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Sunday, March 9th 2014

#HappyMatching

Fourth year medical students are trying to get The Ellen Show to their Match Day in San Antonio. Help this go viral. To that end that have a pretty talented mock up of Pharrell William’s ‘Happy’.

#HappyMatching

Wednesday, December 11th 2013

Psychofunctional Neurosurgery

The future of functional neurosurgery is going to be really interesting.

This isn’t exactly next day stuff they’re discussing in this NPR story, but it is really fun to see it in the main stream media.

I have major concerns about deep brain stimulation as psychosurgery, not because it might not be effective, but because of the patient population and the systems in place to manage such long term. Few surgeons are going to manage the a patient with depression and the implanted device status post implantation. The devices being studied are largely already in use for other indications; most notably movement disorders such as Parkinson’s disease but the movement disorder neurologists managing such have spent years getting familiar with such. Building a large population of psychiatrists managing such is feasible, especially considering reimbursement associated with managing these, but such is going to take time. It is also going to be very circular, as all new technologies are, in that the more that are implanted the more psychiatrist will manage them but the more psychiatrists managing them the more that are likely to be implanted. As another possibility I’m not sure I’d want one physician managing the device and another the patient’s meds.

Better short term targets for functional neurosurgery might be other “neuro”disorders including dementia which is showing some promise as well in studies. Or how about devices coming online for epilepsy?

Pretty cool stuff.

Wednesday, December 11th 2013

You Can Keep Your Doctor

You can keep your insurance plan and you can keep your doctor.

Except even the former is turning out to be problematic. There’s some anecdotal evidence that these plans being offered on the exchanges are achieving their cost by fairly extreme negotiations with healthcare providers.

“My physicians will no longer be in this network of physicians, or the hospitals,” she says.

[...]

She wants to stick with the health care providers that she’s had for years, she says, including the surgeon who cared for her when she had breast cancer in 1998.

“I have full confidence in her,” she says. “And my primary care doctor has been my primary care doctor for 20 years.”

[...]

[Her] experience doesn’t surprise San Francisco-based insurance broker Susan Shargel, who’s trying to sort out all the new ways insurers are contracting with doctors. Some health plans will have fewer doctors and hospitals. Blue Shield, for example, says it will have half the doctors and three-quarters of the hospitals next year as it has this year in the individual market.

[...]

The health plan offered to Shore was a Blue Shield of California EPO — exclusive provider organization — plan. The company says it’s offering these lower-cost plans for the first time next year to buyers on the individual market. Other insurers are offering similar plans.

Patrick Johnston, president of the California Association of Health Plans, notes that the federal Affordable Care Act requires more benefits than most insurance plans have provided up until now. That includes free preventive care, a limit on annual out-of-pocket spending and a ban on lifetime caps for medical expenses. So, to keep health plans affordable for buyers on the individual market, one of the few cost variables to work with is doctor contracts.

[...]

Insurers are negotiating hard, according to Gerry Kominski, director of the Center for Health Policy Research at UCLA, saying to providers, for example: “We’re willing to pay you $50 a visit. If you’re not willing to do that, we know a doctors group across the street that will accept that.”

Rahm Emanuel’s brother, an oncologist and force behind the ACA, was making the television rounds when Chris Wallace took him to task over such.

His response to the question on whether the president promised the public that they could keep their doctors is embarrassing.

Chris Wallace: It’s a simple yes or no question. Did he say if you like your doctor, you can keep your doctor?

Zeke Emanuel: Yes. But look, if you want to pay more for an insurance company that covers your doctor, you can do that. This is a matter of choice. We know in all sorts of places you pay more for certain — for a wider range of choices or wider range of benefits.The issue isn’t the selective networks. People keep saying, Oh, the problem is you’re going to have a selective network–

It hasn’t been the best month for Dr. Emanuel who also shows some naiveté in this New York Times piece on the physician workforce.

I agree with with his logical actually. And reasonably this is a pseudomarket process going on and conservatives should perhaps champion it. It is insurance companies negotiating with physicians for the best rates.

But to me the most troubling thing is how disingenuous the public relations campaign the administration made on behalf of the Affordable Care Act was when it was being debated and passed. The health policy architects behind the plan, including Dr. Emanuel, knew you weren’t going to be able to keep your plan or your physician in more than a few cases and yet they let their bosses unabashedly sell the reform with such promises.

That’s a much bigger problem than any technical glitches with the online roll out.

It really should be unacceptable and there should be consequences for such. It shouldn’t just be ‘well this is the way it has to work, sorry we lied about it to make it happen’. The ends can’t justify the means.

Tuesday, December 10th 2013

Physician Shortage

Organized medicine continues to predict a large physician work force shortfall [PDF]. This will arguably be made worse by the expanded access (and presumably increased utilization that comes with such) granted by the Affordable Care Act.

But a recent New York Times op/ed is perhaps the visible challenge to the very public campaign organized medicine has led to make aware the public of the coming physician shortage. The piece is flat out titled, “No, There Won’t Be A Physician Shortage.”

While I am whole heartedly on board with questioning some of the reasoning models used to figure future physician demand, I’m not sure the authors of the New York Times piece don’t fully account for the real world workings fee for service medicine, in that their arguments seem to ignore the basic fact that physicians create their own demand in our current system.

That’s pretty blunt to say considering the authors are both physicians and notable health policy gurus. But here,

Minimally invasive procedures, like laparoscopic surgeries, can be done more quickly with faster recovery times and fewer physicians. An average patient stay in the hospital is about two days or less following a stent but about seven days following a coronary bypass operation. Research on radiation treatments for breast cancer suggests that 15 treatments can be just as effective as the traditional 30 treatments. Likewise, one larger dose of radiation can be as good at relieving pain from bone metastases as five to 10 separate, smaller treatments. There’s every reason to expect the pace of these timesaving medical innovations to continue.

That’s a naive way of describing technological and procedural innovations’ impact on American health care. The way it works is when you do lap choles faster you just do more surgery. And in such a case the system continues to support the same number, or perhaps more, surgeons.

And, in terms of the workforce, who cares how long a person is in the hospital? That has no influence really on how many physicians we need.

We may indeed not need as many physicians as organized medicine thinks we do. Personally I think we may have some sort of shortage but the real problem is the ratio of primary care to specialists. If however we truly aren’t in the middle of a worsening shortage I’m not sure ‘technology is going to make us more efficient’ is the argument to make considering the way we currently finance healthcare in the United States.

Monday, December 9th 2013

More Medical Students, More Residency Spots?

I’ve been a critic of my home state for its rapid expansion of undergraduate medical education opportunities without concurrent expansion of graduate medical education opportunities. But to be fair, such isn’t unique to Texas.

We continue to enroll record number of medical students across the country.

There was…a 3 percent increase from 2012 in the number of students who enrolled in their first year of medical school. That number, 20,044, exceeded 20,000 for the first time.

Not in itself a bad thing. We just need the residency spots to go along with such.

[T]he Resident Physician Shortage Act was introduced in the U.S. Senate, and the bipartisan Training Tomorrow’s Doctors Today Act was introduced to the U.S. House of Representatives. The bills aim to help meet the nation’s increasing demand for new physicians by funding an additional 15,000 Medicare-supported graduate medical education (GME) positions over the next five years.

While broad bipartisan support the issue isn’t ‘urgent’ enough that these bills are likely to become law before this Congress is finished. Which is a sad state.



Nor are many states doing much to aid graduate medical education expansion.

We should be skeptical of the modeling of the coming physician shortage. But it makes no sense to increase medical school spots without making residency training available.

Sunday, December 8th 2013

Awake Brain Surgery

Sometimes as a matter of a tumor’s (or other lesion’s) location within the brain it is helpful to have a patient awake for part (or all) of the actual removal of such. It aids staying away from important normal parts of the brain.

Similarly, I’ve been doing/seeing a lot of deep brain stimulator surgery lately and having the patient’s awake can aid in making sure the lead is in the right spot, or at least not in the wrong spot.

It is pretty incredible to see.

Saturday, December 7th 2013

Novel Treatments

The history and evolution of novel clinical research is interesting. The old ideal, “Don’t think; try is, perhaps rightly tempered by the new ideal of not just the informed and consented patient but protected patient. Such is interesting considering our move, otherwise, away from paternalism.

The development of the smallpox vaccine or the first artificial heart would have never happened today as is. Of course, neither would these horrific syphillis experiments hopefully.

Not to argue that IRBs and government agencies have made clinical research too burdensome and are hampering progress.

It’s just that a focus and regulations beyond guaranteeing informed consent seems counter to the way the rest of medicine is moving.

I’m not sure many are arguing three glioblastoma multiforme patients of Drs. Muizelaar and Schrot were at UC-Davis were ill informed. But the treatments they undertook for those patients, without approval, have cost both men their jobs. Dr. Muizelaar was in fact chairman of Neurosurgery at UC Davis prior to this scandal bringing him down.

I’ve covered this previously. But with both men resigning earlier this year its worth bringing up again now that we have some resolution.

Two UC Davis neurosurgeons who intentionally infected three brain-cancer patients with bowel bacteria have resigned their posts after the university found they had “deliberately circumvented” internal policies, “defied directives” from top leaders and sidestepped federal regulations, according to newly released university documents.

[...]

The most contentious issue between the doctors and the university – and even within the university – was this: Were the surgeons performing research? Or were they providing “innovative care?”

Research on humans is tightly controlled in the United States and, according to federal regulations and university policy, must undergo a rigorous approval process to ensure that participants are protected from harm. Innovative treatment, more commonly known as compassionate care, gives a doctor more latitude in offering nonstandard care to a single patient where evidence of safety or success is limited.

[...]

Muizelaar and Schrot called their novel approach “probiotic intracranial therapy,” or the introduction of live bowel bacteria, Enterobacter aerogenes, directly into their patients’ brains or bone flaps. The doctors theorized that an infection might stimulate the patients’ immune systems and prolong their lives.

The first patient lived about 5 1/2 weeks. The second survived another year, an outcome that buoyed the doctors and seemed to bolster their theory, they said.

The institutional trouble began in March 2011, when a newly diagnosed third patient developed sepsis, became unresponsive and died two weeks after being deliberately infected. The university’s first internal investigation soon followed.

What they did was highly unethical and dangerous.

But I have trouble with this paternalism later in the article,

“I think sometimes surgeons and doctors can get caught up in the enthusiasm for what they really believe is going to work,” said Caplan, head of medical ethics at New York University’s Langone Medical Center. “That is exactly why we have FDA oversight and approval and the research ethics requirement we do.

“Every time somebody dies or is injured or we have to recall a product, what we find ourselves saying is, there is no short-cut to innovation,” he said. “Finding the truth is a long, slow, arduous process.”

Informed consent for novel treatments can be difficult. “Informed” consent for proven standard of care is difficult. But maybe the focus should be on that and not necessarily on impeding access to even highly dangerous and unproven treatments.

Sunday, November 3rd 2013

There’s Something To Indian Healthcare

Don’t get me wrong, I’ve written previously with some admiration for Devi Shetty. But an op/ed in the Washington Post calling on U.S. hospitals to be more like those in India sugarcoats the major obstacles to such and I think ignores coming changes in rising economies.

[T]he transfer of responsibility for routine tasks to lower-skilled workers. This leaves doctors free to focus on complicated medical procedures. Several hospitals have created a tier of paramedic workers with two years of training after high school to perform routine medical jobs. As a result, surgeons, for example, are able to perform two to three times as many surgeries as their U.S. counterparts. Compare that with the United States, where hospitals reduce costs by laying off support staff and shifting mundane tasks such as billing and transcription to doctors, who are overqualified for those duties.

That task shifting includes things like families of patients performing basic nursing tasks and a stoicism amongst patients that simply is not part of American culture.

At least one true thing,

U.S. hospitals are constrained by regulations and norms unlike those in India.

But they end with this,

The Indian experience shows that costs can be dramatically reduced and access can be expanded even as quality is improved.

Which is silly.

India’s costs are low somewhat because India’s costs of living are low, they have little to no R&D costs, they have far fewer regulations and, most importantly, expectations are currently far less than those in the United States. The U.S. spends at the periphery of healthcare. That spinal fusion of questionable indication or that proton beam for your cancer or that lengthy ICU stay when the prognosis is terrible are not things that contribute really to population based metrics, and they’re not things that Indian patients are currently seeking but they’re major contributors to costs.

I want to see the private forces Vijay Govindarajan and Ravi Ramamurti cite in their op/ed keep control on health care costs eighty or ninety or one hundred years from now when the growth of Indian wealth helps lead to social expectations of health care are on par with what we have here in the U.S. And India is moving that way; we shouldn’t kid ourselves about any notion that current social values and ideas on end of life and health care in Indian culture are immutable. Eventually this “quality of death” is not going to be acceptable.

In such a sense India’s current efforts aren’t some “new” health care. And the Indian health care consumer is slowly moving to be more like the U.S., not the other way around. Only top down/government forces will keep the costs of Indian health care down under such a situation. India’s going to have to learn from Europe. Not America learning from India.

Thursday, October 31st 2013

A Medical Education Bubble

There’s a nice, brief editorial ahead of publication in the New England Journal of Medicine. Everyone needs to consider this when discussing American physician earnings; especially as compared to the rest of the world.

[I]f we aim to reduce the costs of health care, we need to reduce the costs of medical education. We don’t have to believe that the high cost of medical education is what causes increases in health care costs in order to develop this sense of urgency. We just have to recognize that the high costs of medical education are sustainable only if we keep paying doctors a lot of money, and there are strong signs that we can’t or won’t. Only about 20% of health care costs are attributable to physician payments, and many of the current efforts to reduce costs are aimed elsewhere, such as hospital payments, and have only indirect effects on physicians’ earnings. But physicians’ and dentists’ earnings have been sluggish since the early 2000s.3,4 Even if prospects for physicians’ income fall fast, a burst bubble can be averted if schools see it coming before their students do and lower their prices.

Thursday, October 31st 2013

The Falliability of Memory

I am fascinated by the faliability of memory. Especially episodic memory.

You and I really don’t remember what we think we remember. It is rarely accurate and yet people are utterly convinced of that their memory is accurate. There are obviously huge implications. Think criminal or civil law.

[Dr. Elizabeth] Loftus discovered that she could modify memories with startling ease. After showing a film of a crash, Loftus asked some volunteers if they “saw a broken headlight” and others if they “saw the broken headlight.” Those who got the latter question were twice as likely to say yes – though, in fact, the film showed no broken headlights.

Loftus was fascinated, and she soon turned her attention to criminal trials. Suspicious of the accuracy of eyewitness identifications, Loftus conducted an experiment in which volunteers looked at photographs of six faces while listening to a story of a crime.

One face was identified as the criminal, five as innocents. Three days later, Loftus showed the volunteers four photographs: one of an innocent character from the crime story, and three of new people. Sixty percent of volunteers identified the innocent character as the perpetrator from the story. They recognized a familiar face but muddled their associations with it.

[...]

One study in particular bolstered Loftus’ belief that much memory is malleable. In a now-famous experiment, Loftus told a volunteer that she had spoken with his mother and learned four things that happened to him as a 6-year-old.

She then ran through three real memories and one fake one. The volunteer sometimes claimed to remember the fake memory, which involved getting lost in a shopping mall then getting rescued by an elderly stranger. (Planting a more traumatic memory would be even more illuminating for psychologists, but researchers try to avoid permanently scarring their volunteers.)

Even odder, the volunteer would usually be happy to elaborate on this implanted memory. His panic, his confusion, his relief; it was all there, hidden away in his memory. Except that it wasn’t—it was all in his imagination. With just a small bit of coaxing, Loftus could insert this memory even into the most skeptical minds.

Or psychiatric illnesses.

Psychologists Miriam Lommen and colleagues studied 249 Dutch soldiers were deployed for a four month tour of duty in Afghanistan. As part of a study into PTSD, they were given an interview at the end of the deployment asking them about their exposure to various stressful events that had occurred. However, one of the things discussed was made up – a missile attack on their base on New Year’s Eve.

[...]

Eight of the soldiers reported remembering this event right there in the interview. The other 241 correctly said they didn’t recall it, but seven months later, when they did a follow-up questionnaire about their experiences in the field, 26% said they did remember the non-existent New Year’s Eve bombardment (this question had been added to an existing PTSD scale.)

Susceptibility to the misinformation was correlated with having a lower IQ, and with PTSD symptom severity.

I think this is one of the most fascinating parts of not just cognitive study but all of neuroscience.

Functional neurosurgery may hold promises to improve memory, not just in pathology (such as dementia), but in normal individuals. Initial studies show poor episodic improvement, but who knows what the future holds. And I wonder the implications of that for these “false” memories.