Archive for September, 2009

Sunday, September 27th 2009

Homeopathic Medicine

Comedy at homeopathy’s expense is almost too easy. Still this is clever; from a British variety show called That Mitchell & Webb Look.

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Sunday, September 27th 2009

The Hours

I’ve been working some hours of late as my fellow intern is taking vacation and there really wasn’t afforded anything in the schedule to mitigate that. Not to get all ‘I walked uphill in the snow both ways to get to school each day’. I know residency used to be something tougher. Maybe.

While I haven’t gotten into the operating room I’ve gotten some cool procedures, gotten pretty proficient at chest tubes and pigtails and generally had a pretty good weight towards actual patient care this rotation considering the bureaucracy of medicine that falls to residents at academic centers. So don’t number the above as a complaint.

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One Way To Avoid All This…

But the amount of time I’ve spent at the hospital has got me thinking about the way the ACGME polices residency rules. So much centers on self reporting. And there’s huge pressure to not report violations. When residency programs get in trouble with the ACGME there are consequences for the residents. A residency program shutting down can be disaster for residents. You could be searching for a new program, leaving a program you love, maybe even switching specialties or moving across the country.

The medical community does some to help in situations when programs are lost. In many specialties other programs traditionally give preference to those residents who have lost their spots. And the ACGME and most RRCs are helpful in giving residency programs exceptions for extra residency spots when programs shut down. In reality those concessions and that assistance are small potatoes.

Scrambling for a new spot that has funding for you, moving, acclimating to a new environment is major trauma. That is assuming you even get ahold of a new position.

There are major incentives for residents to keep their programs in good standing, including to lie about their hours worked.

Some research indicates almost half of residents lie about their duty hours. And you have to believe that is a remarkable under reporting of the situation.

Now I’ve never lied about my duty hours. And I can’t say I know directly of anecdotal episodes of categorical residents lying about their duty hours to protect their programs but you have to believe it happens. It is just not something that will ever be spoken to. If the ACGME wants residents and others to self report violations; if truthful reporting is going to be the centerpiece of review then it needs to give residents more protections. I’m talking about an extreme shift. I’m talking about emergency funding for residency spots when programs run into trouble, about guaranteed spots for residents whose programs fail including about requiring all programs to agree to participate in helping to take on displaced residents, about relocation expenses.

I’m thinking program violations for all sorts of things must be vastly, vastly, vastly under reported. ACGME policies don’t have a lot of teeth when weighed against the future of your training.

Tuesday, September 22nd 2009

Birthday Grand Rounds

Grand Rounds is six years old. Considering things age in hyper dog years on the internet, that is a lifetime. What Nick Genes put together has been impressive. For the past year I’ve gotten to be a part of it. Today Grand Rounds, in my opinion, continues to serve an important function as part of the social network of medical bloggers. It continues to be a reference point for the medical blogosphere. It’s important; which is why I’m here putting this together at 3 am instead of sleeping prior to my call.

To the wonderful bloggers who make Grand Rounds work each week, “I don’t know half of you half as well as I should like; and I like less than half of you half as well as you deserve.”

I imagine Grand Rounds continuing to go strong but it only does so on the efforts of those who contribute and volunteer. If you’re interested in hosting a future date of Grand Rounds please drop me a line.

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Featured Posts
I’ve picked a few from amongst the dozens of excellent posts submitted. Consider it my quirky self indulgence to go with a couple of narratives this week.

Life In The Fast Lane – Do You Know John Hunter

As the house officer drew up a dose of morphine, the old physician spoke, “Doctor, at which medical school did you train?”

The house officer told him.

“Ah, well then, do you know John Hunter?”

“John Hunter… The man who grafted a human tooth onto a cock’s comb, who stole the corpse of the Irish Giant, who described semen held in the mouth as having a warmth similar to spices and who proved the contagiousness of venereal disease by self-inoculation?”

The Examining Room of Dr. Charles – Analyzing The Hippocratic Oath

I recall the thrill of reciting the Hippocratic Oath for the first time as part of a ritualistic White Coat Ceremony. It felt like the incantation somehow connected me to a long line of great men, from Hippocrates to Benjamin Rush to my childhood family doctor. It marked a distinct line between the life I had already lived and the medical profession that was to become a considerable part of my identity. But is the Hippocratic Oath an outdated, out of touch relic in the complex modern world?

From The Patients Perspective
I’ve learned a lot from the patient bloggers who contribute to Grand Rounds. As well, they’ve been the backbone of making Grand Rounds work. Kerri and Amy and Laurie and others have never shied away from helping make Grand Rounds work. This week they all come strong again with their submissions

Diabetes Mine – Another Diagnosis In The Family

Up until now it’s been all about me and my #$%@ chronic illness. That wasn’t so bad, for me. Far tougher is the realization that someone you love — someone who’s been the rock of your existence — may not be so invincible after all.

Luckily, my brother-in-law is a physician in Germany, and after hearing about the symptoms, suggested we might be facing a case of Lyme disease.

Six Until Me – Invisible Illness

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How To Cope With Pain – Exercise Your Phantom Limb

Phantom exercises help decrease pain in patients with traumatic amputations and phantom limb pain. Although a small study, the researchers showed that “exercising” the phantom limb results in better pain relief than just general exercise.

In Sickness & In Health – Tips for Telling A Potential Partner About Your Health Situation

1. Practice What You Say
2. Never Tell On A First Date
3. Be Casual Yet Confident

Florence dot com – Top 25 Tweeps for Patient Safety Week

Patient safety is a healthcare discipline that takes a critical look at how well intention meets outcome. It’s one of the six key dimensions of quality described in the IOM reports that first quantified how often people are harmed as a result of seeking care, then outlined improvement strategies.

Today’s list allows me to share 25 tweeps I’ve identified as valuable patient safety resources, visionaries, or exemplars.

A Chronic Dose – On Invisible Illness

[My physical therapist and I] talked about writing and teaching and graduate school, and we talked about rescue dogs and traffic and commuting.

And even though she was there because I have PCD and bronchiectasis and I was literally choking in phlegm before she arrived, it didn’t really come up.

It wasn’t that my illnesses were invisible (um, hello hacking cough and vigorous clapping) but they were not defining.

Survive The Journey – We Need An Elephant Specialist

Until three years ago, I was also a marathon walker and a racewalking coach for an organization that trains endurance athletes who raise funds to fight blood cancers.

[...]

I never got better. I never walked another half-marathon. I never got back to my daily routines. I never felt healthy again.

From The Providers
That doctors, nurses, pharmacists and others find time to blog shows the value of online self publishing. Maybe as one of them taking time to do so I’m a little biased. Like most I tend to actually on intermittently touch on actual clinical issues and instead comment on life within the health care system.

Other Things Amanzi – Selfish Bastard

of the things i encounter in my work, the one i find most disturbing is family murders. for some reason they happen with too much frequency in our country. it seems that some people, when life is too much for them are not happy to only put a bullet through their own head, but they feel the need to wipe out their entire family first. in my opinion it is a dastardly and cowardly act for which there is no excuse…ever.

Dr. Ottematic – Doctors Are Dictators

Last month, I was intimidated to learn that all consultation notes had to be dictated, having never had to do this before. Ok, I was downright worried! Fortunately, the hospital has a service that handles the technical side, and they even gave us Residents a little brochure with the standard headings to start us off. I clung to that yellow tri-fold of paper for dear life.

EM Blog

At the risk of being ridiculed, I volunteer to be on the Emergency Medicine Death Panel! I relish the opportunity to establish some futility and idiocy standards. We need to declare what is clearly dead already, what will certainly be dead in a few moments, and identify elements of the system which we would all be comfortable seeing dead.

Death is an important player in EM and yet shockingly, we habitually/traditionally/culturally fail to recognize death and make ridiculous statements about it.

Clinical Cases & Images – Wikipedia Is Not A Reliable Source Of Medical Information

I have commented on this topic multiple times in the past. In short, medical blogs are not a source of “actionable” medical information. The same principle applies to Wikipedia. You must be treated by an expert – not a “crowd” – as in the “wisdom of crowds” concept used by Wikipedia.

ACP Hospitalist – Medical News Of The Obvious

It’s like the scientists think if they keep reporting the same evidence, eventually someone will listen. A new study in Archives found that exercise is still good for you. And it’s never too late to start.

Healthy Business, Policy, Technology & Law
It is a great time to be wonkish. That might be a poor adjective. It is an interesting time to be wonkish. The potential for change of the American health care system is there and likely, even if the change proves less dramatic than some would like. Indeed this week is policy heavy and our bloggers comment on a whole range of issues. One of them even celebrates a birthday to go along with Grand Rounds.

Nuts For Healthcare – The Baucus Bill

Baucus’s 233-page “leaflet” of a health bill captures the essence of President Obama’s reform framework, including key insurance reforms like restricting denial of coverage based on pre-existing conditions, an individual mandate on basic insurance, and the creation of insurance exchanges. In contrast to the other bills, this particular bill can be loosely summarized by a couple of numbers.

InsureBlog – Medicare Secrets

In 1997, after undergoing daily dialysis for five years, she received her first transplant. Most of the cost of the dialysis and the transplant, totaling hundreds of thousands of dollars, was absorbed by the federal Medicare program, which provides broad coverage for those with end-stage renal disease.

By late 2003, her transplanted kidney had failed, and she returned to dialysis, covered by the government at $9,300 a month, more than three times the cost of the pills. Then 15 months ago, Medicare paid for her second transplant — total charges, $125,000 — and the 36-month clock began ticking again.

“If they had just paid for the pills, I’d still have my kidney,” said Ms. Whitaker

Health Business Blog – Happy 4th Birthday To The Health Business Blog

The Health Business Blog is four years old with over 2000 posts.

Health Blawg – Dr. Paul Grundy

Anticlue – Assessing Your Vendor Management Skillset

I wonder who gets the better deal, the car salesmen whose profession is to sell cars all day long or myself whose profession is to manage all day long. It will be like this with the meaningful use implementations. Everyone is going to be running the race, so before you begin the race. Let’s talk about obstacles for the race pertaining to vendor management.

Health Insurance Insider – Emphasizing Science In Health Care Reform

Are some things that we tend to regard as essential really not that important? Could they perhaps be doing more harm than good?

One of the problems facing our health care system is that there are so many people involved who are looking out for their own best interests, rather than what is best for the system as a whole and patients as individuals. The sheer force of the lobbying power that has descended on Washington this summer is evidence of that.

Hopefully as time goes by and CER becomes more common, we’ll see health care that is influenced primarily by science, data, and patient outcomes, without regard for who may or may not profit from the results of the research.

A Few Thoughts From A Tumor Surgeon – Direct Health Insurance Altogether?

[David Goldhill] notes, quite wisely, that “insurance” is generally used to pay for unexpected expenses (tree falls on your roof, car accident) not routine expenses. Thus (his example) nobody would think it reasonable that you would use car insurance to pay for gas while we all expect health insurance to pay for every checkup.

Therefore, he reasons, no amount of mandated cost control can overcome the intrinsic distortion created by a third party paying consumers’ costs.

In my world of oncology, some groups of surgeons and radiation oncologists have teamed up to provide prostate cancer care. Prostate cancer can be often be treated by either modality. In the older procedure-based model, these two groups would have fiercely competed for the same patient. But, working together, they can actually do what’s best for the patient.

Consumer Driven Healthcare will arise as “consumers” themselves slowly chip away at the walls and take over city.

SharpBrains – Alzheimer’s Disease & Healthcare Policy

In the midst of much healthcare reform talk, not Alzheimer’s Disease reportenough attention seems focused on ensuring healthcare systems’ preparedness to deal with cognitive health issues -with Alzheimer’s Disease as the most dramatic example- which are predicted to grow given aging population trends.

ACP Internist – There Are Still Other Health Policy Issues

With the media and political attention focused on the health insurance coverage debate, it may be hard to get anyone in the U.S. to think about other policy issues that affect health. But a group of prominent docs, including ACP president Joseph Stubbs, are giving it a try. They published a letter in BMJ and The Lancet urging politicians to take strong action on climate change.

The Clinical Corner
Patients turn with incredible frequency to the internet for health information. So much of it is questionable, to put the right information out there is a challenge. Here are some fine efforts.

The Fitness Fixer – Prescription Acid-Reducing Drugs Produce Heartburn and Dependency

Forty percent of 120 volunteers taking anti-heartburn drugs called proton pump inhibitors (PPIs) had a rebound increase in gastric acid secretion, resulting in acid levels above their starting levels.

Highlight Health – H1N1 Vaccine Study Summaries

[A] single dose of the H1N1 vaccine will offer protection for most adults within three weeks of vaccination.

Medicine For The Outdoors – Vitamin C & Gout

How does a person prevent gout? The basic tenet is to minimize uric acid production in the body, and/or to prevent its precipitation into crystals within the body’s tissues and fluids. There are risk factors associated with suffering from gout, so doing one’s best to mitigate these is the proper approach.

Allergy Notes – The Term Asthma Is A Greek Translation For Gasping Or Panting

The best clinical description of asthma in later antiquity is offered by the master clinician, Aretaeus of Cappadocia (1st century A.D.). The numerous mentions of “asthma” in the extensive writings of Galen (130-200 A.D.) appear to be in general agreement with the Hippocratic texts.

Miscellaneous
Some of the best things we read are difficult to classify. They’re multidisciplinary or they look at situations in such a new light that we can’t really put them in a box. The following are submissions of note that I enjoyed but didn’t think fit into the categories above.

Teen Health 411 – Thinking About Bullying In A New Way

Bullying is also being defined more broadly now as not only repeated taunts or attacks, but as spreading rumors and social exclusion. Whether it happens on the playground or on Facebook, bullying is destructive to any community or school. Bullies and their victims are more likely than their peers to experience depression, suicidal thoughts, less likely to finish high school or hold down a job. Bullying is traumatic for everyone involved and the grief and the experience and difficulty of moving forward with life is the same as people who have lived through other traumas.

The Cockroach Catcher – NHS & Vogue

I read that McKinsey, one of the leading Management Consultancy firms is expected to recommend 25% cost cuts at Vogue. They have already advised a 10% staffing cut in The NHS to achieve a saving of £20 billion by 2014.

In actual fact the NHS could have saved even more money by doing away with the likes of McKinsey.

That does it for Grand Rounds this week. Marking six years. I hope you enjoyed it. Until next week at MedLibLog take care.

Sunday, September 20th 2009

Homeopathy Is Good For Something…

…a laugh. I’ll leave the debunking to Orac and others but I thought this video of Irish stand up comedian Dan O’Briain was pretty damn funny.

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Friday, September 18th 2009

A Sense of Urgency

A traumatic subdural with a pretty good shift deteriorates on his transfer from some rural area, gets to your hospital as a GCS of 7 and needs to go to the operating room emergently. His next of kin rode on the transport to your hospital. Other family members are en route by car but are some distance out.

You try to consent his next of kin using phrases like ‘emergency,’ ‘right now,’ ‘life and death’. The response is a lot of waffling, a request to wait until the rest of the family gets to the hospital, and calls to those same family members seeking advice.

I seem to have run into the above, or the equivalent, several times over my still young intern year. Not every night or every week, but a few times. Too many times.

I understand such situations are incredibly stressful for those presented with a decision for an emergent procedure (or not) for a loved one. I understand a lot of information is presented to them in a short period and they’re asked to digest it under stress and make one of the most important decisions of their lives.

I’m not sure it excuses trying to skirt the responsibility.

The most frustrating instances involve those legally responsible asking you as the provider to seek the opinion of other family members and to have them decide.

“Oh, I just don’t know! Can you call his sister and have her decide?”
“I’m happy to talk to her and anyone else in the family, but this is something I really need consent from you for.”

Admittedly it could be me. I don’t think so however. I think I present the situation generally with the proper sense of urgency and yet lay out the decision to be made and the options and the consequences of each option in a pretty down to earth and understandable way. The few times I’ve run into this, others – my residents, fellows, faculty – who have come along to talk to the family after me have had the same problem.

True, maybe as the first to attempt consent I’ve spoiled the whole pot for all who follow. More likely the commitment and responsibility owed to a loved one breaks down under the spotlight of the situation for some.

Decisions under time pressure, with limited information, with a loved one at stake are incredibly difficult and I try to check my frustration. However, a sense of responsibility is just sometimes lacking from those asked to choose to either put the pen to the consent form or to refuse to put the pen to the consent form.

Tuesday, September 15th 2009

I Hate Poo

Life as a healthcare provider is privileged. You get to see a lot of humanity. The good, the sad, the humorous.

Probably two weeks into being a physician I had to push neostigmine on a patient. Neostigmine is a powerful cholinesterase inhibitor that among other things causes…significant bowel contraction. Which is why I was using it. My patient had come into the trauma ICU following, literally, a nose bleed. Early onset dementia had left the patient in a nursing home and following a fall at that nursing home no one had been able to stop his epistaxis. Down in the ER they had literally stuck foley catheters deep into his nostrils and inflated them to apply pressure and stop the bleeding.


Typically Doesn’t Go In The Nose

He had a lost a lot of blood and had a lot of comorbidities and was at high risk for rebleed and so he ended up in the ICU. Easily, supposedly the least sick patient in the trauma ICU.

He had significant deconditioning on presentation and likely had some generalized ileus. Being in the ICU and further bedridden didn’t make his condition better and his belly started to grow. A KUB sometime into his stay showed a pretty significant generalized ileus without evidence of obstruction. Enemas and other efforts didn’t do a lot to decompress him. So my resident sent me in to give the patient neostigmine.

Neuostigmine isn’t always a benign drug. ‘Side effects’ include bradycardia and, that persisting, arrest. So my resident had me go into the room to administer the neostigmine with a syringe of atropine should I require it. The rest of the team, in a telling move, stood outside peeking into the room; they feared the consequences of rapid bowel contraction.

I slowly push the neostigmine and I stand there, vigilant, grim waiting to have to urgently give the atropine if needed. I’m tense. I’m a two week old doctor and my resident has made this out to be a serious medication.

Suddently my patient starts with, “I have to go. I have to go. I have to go.”

“Okay, sir, we’re getting you a bed pan,” I say. It does nothing to temper my poor demented patient, “I have to go. I have to go. I have to go.”

The nurse runs out of the room to get a bed pan; an admitted oversight for everyone involved in this endeavor. “I have to go number two!”

“It’s okay, sir,” as we slide a bed pan into position. “You can go if you need to.”

I’m watching his heart rate on the monitor and then the patient starts throwing in a new phrase. At first I think he’s saying, “I hate you.” But as I strain to listen it’s clear, “I hate poo. I hate poo. I hate poo.”

I almost lose it. Sitting there with atropine in hand should this patient have a crisis and brady down, I have to turn around and walk to the corner trying to stop myself from laughing.

I refuse to call it unempathetic; there was something endearing and worth a non-condescending chuckle about what we were putting this man through to treat him and help him. It’s the humanity of practicing medicine.

“I hate poo. I hate poo. I hate poo.” Me too.

Tuesday, September 15th 2009

Grand Rounds Is Back

For just about a year now I’ve helped run the day-to-day operations of Grand Rounds, the premiere medical blog carnival.

Now I have a new personal blog. It also happens to be, I believe, the 6th anniversary of Grand Rounds. Combine the two and you get me hosting Grand Rounds; a one time deal.

I’ll be hosting it Grand Rounds Vol. 6, No. 1 here on Tuesday, September 22nd. Consider this a call for submissions for a Birthday Theme Edition. Please send any and all of your best to colinson(at)gmail(dot)com with a subject of ‘Grand Rounds Submission’. I’m looking forward to it.

The deadline is going to be Monday, September 21st at Midnight (Central Standard Time; GMT – 5).

Monday, September 7th 2009

Obamacare: Health Care In America

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President Obama is set to address a joint session on September 9th specifically on health care

President Barack Obama will address a joint session of Congress on health care reform in prime time on Wednesday, Sept. 9.

Obama plans to give lawmakers a more specific prescription for health care legislation than he has in the past, aides said.

Presidential aides have promised Obama will take back the reins after allowing Congress to work its will on his idea, without one specific plan for Democratic lawmakers to defend back home. We’re entering a new season,” senior adviser David Axelrod said in an interview Tuesday. “It’s time to synthesize and harmonize these strands and get this done. We’re confident that we can do that. But obviously it is a different phase. We’re going to approach it in a different way. The president is going to be very active.”

Not exactly a return to form. This administration has never been terribly specific on health care. They’re ‘for a public option’, then a ‘public option isn’t a necessity for reform’. This effort at healthcare reform has been anything but fixed with a message. This wasn’t Edwards’ campaign, this wasn’t the Clinton’s first effort. And perhaps those examples gave him some reserve.

It isn’t like the House and Senate are currently being led by the likes of Sam Rayburn and Mike Mansfield. Strong leadership was probably in order on this issue from the White House. And while the President may be attempting to provide it now with this prime time address, it is very late. In purely political terms Obama’s wishy-washy wants and generally hands off approach has been catastrophic to the chances of ‘meaningful’ healthcare reform. The administration’s management of Congress to date has been something less than Johnson-esque.

What exactly have they screwed up however? What exactly is being discussed when we talk about healthcare reform efforts in Washington right now?

I thought it only fit that one of my first posts on Residency Notes be a primer on the current healthcare reform debate.

I’ve commented pretty extensively on healthcare policy in the past. Hopefully my previous posts from From Medskool will be up soon and so I don’t want to repost simply what I’ve said in the past. I don’t think I shy away from the nitty-gritty. I’m not a wonk but I’ve dug through the published comparative quality data, the cost breakdowns, the history of healthcare reform in this country, the proposals. I enjoy this stuff. My point is this post isn’t a rant on the subject, this isn’t (in entirety) an op-ed; I’m pretty well read on the subject and I want to break it down because when talking with people I sense a lot of confusion on what exactly is going on with reform and I imagine the immediate future will get even murkier in Washington.

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Thursday, September 3rd 2009

How The AARP Got It Wrong

For an organization touted for an apparently powerful lobby, especially on health care, how has the AARP gotten it so wrong, so often?

They failed miserably with their support of Hillarycare and they appear to be failing on reform now.

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Amidst reports on defecting members, the AARP continues to support healthcare reform centered on a public option.

Here’s the reality however: America’s Medicare beneficiaries are scared about rationing.

The closer a health care system is to a global budget (and don’t kid yourself the public option is a backdoor to a single payer system) the more overt and systemic its rationing becomes. And one of the places such rationing is going to preferentially occur is at the end of life.

Now, if we’re rational about it such rationing is defensible. But hard to argue that to many elderly, especially with opinions on end of life care being what they are in this country.

I’m not talking about ‘death panels’ but we should be realistic. Expectations in the United States for end of life care outpace a good chunk of the rest of the world and the utilization of healthcare resources and dollars at the end of life in America is profound. The value of such jusn’t in there, it does not change outcomes. Despite that the American elderly are more likely to expect everything be done, that the money be paid, that the technology be used.

That do everything mentality may have to change the closer America gets to a global budget system. And yet the AARP is trying to convince their constituents that such rationing isn’t coming; that their expectations can remain the same as the American healthcare system is reformed.

It is a poor message.

I think part of the problem is that the AARP no longer has a constituency. It is not an advocacy group for retired people anymore, there are almost no shared characteristics for individuals over 50 that necessitate a specific advocacy group. That 52 year old gentleman who is working and insured and years from retirement has little in common with that 55 year old laid off from his job and stressing over his health bills who has little in common with that 72 year old who is retired and getting his care paid for by Medicare.

Who is the AARP representing on this issue?

As well, the AARP has long had a conflict of interest in lobbying on healthcare because so much of its operating budget comes from selling packaged healthcare services which it has lent its name to. Medicare part D plans and others.

The AARP once again has misjudged the mood of its members and the country and, to be blunt, simply needs to get out of the debate.

Wednesday, September 2nd 2009

How Neurosurgery Hasn’t Changed

1933 removal of a CNS tuberculoma in the United Kingdom. Published by the Wellcome Library.