Archive for July, 2007

Monday, July 30th 2007

Roberts Has A 'Seizure'

Chief Justice John Roberts suffered some sort of seizure which sent him to a Maine hospital. Not a lot of information so far but I thought this was interesting, no only because it’s a big deal, but because I just started my neurology rotation.

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Monday, July 30th 2007

SCHIP Renewal

I’ve always been torn on CHIP. It is those far and few between who doesn’t think society owes guarantees to children. The question is merely where to draw the line in terms of family income and such. Well, taking up that issue, the Congressional push to expand the SCHIP program is likely to see Bush get his first veto overturned.

Public support for the State Children’s Health Insurance Program (SCHIP) has begotten a bipartisan push in Congress to increase its scope, with Democrats and even reputedly conservative members of the Senate Finance Committee advancing a measure to increase SCHIP’s funding by $35 billion over the next five years.

The expansion would bring total five-year SCHIP spending to $60 billion. Currently, most children covered under the federally-financed and state-administered entitlement live with families earning up to 200 percent of the federal poverty level (FPL) and do not qualify for Medicaid. Some states have secured federal approval to cover a limited number of adults and middle-income children under the program.

Open Congress has a great blog post on the SCHIP bills in both houses (House version & Senate version) and what Bush has said about the bills. I would very much like to see these bills get through and there’s a really good chance of that.

Monday, July 30th 2007

DNI/DNR

I rolled through my first month on the wards. I’ll wait for the applause to die down.
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I’ll echo virtually every medical student who has come before me in saying that it is gloriously better than the hours upon hours in the classroom that constitute the first two years of school. There is something, right off the bat, that has disturbed me and I get a feeling talking to physicians that what I’ve seen in my first month is not somehow isolated to my first facility or medicine team. What I’m a little peeved about is the hard sell of the DNI/DNR choice.

A made up situation: A patient with lung mets who develops recurrent effusions and keeps bouncing back for basically symptomatic thoracentesis. His/her prognosis is terribly poor and indeed if it was me I’d would think the best place for me would be hospice and I’d probably want to be DNI/DNR. But it isn’t me. If the patient is informed, as best as possible, and wants to be full code, doesn’t want hospice…why is that such a problem.

I understand that as health care professionals they’ve seen the consequences of full interventions on these patients. They’ve seen the futility and the actual prolonged suffering of such and they understand it in a way that just talking to the patient probably cannot relate. But shouldn’t it work that you try your best to convey your opinion and the consequences of both choices and then respect the patient’s wishes?

Do you really need to be frustrated back in the team room? Do you really need to revisit the issue with them everyday? These sales pitches I hear made to some of these patients go far beyond advice, they’re approaching car salesman level.


What Is It Going To Take To Get You DNR?

There is real futility in these choices and it burns me inside that these patients sometimes choose prolonged suffering for themselves. I know these physicians think they’re doing what is best for the patient but paternalism dropped out of vogue a while ago.

I’m also disturbed by the contention that futile full codes or hospice refusal wastes health care resources. He should be in hospice, then we’d have another bed. This health care system is the least efficient in the western world. I don’t think these patients represent a real comparable drain on the system.

Thursday, July 26th 2007

Grand Jury Doesn't Indict Anna Pou

And a cheer goes up from the whole of medicine. Anna Pou, the New Orleans’ otolarynologist, accused of euthanizing patient’s in the midst of Hurrican Katrina will not be indicted.

A New Orleans surgeon accused of killing four patients in the aftermath of Hurricane Katrina will not face trial, a grand jury has decided.

This is after it looked like the prosecutor was targeting Dr. Pou by giving nurses, previously charged in the case immunity for their testimony.

[Two nurses] testified to the grand jury under legal guidelines that prevented their testimony from being used to incriminate them.

Lawyers for all three medical workers said they had worked heroically to treat patients instead of evacuating the hospital during the chaotic days after Hurricane Katrina struck.

“[The grand jury] concluded that no crime had been committed,” New Orleans District Attorney Eddie Jordan said after the decision was made.

“And that is the decision of our grand jury, and I think justice has been served after due process.”

This is all good news. You can visit Dr. Pou’s defense fund here.

Wednesday, July 25th 2007

Charlie Weis Loses Malpractice Suit

I’d make fun of him, but it is just too easy. As a University of Southern California alumn I have to hate Charlie Weis. Even if I wasn’t a USC grad, he ain’t exactly a hard guy to dislike with this malpractice suit brought after gastric bypass surgery.

A jury on Tuesday found against Notre Dame football coach Charlie Weis in his medical malpractice lawsuit against two doctors he claimed botched his care after he had gastric bypass surgery five years ago.

Weis, 51, who won three Super Bowls as offensive coordinator for the New England Patriots, accused the surgeons of negligence for allowing him to bleed internally for 30 hours before performing a second surgery to correct the complication.

Weis became gravely ill after the 2002 surgery and nearly died. He testified he still has numbness and pain in his feet and sometimes has to use a motorized cart.

Ferguson, director of Massachusetts General’s surgical residency program, and Hodin, a surgeon and professor at Harvard Medical School, said internal bleeding was a well-known complication of the stomach stapling surgery. They said they believed the bleeding would stop on its own and were concerned about performing a second surgery because of the risk of a pulmonary embolism.

While obviously I know oh so little about this case and oh so little about medicine in general, I was under the impression these gastric bypass surgeries had pretty significant morbidity and mortality rates.

[OR Live: Roux-en-Y Gastric Bypass]

Wednesday, July 25th 2007

Signs Of A Bad Call Night For My Intern


Your Signout Made No Mention Of This

Signs it’s going to be a bad call night include early weird cross cover issues:

  • A patient, discharge orders pending signature, codes after aspirating on cranberry juice
  • A nurse “Oh yeahs…” you about incidenta anisocoria in a patient. Is it something new? Hard to say as on chart review the patient’s medicine team has written “HEENT: Regular rate and rhythm.”
Monday, July 16th 2007

So What Doesn't Contribute To Cancer?


Only Tasty With Sugar On Top

Apparently the grapefruit diet isn’t the way to go, as a study in the British Journal of Cancer shows eating grapefruit everyday increases a woman’s relative risk of developing breast cancer by a third.

A study of 50,000 post-menopausal women found eating just a quarter of a grapefruit daily raised the risk by up to 30%.

The fruit is thought to boost levels of oestrogen – the hormone associated with a higher risk of the disease, the British Journal of Cancer reported.

Saturday, July 14th 2007

John Edwards Knows Healthcare?

I’ve applauded Edwards’ willingness to provide more concrete plans on a whole host of issues rather than the jibber jabber, filler that most politicians put out there. Included in that is health care. I don’t agree with him, but more than most in his shoes, John Edwards was willing to put a plan out there for the voters to judge.

But Slate’s Chatterbox thinks it’s smoke and mirrors and not feasible.

Chatterbox is a column who thinks that the debate on health care needs to shift leftward. True, as Graham loves to point out in discussions on health care access, they don’t even know enough to distinguish single payer from socialized medicine…

Open discussion of a “single-payer” system in which the government pays for and regulates health care is verboten within the political mainstream because it is presumed that Americans would never accept socialized medicine.

…so the fact they jump on Edward’s plan is nothing but a strike against it.

[I]n the health-care primary, John Edwards is the candidate to beat.

They laud it for tricking the public into “socializing” medicine.

As I explained above, the “health markets” component is a Trojan horse (a very elegant one) to replace existing private health insurance with government funding. That’s what I like about it.


With Looks Like These The Substance Is Just Icing On The Cake

This is a column written by a man who thinks that:

As I’ve explained before, the best way to limit medical inflation would be to end fee-for-service medicine and put all doctors on salary. Ending fee-for-service payments would eliminate the incentive doctors now have to perform unnecessary tests and procedures.

So I’m not sure appluading Edwards’ regional health care markets is a boost or burden. Like all positive obligations left wingers try to attach to tax payers, health care is not a right. End of story. It’s a business and should run like one. Yes, the system is broken, but only in the sense of the lack of competition and transparency currently inherent in it.

I truly believe a move towards transparency and the free market can lower costs. Will it allow everyone the health care access they need? No. But, as heart wrenching as individual stories of suffering are, access for everyone shouldn’t be the government’s goal.

Chatterbox is running a whole series on candidate health care plans. They’ve already posted on Obama’s plan. You can find their archive here.

Thursday, July 12th 2007

It\'s Probably All Right To Get Sick Right Now


The Intern Will Be In To See You

DB revisited the “July phenomena” recently. That is wherein you, by medical legend, get poorer care during the month of July at teaching facilities when all the new interns and residents start. Dr. Bob says that,

[T]here is no July phenomenon. Is There a July Phenomenon? We should oppose any mention of this urban myth.

I have a few thoughts about why we do not have a July phenomenon. Those who supervise in July (and I have done July wards for at least the last 10 years) are acutely aware that the new interns need careful supervision. The supervising attendings and residents are hand chosen for this task.

And, indeed, putting aside the potential for bias and thus error in any self evaluation, the literature supports him. Not just the study he linked to but others. See here and here and here. The only evidence for a July phenomena is anecdotal. Case studies and stories and such.

What I think some fail to realize is what goes into making the plan of action for the care of every patient. Everything is talked out; every decision is ultimately in the hands of the attending. It isn’t like new interns are running around ordering procedures without talking to anyone.

Being on your first rotation, as I am, provides a unique perspective. On one hand, you don\’t have something on hand to compare the workings of the wards in July to. Are errors and inefficiencies I\’m seeing systemic? Will they improve as the interns and residents mature into their positions? On the other hand, your view isn’t tainted by years through the looking glass. You settle in as a resident, and in the second and third year or as staff you may lose perspective.

I\’ve admitted my ignorance, this being my first rotation, but I will say I’m probably better informed than most MS3s in the same position. With two parents who have been academic physicians for most of my life I’m not completely blind on the maturation process of interns, residents, and even medical students. And how all that effects patient care.

With all that said, if at all avoidable I would still not want to be in the hospital in July versus September. The efficiency is just not what it will be. There is evidence interns make more mistakes earlier in the academic year (at least in other countries). There is some evidence they’re poorer documenters. And they’re just less efficient. The measurable effect that has on adverse outcomes appears nill but what the effect on what I’ll deem “quality” of stay is less documented and I for one think it’s a real thing.

A young intern forgets to document consent and it\’s four o\’clock by the time the resident notices…whoops, you don’t get that procedure until tomorrow.A young intern doesn’t ask the right questions when he just pops in to check on you after lunch. Blah, blah, blah.

I’ve got some really talented and smart interns, but I know they\’ll be even better later in the year. My attending and/or my resident can\’t stay on top of all 12 patients with the same detail my interns can of their six. Sure, the attending is immensely more skilled at knowing what to look at and picking out what is relevant and thus needs less time to keep up with each patient but It ain\’t the same though.

By choice, I’d wait for July to come and go before I went out and got myself sick enough for an admission. No matter what the mortality figures say.

Sunday, July 8th 2007

For Profit To The Extreme

What should we think of Prem Reddy and his company, Prime Healthcare? This cardiologist’s multi hospital group sounds about as for-profit as you can get.

On the one hand I agree with this:

“Why is it in healthcare we expect to have the same?” he asked. “It’s an entitlement mentality. Why aren’t the same people asking why everybody shouldn’t be eating the same foods, or have the same clothes or same homes? Those are as essential services as healthcare.”

What distinguishes a positive right to health care versus other “necessities”?

Where do you draw the line? Patient A, per the algorithm, has a 45% pretest probability of CAD, and gets the stress test or the angio…patient B’s atypical pain only has a 15% chance and he gets pushed out the door. Even with the numbers, those cost control measures, are nothing if not subjective. If that’s the case can you really even define a ‘right to health care’? What is that right even?

That rant aside, Prime Healthcare doesn’t seem like the example of compassion in health care. Dr. Reddy has done away with contracts with private insurers. Instead,

“Somewhere along the line, the insurance industry has gone bad,” he said. “They want to pay $1,100 a day for patients that cost $1,700 to treat. They are bilking the system and getting rich at everyone else’s expense.”

While in his office one night, Reddy had an idea about how to make Desert Valley profitable. If his company canceled the hospital’s private insurance contracts, it might be able to make up for the loss in patients by increasing traffic through the emergency rooms and admitting those who needed more care into his hospitals for longer stays.

To ensure business, Reddy said, he did everything he could to speed up care in his emergency room and treat as many patients as possible.

To save diagnostic time, the hospital had laboratory equipment moved to the ER. Emergency beds and medical staff were increased. Reddy demanded that patients be seen within 20 minutes of arrival. With few options, paramedics eagerly showed up because, unlike many hospitals these days, it was rarely too full to accept patients.

I’d like to know what the California law is like. Are Prime Healthcare’s hospitals billing the remainder to the patients? If so, what is protected? For instance, in Texas they can’t take your primary residence to pay off expenses, healthcare or otherwise. Or, do the insurers have to pay whatever they’re billed?

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