Tuesday, May 31, 2005

Take a Tour of at Dr. Sanity.

Monday, May 30, 2005

Walter

As a young child, Walter seemed a little withdrawn, but was OK, overall.

He stood on the long road. He didn't know where he came from, but could see the long road ahead. He feared the travel, but didn't really know why.

Unfortunately, soon after getting his new bike for his seventh birthday, he had an accident. Despite repeated entreaties and even threats from his mother, he wasn't wearing his helmet.

Without conscious will, he moved toward the edge. Alarmed, he tried to stop. As abruptly as he started, he stopped.

He continued in school, but was not able to keep up with his age group. He slowly fell behind.

The edge would, without warning, occasionally creep closer. Perhaps there was something good there. He began to focus more on the edge, and less on his surroundings.

Autism, mental retardation. Living inside his own world. Wasn't so bad most of the time. Wasn't hurt by the death of his parents when he was 17, although his sisters weren't prepared for the difficulties of his care.

He was unable to see over the edge, but had, by now, become convinced there was something desirable there.

He lived in a home where people were nice to him. He didn't like the drugs, they made him sleepy. One made it very difficult to swallow.

Sometimes it was foggy here and he couldn't see the edge, but always knew where it was.

He couldn't swallow regular foods very well, but still loved them. Especially the sweets. Things just weren't as good pureed.

It's OK that no one else is here. There's the edge.

One day, the others in the house baked cookies. They left the cookies on a rack on the counter to cool.

He can almost see over the edge, but it hasn't become closer in a long time.

Unwatched, he found the cookies. Oh, joy, he ate and ate and ate.

Now the edge began to approach quickly. Or was he moving towards it?

Unable to swallow properly, he aspirated a large cookie bolus. He fell to the floor, alerting the house staff.

Wow, it is pretty here.

His chest heaved mightily, but was unable to bring in sweet, life-sustaining breath. Inside his lungs, the negative inspiratory pressure pulled fluid into the alveoli. Massive negative pressure pulmonary edema. Now, anoxic encephalopathy.

At the edge, he began to fall.

Flaccid, unconscious. Hypotensive. Minimal ventilatory capacity.

Floating, falling, he could no longer see the road he had been on.

Removing life-sustaining measures. Becoming hypoxic and increasingly hypotensive.

Who is crying? Is there someone here?

Funeral arrangements.

Gone

Sunday, May 29, 2005

Interesting comments on this post by "MD."

MD, thanks for your comments. I can certainly agree.

Dr. Bell was not the ER doc. The ER doc settled. Dr. Bell was the admitting physician, who apparently did not see the patient. I don't understand how the patient got discharged without being seen by the admitting physician.

I agree that it looks like the dx of CVA was missed. The article doesn't describe whether any treatable etiology was discovered.

You wrote, "surely you concede..." I didn't take any position one way or the other. But you are right, a simple referral when you don't know what's going on is certainly appropriate.

In the composite case I described, the ER doc did make a referral, to the ophthalmologist, where further testing did make the dx. I actually think the referral to the ophthalmologist made the dx more quickly that admission would have, as the hospital didn't have a neurologist and it is not likely that the local MD would have made the dx.

You talked about transfer to a stroke center. My experience in small to large community hospital ER's and as a hospitalist is that the referral hospitals, whether a stroke center or just a larger hospital with a full-time neurologist, wouldn't take the patient in transfer.

I recently had an inpatient woman, relatively young, with right sided hemiplegia and expressive aphasia and a very large stroke. Likely related to methamphetamine use. Anyway, despite the fact that her stroke enlarged and became more dense on CT, and that her symptoms were worsening, no one would accept her in transfer. I was advised that we could do everything for her that they could as the presentation wasn't acute.

It is unlikely that either of the docs I discussed would have been able to effect a transfer.

Thursday, May 26, 2005

Senate fillibusters Bolton

The leaders of the Democrat fools in the Senate asked them to vote against cloture, but stated, "This is not a filibuster." Gee, what else is it? Isn't the vote for cloture a vote to stop debate, and continued debate is a filibuster, right? Maybe it's just plain extortion. Is that a better word? You give us what we demand or you don't get a vote!

The Senate is now in recess for the Memorial Day weekend and won't return until June 7, at which point Sen Frist has asked that they reconsider this vote and also that they vote on other nominations.

Interestingly, when the final votes were tallied, Mr. Frist voted against cloture. This was procedural. Only someone on the winning end of a cloture vote can ask for reconsideration. Sen Frist had voted for cloture but changed his vote when he saw it wasn't going to pass so he could move for reconsideration.

I would love it if Pres Bush made recess appointments tomorrow for his filibustered nominees and for Mr. Bolton. Then debate could continue on the actual "consent" while the jobs are filled and the work is being done.

The Dems claim that they only want to force the administration to submit info they have requested. They don't mention that the info they want is detailed intelligence info including the names of operatives. Can anyone say, "Valerie Plame?" The Senate is a sieve when it comes to sensitive info and you know the info won't stay private, but will be leaked.

Besides, this info is being requested by people who wouldn't vote to confirm Bolton if Jesus appeared and testified for him. If they got this info and it was exculpatory, they still wouldn't vote for him. They admit that there is nothing unusual about his request for redacted names, anyway.

In medicine, we are hesitant to order tests that won't change what we do with a patient. Why should the administration respect a request from a bunch of obstructionists who are going to oppose the administration every chance they get? The best the administration could hope for would be a big nothing, but would face Dems who would leak anything they though would embarass Mr. Bolton or Mr. Bush.

Tuesday, May 24, 2005

Stop Kicking Me!

Drug to calm sleep-robbing leg syndrome OKd by FDA
Earlier this month, the FDA gave the green light to pharmaceutical company GlaxoSmithKline to market Requip for moderate-to- severe RLS. The drug is a so-called dopamine-agonist, a class of medications commonly used in much higher doses to treat symptoms of Parkinson's disease, although doctors stress that the two conditions are unrelated.

At last

And they say women aren't respected in medical research!

New drug delays male orgasms, study finds
The drug, called dapoxetine, helped men delay their orgasms significantly and doubled the numbers of men and their female partners reporting "good" sexual satisfaction, they told a conference.

And now...the rest of the story

Here, I told you about Dr. Kevin Bell being sued. Here is the jury verdict.
Genentech says eye drug improves vision
Preliminary trial results also show that Lucentis met the primary goal of stabilizing vision in patients with wet age-related macular degeneration, which afflicts an estimated 1.2 million Americans, mostly over the age of 50.

Once Again...


Grand Rounds is up!! The Quotable Grand Rounds, by Dr. Chaplin.

Monday, May 23, 2005

TennCare Fraud?

New investigators' lack of TennCare fraud convictions worries state lawmakers
''Either there's not as much abuse going on as they think or they're not doing a good job finding it,'' said Sen. Kathryn Bowers, D-Memphis. "Either way, I think $5 million is a lot for not a lot of cases."
Geez, if they want to find TennCare fraud, all they have to do is come work a shift with me in the ER.
If you are following the recent MSM boondoggles, you may find this interesting.
It’s worth mentioning here that the unrepentant Rather and his colleague Mary Mapes, who was fired for her role in presenting the forged documents, received a major industry award last week, a Peabody, as well as “extended applause” from the journalists in the crowd. (What’s next? A lifetime achievement award for New York Times prevaricator Jayson Blair?)
Don't they get it? These two screw up royally and then get a major award? This reminds me of the movie "A Christmas Story" with Darrin McGavin. Remember the Major Award he got? Electric Sex!

SODDI Defense

An interesting variation on the SODDI (Some Other Dude Did It) defense:
Defence lawyer Yariv Ronen said the soldier should be acquitted of a manslaughter charge because Hurndall "did not die from the wound but because the doctors, together with the family, made a very clear decision to end his life". Ronen said the doctors denied Hurndall antibiotic treatment and gave him an overdose of morphine.

Sham medicine?

Anti-depression implant may gain U.S. approval
It has been approved since 1997 for the treatment of some epilepsy patients, and the drug agency has told the manufacturer that it is now "approvable" for severe depression that is resistant to other treatment. But in the only rigorously controlled trial conducted so far in depressed patients, the stimulator was no more effective than sham surgery.

Expert witness roundup

Recently I wrote a story about a patient visit to the ER with a stroke and the resulting lawsuit because the ER doc didn't treat with TPA. I was prompted to look into the expert witness subject. A search on Google for "medical malpractice expert witness" resulted in 564,000 hits. I refer you to these:

  • An interesting site describing one physician's interactions with the medicolegal system as a plaintiff, expert reviewer, plaintiff's expert and defendant's expert. I really enjoyed reading this article and that's why it's the first listed.
    Three years later I was called to see a woman in consultation in the hospital. When I saw her and recognized the name, I realized it was the wife of the patient who had sued me. When I called this to her attention she said “Oh, we weren’t suing you, we were suing the insurance company.” I told her it would be difficult for me to have a satisfactory doctor-patient relationship with her and arranged to have another consultant see her. [emphasis added]

  • NJ law bans "retaliating" against expert witnesses

  • Malpractice: Who should judge the experts?
    The FMA's review program was launched a few years ago by its Council on Ethical and Judicial Affairs, spearheaded by Tampa head and neck surgeon Dennis Agliano. Upon a complaint from a member physician, the CEJA's expert witness subcommittee will review expert testimony and take "appropriate" action if it's judged inaccurate or dishonest. "We see it as our duty to expose those doctors who engage in deceit or fraud," says Agliano, now FMA's president, "and nothing could be more fraudulent than false testimony."

  • Why I'm a plaintiffs' expert
    When I was approached about 10 years ago by a representative of our state medical association and asked if I'd be interested in serving as a plaintiffs' expert, I was dumbfounded. I couldn't believe that anyone on "the doctors' side" would want to encourage more plaintiffs' experts. After some discussion, however, the reason for his request became clear: If honest practicing physicians aren't willing to review cases for plaintiffs' attorneys, they'll turn to "hired guns" who sell their opinions to the highest bidder.

  • Guidelines for Expert Witness Testimony in Medical Malpractice Litigation
    The interests of the public and the medical profession are best served when scientifically sound and unbiased expert witness testimony is readily available to plaintiffs and defendants in medical negligence suits. As members of the physician community, as patient advocates, and as private citizens, pediatricians have ethical and professional obligations to assist in the administration of justice, particularly in matters concerning potential medical malpractice. The American Academy of Pediatrics believes that the adoption of the recommendations outlined in this statement will improve the quality of medical expert witness testimony in such proceedings and thereby increase the probability of achieving equitable outcomes. Strategies to enforce ethical guidelines should be monitored for efficacy before offering policy recommendations on disciplining physicians for providing biased, false, or unscientific medical expert witness testimony.

  • On the hot seat: Physician expert witnesses
    The years when doctors would not testify for plaintiffs in medical malpractice cases because they didn't want to break a code of silence are long gone. Although a physician still may not want to testify against a colleague in his own community for professional reasons, many physicians are willing to step forward to testify in cases where they don't know or work with the physician on trial. They say it's a matter of social responsibility if the facts show that a patient was harmed because of negligence.

  • Expertise in Medical Malpractice Litigation: Special Courts, Screening Panels, and Other Options. This one I found particularly interesting, especially the discussion of specialty courts.
    The third proposed reform considered in this report - for specialized medical liability courts—does not currently exist in any state. A medical liability court system has recently been proposed in Pennsylvania, and the national reform organization Common
    Good supports specialized medical malpractice courts as a way to provide "expert judges ruling on standards of care." In the abstract, a specialized court may seem like a promising way to increase judicial expertise and consistency. An examination of the court proposed for Pennsylvania, however, reveals serious risks of increased politicization, narrowed judicial perspective, and greater costs to litigants.
For those of you interested in honing your expertise as an expert, or who simply want to become more comfortable in deposition, I found this group to be useful.

UPDATE


Adding this one, via GruntDoc. From the Coalition and Center for Ethical Medical Testimony, a Statement of Direction.
The Mission of CCEMT is to make honesty and ethicality the sine qua non of physicians and others engaged in healthcare who serve as expert witnesses, and to eliminate the ability of unethical experts to testify with impunity in medical-legal matters on the assumption or under any law or regulation that makes such testimony privileged or protected from scrutiny by peers.

Friday, May 20, 2005

A very scary law

PointOfLaw, via MedPundit, writes that N.J. bans "retaliating" against expert witnesses.
Last year, in a little-noted and last-minute amendment to medical malpractice legislation, the New Jersey legislature enacted a measure banning "retaliatory action" relating to the employment or credentialing of persons because of their delivery of expert testimony in legal proceedings. Specifically, the bill provides as follows:


An individual or entity who threatens to take or takes adverse action against a person in retaliation for that person providing or agreeing to provide expert testimony, or for that person executing an affidavit pursuant to the provisions of P.L.1995, c.139 (C.2A:53A-26 et seq.), which adverse action relates to that person's employment, accreditation, certification, credentialing, or licensure, shall be liable to a civil penalty not to exceed $10,000 and other damages incurred by the person and the party for whom the person was testifying as an expert.


What about the case I described here? While not completely an actual case, the testimony of the neurological "expert" was from an actual case. Shouldn't that neurologist be sanctioned in some way? Why should he be allowed to say anything he wants without any concern for his reputation or privileges?

Making bad law

It's unfortunate when blatant politics affect the attempts to make law. This article described such a circumstance:

One side is trying to "embarass" the other:
Others say the unusual amendments are part of an attempt by opponents to dredge up every worst-case scenario in medicine, to embarrass caps supporters into backing down.
...
Among Fritchey's proposals was one that failed last week. It would have prevented any caps on damages against any doctor whose patient is injured by medical neglect because the doctor is engaged in sexual intercourse while on duty - a scenario that reportedly occurred in the Chicago area.

"If legislators think doctors should be protected in every circumstance then let them vote against these amendments," said Fritchey. "But I would like to think even the most ardent supporter of caps would recognize there is some conduct that doesn't deserve caps."
Basically, let's try to put something in the bill that is rare and is almost impossible to vote against, because we aren't politically secure enough to vote against the whole bill. We are too beholden to the trial lawyers:
State Rep. Ron Stephens, R-Greenville, a vehement caps supporter, said the amendments were a way for cap opponents to "make us look bad." He said Democrats proposing the amendments were doing so because if cap supporters come out against them, they will look as if they are not in favor of compensation for legitimate medical malpractice victims.

"Democratic leaders are in a box and they're looking for a way out," he said. "Democrats' number one fundraiser is the trial lawyers, so they are faced with either addressing a public policy issue, or do we do what our main donors say we should do?"

Mooney, the political scientist, said the proposed changes to the bill might also be an attempt to "water down" the legislation. He said because the public seemed to be so supportive of caps, legislators didn't want to come out fully against them.

"These are the kinds of things opponents do when they can't really find a way to defeat an idea if they take it head on," he said.
Sort of like a filibuster. When you don't have the votes to defeat something, abandon majority rule and just be obstructionist.

AMNews

KevinMD has a good round up of comments regarding the AMA's decision to make amednews.com a pay site. He linked to this AMA response, which stated, in part:
That said, the cost of presenting AMNews online is borne almost entirely by AMA members and is offset only somewhat by ad revenue. The decision was made, therefore, that members should benefit from their support by retaining access to the site. In the same spirit of rewarding those who underwrite the publication, paid print subscribers will also be allowed online access.
Of course, this move will not decrease the costs of maintaining the site and will not benefit the paid members at all. Did they think that when they restrict access, hits will drop and so will ad revenue. So the members will continue to bear the cost, as they do now, and their share will go up as the ad revenue decreases. All this will do is remove access from those of us who don't pay, without benefiting anyone else.
Via Instapundit:

I agree that this article is very disturbing. However, this statement is one of the most important in the article:
an action Army prosecutors recently classified as criminal assault.
What is important is that the chain of command recognizes these activities as criminal and will prosecute them. Look, the source of the article was "a nearly 2,000-page confidential file of the Army's criminal investigation into the case..."

At least, in our country, our society and our military, these things are not tolerated. Even those of us who support the use of force deplore the use of these types of techniques. This is what makes us different from those we oppose. This type of behavior would have been celebrated, even demanded and expected, in Saddam's Irag and the Taliban's Afganistan.

I agree with Instapundit in that I hope this is thinly sourced and that this didn't happen. Just as much because I wouldn't want something like this to happen to someone as that I don't want our reputation damaged, again.

What happened at Abu Graib was disturbing, but I don't think it was systemic. I was in the Navy during the Tailhook scandal and was in a working relationship with a number of pilots, many of whom attended that particular "conference." I have faith in those men and believe that the behavior then was not systemic, as this is not now.

Thursday, May 19, 2005

Boehringer HIV drug helps some, says US FDA staff

Now be careful. This drugs helps some, so not as good as those that help a bunch, but better than those that help just a smidge. Gosh, those technical terms just confuse me.

Blogs vs MSM

From Transterrestrial Musings, (via Instapundit):
The folks at ABC News apparently need to go back and read their history books. They seem to fantasize that it was Republicans who blocked the Civil Rights Act. In a piece on the current filibuster debate, they write the following, titled "Historical Perspective":

The filibuster has been used historically by the minority party, which can't win with a vote count. Democrats have opposed the filibuster before — in the 1960s, they accused Republicans of using it to block civil rights legislation.
According to the Senate Historical Office, the record for the longest individual speech is held by the late Sen. Strom Thurmond of South Carolina, who filibustered for 24 hours and 18 minutes against the Civil Rights Act of 1957. To keep the floor, he read some of his wife's recipes and passages from novels out loud.
...
The ugly fact, of which ABC is either unaware, or worse, deliberately misleading their readers about, is that the Civil Rights Act of 1964 would not have passed without Republican support, due to the continued opposition by southern Democrats. Contra ABC's implication, it was not the minority Republicans who filibustered it, but the majority Democrats, and the cloture vote to end debate was achieved only with the votes of many Republicans. Former Klansman Robert "Sheets" Byrd (shamefully still representing the state of West Virginia, even in his dotage and senility) was the last debater on the floor before that cloture vote (it then required 67 votes, rather than the current 60) was passed. Other stars of the filibuster were Richard Russell (D-GA), Albert Gore, Sr. (the last Vice President's father) (D-TN), and William Fullbright (D-AR) (Bill Clinton's mentor).
There's more, go there and read.

Two indicted on TennCare fraud

Will these two get the "soft landing?"

TennCare lite?

Bill to help TennCare disenrolled passes Senate committee
Thousands of people who could be cut from TennCare would receive a pharmacy discount card and other benefits under legislation that's moving through the General Assembly in its final weeks.

``The goal is to give all enrollees to be disenrolled some help,'' Senate Minority Leader Jim Kyle said Tuesday.

Kyle sponsored the so-called ``soft landing bill'' that was unanimously approved Monday by the Senate Commerce, Labor and Agriculture Committee and sent to the Senate Finance Committee.

Another stroke malpractice case

Medical malpractice suit takes shape
In the first day of testimony at a medical malpractice trial at the Madison County Courthouse, attorney Robert Wilson alleged that after George Wolfe was admitted to the emergency room at Anderson Hospital on June 13, 2002, Dr. Kevin Bell failed to realize that Wolfe had suffered a stroke.
...
Wilson noted that Wolfe complained of symptoms that should have indicated a stroke, including drowsiness, confusion, losing track of time, and memory loss.


He was discharged from the hospital after about five hours and was advised to begin taking 325 mg of chewable aspirin as part of anti-platelet therapy.


He was re-admitted June 15 after Wilson said the stroke worsened.
...
On June 17, Wolfe was transferred to St. Mary's Health Center in St. Louis where he was placed in a drug-induced coma.


In opening statements, attorney Tim Richards argued that Bell was not given enough information to make a diagnosis and that Wolfe's options were extremely limited. "The appropriate treatment is the miracle treatment of aspirin," he said. "No doubt Mr. Wolfe had a devastating injury that medical science could not have prevented. Even had he been admitted, medical science could not have prevented this."


On Monday, Sarah Scott [the ER doc] and Southwestern Illinois Health Facility, Inc., doing business as Anderson Hospital, settled their case with Wolfe for an undisclosed amount.
Based on this report, did Dr. Bell do anything wrong? Would admitting the patient to the hospital on June 13 have made any difference?

Medical malpractice requires four elements, all of which must be met in order to satisfy the definition:
  1. Duty to treat. From the standpoint of an ER doc, this is usually fairly obvious. In this case, the doc represented the patient's regular primary care clinic. OK, met.
  2. Tort. The patient has to have incurred an injury. This patient is now in a wheelchair and requires assistance with ADL's. OK, met.
  3. Deviation from standard of care. In this instance, is it clear that the SOC was not met? What is the SOC for an established stroke in the ED? Should this patient have been admitted? What would you have done differently? And yes, I acknowledge that all we have to go on is a short newspaper article, but use your imagination. It is obvious that this patient was not a thrombolytic candidate.
  4. The deviation from SOC has to have caused the tort. Again, not clear here. Did the absence of some sort of treatment result in the injury? If so, would that treatment have been considered SOC?

Dong-A?

This is either a joke or really bad PR advising:
According to the Korea Food and Drug Administration (KFDA), DA-8159, a drug for erectile dysfunction by Dong-A Pharmaceutical, is being reviewed for sales approval.

Wednesday, May 18, 2005

Now, this is funny!

Just amazing!

Now,this is just plain wierd!

Tuesday, May 17, 2005

Enter the lawyers

Part I is here.

Discharged from hospital on Plavix. Continued smoking.

Now January 2002.

ER doc (now Defendant) notified via court documents that patient (now Plaintiff) has filed a lawsuit alleging malpractice. In that the Defendant did not adequately diagnose and treat the Plaintiff's CVA with thrombolytics, the standard of care at the time of the ER visit.

Thus begins the saga. The Defendant goes through disbelief, denial, anger; all at the same time. Gets a phone call from a representative of his malpractice insurer and is referred to a defense attorney.

Over the next year, the Defendant attends several depositions. His, of course, and those of the Plaintiff, the Plaintiff's sister, the ER doc from the tertiary referral center and the treating neurologist.

Elements of the depositions/trial testimony:

  • Plaintiff can't remember the ER visit. Testifies she awoke with symptoms after having gone to bed at 9pm asymptomatic.

  • Optometry note indicated history that the symptoms began the day before.

  • Dr. X, the plaintiff's ER doc witness, can't describe what he thinks happened at the initial ER visit and can't describe what he would have done differently, except that he would have done Visual Field testing.

  • Dr. X stated that he did the VF testing at his facility with the Plaintiff lying on the gurney.

  • Dr. X admits that, despite working in a referral center and seeing many acute CVA's, he has never administered thrombolytics for a CVA. And yet, he testifies that it is standard of care for ER docs. He testifies that he just calls the neurologist and the neurologist gives the thrombolytics.

  • Dr. X testifies that he is unaware whether there is a neurologist available at the initial hospital.

  • $600 per hour of deposition for 5 hours. Not bad pay, huh?

  • Dr. Y, the Plaintiff's neurologist, testifies that the Defendant violated SOC by not administering thrombolytics and that this failure caused the Plaintiff's visual field defect.

  • Dr. Y is informed that the Plaintiff admitted during her deposition that she was asymptomatic when she went to bed at 9pm and awoke just before going to the ER with symptoms. He testifies that if you awaken with symptoms, the three hour window starts when you wake up. He is offered a copy of the NINDS study and continues to testifies to this.

  • Dr. Y is informed that the Plaintiff had been hospitalized two weeks before her presentation to the Defendant for a retroperiotoneal bleed. He insists that she was still a candidate for thrombolytics.

  • Dr. Y's admits he knows nothing about the capability of the small community hospital. He feels he is familiar with the SOC for an ER doc because he sees patients referred to him from small community hospitals.

  • Dr. Y testifies that eye pain is a classic symptom of an occipital stroke and should have been recognized as such right away.

  • Dr. Y testifies that it is SOC for an ER doc to perform visual field testing in the ER when faced with an eye complaint.

  • Dr. Y stated that, at his hospital, they have a 90% improvement rate in patients treated with thrombolytics.


  • Dr. X refused to testify at trial. This meant the Plaintiff did not have an expert on SOC. In their state, the law requires that the SOC expert witness practice in the same field of medicine as the Defendant. The causation expert can be anyone with knowledge. However, the trial judge allowed the neurologist to testify as the SOC expert.

    At trial, 12 months later, the Defense presented large posters of the NINDS guidelines regarding the three hour window and the statements of the ACEP and AAEM that thrombolytics for stroke is not SOC for ER docs. The Defense presented an ER doc and a neurologist as defense experts who testified that the Plaintiff did not qualify for thrombolytics.

    Verdict for the Defense.

    Issues I noted:
    • Should the Defendant have performed VF testing in the ER?

    • Why did the judge allow the Neurologist to testify as to SOC? Sure, he is aware of the types of patients that are referred to him, but is he, in any way, aware of how many "eye pain" and potential stroke patients we see in the ER every day that don't get referred to neurology? Aren't those patients as important in determining SOC as the ones the neurologists see?

    • Should this neurologist be sanctioned for such blatant false testimony as the clock starts when you wake up with symptoms? Is there anything in the literature to support this? Do you think the plaintiff would have been able to get any other neurologist to make this statement?

    • Why should the Defendant have no recourse against the Plaintiff, her lawyers and her experts for the disruption to his life and the damage to his reputation?

    • Do you really think it is SOC to administer thrombolytics for stroke, in light of all the controversy?

    • What do you think about the neurologist's assertion that his hospital observes a 90% improvement rate in patients treated with thrombolytics for stroke?

    • Note that the daughter was upset about the Defendant's manner and the fact that he was reading a book. What do you think about this?

    • Do you want some of that $600/hr?


    GruntDoc fisked the WSJ article (link is to outside repeat of article, as the WSJ site is subscriber only)regarding thrombolytics for stroke and has a boatload of interesting comments.

Keep PETA out of my kid's classroom!!

Go away, you morons.

Thanks to Tales of a Wandering Mind.

Ya gotta see this

This is hilarious, and very well done.

Grand Rounds 34

In case you didn't notice, we've made the leap to Arabic numbers. Grand Rounds 34 is up at Galens Log, where we get a tour of Blogger General Hospital.

Malpractice reform

How do you reform malpractice at the state level when the legislators are part-time and their "day job" is as tort lawyers? See this article form Illinois.

And this from RI:

AMA calls R.I. liability ‘crisis’ state
The American Medical Association has designated Rhode Island as medical liability “crisis” state, citing a “deteriorating” legal climate and a “growing threat of patients losing access to care.” Rhode Island joins 19 other states, including Massachusetts and Connecticut.

“Patients bear the brunt of the nation’s broken medical liability system,” said Dr. William G. Plested, an AMA trustee and former president who visited Providence on Monday. “The cost of unrestrained litigation not only jeopardizes patients’ access to physicians, hospitals and clinics, but also inflates the cost of medical services.”

The AMA classifies states as “OK,” “showing problem signs” or “in crisis” on the basis of three major factors, Plested said: how fast medical malpractice insurance premiums are rising, whether doctors say the costs are pushing them to move or retire, and whether doctors say they are limiting the services they offer to avoid liability.

Since 2002, malpractice insurance costs have risen 286 percent for hospitals, 200 percent for general practitioners, and 175 percent for surgeons, the Rhode Island Medical Society says. And a RIMS survey of local doctors found 47 percent were considering moving or leaving clinical practice, 41 percent were considering no longer performing certain procedures, and 71 percent had found it hard to recruit new doctors.

The numbers make it clear, RIMS president Dr. Fredric V. Christian said: The state’s medical liability system is “in desperate need of reform.”

Monday, May 16, 2005

Disabled inmate sues Georgia

Inmate's disability case goes to justices
Goodman, who uses a wheelchair, was convicted of aggravated assault, possession of a firearm by a convicted felon and illegal drug possession with intent to distribute. Since last year, as well as from 1996 to 1999, Goodman says he has been held in a cell measuring 12 feet by 3 feet for 23 hours per day in a high-security section of the Georgia State Prison in Reidsville.

Goodman sued Georgia in 1999, alleging cruel and unusual punishment in a variety of ways.

He says prison officials have often failed to provide the assistance he needs to get to the toilet, shower or bed.

As a result, his cell floor is covered with his feces and urine, and he has often sat in his own waste while officials have ignored his requests for cleaning supplies and assistance, Goodman says.

He also says the small size of his cell prevents him from turning in his wheelchair, leaving him essentially immobile. In addition, Goodman alleges that the lack of assistance and wheelchair accessibility has prevented him from getting to the prison's law library, counseling, educational services, vocational training and recreation, which are available to other inmates.

He says his efforts to get to his toilet and shower without assistance have resulted in broken toes, knee injuries and a fall-induced epileptic seizure. Goodman also says his confinement in high security was because of his disability, not because he presents a threat to anyone.
Normally, I don't have much sympathy or empathy for prisoners. I usually feel they earned what they get. But, if this description is true, I think GA should do something different.

Drug Imports Not Always Genuine

FDA Warns About Counterfeit Viagra, Lipitor in Mexico
The Food and Drug Administration (FDA) is warning the public about the sale of counterfeit versions of Lipitor, Viagra, and an unapproved product promoted as "generic Evista" to U.S. consumers at pharmacies in Mexican border towns.

Keeping premiums low-an alternative method

In MD, Governor Prepares To Release Malpractice Funds
Almost five months after the General Assembly passed legislation to reduce malpractice premiums for doctors in high-risk specialties, the Ehrlich administration is ready to release state funds that will be used to reduce premiums for many physicians and surgeons.

Budget Secretary James "Chip" DiPaula said Monday he and Gov. Robert Ehrlich were prepared to sign off on a request for funding from Alfred Redmer, state insurance commissioner. The money will be used to hold premium increases to a maximum of 5 percent instead of the 33 percent that was planned by the company that insures most Maryland doctors.

"That will certainly be good news for physician's offices, many of which are feeling quite squeezed," T. Michael Preston, executive director of the Maryland State Medical Society, said.

Third quarter bills from Medical Mutual Liability Insurance Society of Maryland are due to go out next week, and lawmakers have been pressuring the Ehrlich administration to release the money so the reduction in premiums could be included in the May bills.

Clearing acne clears depression!

Again, whoda thunk it? You clear up a kids zits and he gets less depressed, not more!

Acne drug not linked to increased suicide risk
A recent study has found that the popular acne-fighting drug Accutane, which has been linked to birth defects, did not cause depression in a group of adolescents.
Accutane was one of five drugs cited by veteran Food and Drug Administration (FDA) scientist David Graham at a congressional hearing last year as approved drugs that ought to receive closer scrutiny.

The FDA is monitoring the drug to determine if it causes depression and suicide. The agency also ordered creation of a registry to ensure pregnant women, or women who may become pregnant, do not take it because of a risk of birth defects.

Roche's drug Accutane, is also sold in generic versions as isotretenoin.

In the study Accutane was given to 59 patients and it was found that their overall incidence of depression declined.

The Doctor and The Patient (and the lawyers)

Jan 2, 2000.

Data from triage sheet:
Time of presentation to ER: 2:45 a.m.
Time of vital signs and triage: 2:32 a.m.
Time of evaluation by position: 2:35 a.m.
History: Ms. Walker, a 78-year-old woman presented to the emergency room at a small community hospital with a chief complaint of left eye pain and diplopia 2-3 hours (indicated as 2-3 and then the small circle symbol) prior to presentation, left face pain and weakness. Pain was constant, sharp and stabbing and not ameliorated or exacerbated by anything. No photophobia. Further history revealed that the "weakness" was more fatigue and she had no complaints of any paresthesias or focal weakness.

No h/o glaucoma. No significant history of headaches.

PMH: hypertension, peripheral vascular disease. No h/o CVA, CAD. No known carotid stenosis.

PSH: cataract surgery with lens replacements years PTA.

Soc: Lives alone. Manages her own affairs with some help from her granddaughter. Smokes 2-3 packs per day. No alcohol use.

FH: no specific recall

ROS: Anxiety. no specific c/o chest pain or respiratory complaints. No difficulties walking. No bowel or bladder complaints.

PE: BP 145/88. Temp 98. HR 105. RR 16. Pulse ox 98% on RA.
General: Elderly appearing woman in no acute distress. Seems agitated and uncomfortable.
HEENT: normal ears, mouth and skin. Muscles slightly tender to palpation left frontoparietal area. No temporal artery tenderness.
Unable to visualize fundi secondary to patient agitation. Pupils slightly eccentric and slowly responsive to light.
No relief of left eye pain with gentle massage. Tactile tonometry normal.
Ocular pressures with TonoPen approx 17 bilat.

Neck: No carotid bruits. Supple, NT, no masses.

Chest: Lungs slight wheezing, no use of accessory muscles. Heart Reg, slightly tachycardic, normal S1S2, no murmurs.

Abd NABS, soft, NT. No HSM or masses. No pulsatile mass.

GU not examined secondary to patient request.

Ext: no edema, no cyanosis. FROM. No lesions.

Neuro:CN 2-12 intact except as noted above (pupils)
Motor 5/5 throughout
Sens intact to LT throughout
DTR's 1+ and symmetric with downgoing plantars. No frontal release signs.
Gait not tested.

What is your differential? What would you order? What other history or PE would you like?

Orders written at 0300: CBC, CMP, PT/PTT, UA, EKG, CT HEAD, CXR. Old records requested.

Labs relatively normal. No old records available. CT head done at 5:15 a.m. with radiology intepretation officially timed at 7:15 a.m. Wet read called to ED at 6:00 a.m. Read as "normal head CT."

What would you do now?

Call placed to ophthalmologist. Case discussed. Agreed to see patient in clinic when they opened at 8 a.m.

Discussed with patient and granddaughter. Uncertainty of dx discussed with concern for primary ophthalmologic problem. Patient elected to go home and agreed to present to Ophthalmology at 8.

Review of medical records from the eye clinic on Jan 2, 2000: Patient presented to the ophthalmologist's office at 9:15 a.m. Was seen quickly by an optometrist and reported that she awoke with her symptoms at about 2 a.m. VA was normal for her but VF testing revealed right nasal and left temporal visual field defects. Optometrist spoke to ED physician at a large referral hospital and was told to send the patient right over. Recorded diagnosis as "Occipital stroke RIGHT NOW."

Patient reportedly left the Optometrist at 9:45 a.m. ED records from referral hospital recorded her arrival as 12:45. (The hospital was about a 30 minute drive from the optometrist's office.)

Evaluated by ED physician at 1:15 p.m. History recorded as awoke with left eye complaints (didn't specify the complaints) at 2 a.m. and presented to local emergency room. Referred from eye clinic for VF deficit and dx of stroke. PE: patient lying on exam table in NAD. Neuro exam normal, including CN II-XII normal, then recorded "obvious VF deficit to confrontation." CT scan revealed mild area of edema in left occiput consistent with acute CVA. ER record did not record motor, sensory or gait examination. Nurse's note recorded that the patient was taken to the room in a wheelchair and transferred with assistance to the exam bed.

Consulted neurology who recommend IV heparin infusion. Patient was hospitalized for 2 days and discharged. While an inpatient, MRI revealed acute CVA left occiput.

Continued tomorrow.

Saturday, May 14, 2005

Please share your opinion

What do you think about this book? I have been thinking about switching to something besides Blogger, for all the reasons other have experienced: lost posts, down time, etc.

Please let me know what types of software you use and what references you prefer. I like what I've seen about Movable Type and have seen some good reviews of this book.

Blind day care supervisors

Would you trust your children to strangers running a daycare, especially when the daycare providers were both blind? Well, in this post by RightWingNews, we see a description of a case in Colorado.

I am a firm believer in the free market, but there is also a role for the government to protect those who are not able to protect themselves, such as children. Personally, I think it is risky for the state to license two blind people to run a day care. Risky for the children, first of all. Also risky, from a liability standpoint, for the state.

As is mentioned in the comments at RWN, children who are raised by blind parents are special. They understand their parents' limitations and are taught how to work with these parents.

However, 4 or 5 year old kids who have never been around blind caretakers are going to be too much for them, IMHO.

Perhaps this daycare can cater to the children of blind parents.

Friday, May 13, 2005

A tiny, tiny baby

Red State Moron has a question for us.

Better be careful!!

Specialty hospitals: Good or Bad

MedPAC, CMS Studies Raise More Questions, Offer Few Answers

Proponents of physician-owned specialty hospitals -- those that provide exclusively cardiac, orthopedic and/or surgical services -- claim that such facilities take advantage of a convergence of financial incentives for physicians and hospitals, producing more efficient operations and better patient outcomes than do conventional community hospitals.

Opponents counter that physician-owners who refer patients to hospitals in which they have a financial interest are competing unfairly with nonowner physicians referring patients to community facilities. Furthermore, these critics say, specialty hospitals concentrate on only the most lucrative procedures and treat the healthiest and best-insured patients -- leaving community hospitals to shoulder the burden of providing less profitable services and caring for the poorest, sickest patients.
This article focuses mainly on the financial risk to non-specialty hospitals if the specialty hospitals siphon off the best paying cases. In addition, there is the problem that specialists will find they no longer need the non-specialty hospitals. Currently, hospitals can force certain behaviors, such as being on call, becasue the speicalists need the hospital to perform their procedures.

Medblogs (symtym for example, has a good link) have discussed the problem with poor availability of specialists on call, and the fact that many hospitals, especially trauma centers, are having to pay specialists to be on call. At my hospital, all medical staff members are required to be on call. However, if a facility, either an outatient surgery center or an independent specialty hospital, can give the specialist what he needs, he could shift his privileges to courtesy, or even resign, to avoid call responsibilities.

On the other hand, it is not the responsibility of the insurance companies to subsidize poorly reimbursed care at the "community" hospitals. I wouldn't be surprised if the insurance companies encourage this trend and then cut payments to the specialty hospitals. Anything to save money.

I was surprised by this:
The proportion of total net revenue specialty hospitals devoted to uncompensated care plus taxes exceeded the proportion community hospitals devoted to uncompensated care.
Of course, don't miss the "plus taxes" in there.
Relative to net revenue, specialty hospitals provided only about 40 percent of the amount of the uncompensated care community hospitals provided. However, specialty facilities paid various taxes nonprofit community hospitals did not pay.
So, will the communities court specialty hospitals because they pay more taxes?
Heinemann warned physicians and policy-makers not to allow themselves to be led off-target. "Payment is not the real issue; physician self-referral is the real problem here," he said.
Yeah, but why not make the physicians divest, as opposed to not opening the hospitals in the first place. If, as the article states, outcomes are better and patient satisfaction is higher, why not?

Good news

Accessing Prescription Assistance Programs Just Got Easier
If you and your staff have spent countless hours trying to hook up low-income patients with the prescription medications they need but can't afford, you'll welcome a new resource.

A national coalition headed by the Pharmaceutical Research and Manufacturers of America launched a nationwide initiative April 5 -- Partnership for Prescription Assistance -- that aims to ease patient, caregiver and physician access to the more than 275 public and private programs providing no-cost or low-cost prescription drugs to low-income patients.

How? By encouraging people to use a new toll-free call center. When callers punch in (888) 477-2669, trained operators take center stage, asking a set of basic questions to ascertain what programs might be available for patients in need.

Both English- and Spanish-speaking operators are available; translators can be provided for 17 languages. The phone line is available Monday through Friday, 9 a.m. to 11 p.m. EDT.

If you'd rather gather information online, visit Partnership for Prescription Assistance.

Another reason to non-par Medicare?

Congress Likely to Link Physician Reimbursement to Pay-for-Performance
PfP. P4P. Pay-for-performance. Call it what you may, the newest buzz term for physician reimbursement is probably going to affect Medicare payment in the future. Most likely, P4P will be wrapped into legislation that addresses the sustainable growth rate [SGR], the formula with which CMS determines physician reimbursement, say political observers.
Congress/CMS will only implement what they think will save money. I don't believe that quality of care has anything to do with the motivation.
Some lawmakers may see P4P as a cost-cutting solution. That potential grew when the Medicare Payment Advisory Commission recommended withholding money from all Medicare payments to distribute to physicians who meet performance measures.

"To minimize major disruptions, the program should be funded initially by setting aside a small portion of budgeted payments -- 1 percent or 2 percent," the commission recommended in its March report to Congress. "The program should be budget-neutral."
Here in Tennessee, we had a disastrous experience with withholds. The TennCare Managed Care Organizations (MCO's, companies with whom the state contracted to administer TennCare) negotiated to pay a certain capitated amount, say $10 per patient per month. Of this, a certain percentage, say 15%, was withheld in order to create a fund from which to pay specialists that weren't capitated, costs of ER visits, and other unexpected costs. At the end of the year, each participating provider would be awarded a part of the money that remained in the "withhold fund." Providers who overutilized by sending too many patients to specialists or the ER, would get less or maybe none of the withhold fund.

The problem was that, year after year, there was never any money left in the "withhold fund." This meant that no one got any of this money. So where was the incentive to avoid overutilizing? Why work your tail off when you could just send everyone to a specialist or the ER? Clinics were enrolling far more patients than they were capable of taking care of because there was no penalty if you just sent them all to the ER when your appointments were booked.

I suspect that the withhold fund this article describes will also be used to pay other expenses, resulting in no money left over to pay "the good docs." There is a lot of talk about the expenses clinics will have trying to implement the programs necessary to comply with the requirements and that the program should reimburse these expenses. Do you think, maybe, that the withhold fund will be the source of these moneys?

A recommendation by the AAFP:
P4P programs "should utilize new money funded by using a portion of the projected health plan savings. There should be no reduction in existing fees paid to physicians as a result of implementing a P4P program."
This ain't going to happen. Trust me, anything that happens will be designed to reduce expenses. This program will not pass if it means that it will cost more. This program will be used to reduce payments to lower performing physicians, not increase payments to higher performing physicians.

Other excellent posts on this subject: Medrants and Medpundit

Wednesday, May 11, 2005

More on the filibuster

In an earlier post, I discussed the issue of the Senate majority with Curious JD. Here is what Captain Ed had to say:
The pinnacle of this stupidity came last month, when a rash of comments led by Senator Joe Biden claimed that the GOP didn't have a majority at all. His reasoning was that the Democrats in the Senate represented a larger percentage of the population and that meant that the 44 Democrats had more of a mandate to run the Senate than the 55 Republicans did. Despite the questionable nature of this calculation -- does Minnesota count for Mark Dayton or Norm Coleman? -- the idea that the Democrats have a mandate for rule is ludicrous on its face. First, they lost a swing of eight seats in the last election. Second, the House and the Presidency both went to the GOP, and the former is actually based on population. Third, and it's embarassing to have to explain this to one of our nation's leaders, the Senate isn't supposed to provide proportional representation in Congress. Senators represent states, not people, which is why they have the duty to confirm executive-branch nominations. That duty went specifically to the Senators so that the states could ensure that the federal government composed itself in a manner acceptable to the majority of the states. Not a supermajority, for that matter, which the Constitution explicitly reserved for other purposes.

Rich Ideas

by Thomas Sowell, one of the most sensible authors/economists you will find.
Recently a friend described a meeting with a nasty-tempered leftist who was from a rich family. Unfortunately, there are a lot of leftists who were born with a silver spoon in their mouth -- and, instead of being grateful, are venomous against American society.

Conversely, there are people like yours truly who were born on the other end of the economic scale and think this is a great country. No one has really explained either of these phenomena.

National Police Week

Michelle Malkin asks,
When was the last time you thanked a cop? And wouldn't it be nice if, for just a brief moment, the mainstream media would hold a ceasefire in its incessant cop-bashing crusades?
Whenever we read about some bad thing that happened in connection with a traffic stop, we should stop to think about how many traffic stops happen every day. Heck, it's amazing there aren't more bad traffic stops than there are!

Nutritional myths

A good patient education column, by John Stossel.
1. True or false: If you give a kid sugar, he'll get hyper.

2. True or false: Eat sugar, and your energy may slump.

3. True or false: It's a good idea to drink eight glasses of plain water every day.

With so many myths in our lives, perhaps the surprise is that one of these familiar theories is actually true.
Guess which one. Read the whole thing and put copies in your waiting rooms.

How to blog successfully

A great list of tips for bloggers, from John Hawkins at Right Wing News. Read the comments, too.

Tuesday, May 10, 2005

Penicillin Allergy? Cephalosporins Okay—Really!

So residency training works!

Who new?

Primary Care Physicians Often Mistake Lesions
Dermatologists diagnosed nearly twice the number of neoplastic and cystic skin lesions correctly than did nondermatologist physicians, according to research presented at the annual meeting of the American Academy of Dermatology.

Exercise your troubles away

Recommended Exercise Level Curbs Depression, Too
The amount of exercise that is recommended for general public health is also an effective treatment for depression, Andrea L. Dunn, Ph.D., reported at the annual meeting of the American Psychosomatic Society.

Despite many intervention studies suggesting that exercise alleviates symptoms of depression, it still isn't recognized in the same way as medication and psychotherapy as an efficacious treatment for depressive illness. Indeed, only one previous study had met the standard, a 50% reduction in symptoms during the acute phase (6-12 weeks) of treatment (Arch. Intern. Med. 1999; 159:2349-56).

But in that randomized trial, the exercise was done in a group setting, so the social support may have contributed to the 50% drop in symptoms. “In order for exercise to be an accepted monotherapy for depression, we must clarify issues of dose response,” noted Dr. Dunn, now a research scientist at Klein Buendel Inc., in Golden, Colo.


But then:
Halting Exercise Can Increase Symptoms of Depression
Regular exercisers who are forced to stop may experience depressive symptoms, Ali A. Berlin reported at the annual meeting of the American Psychosomatic Society.

The findings of a study of 40 regular exercisers do not suggest that stopping exercise will induce clinical depression in otherwise healthy people. However, previous research with athletes who were forced to stop exercising because of injury or illness suggested levels of depression, anxiety, and other mood disorders were increased and recovery was slower among those who already had depressive symptoms.
Wow, another week, another Grand Rounds!

Monday, May 09, 2005

Prescribing controlled substances

When I was in private practice, I would not write for refills on controlled substances. If my patients needed ongoing supplies, I would rewrite the meds each month. I didn't require the patient to see me, but just to take a piece of paper to the pharmacy. This way, if anyone presented a pharmacy with a prescription for a controlled substance, purported to be from me, with refills (as most forgers do) the pharmacist would know it was a forgery. My policy was known by all of the pharmacies in town, and resulted in several forgery discoveries.

The DEA forbids refills on C-II prescriptions. Read this article in The Prescriber's Letter (link requires subscription, but the whole article is reprinted here. BTW, you should subscribe to this valuable newletter.):
There’s HUGE confusion over the legality of writing multiple C-II Rxs on the same day, for the same patient, for the same drug.
Prescribers often write multiple Schedule II Rxs on the same day...and write instructions to not fill until a certain date.
This allows stable patients to get chronic therapy for pain, ADHD, etc...without having to see the doctor every month.
The DEA used to say this was okay. In fact, up to the fall of 2004, the DEA website specifically described how to do this.
But recently the DEA changed its tune.
DEA now says that writing multiple C-II scripts on the same day is illegal because it’s like refilling a C-II.
This is causing a huge uproar.
Many legal experts and state boards say it STILL is legal.
Experts point out that the law has not changed...just current DEA interpretation has changed.
Keep in mind that the DEA’s emphasis is to use the law’s power to nab the bad guys and stop drug diversion. DEA is not out to interfere with legitimate medical or pharmacy practice.
Responsibly writing multiple, same-day C-IIs for a medically necessary use...in a stable patient...is extremely unlikely to cause a DEA problem.
Be sure to always date any Rx on the day you write and sign it. Do NOT future-date any Rx.
You can also write a future FILL date on ONE C-II Rx...for now. There is dissension inside the DEA, but so far the higher-ups have not come out against this.
You can mail an Rx when the time is due. Make sure you’re comfortable that this meets other standards of practice.
Consider having a medication agreement with patients that outlines how to use their medications and get new Rxs.
What do you folks do/think about this?

Single payer in Vermont

Or maybe that should read "Single Non-Payer in Vermont." The Wall Street Journal contains this story about Vermont's efforts to pass single payer health care legislation.

I found this comment particularly interesting:
From 1995 until late 2004, health care "reform" in Vermont consisted of Gov. Dean's constant expansion of Medicaid to higher income workers, known as the Vermont Health Access Plan. Since the plan's costs rose much faster than the revenues assigned to pay for it, Gov. Dean financed the expansion by progressively underpaying doctors, dentists, hospitals and nursing homes.
We have all experience this with MediCare cuts and, here in Tennessee, cuts in TennCare. In addition, delays in payment from TennCare have, in effect, caused health care providers statewide to subsidize the state with interest-free loans.

As health care payers, whether commercial or government based, continue to decrease what they pay to health care providers or just hold the payments steady despite inflation, income for participating providers drops. As this happens, more and more providers drop out. It has become very difficult to find participating specialists in TennCare nowadays.

Let's take a situation where a state legislates universal health care with the state as the single payer. The state will, undoubtedly, try to control costs by limiting and reducing payments to participating providers (including hospitals.) As reimbursements decline to unacceptable levels, providers will drop out or refuse to enroll more patients. This, as with all price controls, will result in a shortage of providers and lack of access. In addition, privately insured patients will be fewer and fewer, as employers will have no reason to continue to provide this benefit. Those companies providing private health insurance will likely refuse to reimburse at rates higher than those mandated by the state.

So, you see, the state will now have a "crisis" of access. This will lead the state to mandate participation. If you want to practice medicine in this state, you will have to accept the state-run program beneficiaries. Hospitals will go bankrupt and physicians will leave the state in droves.

Price controls don't work. Period. The short term looks good, but, in the long run, the only consistent results are shortages. Look at price controls of gas prices in the '70's, rent control in major cities and the dismal failure of central pricing in the Soviet Union. Nothing but shortages.

UPDATE



Cut to Cure has comments on this as well.

Relieve stress by making music

This months American Family Physician, in the Quantum Sufficit column described this study:
Stressed? Try joining a band. A recent study published in the Medical Science Monitor found that music-making may be a viable stress reliever. In the study, 32 participants completed a stress-inducing puzzle, and then were randomized to use a Recreational Music-Making (RMM) machine or to sit quietly and read in the waiting room. After analyzing the participants' stress-gene activity through blood tests, researchers found reversal in 19 of 45 stress markers in those who used the RMM instrument after completing the puzzle, but they found only six reversals in those who read.
But what about blogging?

Saturday, May 07, 2005

Professionalism vs income?

DB, at Medrants, wrote about his idea of professionalism. Interestingly, the comments debated income, not the idea of quality care.

But does income have to suffer because we devote more time to our patients?

Not surprisingly, we have become so used to accepting what someone else says we are worth, that I think the comments on his post miss something. The secret to seeing fewer patients, providing quality visits in the appropriate time span and still making the income you desire is to charge what you think your time is worth and not accept less.

How do you do that? Well, explain to your patients that their relationships with their insurance companies are just that, their relationships, not yours. Explain that you set your rates at a level that you feel is reasonable for the service you deliver and you will see them for that rate, not less. Of course, you would probably make accomodations for low income, etc.

You may want to file the insurance paperwork for them or provide it to them to send to their insurance companies. Ask for payment at the time of service and explain that the check from the insurance company will come to them, not to you. Stay out of that relationship.

If the patient thinks you are worth it, they won't mind paying a little extra. So what if you lose 1/3 of your patients, you need to trim your panel anyway, as you won't have time to see them all with your new practice style.

I have written about what good business the dentists run, but so many of them are heading into the insurance trap we are in.

Friday, May 06, 2005

I just bought one of these:



Now I can't wait to use it. I guess I'll have to as I bought it on-line.

Any suggestions as to the best recipes or mixes?

Thursday, May 05, 2005

More EMR stuff

If this works, this is an ideal implementation. I would love to have acccess, in the ER, to a patient's full medical record.
BlueCross BlueShield of Tennessee wants to put TennCare enrollees' medical records online as part of a plan to reduce costs and fraud, and improve care under the state's troubled health plan for people without insurance.

The program would put the files on a secure Web site so doctors in different offices — or even in different cities — could see a patient's medical chart and avoid duplication or prescribing drugs and tests that may be harmful.

Now, this is what gives us a bad rap.

I mean, operating while stoned on crack!

Importing from Canada

Drug companies have argued that Canadian law requires them to sell drugs to Canadian pharmacies at below-market-value prices. These drugs are then sold to US customers, saving their insurers money.

So, the drug companies have refused to increase exports to Canada to replace the drugs sent back into the US. This article describes resolutions submitted by shareholder groups to the boards at three pharmaceutical companies, requesting a change in this policy.

Shareholders at three of the United States' biggest drugmakers have voted down a Minnesota state-sponsored resolution urging them to keep supplies flowing to Canadian pharmacies that cater to American customers.

But the Minnesota Board of Investment's resolution garnered significantly more support than shareholder-sponsored moves usually do. At Pfizer Inc.'s shareholder meeting last Thursday, 28 per cent voted to examine the company's policy of restricting Canadian inventories.

The resolution got 24 per cent support at Merck & Co.'s April 26 meeting and 14 per cent at Eli Lilly & Co.'s April 18 meeting. A similar resolution won 23 per cent of shareholder votes at Wyeth's April 21 meeting.

Executives at all four companies opposed the resolution for safety reasons, saying that importing Canadian drugs puts consumers at risk of getting counterfeit or substandard products.

As more Americans have turned to Canada for cheaper medications, the drugmakers have responded by cutting supplies to pharmacies that fill American orders.

Without management support, it's unusual for shareholder resolutions to collect more than five per cent of the vote, said Howard Bicker, the state investment board's executive director.

"I assume we've got to be getting some institutional support" from other large pension plans, Bicker said. He didn't have details on investors that supported the state's move.
Now, why would a shareholder want a company, on whom they depend for income, to participate in an activity that would decrease the income of the company? Is it altruism? Perhaps these "shareholders" are pension companies that lose more money paying for drugs than they earn from the pharmaceutical companies. Is it even legal for a board of directors to approve a resolution requiring the company to participate in an illegal activity? Isn't this conspiracy to commit a crime?

Don't get me wrong. I believe in the free market and the right of shareholders, regardless of their motivations, to bring resolutions to the board. But when the board votes, don't portray them as evil or greedy, especially if the primary motivation of the shareholder is financial.

Wednesday, May 04, 2005

I have written previously (here, here, here, here) on disability topics. It has been a while and I think the topics deserves revisiting, especially for newer readers. I'll try not to repeat myself too much. Please go back and read those posts.

Frequently I speak to docs on the phone who say that they have to be advocates for their patients. True enough, but for what should they advocate: what is best for the patient, or what the patient wants?

Do you give your patients everything they want? Even if it results in no harm to the patient? What would you say to a 25 year old man, with no medical problems and no complaints, who, just to check, wants a ETT? Most likely, you would say no. It would not result in harm, but is not medically indicated and would be a burden to the system, right?

But when asked to "fill out this disability form" many physicians do not critically evaluate the criteria, or feel sorry for their patients, and will write "no work."

The American College of Physicians have published their Ethics Manual: Fifth Edition. Link is to the abstract, the full article requires subscription.

On page 566, the articles states the following regarding disability
certification:
Some patients have chronic, overwhelming, or catastrophic illnesses. In these cases, society permits physicians to justify exemption from work and to legitimize other forms of financial support. In keeping with the role of patient advocate, a physician may need to help a patient who is medically disabled obtain the appropriate disability status. Disability evaluation forms should be completed factually, honestly, and promptly. Physicians will often find themselves confronted with a patient whose problems may not fit standard definitions of disability but who nevertheless seems deserving of assistance (for example, the patient may have very limited resources or poor housing). Physicians should not distort medical information or misrepresent the patient’s functional status in an attempt to help patients. Doing so jeopardizes the trustworthiness of the physician, as well as his or her ability to advocate for patients who truly meet disability or exemption criteria.

Numbers to ponder

According to 4/30/05 Physician's Money Digest (online version lags behind paper version, so no link):


  • 4% of Americans say the opinions of reporters rarely or never influence the news.

  • 50% of all homicides in Chicago are gang-related.

  • There are 8500 Lipitor presctiptions dispensed each hour.

  • 85% of men with erectile dysfunction have not sought drug therapy.

  • 1164 victims of 9/11 remain unidentified.

  • Nevada has been the fastest-growing state in the union for 18 years.

  • 4.7 million Americans are barred from voting due to criminal records.

  • $38.8 billion spent in 2004 by US biotechnology and pharmaceutical companies.

  • 20% of all electrical energy in the US is generated by nuclear plants.

  • US citizens donate $1600 to charity per year, on average.

Air ambulance services

Good find by symtym: As Medical Airlifts Proliferate, the Public Price Tag Is Rising.

This is interesting from several viewpoints. We have seen articles on several blogs about office practices refusing to see drug reps. In the ER where I work we do occasionally see drug reps, but I was surprised to get a visit from a private, non-hospital affiliated air ambulance service.

We have actually had several visits from them while I was there and I don't know how many during other docs' shifts. One day we got a radio call to prepare our helipad for an incoming helicopter. We had no idea why a helicopter was inbound. The private air ambulance service was bringing us pizza!!! Hey, beat that, Dominoes!!

That was pretty cool, but who ultimately pays for the cost of those pizzas and the delivery?

Another viewpoint would be to analogize this to tow trucks. It used to be that individual police officers could call whatever tow truck service they preferred. Or it might be up to the dispatcher. Frequently, there would be fights among tow truck operators when several, listening to their scanners, would show up at a wreck at the same time. Now, most large communities have laws regulating "jumping a wreck" and a rotation listing at dispatch. The towing service has to be certified and registered or they are breaking the law by responding.

At our ER, most of our air transfers are to one of the local Level I trauma centers. We call the ER or one of the admitting services, get acceptance and the hospital sends its intrinsic air ambulance service. However, occasionally we need to fly a patient to a referral hospital that doesn't have its own helicopter service. I guess we could call the private service, but, out of habit, we usually call the trauma center and use their helicopter.

We certainly can't have helicopter services, hot on deck, listening to their scanners and racing to the scene when a helicopter is requested.

Perhaps there will need to be a central dispatch service, as there is for ambulances and tow trucks.

Previous post on air ambulances.

Tuesday, May 03, 2005

An ingenious MedMal solution!

PointofLaw blog has this column that proposes the most ingenious solution to the MedMal and tort reform arguments I have ever seen!

TANSTAAFL - pain meds

Nice post by DB at MedRants.

Here's your SWAT story, Nick

So we got a call out to serve a warrant on an escaped convicted murderer. Ho, hum, another day at work.

This guy just walked out of the courtroom as they were waiting for the judge to come in and sentence him.

Anyway, an informant had given a tip as to where he could be found. So we suited up, checked our equipment and loaded into our SWAT truck. (Hey, just like on TV!)

Our snipers in their Gilly suits went into the woods to scope (no pun intended) the situation. They spotted two guys hanging out behind the house near the cars. They couldn't tell if there was anyone in the house, or if one of the two guys was the one we were looking for.

While part of the team controlled the two out back, the others took the door and cleared the house. No one there. Unfortunately, neither of the two out back were our guy.

But it wasn't a total loss. Those two were smoking a little dooby and had other drugs as well. Handcuffs all around.

So we had them kneeling out front beside an unmarked car, with its blue lights on, as well as several other vehicles with blue lights on, when another car pulled up behind the only marked cruiser on scene.

A guy got out and walked up to see what all the excitement was about. Now remember, there are a dozen SWAT members standing around with M-16's as well as about another dozen officers, some in uniform.

Guess who it was.

Yep, the convicted murderer. "Excuse me, could you put your hands on the hood of that cruiser, please? Yes, the one with the flashing blue lights."

Good thing when criminals are so dumb.
Physicians rally on Capitol Hill for tort reform.

I can here the chants now:

Hey, you! You don't get to sue!

Poor me! Lower my fee!

Tort reform, apply as directed, refill prn!

Save our docs! Lawyers are crocks!

Please add more

Transparency in gifting

Hey, I'm all for transparency. But why do legislators spend so much time worrying about what we get and shouldn't this law apply to them as well?
Legislators in at least 14 states introduced bills this year that would require pharmaceutical sales representatives to file reports detailing the gifts they give to physicians. Drug manufacturers are opposing the bills. Most medical societies are keeping an eye on the bills but haven't gotten involved so far because doctors won't see the financial and administrative burdens that the drug industry would see if the legislation passes.

Monday, May 02, 2005

Grand Rounds XXXII

is up at Mudfud.

An interesting look at the daily schedule of an MD/PhD student.

Wha, that ain't nuthin but lizard spit!

Using lizard spit to control diabetes:
Byetta [exenatide] is the first among a new class of diabetes drugs called incretin mimetics — synthetic medications that mimic action of a hormone that spurs insulin production after a person eats and blood sugar levels rise above a certain threshold. Traditional diabetes drugs that promote insulin production do so even if glucose levels aren't high enough, which could cause a dangerous low blood-sugar condition called hypoglycemia.

Byetta, derived from the lizard's saliva, mimics that action of the human hormone GLP-1, which prompts the body to secrete insulin and is also thought to play a role in deciding when a person feels full.
Hey, if it makes you feel full and won't cause hypoglycemia, maybe it will be the next great diet pill!

Filibuster buster?

Those in favor of the filibuster keep arguing that "the minority" voices should be heard. That "freedom of speech" is for everyone and not just the minority. See this post by Instapundit.

One point I haven't seen addressed is just how small a minority should get to be heard. The Senate rules used to allow a complete filibuster by just one Senator. This was changed to two thirds, then to three fifths. The minority party is OK with that right now, because they have in excess of three fifths. But what if they only had 39 Democratic Senators? Would they then argue for the two thirds again, because without that their voices aren't heard?

Doesn't it matter that the voters have placed one party in the majority, perhaps on purpose? It's interesting that the Dems argue that the filibuster is necessary to produce "the will of the people." Perhaps if the Democratic plan was the will of the people, Tom Daschle would be the majority leader, and the Republicans would be arguing for the filibuster.

For, have no doubt, if the roles were reversed, I would expect the exact same arguments, only reversed.

UPDATE


In reply to comments:
Kathy, I haven't heard that anyone is attempting to kill the filibuster outright, but simply to get an up/down vote on the judicial appointments.

Curious jd, fortunately, the framers of the constitution anticipated your argument. We do not have a democracy, or even a truly representative government, but a republic. Arguing that there are more people represented by Senate Democrats than Senate Republicans either misses the point or deliberately attempts to confuse the issue. As you are a JD, I suspect you did not miss the point...

As you know, the intent of the House of Representatives is that each representative will represent approximately the same number of people. The Senate was created with 2 Senators from each state to allow the less populated states equal representation. There was never any attempt to account for how many people were represented by each Senator.

Again, this is why the writers of the constitution desired that the Senate give advice and consent, not the House.

There is no question about who represents the majority. In the House, there are more people represented by Republicans than by Democrats. In the Senate, there are more states represented by Republicans than by Democrats. This is how these were meant to be counted.

I don't necessarily disagree with your argument that the Republicans may be making a mistake by fooling with the filibuster. As I said in the original post, if the rolls were reversed, I suspect the arguments would be also.

Thanks for the nice things

Hey, Kathy, who has Daily Kos on her "High Value Blogs" has this to say about me:
For something completely different, check out this ER doc's blog. It's interesting, well-written and in the occasional post provides real insight into our country's health care system and the related insurance industry. It's definitely a worthy read, mixing information, personal stories, and linky love in a regular 'Grand Rounds" column that is the doc's version of the Random 10". Based on the links and some posts I'm sure this doc is conservative. But I won't hold that against his blog. It's too interesting.
Of course, Grand Rounds was not my idea, but Nick's.

Med Mal legislation update

Here is a good state-by-state summary of pending/signed legislation regarding Med Mal.

The Arizona legislation is interesting to me because TN has a similar law. The constitutional challenge referenced is that some (the trial lawyers) say that the constitution leaves it up to the courts to rule regarding who can be a witness.

In TN, we have a locality rule in addition to the requirement that the expert be in the same field of medicine. It states that the physician must not only be in the same field of medicine, but must practice in a similar locality. So an ER doc from a huge referral hospital in Knoxville would not be able to testify against a doc from a small rural hospital. The courts threw this out long ago, arguing that small town patients should benefit from the same standard of care as big town patients, within the capabilities of the hospitals.

However, I am familiar with a doc who was sued for failure to give thrombolytics in a stroke case. In a malpractice case, the plaintiff needs to establish deviation from standard of care and that the deviation caused the injury. So the plaintiff needs a standard of care witness (required to be in the same field of practice) and a causation witness (not necessarily in the same field.) The plaintiff was unable to find an ER doc (that they could afford) to testify against the defendant and, as such, should have been unable to demonstrate deviation from standard of care. However, they had a neurologist testifying for causation and the judge allowed him to testify to standard of care.

In my role advising the defendant's attorney, I suggested that they challenge the neurologist's claim that he understood SOC because of the patients he saw referred from the ER. My argument was that you can't define SOC by who gets admitted or referred, but you have to understand and appreciate the screening process. This means that you also have to be familiar with the numerous patients who are discharged from the ER without referral to a neurologist or the patients who are admitted to primary care docs and are not subsequently referred for neurology consultation. This is exactly the purpose of the requirement that the experts practice in the same field of medicine.

That case didn't make it to trial, as the plaintiff voluntarily dismissed. But the defendant's lawyer was eager to take to the the state supreme court for clarification. So dismissal was good for the doc, bad for the lawyer.

What's wrong with WV?

Well, perhaps I should stay away from medical politics. Maybe I should just discuss something safe, like national politics.

Here's something interesting from the Wall Street Journal's Best of the Web:
What's the Matter With the Charleston Gazette?
Today's edition of the ultraliberal Charleston (W.Va.) Gazette has one of the (unwittingly) funniest editorials ever:


Several times, we have posed this question for political experts: Why did West Virginia--long a Roosevelt-and-Kennedy Democratic "blue state"--become a Republican "red state" in the past two presidential elections, despite 2-to-1 Democratic registration?

Why did this low-income state vote for the party of the rich--a party openly slashing help for common Americans and giving huge rewards to the wealthy?

We never received an explanation from any of the state's political professors or other societal analysts. But an answer was offered by one of the world's premier journals, Le Monde of Paris.

In a long report titled "What's the matter with West Virginia?" the French newspaper said the Mountain State has been pulled to the right by exaggerated patriotism, love of guns, Bible Belt fundamentalism, resentment of liberal intellectuals, and defense of the coal industry against environmentalism.


Maybe the reason West Virginia turned red is that its liberal elites, such as the editorialists at the Gazette, are so out of touch that they have to rely on Le Monde to explain the state's politics.

Or maybe abortion, also from Best of the Web:
"The House passed a bill Wednesday that would make it illegal to dodge parental-consent laws by taking minors across state lines for abortions, the latest effort to chip away at abortion rights after Republican gains in the November elections," reports the Associated Press.

"Chip away at abortion rights"? That's editorializing, isn't it? Since a pregnant minor is, by definition, a victim of statutory rape, one could just as easily characterize this as an effort to prevent the destruction of criminal evidence.

Then there's this, from another AP dispatch on the same subject:

Four bills aimed at reducing the number of abortion [sic] have been enacted since Bush won the White House in 2001:

Last year, Congress made it a separate crime to harm a fetus during an assault on a pregnant woman. . . .


So according to the AP, assaulting a pregnant woman and harming her "fetus" constitutes abortion. Do "pro-choice" advocates want to keep violence against pregnant women safe and legal?