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Archive for April, 2008

Tuesday, April 29th 2008

Hygiene For The Obese


In Case You Couldn’t Figure Out How To Use It

The Bottom Buddy is a device which helps the morbidly obese wipe after using the bathroom. I’ll hold my tongue a bit except to say that it probably says something about the state of and concern for public health in this country. *Sigh*

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Tuesday, April 29th 2008

The Privacy Thing Stops At The Border


While You Were Busy Watching Dancing With The Stars A Little Bit More of Your Right To Privacy Died

So this 9th Circuit Court decision looked a little more outrageous when I first saw it, but it still remains a fine excuse to bring up the political topic most important to me. Civil liberties.

I’m sure it will come as a surprise to many but Border and Customs Agents can essentially seize any electronic device you are transporting into the U.S. and hold it for as long as it takes them to ‘search’ it. And such is what they’ve been doing more of late.

Laptops may be scrutinized and subject to a “forensic analysis” under the so-called border search exemption, which allows searches of people entering the United States and their possessions “without probable cause, reasonable suspicion or a warrant”…

The 9th Circuit Court recently reaffirmed the legality of data on electronic devices being scrutinized under the border search exemption to the 4th Amendment. What I really disagree with is the breadth of the border search exemption, but ruling it extends to data on electronic devices is nothing new. As Wired and Yahoo! blogs point out such searches of computers has been upheld since at least 2004. But the claim that searches of US citizens at the border “are reasonable simply by virtue of the fact that they occur at the border,” (as the Supreme Court has put it) and current U.S. Customs law are far too broad of a mandate for current U.S. Customs.

Some discretion is being used in determining who gets searched and who does not. Allowing Border Agents such authority has some benefits, they are the ones on the front line, but it also has major pitfalls in terms of our privacy.

Let me frame the the security versus freedom issue. These are on a scale. We could always be safer at the expense of further rights. We could all renounce our right to privacy further and have cameras in our homes and renounce our right to property further and have the taxes to pay for people to monitor those cameras. True, the yield for each further bit of privacy we forfeit is probably less but the maxim holds.

That might seem like an obvious definition of the debate but I’m currently annoyed by arguments such as those claiming that if you’re not a criminal you have nothing to fear or asserting that the U.S. has to protect its borders. Such are ridiculous in that they contribute nothing in trying to define how to tilt the scale of freedom versus safety.

In any case, the border exemption is far too broad at present. I hate it.

As for the extension of such to electronic data, there is a reasonableness to the legal argument considering how the border exemption has been defined. However, the pragmatic result seems fishy at best.

We should try to maximize the return on our forfeit of liberties (such as the right to privacy). The return for checking IDs, checking citizenship, checking large vehicles for illegal immigrants or devices of terrorism is considerably higher than that for checking a number of laptops based on the suspicions of some GED carrying Border Agent.

I would’ve hoped, however much their legal arguments were in line with prior court holdings, that the 9th Circuit Court (here and here and here) would’ve had some gall and would’ve help reverse the general decline in our civil liberties.

Thursday, April 24th 2008

A Bad Cross Cover Call

Can something be both annoying and touching at the same time? The story I came into the hospital to this morning certainly comes close.

I went in to pre-round this morning on my gyn patients. Getting report from the nurse and reading the notes on one particular patient revealed a rather strange call the OB/Gyn resident had taken last night.

It seems sometime in the early, early morning the patient had started complaining to her nurse that her “heart hurt.” The patient has a history of these vague complaints without elaborating. She’s been in the hospital a long time and craves attention.

In anycase, apparently without further assessment the nurse pages the on-call resident at about 2 am and relates “chest pain.”

The resident shows up at the patient’s bedside and the patient denies “chest pain” but tells the resident she wanted to see a doctor because her “heart is breaking,” because her children haven’t come and visited her in the hospital.

Sigh. I think everyone can agree having the doc (or anyone) woken up at 2 am so you can tell them something like this is inappropriate and inconsiderate. But boy is that a sad story.

Thursday, April 24th 2008

Patient Privacy Only Half Applies To Physicians

Brittney Spears underwent a very publicly reported invasion of her privacy during two stays at UCLA affiliated hospitals. As happens with celebrities many hospital employees took a look at her records without a need to.

The trouble is that physicians who did so apparently got off lighter than other employees.

[A]t least 53 UCLA staffers — including 14 physicians — looked at Spears’ medical records on the two occasions, even though they were not treating her, according to statistics from the state and UCLA officials. Eighteen non-doctors resigned, retired or were dismissed after their prying was discovered, according to data provided to The Times by UCLA. No physicians quit or were fired.

“Historically, doctors have been treated in a way that may be more lenient than non-physicians, and we will address that,” said Dr. David Feinberg, chief executive of the UCLA Hospital System.

“We will do everything possible in the future not to be accused of that.”

Watcher’s World goes over some of the reasons that physicians typically get off lighter. One of the reasons is that physicians, in the private world, are not typically employees of a hospital. They simply have priviliges to practice at that hospital and in return for such, that is where their patients get admitted when they need to be in the hospital. In this case however I would imagine that the majority of physicians with priviliges at the hospital are UCLA faculty and salaried employees. Firing them might have been a real possibility.

In anycase, the moral of the story is simple: don’t look at patient’s medical records unless you need to. No duh.

Wednesday, April 23rd 2008

Surgeon Removes Live Grenade


A Colombian Surgeon Removes A Grenade From A Man’s Leg

From Sky News

Monday, April 21st 2008

Music For Being Sick

I’ve got a sinus infection probably and was quite a bit under the weather yesterday and today. A good day though for sleeping and putting on the iPod. I’ve been toying around with some of the social music/internet radio sites around and so below is pretty much the playlist of what has gotten me through this little blip.


Eclectic But Oh So Commercial

Sunday, April 20th 2008

Four Myths of The Primary Care Crisis

If there’s a bigger single topic discussed in the medical blogosphere than the primary care crisis I’m not sure what it is. It permeates blogs (here and here and here) and the media (here and here and here).

I do believe that the distribution of primary care physicians to specialists in this country is askew but I’ve taken a critical view of some of the claims made by the primary care community. In part there is an argument that the efforts of the organized primary care and the medical blogosphere are merely rhetoric. No one pays attention until there is a ‘crisis’ and the flamboyant and exaggerated claims on the condition of primary care are perhaps merely part of a PR campaign. But in a deeper sense I think that the ‘whining’ coming from primary care is actually contributory to the primary care crisis. I’ve made several posts to that effect.

I thought what was in order was one summarizing post on the issue, something that might stir up some comments. That’s what I’ve put together here: the four myths of the primary care crisis.

The conclusions I reach are based on what I feel is sound data, but the post is obviously far from comprehensive. If there is data from non-interested parties that I didn’t consider or arguments I’ve ignored then let me know in the comments.

Myth #1:There Is A Worsening Shortage of Primary Care Physicians
I’m just going to flat out say it, the fact that physician bloggers and agenda minded think tanks continue to substitute anecdotal evidence of a shortage as a surrogate for the actual figures is distressing. Take this recently touted article from the WSJ. While I won’t speak to the Massachusetts experience the cited study about a nationwide PCP shortage is flimsy.

One of my biggest pet peeves is that these primary care physician-scientists seem to refuse to characterize the evidence they use in their opinions. I would hope that we can all agree that the HSC Community Tracking Study Physician Survey, cited in the WSJ article, falls short of the best evidence on primary care physician numbers. A 6000 physician sample with nearly less than a 50% response rate. Lovely.

The same can be said of the claims for the organized primary care think tanks.


This Graph Is Meaningless

Indeed, the HSC survey is the only original dataset put together by a non-involved entity that I can find that seems to back up a drop in the per capita primary care workforce.

While we have seen a drop in allopathic medical students going into primary care it has more than been offset by IMGs as the GAO says.


From 1995 to 2005 Using AMA and AOA Master Files and HRSA Data

There are probably regional deficiencies in the primary care physician workforce but there are regional shortages for physicians no matter their specialty and it does not speak to a systemic problem facing primary care.

Nor is there good data that demand for primary care will grow with an aging population and cause a shortage. Such predictions by organized primary care are pretty low on the pyramid of evidence. While such a deficit may pan out, trying to predict such (even if you think it is just sooooo obvious a conclusion) is notoriously difficult. Predicting the physician requirements of this nation a decade or more out is essentially impossible. See this IOM report from the mid-nineties on efforts to do such. That’s why the major players over the past decade have flip flopped on whether we need to be graduating fewer or more doctors.

Certainly, even if the above scenario plays out, it would be hard to imagine it as a “crisis.”

I think the best evidence says there is not a general primary care shortage. At least not a new one. As I said, I think we have always needed more primary care physicians in this country but the situation isn’t getting worse. The primary care per capita numbers have been maintained and probably even grown a bit over the decades thanks to an influx of international medical graduates. Let that claim rest in peace.

Myth #2: The RBRVS and RUC Are Responsible For The Primary Care Income Disparity
I’ve posted long and hard on the RBRVS and the AMA’s RUC. I admit that I do not believe that primary care physicians are compensated appropriately and I may even buy that the RUC has not done enough to fix the primary care-specialists income disparity. That being said, the evidence clearly supports that the primary care physician has not done worse versus the specialist since the implementation of the RBRVS.

The RBRVS came into existence in 1992. I think a larger review of income data backs me up but for the sake of this post let me take a couple of examples to highlight the condition of primary care before the RBRVS in 1988 versus today. The data sources are the 1988 Health Care Financing Administration’s PPCIS and the 2007 AMGA Physician Income Survey.

I understand the limitations of comparing these two survey datasets, constructed under two different methodologies by two different groups. For example, below I have to use family medicine income as a surrogate for all of primary care. Even today the major physician income surveys show some wide discrepancies but I do believe that comparing this data gives us at least a general idea that the RBRVS has not screwed the primary care physician. In the end, that is the general point of the myth – the RBRVS and RUC have been bad for primary care. Such doesn’t appear to be the case.

In 1988 all self employed Family Medicine physicians earned a median of $102,500. In 2007 the median Family Medicine physician earned approximately $185,700. That is an increase of 81% in 20 years.

That is better than the orthopedic surgeon (56%), the cardiologist (61%), the anesthesiologist (78%) over the same time frame. There are medical specialties that made off better over that time frame (see radiology) but in general the RBRVS has been progressive for primary care physician income.

Nor, in terms of hours worked, are family practice physicians working more than they did immediately pre-RBRVS.

If you include all primary care physicians the primary care physician earned 65% of what the medical specialists did in 1988 (i.e. the cardiologist, the gastroenterologist, the pulmonologist, etc) and 44% of the average income of all surgical specialists.

2006 data put together from various sources by the Congressional Research Service says that the primary care physician today earns 70% the medical specialist and surgeon.

No the RBRVS may not have closed the gap in the income disparity completely and/or appropriately but it has made some progress and has not contributed to a worsening of the gap. The income disparity has narrowed since the advent of the RBRVS and the creation of the AMA’s RUC. End of story.

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Sunday, April 20th 2008

Study Medicine Abroad


Not The Appropriate Path To Becoming A Physician

The above is an ad for americandreamabroad.com, which seems like a front to place Americans in a questionable medical school in China. Still a pretty funny ad.

via How To Split An Atom

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Photo: urbanwild/CC License

Sunday, April 20th 2008

The Perfect Medical School: Admissions


Our Dean of Admissions Welcomes You

Pre-Requisites
Pre-requisites for medical school admission should be extremely limited. Indeed, I think in the perfect school, they would not exist at all. Completion of say an undergraduate biochemistry has absolutely no independent predictive value of medical school success. A reliance on standardized tests to assess the pre-medical school basic science knowledge base in appropriate and required pre-requisite classes are simply redundant. Indeed the MCAT is an excellent predictor of medical school success; probably the best single predictor.

As many medical schools there would be no specific requirement for an undergraduate degree. Indeed, I would propose allowing mature high school students sure of their future to study for and take the MCAT without any college preparation and to enter medical school immediately following high school. And I’m not talking about an extended course here (like the 6 year European programs).

Admissions Criteria
As above, great emphasis would be placed on standardized measures (i.e. the MCAT). True, there are anecdotes of those who are merely poor standardized test takers and otherwise excellent students and perform as excellent physicians but in general the MCAT is an excellent predictor, not only of future standardized test performance, but of performance in medical school in general.

Very little weight would be put on prior GPA, which is entirely impossible to standardize versus other applicants. Such would probably help the pre-med attitude a bit.

More than lip service would be given to the intangibles that make a good physician and a demonstration of the right motives for going into medicine, a commitment to research, etc. would be elicited in part through self reporting, letters of recommendation and the unique interview process.

Interview Process
The admissions committee interview team would be entirely limited to physicians and current medical students and basic science faculty would be barred. The idea is that the interview process should solely serve in trying to determine the intangibles which make a good clinician. Hopefully things like a dedication to research can be derived from the applicants’ previous activities.

The interview process would be given a huge amount of weight, as a measuring tool of applicants’ intangibles as mentioned above. I imagine a full day ‘interview’ or perhaps two half day ‘interviews’ to standardize the rankings the admission committee members give to the applicants they interview.

What I mean, is that the admissions committee members would give an entire half day to interact with the applicant. Your a clinician in clinic then the applicant comes along or he scrubs into that surgery. The applicant and interviewer sit down for lunch together and then perhaps dinner with a second interviewer.

Summary

  • No pre-requisite courses
  • Potential for admission directly from high school in unique circumstances
  • Essentially ignore undergraduate/high school GPA
  • Strong emphasis on MCAT performance
  • Day long, informal interview process

[Return To The Perfect Medical School]

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Photo: Laffy4k/CC License

Saturday, April 19th 2008

The Perfect Medical School


Prestige, Baby, Prestige

If I was creating a medical school from scratch there are some specific things I would incorporate. Many of these ideas exist at various medical schools here or across the world. Some of these ideas are wholly new. This is essentially just a random collection of thoughts and not exactly an outline of how to start a school (no duh). For obvious reasons these ideas ignore current accreditation standards.

This series was inspired by a lengthy conversation I participated in (admittedly over drinks) concerning the perfect medical school. It was a group discussion amongst second and third year medical students from schools all across the country. It obviously focuses largely on ‘undergraduate’ medical education, which should be the primary focus of any medical school (many medical schools lose sight of this).

1. Pre-requisites & Admissions
2. Basic Science Education
3. Clinical Education
4. Special Topics

If you have any ideas on the perfect medical school please leave them in the comments.