Thursday, January 27, 2005

Terrell Owens wants to play in the Superbowl. Well, who doesn't?

His doctor hasn't cleared him. What does that mean? Well, it means that the doctor has told him that, if he plays, he has a risk of serious injury. KevinMD says that if the doctor clears him to play, "it's the physician's butt on the line in court."

Whenever a bunch of sports med docs get together, we frequently talk about this issue, and this one. Which are really both the same issue. The athlete, the team or both wants the athlete cleared for participation in the sport. We can never guarantee that the athlete won't get hurt in a game. So how can we ever clear any athlete for participation.

If I clear an athlete to participate in a sport, how much liablity do I have? Most physicians have participated to some degree in athletic physicals. We are supposed to reassure that 250 pound 14 year old and his parents that he won't drop dead during 2 a day football practices in Tennessee in August. I can't do that.

What I can do is explain where the uncertainty is and why. I can explain ways to reduce risk and try to ensure the safest possible play. Certainly, I can try to discourage play. I can try to educate the athlete and his parents and I can refuse to sign the physical. But he'll eventually find a doc who will sign it. By maintaining engagement, I can reduce my liability and provide the best advice possible.

When working with professional athletes, we are usually employed by the team. So there is a perception of a conflict, and sometimes there is a real conflict. In the Owens case, both the athlete and the team have the same goals, for him to play, so the physician doesn't have a conflict between responsibility to his employer, the team, and to his patient, Owens.

However, he does have an obligation to provide the best advice and care possible. Should he just throw up his hands and say, "I'm out of this!" If he does, he can deny subsequent liability, but he may well loose his job. There are plenty of Sports Med and Ortho docs out there to replace him.

Look at it like this. How many times in clinic today did you give advice that you knew or suspected wasn't going to be followed? Did you throw up your hands and refuse to participate in that patient's care anymore? Or did you realize that to adhere or not is the patient's decision and your best option was to give the best advice you could and deal with the results of the patient's decisions? I bet you routinely choose the latter.

Owens is a man who desperately wants to play in this game. Is there a risk of life here? No. Is there a risk of a career ending injury? Yes. Well, just tell him this and let him balance the issues. Would most of us risk a career ending injury for what may be our only opportunity to play in the Superbowl, especially if we were financially secure? Maybe we would.
Ann Althouse finally gets a new car.
Voter fraud is the great unacknowledged issue of our time. Nothing will change unless an outraged citizenry demands change.


Amen. Read this from Powerline.

Wednesday, January 26, 2005

DNA technology is making its way into daily clinical use for screening. See this article about bladder cancer and this one about colon cancer.
As mentioned earlier, Thomas Sowell has often commented about price controls and government decision making as a cause of failure of the free market. See this article for an example.

Here is another case where government interaction will not improve access to malpractice insurance, but will cause companies to stop insuring doctors in Missouri.
Dr. Henochowicz wrote, regarding this post:


Thanks for reading the blog. Externalities are thought of as "market failures" in economics textbooks. When externalities are positive, such as when a person benefits from the activity of others without having to contribute to that activity, there is no incentive on the part of the passive, unintended beneficiary to change. Why would there be? The benefiting person is a "free rider". As regards to government involvement, what other organization could have the authority and universal representatation to correct the externality? The remedy need not be with taxation. For example, companies are given pollution credits based on the amount they pollute. Those that pollute more can purchase credits from less polluting companies. The polluting companies don't need to retool if they don't want to, and the "cleaner" companies make some extra cash from selling the credits. Economists also increasingly feel that incentives are preferable in correcting externalities as compared to taxation (the honey/vinegar thing).


Stuart, I appreciate your response and am enjoying this conversation.

Why would an externality be defined as a "failure" of the market, as opposed to a result of the market that doesn't have a quality of success or failure independent of the opinion of each viewer? I think this consistent with definitions I have found of externality, here and here.

Look at the internet. The existence of the internet as we view it is an externality of the creation of ARPANET by the Defense Department. I don't know of anyone who would be seriously regarded if they felt this was a "market failure."

Your example of pollution, for one. One may view industrial pollution as undesirable, fair enough (and a view with which I agree.) Most would recognize that the industrial activity, and as a result the pollution, is an effect of the marketplace. A factory making cars pollutes as a result of the marketplace desire for the cars. If the buyers viewed the pollution as more undesirable than the car made at Factory A, they could switch to cars produced at Factory B, a factory producing less pollution. This would be the market in action.

Free market results are not, in and of themselves, "failures" or "successes." These are value qualifications place on the results by an interested party, biased by the opinions of that party. Different parties, with different values, may view the exact same result with different resulting opinions regarding failure or success.

When a concrete truck company washes out their trucks in an open field, this results in a large area of flat concrete. John, a very adamant naturist, views this externality as a failure. He would prefer the open field in its natural condition. Bob, OTOH, is a skateboarder. He views this new skating area as a success.

Same externality, or result of activity that is external to the primary result benefiting the company (clean trucks), different opinions. Failure or success is in the eye of the beholder. But if a large enough proportion of the concrete truck companies customers could be persuaded to agree with John, the resulting market forces would cause the trucking company to change their practices. If the government became involved, a very few Johns might cause the passage of a regulation prohibiting what the majority of community members felt was a success.

Thomas Sowell writes extensively about the results of housing regulation in California, and San Francisco in specific. The activities of a minority, interested in protecting the environment, have created a housing shortage that has impacted thousands. This shortage has resulted in greater commuting distances, causing greater pollution. If the free market were allowed to dictate results, it is reasonable that more housing would be built closer to where the people wanted. This might destroy some amount of ecology, but the resulting decrease in needed highway construction and the decreased commuting might well create ecological savings to a greater degree.

This is an example of a few with control over governmental processes creating a situation that is undesirable to the majority and creating its own externality, that of a housing shortage and, ironically, increased pollution and ecological damage.
via Instapundit:

From CNN.com:
ATLANTA, Georgia (AP) -- When two men walked into a popular country store outside Atlanta, announced a holdup and fired a shot, owners Bobby and Gloria Doster never hesitated. The pair pulled out their own pistols and opened fire.

The armed suspect and his partner were killed. The Dosters won't be
charged, according to local officials, because they were acting in
self-defense.

I carry mine, but then I carry a badge, also. I don't have a problem with
well-trained people carrying for self-defense. That qualification, well-trained,
worked for the Dosters, but is not observed by some. I train extensively with the SWAT team.
I like to read Dr. Henochowicz's site, Medviews. I find his views interesting but his post on externality I found incredulous.

I have to fight against only reading sites that say the same things that I already think. When I read something that I don't agree with, I hope that I am open to persuasion. However, I can't agree to some of Dr. Henochowicz's comments on this post.

Externalities are flaws in the market; they need to be corrected by government through regulation, taxation, or incentive programs.
Why do you assume that they "need to be corrected by government?" If the people are concerned about externalities, why don't you think that market forces, especially in your example of pollution from industry, have a role in the solution?

How is this a "flaw in the market?" People are aware, or can be made aware, of a company/industry's behavior and "externalities." Then the people make a decision. Do I interact commercially with this organization, thereby supporting these externalities, or do I withhold such support, by refusing to buy those products?

This is the market in action. Not a flaw in the market. It is an area of a free market society with which you disagree, so you want the government, at gunpoint, if necessary, to make the market actions conform to your version of what is fair. "Externalities are unfair."

I can agree with this statement: "We as a society need to do more to fix them [externalities]." I don't agree that "we need to force everyone to contribute" or that the government is the answer. I think publicizing the externalities to which we object and education in the hope that enough people will agree with us that market forces will force a change in the objectional behavior is the answer. If this doesn't work, perhaps your evaluation of what is "unfair" is not what society agrees with as a priority.

People make choices everyday. "I know that industry pollutes, but I think the products are worth it." "I know that product is bad for me eventually, but I will trade that for the immediate benefit I get today." This is similar to my earlier posts regarding paternalism in the FDA.

I don't disagree with your comments or even your priorites regarding the externalities you mentioned. I just disagree with your opinion that the government is the answer or that people should be "forced" to correct what you and I disagree with. We should attempt to persuade them to agree with us and encourage proper corrective action through the marketplace. The reason that this often doesn't work is the government, not vice-versa.

For example, I face a high risk when I try to educate someone regarding inappropriate use of the emergency room. If I screen them and send them out, I face potential EMTALA complaints and malpractice lawsuits. If I was allowed to refuse treatment to someone for a cold at 10 pm on Saturday because I know I am not going to be paid, that person would be encouraged, by the marketplace, to get insurance. But the government, by passing laws that increase my risk, discourages proper use of market forces.

Tuesday, January 25, 2005

The old saying is if you criminalize gun possession, only the criminals will have guns. Most of my posts have been medical, but, as the header says, I am on the SWAT team. Guess what my gun views are.

Here's an example of a the opposite of what gun control folks would have you believe, from Alphecca. Fewer guns in the hands of the law abiding means more gun violence because the criminals aren't afraid of the law abiding folks.
Dr. Charles has a very entertaining story about an occult encounter of the clinical kind.

It was important that I leave the room as soon as possible, before the
exchange of sorcery escalated any further. We had matched wits and I was satisfied that I had withstood her.

Read the whole thing. And, of course, in the comments section, the epilogue by yours truly.

Monday, January 24, 2005

More about Governor Bredesen and TennCare.
Bill Hobbs has instituted Bredesen Watch to keep an eye on Tennessee Governor Phil Bredesen, on whom I commented earlier.
As a new blogger, it is interesting to me to see other, more experienced bloggers write about getting comments and e-mail criticizing what they chose to write about, not necessarily the opinions stated. Oh, they get those, too, but that is part of the reason to blog, to stimulate discussion.

I am currently reading The Weblog Handbook, Practical Advice on Creating and Maintaining Your Blog, by Rebecca Blood, of Rebecca's Pocket.

She wrote about the audience of one:

If you allow yourself to begin posting entries based on what you think someone else wants you to write, you are missing the point of having a weblog...So understand that the attention you pay to your audience is not aimed at impressing them. Your only objective is to avoid sorely offending them.

The distinction is crucial. If you begin to write or link to pieces that are intended to impress your imagined audience, you will quickly become bored, and probably boring. It was once a truism that any new weblogger would, in three months' time, announce that they "needed a break" only to return a week later, proclaiming that they were no longer writing for their audience, but only for themselves. What audience? I would always wonder, imagining angry emails demanding "more links about dog food!" If you want to create a compelling weblog, you must write for an audience of one: yourself.

Medrants discusses this study, described in the NYTimes, about Plavix causing more stomach problems that aspirin plus Nexium.

Medrants' point is that they didn't compare Plavix + Nexium and that it is a no-brainer that Plavix can cause ulcers. These ulcers would then be prone to bleed, as Plavix is an anti-platelet agent.

Well, yeah, but I interpreted the point of the study differently. The point, as I can tell, was to show that an expensive drug was not better, and, in fact, was worse, than a cheap drug plus a middle cost drug. Plavix is more expensive that ASA+Nexium and yet is no better. Why study Plavix+PPI when it would be so much more expensive?

One of the main reasons I see Plavix prescribed is for patients who have an "aspirin sensitive" stomach. Well, if adding a PPI is cheaper and better than switching to Plavix, why not do this instead?
From Common Good:


The New York Times has called on Congress to launch a "wide range of demonstration projects," including special health courts, to solve the problem of unreliable medical justice.

Hat tip: Medrants



The US Supreme Court has ruled in the Terri Shiavo case.

If Terri Shiavo didn't have a DPOAHC or a living will, isn't this the decision of the next of kin, in this case her husband?

I can understand her mother's angst, but isn't the law clear?

Another reason to encourage our patients, of whatever age, to formalize their desires in a durable power of attorney for health care and a living will. Keeps down the bickering in the family that is left.

via Drudge
Is there any reason, other than political, to make this drug OTC when others, with broader applicability and less risk, aren't.

There was still no word over the weekend on whether the U.S. Food and Drug
Administration would approve over-the-counter sales of levonorgestrel, the
so-called "morning-after" birth control pill.

How to Talk to an Atheist

Please read this essay by Mike Adams. And all of his others, by the way.

If a Christian really believes the things he professes to believe, he
will go to great lengths to share it with others. He would even crawl on his
belly across a desert of broken glass if he thought he could reach an atheist.
He would certainly do more than utter profanity and show contempt for the
atheist.


"At gunpoint, if necessary"

There are so many good points in this essay that it was difficult to pull quote it. You need to read the whole thing. It relates well to earlier comments by Dr. Rangel about moving Mevacor OTC.

By using aggression to avoid medications that harm us, we lose access
to life-saving drugs.


If our neighbor George were terminally ill, we'd never dream of
entering his home at gunpoint to take away a medicine that might save him.
Similarly, we'd be furious if a family member had an incurable disease, but
George stopped our loved one at gunpoint from taking a medicine that might help.
As individuals, we honor our neighbor's choice. If we think our friends are
choosing poorly, we might try to dissuade them. However, the final decision has
to be left to them, in consultation with a physician, if that's what they wish.
After all, it is their health at stake, not ours. Most of the time, they will
know better than we what is best for them, and we'll know what's best for us. We
practice non-aggression by taking responsibility for our own choices and by
letting others do the same. Forcing our choices on others is an attempt to take
responsibility for their lives.
When we deal with our community, state, and
nation, however, our attitude is entirely different. Somehow, we think that
forcing our choice on others becomes transformed into benevolence. For example,
we support laws that stop manufacturers- at gunpoint, if necessary-from selling
medicine that has not been licensed or approved by the Food and Drug
Administration (FDA). We refuse to honor our neighbor's choice; instead, we
instruct our FDA to make up their minds for them at gunpoint, if necessary. The
effect is the same as if we used such aggression against George. Life-saving
medicines are ripped out of the hands of our fellow
Americans-literally!


Glenn Reynolds has been discussing TN Governor Phil Bredesen as a possible 2008 Democratic presidential candidate, or at least as someone the left could learn from. Today, at GlennReynolds.com, he discusses the cover article of The New Republic, about Governor Bredesen.

Now, Governor Bredesen is not my boss by any stretch, yet I agree with Professor Reynolds about this issue. I am particulary impressed by the Governor's efforts to control the budget (by controlling spending) and efforts to reign in TennCare.

Watch this site for further comments about TennCare.
Doctors, lawyers back malpractice truce in Assembly

The legislation would require trial attorneys to obtain confirmation from a medical expert that a physician has committed malpractice before a lawsuit could go to trial.

Doesn't the plaintiff already have to have an expert causation and standard of care expert(s) in order to get all the way to trial? Or do they mean to file a lawsuit?
Isn't it to the advantage of the defense to delay?

Medical Crisis Derails Malpractice Trial

Saturday, January 22, 2005

Nanomedicine

This is so cool.

I am a nanotechonology neophyte but this is fascinating.

A great book, written in 1986, that foreshadows the future and explains the basics and possibilities of this technology is Engines of Creation: The Coming Era of Nanotechnology, by Eric Drexler.


Funny

HeHe

From Carotids

He could be triplets!

Health Savings Accounts

Medviews comments about health savings accounts. I have an account with my employer where I can be reimbursed for certain eligible expenses, with pre-tax money. However, this is limited in amount and you have to predict at the beginning of the year how much to have withheld from your pay. At the end of the year, whatever you haven't claimed is forfeited.

THAT'S RIGHT>>your money is GONE. But not with a HSA.

The advantages to the HSA are several:
  • rolls over to next year if not spent
  • based on a high deductible medical insurance plan, so your premiums are smaller
  • rewards fiscally conservative medical decisions
  • because your doctor is paid by you and not the insurance company, she is encouraged to cater to you, at least to some degree.

My wife uses a dentist that is not on our dental insurance panel and we have to pay a little more. However, when she walks into the office, they greet her by name, smile and cater to her. The waiting room is nice and the dentist sees her on time. He sits down and talks to her as she needs. She fired her previous dentist because he was dismissive.

I am a firm believer in the consumer being aware of the costs of services and making informed choices based on this awareness.

As an ER doc, I frequently see patients who would not be there if they had to absorb, in any way or any amount, the cost of the visit. Six months of back pain that just can't wait until tomorrow morning. I can't count how many times I've seen someone on Sunday afternoon for a problem they've had for months and who has an appointment the next day. Or the patient who has been evaluated by multiple physicians, including specialists, with multiple tests far beyond my capability in the ER, over many months who presents because she expects me to be able to tell her what's wrong with her. These patients would not be in the ER if they had to deduct the cost of that visit from their HSA's.

Friday, January 21, 2005

Dentists as businessmen

Dr. Smith, at Medpundit, notes "While medical reimbursement declines, dentistry is booming."

I had a similar discussion with our vet recently. They are just getting into the insurance business, and, for now, are being paid fee for service.

I told him the story of the hunters of wild pigs. The hunters would select a field known to the wild pigs and put food in the middle of this field. Initially, the pigs were afraid and wouldn't go to the field. Eventually, they were overcome by the desire for the food and lost their fear.

Next, the hunters fenced in one side of the field and continued to place food in the middle. Again, the pigs were nervous and afraid, this time of the fence. However, they overcame their fear, realizing that they could come and go as they pleased and this was easier than getting their own food, plus they got as much as they wanted.

Over time, the hunters fenced in the rest of the field, leaving only an open gate. The pigs learned they could come and go through the gate and eat what they wanted. Then, when the field was full of pigs, the hunters just came up and closed the gate. Now the pigs were theirs.

Insurers did this to doctors. We have become so dependent on the insurance industry that the insurers are now dictating what we get paid. What other profession lets someone else establish their rates?

There is some effort out there to return to a cash practice, but mainly with boutique services.

Eventually, dentists and vets will find the gate shut on them, too.

UPDATE: More here

Med Conference in Barbados

The pictures sure look nice. What could be nicer than a tax deductible trip to Barbados?
Excellent commentary by Dr. Rangel about the Mevacor OTC issue.

I would add that, as in some of his examples, the patients were trying to treat existing (although not necessarily know or diagnosed) medical problems; but with the wrong approach.

I agree with Dr. Rangel that we can safeguard some of our patients from some of the adverse effects of medications and that this is a very important role and a good reason to keep some of these meds from the OTC market.

I would add that a large number of the patients I see misinterpret their symptoms and misdiagnose. In a system where they could get anything OTC, they may use the correct drug for what they think they have, and in safe doses, but the actual disease process might continue unabated and even worsening.

Taking Mevacor because you are "not feeling well" and think your heart needs help may not result in an injury from the Mevacor, but may delay the correct diagnosis. This could result in a more difficult to treat disease or even death.

Update: Don't forget that most commercial insurers won't pay for OTC meds. Don't be fooled when you see support from these companies, it is in their financial interest, not in the interest of what is best for you.
Cancer surpassed heart disease as the leading killer of Americans:

For the first time, cancer has surpassed heart disease as the top killer of Americans younger than 85, health officials said yesterday.
The reason is that while the number of deaths from both causes has fallen, the improvement has been more marked for heart disease.

"It's dropping fast enough that another disease is eclipsing it," Dr. Walter Tsou, president of the American Public Health Association, said of the incidence of heart disease.
A good read, via Blackfive
I ordered this book today for my wife, who is a dog trainer (see her blog HopOnOver):

Training for Speed, Agility, and Quickness

I'll let you know what we think of it. Speed, agility and quickness can be very important during dog agility competitions. The only time I tried it I got my feet all tangled and did a somersault!

UNSCAM

Via Instapundit, we find that Jack Kemp, former Republican vice presidential candidate and New York Congressman, has been linked to "Virginia-based oil trader Samir Vincent, who earlier this week became the first figure to be formally charged with criminal wrongdoing in the $21.3 billion global scandal."

Now that a Republican has been linked to the scandal, maybe the Democrats will admit that something wrong has occured.

Thursday, January 20, 2005

Blog Book

I recently bought Blog, by Hugh Hewitt. If you are interested in blogs, and you wouldn't be here if you weren't, you ought to read this book.

What's the Poop

I appreciate MedPundit's pointer to Dr. Henochowicz's blog, Medviews.

I liked his point about the inconsistency of physician recommendations to patients, What's the Poop.

I review medical records every day from all over the United States. The inconsistency of quality of care is astounding.

I recognize that medicine is an art, but, as Dr. Henochowicz pointed out, there are best practices for a reason.

It is disappointing to review a record and see the physician dutifully checking a HgbA1C and yet failing to do anything different when it comes back 10.

Planned Parenthood conspiracy

Planned Parenthood's income is increasingly coming from performing abortions, Planned Parenthood annual report, albeit at fewer clinics.

Men's Health reported that Planned Parenthood's condoms failed at the greatest rate of any tested by Consumers Union.

Is this a coincidence? Let's see:

Using a Planned Parenthood condom means more failures

More failures means more unwanted pregnancies

More unwanted pregnancies means more potential abortions

Now, who was it again that is making money from performing abortions?

Sometimes I wish I was a woman

Boy, when I read things like this I have to wish I was a woman. Most of the time I don't, though, but it would be nice to be told to drink more.

MSM bias

Obviously, the MSM exhibits its bias by which stories it chooses to cover. It also shows the bias by whether it includes both sides of a story. A classic example is the Swift Boats Vets coverage. The MSM only interviewed people who would describe the SBV allegations as unsubstantiated. Remarkably, the MSM made to effort to substantiate any of it.

I used to listen to the ABC news top of the hour radio broadcast religiously. I was much attuned to the time and would switch to a station that carried the news when it was on. Then I became dissatisfied with the bias and am not so careful about hearing it.

However, this morning I heard something that might indicate a change in the way they do business. When discussing Condoleeza Rice's confirmation hearings, the broadcaster stated that the confirmation was not likely to happen today as "Democrats say they need more time for debate." What was surprising was this, "In other words, to criticize the administration's handling of the war in Iraq and to try to influence policy."

Wow. I think 6 months ago the report would not have included that last statement.