyrant and any aspiring terrorist. In that fantasyland, all such phenomena are independent events.

Gambling Addiction or Drug Side Effect?

Parkinson's Drug Tied to Gambling Addiction
Joe Neglia was a retired government intelligence worker with Parkinson's disease (search) when he suddenly developed what he calls a gambling habit from hell.

After losing thousands of dollars playing slot machines near his California home several times a day for nearly two years, Neglia stumbled across an Internet report linking a popular Parkinson's drug he used with compulsive gambling.

"I thought, 'Oh my God, this must be it,"' he said. Three days after stopping the drug, Mirapex (search), "all desire to gamble just went away completely. I felt like I had my brain back."
But there's more:
Neglia, 54, now living in Millersville, Md., was not treated at Mayo or involved in the study. He said the problem is underreported "because of the embarrassment factor" and is one of several patients suing manufacturer Boehringer-Ingelheim Pharmaceuticals Inc., accusing the company of failing to adequately warn patients about the potential side effects.

Two Tales of Bad Care wrote about bad care rendered to one of her patients by a new intern. I would like to share a story, too. Not to say, "Hey, nurses do it, too," but to say, "Here is another example."

When I was a medical student, my first clinical rotation during my third year was OB. I was on the high-risk service, on 4N. As I entered the ward, I saw a patient leave the first room on the left and begin to walk down the hall, trailing her IV pump. I asked her if she needed help. She replied that her IV pump was beeping and that she had been pressing the nurse call button for several minutes without an answer.

I escorted her back to her room and went looking for help. I mean, come on, I knew enough never to mess with an IV pump. I didn't want to risk the wrath of the nurses.

Anyway, when I got to the nursing station, there was no one there. No secretary, no nurses, no one.

I found the entire day crew in the lounge behind the nurses station eating fried chicken. When I asked if someone could go help the patient this was, nearly verbatim, the reply:

N: 401? (pronounced foh-oh-one)

Me: Yes.

N: Well, she ambulatory, ain't she?

Me: Yes.

N: Then she can just come down here.

Me: (incredulous) You mean if the patient can walk they have to come to the nursing station to get care?

N: Yeah. And, hey, don't you backtalk me. I got's my degree!

No kidding, true story.

Hat tip: GruntDoc

Tuesday, July 12, 2005

Should a government be able to steal the patents from a drug company?
is up at Shrinkette.

Sunday, July 10, 2005

Catty Warhol

Friday, July 08, 2005

More depo tips

Read this as well.

  • You may bring notes, but the opposing attorney will probably ask to see/copy them, and you will have to produce them.

  • If you are a party to the lawsuit, anything you produce when working with your attorney is privileged. If you are an expert, any notes you took or any materials you created or provided are discoverable. This may vary, I don't know.

  • During deposition, you want to limit the opposing attorney's access to information. Anything you say may be used to impeach your testimony at trial. The deposition transcript will be evidence at the trial. Don't expand on answers when a simple yes or no will suffice. If the opposing attorney is smiling, shut up.

  • At trial, the jury is your audience. You should expand on your answers to the degree necessary to educate the jury. Be careful not to contradict what you said during the deposition. You should have reviewed your deposition testimony prior to your trial testimony.

  • Be aware of body language. Angle your body between the opposing attorney and the jury so you can look back and forth comfortably. If the attorney moves to the other side of the courtroom, you may want to shift, but primarily address your comments to the jury.

  • Again, pause between the question and your answer to give your attorney an opportunity to object. Wait for the judges ruling before answering. If you don't understand what the ruling meant, ask the judge if you should answer the question.

  • Don't lie. Tell the truth. You'll be found out and BOOM!

  • Be confident. You are right. Don't be afraid to state your opinion in confident terms and don't be wishy-washy.

  • Especially if you are the defendant in a malpractice suit, ask your attorney if they can arrange for a mock deposition and a mock cross-examination. These can be very helpful if the examiner is realistic. You may learn a great deal about yourself, especially if you get to watch a video of your mock cross-examination.

  • When asked to review a case as an expert, you should contact the attorney and discuss the case before you write anything down. Your report will be discoverable.

  • The opposing attorney will probably ask you if you have discussed the case, or a particular question/issue with your attorney. Hopefully, you have, and answer, "Yes."
    You will probably be asked if your attorney told you what to say. A good answer is, "No. I told her what I had to say and she helped me frame it a way as to make my opinion most clear." This is especially useful if you are an expert and not a party to the lawsuit."

  • Make sure you read any affadavits prepared by your attorney before you sign them. I have seen good testimony rendered unuseable because it contradicted the poorly written affadavit.
If you have your own experiences or suggestions, please add them.


I forgot, never agree that anything is authoritative. It will be used against you later. Also, whenever the opposing attorney says, "Wouldn't you agree..." you should probably say no.

A brief legal post (maybe not so brief)

Now, I don't pretend to know as much as an attorney about legal issues, but I have been involved in enough depositions to feel like I can offer a few ideas and thoughts. Of course, I would appreciate any comments from those out there with additional knowledge.

As a doctor who reviews medical records for an insurance company, I know that I have the potential for being deposed on just about any file I review. Claims that are governed by ERISA law are, technically, to be adjudicated solely on the administrative record, the claim file, and the law does not provide for depositions, but I have been deposed on ERISA claims. Go figure.

I have been deposed as an expert witness, a fact witness and as party to the lawsuit. I have testified as a witness to a crime.

I have been very fortunate that the company for which I work has provided training in legal writing and deposition/trial testimony skill. In addition, attorneys with whom I have worked have been very good about depo prep.

Unfortunately for the witnesses for other side, in the cases in which I have been involved, the opposing attorney is usually very bad about depo prep. If you are sued or are acting as an expert, demand adequate depo prep.

In one of the first malpractice suits with which I was involved, the expert for the plaintif was an ER doc. I was working with the defense attorney and attended the doctor's deposition to help the attorney with the medical issues. The ER doc had never met the plaintiff's attorney before his deposition, but had just talked to him on the phone to schedule the deposition. They took him aside for about 15 minutes before the deposition. They allowed the deposition to be scheduled after a night shift in the ER, on a day that he had to come back that night for another night shift. The attorney with whom I was working knew this and deliberately prolonged the depo. Imagine, after a night shift in a busy ER, and anticipating another busy night shift, what would be on your mind? Going home and getting some sleep, perhaps?

Anyway, the defense attorney stretched out the preliminaries as long as practical and took numerous breaks. After about 4 hours, she got to the meat of the case and the ER doc was wiped out. He made such a mess of his testimony that the plaintiff's attorney didn't allow him to testify at trial. There was no way to resuscitate him. Now, if he had been properly prepped and the depo had been properly scheduled, this could have been avoided, to some extent.

When I refer to "your attorney" I mean the attorney for the side for which you are testifying. If you aren't the plaintiff or the defendant, you should have a stake in the truth, not in the use of your testimony.

So, after this example, here are some tips:

  • Be well rested. A no-brainer, I know, but read the above example, a true story, again.

  • Dress comfortably. If you are going to be videotaped, you should wear a coat and tie or, for women, similar professional garb. Don't wear your white coat, or at least ask your attorney her preference. Juries can perceive the white coat as arrogant. Don't primp with your hair, mustache or clothes during the deposition.

  • Feel free to take breaks. Don't let the opposing attorney set the tempo. If you want a break, tell them that you are taking one. To be polite, you might ask if anyone objects, but take it anyway. The more the opposing attorney objects, the more important the break is.

  • If there is no video, you can take all the time you want to think and answer a question. Pauses don't get transcribed. However, you don't want to look unsure on the video. Try not to overthink and take long pauses if on video.

  • However, don't rush to answer. Let the questioner finish the question and look for modifiers, like on test questions, that might change your answer from a yes to a no. Additionally, a brief pause between the question and the answer will give your attorney a chance to object, if necessary. Most of the time you will have to answer the question anyway, but at least the objection is on the record.

  • Listen to anything your attorney says. Especially the objections. If your attorney say, "Objection, calls for speculation," your answer should be, "I'm sorry, I don't feel comfortable speculating about this subject." The wording of the objection can clue you in to traps in the question, such as an objection to a multipart question. You might say, "Could you break that question down into single parts, so that I can make sure my testimony clearly addresses them and there is no confusion?" If your attorney asks you, "Do you need a break?" you can bet that you do.

  • Look primarily at the deposing attorney, but you shouldn't stare or be fixed. Don't fidget, but look at the other participants occasionally. Be careful, but casual.

  • When asked a question about a document, look at it. Every time. Every time. Every time. Don't trust your memory or the opposing attorney. Make sure you are absolutely positive about the document before you answer. Just say, "May I see that, please?"

  • Don't be emotional. If you feel yourself getting defensive or angry, ask for a break. Remember, these snakes people are experts at this. They will try to get you upset and make you lose your cool.
More here.

Tuesday, July 05, 2005

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This week's , at Medical Connectivity.