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Archive for March, 2008
As I type, front page on CNN is a profile piece on a plastic surgeon and several of his patients who are upset he continued to operate while in an alcohol treatment program.
[Dr.] West is an alcoholic, according to a Medical Board of California decision, and a member of the state’s Physician Diversion Program.
The program keeps the doctors’ identities private, so it allowed him to continue to treat patients, even operate on them, while he was secretly getting treatment for his addiction.
A study by the Federation of State Physician Health Programs found about one percent of all physicians practicing in the United States are in confidential treatment. That’s about 8,000 doctors whose patients may have no idea they are addicts.
A physician doesn’t have to disclose his drug or alcohol troubles and gets to keep practicing on unaware patients. A little shocking at first light. Let me tell you why it isn’t and why I think these confidential treatment programs are extremely important.
The most important point to make, and the one that the CNN story blindly misses, is that in most states, certainly in Texas, these are programs for physicians who voluntary come forward.
A Martini And A #11 Scalpel
These are not programs for physicians who have been caught practicing under the influence, who have made mistakes because they’ve been inebriated. The way I understand it, these are physicians who sought help of their own volition. Physicians without documented professional troubles secondary to substance abuse.
That is an incredibly important point. It is highlighted in this quote from the CMA president,
[T]he California Medical Association, a physicians advocacy group, is fighting to keep the program running, and to keep the names of doctors enrolled confidential.
The association’s president, Joe Dunn, told CNN, “We believe very strongly this is the absolute best way to ensure patient safety. We need to get physicians out of the shadows.”
Dunn believes if the program is shut down in July, doctors will continue to feed their addiction privately and not get help. He argues, “Without a diversion program, no one knows. Patients don’t know. Health professionals who could help don’t know.”
It absolutely positively is the difference between having more physicians out there who are actively abusing substances with patients none the wiser and having physicians out there who are getting treatment for abusing substances with patients none the wiser. I don’t think, when framed appropriately like such, that that is really any choice at all.
These are important programs.
Dr. Jerome Goopman, author of How Doctors Think, has an upcoming webinar on the subject next month. The web broadcast is intended for medical students, residents and academic faculty at various medical schools across the country.
Let me be equivocal in saying that I would never dare to pass judgment on the merits of the claims Dan Walter makes or on the anger he appears to harbor. I’ve never been through anything like he lays out. What I do question is his strategy in trying to seek some sort of remedy and the generalizations he makes from his experience.
Okay, Not An Ablation But The Only Cath Image I Could Find Under A CC License
For a while national email listservs for use by medical students have been getting strange emails from a man named Dan Walter. Most of them reference back to a blog he’s running called Adventures in Cardiology. In the blog he details what he perceives as terrible medical care his wife got at the hands of Johns Hopkins staff. Specifically he targets an electrophysiologist whom his wife presented to for an ablation to correct her apparently chronic a fib.
His efforts extend away from the blog and out onto internet forums, about.com (see here and here), and even to posting phony profiles of the cardiologist he is targeting on physician review sites. At Wellness.com, Mr. Walter appears to have posed as the cardiologist and posted this,
I’m an ambitious doctor who puts my career above the safety of my patients.
This seems like a terribly inappropriate way to address an issue like this. I can understand why one, after going through something as terrible as what Mr. Walter describes, would like to find a place to rant. But emailing medical students, posting an obscure blog, posting phony physician profiles aren’t going to cost JH hospital or the cardiologist a lot of business I imagine. And in some cases you have to wonder if what Mr. Walter has done rises to libel.
In addition, I think some of the generalizations about medical care he makes are misleading for any future patients who may visit his website,
What we didn’t know is that [our electrophysiologist] – according to what he later told colleagues – follows the practice at most teaching hospitals wherein “the attending shows up to be there during the burn.”
His offense with trainees (mind you these are medical doctors) providing care to patients doesn’t appear limited to the comments above.
This presents another teaching opportunity, so they find someone who has never actually repaired a mitral valve. He opens her up and decides upon seeing the mess that he will just replace the valve, sentencing my wife to the high-wire balancing act of taking warfarin for the rest of her life. (You should look up Warfarin. It’s more commonly known as rat poison. No kidding.)
As Mr. Walter presents it, it doesn’t appear that anyone but who was in the cath lab and the operating room knows if the fact that trainees were involved in his wife’s care contributed to the terrible and tragic outcome she had. The fact is though that research, in general, does not support poorer outcomes when residents are involved in patient care. This is across a whole host of specialties, a whole host of procedures and operations. Mr. Walter seems to be drawing a whole lot of generalizations from his anecdote.
I think we can be reasonably sure (but obviously not know with certainty) that the CT or GS resident who aided in the heart surgery did not, singlehandedly make the determination that the mitral valve needed to be replaced. And I would hope Mr. Walter and his family could take some solace in knowing that the balance between whether to put in a bioprosthetic versus mechanical valve is one without a clear tilt often. So while we can rant against life long anticoagulation and the dangers of coumadin, different dangers exist with putting in a biologic valve and sparing a patient the coumadin.
These serve as just examples of what I think are overly general criticisms. There are more throughout the blog.
I feel for Mr. Walter and his wife. The concern I have is that Mr. Walter seems to be making broad claims and implying, for other patients who might visit his site, that some of the things his wife went through, some of the choices made in her care are ALWAYS inappropriate. I would just say: A resident or fellow being involved in a patient’s care does not generally put that patient in danger, a mechanical valve isn’t always the wrong thing, etc.
Lying In A Beach Chair Does A Number On Your Hips
This survey of British physicians was published in a British magazine a while back and I only now picked it up. In it a majority of respondants say that some care, apparently especially some operations, should be limited by patients’ age and lifestyles.
Smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.
About one in 10 hospitals already deny some surgery to obese patients and smokers, with restrictions most common in hospitals battling debt.
Managers defend the policies because of the higher risk of complications on the operating table for unfit patients. But critics believe that patients are being denied care simply to save money.
One in three said that elderly patients should not be given free treatment if it were unlikely to do them good for long. Half thought that smokers should be denied a heart bypass, while a quarter believed that the obese should be denied hip replacements.
Tony Calland, chairman of the BMA’s ethics committee, said it would be “outrageous” to limit care on age grounds. Age Concern called the doctors’ views “disgraceful”.
That’s taking voluntary, transparent rationing to a pretty incredible level. When resources are scarce, as in most of medicine, then lifestyle can play a role in who gets what. I have no problem, along with 94% of British doctors in the survey, in saying an alcoholic who is likely to return to drinking shouldn’t be at the top of the liver transplant list.
Ninety-four per cent said that an alcoholic who refused to stop drinking should not be allowed a liver transplant…
Roger Williams, who carried out the 2002 transplant on the former footballer [George Best,] said doctors could never be sure if an alcoholic would return to drinking, although most would expect a detailed psychological assessment of patients, who would be required to abstain for six months before surgery.
But rationing based on age and some of the other suggestions put up in the survey just elicit a ‘yikes.’ Such transparent, open and flamboyant rationing efforts are inevitable in any limited global budget health care system (i.e. Britain’s socialized NHS).
h/t Grunt Doc
Dennis Quaid’s twins received an overdose of heparin recently, partly due to a drug labeling problem. Now, understandably, he’s taking up the cause of medical errors.
Quaid said he applauds the hard work of individual health care professionals, but said the medical system is inexcusably broken. As a pilot, he offered up the airline industry as one the medical system can learn from, using the oft-quoted analogy that the number of people who die from preventable medical mistakes would be “equivalent to one commercial airline crash every day of every year.”
Airplane crashes are dramatic, and thus attract public attention, which then demands accountability. Unfortunately, most patients who die unnecessarily in hospitals from medical errors, do so silently with only their family and friends as witnesses, he said. He plans to end the silence.
“Public accountability spurs innovation,” Quaid said.
There are unique components of medical care which obviously make preventing errors in health care different than preventing commercial airline crashes. But it isn’t such a terrible analogy; the rate of medical errors is obviously unacceptable.
There were 745 million passengers flown by commercial airlines in 2005. There were 22 airline passenger deaths that same year. Or approximately one for every 33.8 million passengers.
In 2006 there were 37 million hospital admissions. No specific data on fatal hospital errors for that year are available. The IOM’s now famous To Err Is Human report cited several older studies. If we are as generous to health care as possible and use the old, lower estimates of yearly fatalities then that is still 44,000 deaths a year (likely higher in reality, if for no other reason than the US hospital admissions have grown since the studies which concluded that figure). In any case, that’s one for every 851 patients.
Like I said, there are plenty of problems with trying to compare these two figures but learly there is a lot of work to be done. If unrealistic, the attitude should be that a single death due to medical error is inexcusable.
This Fundraiser Had A Very Cool African Drumming Group
I was at a fundraiser recently for a program to send several first years over to Ethiopia for 4-6 weeks. They had this interactive drumming group come in who are actually a lot of fun. And while I’ve been on some international mission trips, hearing the kids who did it last year talk it made me really wish I had gotten to do this in between my first and second year.
It is becoming a trend to get students far more involved in clinical experiences during their first two years. Indeed, my school may be a little slow to the party. But if you can find the funding for it, it seems very important to send first and second years on international experiences. Listening to the second years who had been last year, they were getting to operate with an incredible level of autonomy, see incredible things, in a small way help a lot of people. I’m sure all of them are better medical students and eventually better physicians, for their experience over there.
For the first years going this year, good luck and do some good over there guys.
Saturday, March 29th 2008
A week ago hackers attacked an Epilepsy Foundation online forum and directed visitors computers to seizure inducing patterns of flashing lights.
The nonprofit Epilepsy Foundation, which runs the forum, briefly closed the site Sunday to purge the offending messages and to boost security.
RyAnne Fultz, a 33-year-old woman who suffers from pattern-sensitive epilepsy, says she clicked on a forum post with a legitimate-sounding title on Sunday. Her browser window resized to fill her screen, which was then taken over by a pattern of squares rapidly flashing in different colors.
Fultz says she “locked up.”
“I don’t fall over and convulse, but it hurts,” says Fultz, an IT worker in Coeur d’Alene, Ohio. “I was on the phone when it happened, and I couldn’t move and couldn’t speak.”
After about 10 seconds, Fultz’s 11-year-old son came over and drew her gaze away from the computer, then killed the browser process, she says.
This is, based on the actual physical nature of the attack, one of the worst hacks ever if the report is accurate. A terrible tale and these guys should go to jail under some kind’ve assault statute if there’s any justice and serve non-consecutive time for illegally accessing the forum as well.
Thursday, March 27th 2008
Patients need to be advocates for themselves. They often aren’t enough. But there is a very clear, may I say bright and flashing, line between advocating for your care and complaining when you’re in the hospital. And if there’s one complaint I think many roll their eyes at it is the uninsured patient who thinks they’ve been in the hospital too long. I heard a story about a resident giving a patient with just such a complaint a mildly apt analogy.
“If McDonald’s was giving away hamburgers for free you’d take one right? And don’t you think there would be a line for those hamburgers? Everyone would want one for free, right? And would you complain about the line?”
Tastes Even Better Because It Is Free
No doubt no one likes their time being wasted. No doubt, from all I’ve seen and heard, public hospitals are a helluva lot less efficient than the rest of healthcare. But, unless such a wait is actively and significantly endangering a patient and absolutely opposed to the concrete standard of care then I don’t think many want to hear the complaint of inconvenience from a patient for who the taxpayers are picking up the tab.
At the bedside it’s a sigh and a nod of the head but maybe someday I’ll have the gall to repeat the analogy above and kind’ve put the situation in perspective for a patient.
A science fiction writer says we should solve the rising costs of health care by scaring illegal immigrants into not coming into the hospital…
sounds like a gre-…wait, what?!
[Larry] Niven said a good way to help hospitals stem financial losses is to spread rumors in Spanish within the Latino community that emergency rooms are killing patients in order to harvest their organs for transplants.
“The problem [of hospitals going broke] is hugely exaggerated by illegal aliens who aren’t going to pay for anything anyway,” Niven said.
“Do you know how politically incorrect you are?” Pournelle asked.
“I know it may not be possible to use this solution, but it does work,” Niven replied.
I don’t even know how you respond to the stupidity of a comment like this, except just to denounce it as such. Larry Niven simply doesn’t know what he’s talking about…or how to write a novel.
I’m on a surgical rotation right now with one other medical student and, on this particular day, only one operating room for the service. It’s near Spring Break, so many faculty have taken some time off, and so the service only had two cases scheduled for the day. Anyone who knows the speed at which public hospitals move knows that doesn’t guarantee a quick and easy day.
In anycase, the other medical student had scrubbed into the early case. That one finished up around 4 in the afternoon. Well, it turns out that a bunch of scrub techs and circulators called in sick and there isn’t enough hospital staff for our next case to go right away and they can’t tell us when the case will be able to go.
Now, my service has two interns, a junior resident and a fellow. I’m hanging out with the junior resident, helping to put in a chest tube. He tells me I should probably stick around and scrub into the next case and then he lets the other medical student go. An hour passes and I’m literally just twiddling my thumbs, admittedly just slightly annoyed I’m still up at the hospital.
My resident is a good guy, don’t get me wrong. But he’s made it clear I should stick around and I’m not thrilled about it. I’m hanging out at the hospital despite the case being indefinitely delayed and despite the fact I have my NBME shelf exam in a week and I could be studying. The patient isn’t even in the holding area and although the OR is clean, even if the patient was sent for right now it’ll be at least an hour before they make an incision. Add at least two hours for the operation (it ended up taking longer from what I understand), and I’m probably looking at getting out of the hospital at 8:00 or 9:00 at night. Not totally unexpected as a medical student, but to just be sitting around waiting and the fact my exam is so near makes the experience a little miserable.
I go down to see if the patient is in pre-op holding and I run into my fellow, who will be doing the operation. He wants to know what I’m still doing at the hospital and tells me to scram. I obviously jump at the chance.
It isn’t like I went looking for the privilege to leave. The fellow, the man both I and my resident answer to, told me to leave without me even mentioning it. But clearly my resident thought it was my responsibility, as part of my surgical education, to stick around and scrub into this last surgery. My fellow is in charge of the service, the one the residents and I answer to but it still seemed a little sketchy to just bolt without even going and finding my resident.
Not sketchy enough that I didn’t get to my car and home as quick as I could. And as far as I can tell the next day my resident didn’t care; but getting conflicting instructions from two of your superiors on any service makes things a little bit awkward.