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Archive for November, 2009

Thursday, November 26th 2009

The Patient We Fear

If I’m ever in an acute care setting I want to be the specialist. I want to be hidden behind the wall of a consult. I don’t want to be the front line guy.

As much as I love shift work, detective work, immediacy in medicine I was turned off of specialties like emergency medicine because of scenarios like this:

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That is pretty much how it happens.

Thursday, November 12th 2009

Marketing On Facebook

I think just about anything should be able to be marketed to us, through any commercial medium. That’s not a terribly popular opinion however. The United States is one of the few in the world where direct to consumer marketing of drugs and medical devices is prominent. And you find medication adds all over the television and publications and even sometimes on display media. Increasingly your finding direct to consumer advertising of pharmaceuticals online as well. Like all advertising online advertising is regulated by the FDA. However, some of the online marketing opportunities fall into highly grey areas, as you might imagine as new technologies are utilized to pitch you drugs.

The FDA is holding a public meeting today about online and social media use by big pharma and medical device makers. Here’s the WSJ Health Blog describing the goals of the meeting.

The FDA says its holding the meeting this week to get input on “making policy decisions on the promotion” of drugs and medical devices on “the Internet and social media tools.”

Those schedule to speak at the meeting include people from trade groups (AdvaMed and PhRMA); Internet companies (Yahoo, Google); drug makers (Pfizer, J&J, among others); and assorted ad agencies, consumer advocates and the like.

As you might imagine whenever an internet and social media-saavy group is engaged, the commentary on the meeting has been real time and copious. You can find threads on Twitter or numerous blog posts detailing what went down during day #1 of the public hearing. Eye on FDA has some commentary on the conflicting agendas of various groups who have been given voice at the meeting.

If you missed the first day, the entire thing is on webcast and you can watch it live tomorrow when they pick back up.

Tuesday, November 10th 2009

Anatomy In The Victorian Era

New Scientist profiles the Wellcome Collection’s Exquisite Bodies exhibit looking at the portrayal of human anatomy in the Victorian era. I can almost guarantee that the next time I’m in London I will be at the Wellcome Collection; looks very interesting.

Monday, November 9th 2009

Physician Pay In The Reform Era

There’s no doubt that American physicians earn more than the rest of the western world. Even when you factor in the cost of medical education in the United States (and it is substantial) a medical degree remains something of a better investment in this country than essentially anywhere else. This is largely because doctors has far more control over their earnings in this country than do those in other western countries. As physicians here in the U.S. we’re largely fee based and not salaried.

Now physician income, likely, tallies somewhere between 10 and 20% of all health care spending in America. Depending on who you talk to that’s either substantial or it’s not. But the fact is that even when physicians don’t earn directly they drive health care costs with incentives, even if not financial, to promote health care spending in the form of tests/procedures/referrals.

As you might imagine, health care reform likely foreshadows changes to physician reimbursement in this country…at least in the long term.

Both NPR and the NY Times have recent articles on physician earnings under the shadow of healthcare reform.

Doctors who choose to work in nonprofit clinics seem to view their professions more as a calling than as a job. There is evidence that when medicine was less adversarial than it is now, American doctors were both happier and more respected, even though their incomes were much lower. Doctors elsewhere also remain satisfied and respected, though they are paid less than their American counterparts.

In time, medical schools will be able to attract plenty of talented people willing to accept positions under the Mayo model, where they would spend more time healing patients and less time fighting insurers. Any of the current health reform bills would help start this transition.

I’m not saying that physicians earn too much in America. They don’t. Indeed most healthcare systems undervalue physician services. I know much economic work goes towards valuing human life, which is always questionable, but I have hard time believing anyone would truly value the life of a loved one when it comes to health care services. Especially acute care services where mortality or severe morbidity are on the line there is essentially topless value to the services provided by physicians and the rest of the healthcare professions.

Despite that healthcare reform MUST eventually level off physician reimbursement in order to control healthcare costs. It is coming, whether it is fair or not, so get ready for it.

Sunday, November 8th 2009

From Cuba With Love

A Cuban gynecologist moves to America, becomes a car salesman and Tim & Eric help him make this hilarious commercial.

Sunday, November 8th 2009

Saturday Vote

The U.S. House of Representatives passed its version of healthcare reform yesterday. The amended and chopped up bill, as it came out of its three committees, was H.R. 3962.

The House bill has some key points. It has both a limited individual and an employer mandate. It sets up a national health insurance exchange. It has a public option, without an opt out clause; the public option exists as a free standing market institution (it must survive on its premiums alone) within the exchange and has no eligibility levels although no employer is required to offer the public option. It severely limits insurance companies, including when/if they can cancel policies and the maximum allowable out of pocket costs/yearly for anyone covered. It places a 5.4% tax on individuals earning at least $500,000 and families earning at least $1,000,000 to help fund the bill. It lacks an SGR fix, which makes it a surprise the AMA supported it. Here is a fine plain language summary of the bill. The WSJ has a summary as well about how the Bill plays to various staked groups in healthcare.

Pelosi lost nearly 40 Democrats and gained a single Republican in passing the bill. The New York Times has a great interactive graphic looking at the Democrats who opposed the bill.

This is a big step, no doubt but if reform is to happen much remains.

The path ahead remains shaky – for the bill and for many of the Democrats who voted to approve it. Party leaders need to mend the bruised feelings that will linger from this debate before they can address whatever legislation the Senate can produce.

And in the Senate, Majority Leader Harry Reid is still struggling to find 60 votes for Senate legislation and made clear he might not meet the White House’s Christmas deadline to pass a bill. Obama said in his statement, however, that he expects to sign a bill this year.

I don’t know what to make of the Senate situation. I’m not even sure the people in the know know what to make of the Senate situation. Certainly all the pressure is now on Reid.

Even before Saturday’s House vote, senators had begun to question why Reid suddenly embraced a public health insurance option – one that he didn’t yet have the 60 votes to pass.

In the process, the Senate debate over health-care has stopped dead, raising the possibility the Senate won’t even begin floor debate until after Thanksgiving. Reid himself recently left open the chance the final bill could slip until early next year.

That remark earned him a visit from White House Chief of Staff Rahm Emanuel, who showed up in the majority leader’s office a day later to press him on the urgency of the Christmas deadline, according to two Senate aides.

But it’s not just timing. Reid’s first task is finding a way to bridge the divide in his caucus between liberals pushing for a public option and moderates who have resisted the most ambitious version of that plan.

I’ll refrain from making a prediction that Reid will never get a full fledged public option, as appears in the House bill. Not after declaring the public option, in any form, dead earlier and being shown up. But obviously it isn’t likely that the Senate is liberal enough for such a public option. Even if Reid gets some form of the public option, such as with the opt out provision, it remains to be seen what happens when the Senate and House try to reconcile their bills; how far the Senate pulls the public option to the right.

We’ll see I suppose. My bet: A public option with an opt out, the tax increase is killed and Reid gets it passed sometime between Thanksgiving and Christimas. And the conference committee puts something out that looks a lot more like the Senate bill than the House bill.

Thursday, November 5th 2009

Tax Credits For Health Care

HT to reddit for linking to the OB&G in turn linking to the following appearance on Anderson Cooper and to Paul’s effort to prohibit a health insurance mandate and to his effort to give a 100% tax credit to all Americans for health care expenses and to his effort for national tort reform.

To call Dr. Paul’s ‘Comprehensive Health Care Reform Act’ reform, as the word has become common lexicon in Washington, would not be fair. The tax credit Dr. Paul proposes would probably do little to broaden health care access for those with current mediocre care. Even with the tax credit we probably don’t reach a place where most Americans can continue to fund an increasing percentage of their health care out of pocket. As well, as with most of Dr. Paul’s impressive proposals, it is a political non-starter. I think cutting government spending by dramatic levels is a noble goal, and such would be required to give all Americans 100% credits for every health care dollar they spent, but it certainly isn’t politically feasible. No matter how many Tea Parties are hosted.

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It doesn’t mean that the proposal isn’t a good one. As I’ve said I’m not sure our goal should be increased coverage; that we should be so fascinated with these kind’ve global health care outcome measurements. That health care should be a social concern. Certainly it shouldn’t be one with a government vested interest.

Essentially reform, as it is thrown around in Washington, calls for a trade of liberty for some ill defined right to health care. I’m not comfortable with that. And I understand, and concede, that only government intervention will improve these utilitarian metrics used to grade ours and all health systems. I understand, and concede, that only government intervention will further health on a population scale. But what it is going to cost, in terms of a further broadening of the role of government and an erosion of the right to property, to get that ‘universal’ access and to improve these numbers is unacceptable.

So I’ll continue to cheer on proposals like Ron Paul’s.

Thursday, November 5th 2009

Remember, Remeber The 5th of November

Today, in Commonwealth Nations, is Guy Fawkes Day. I’ve written about the history of the Gunpowder Plot; an interesting point in British history.

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Remember, remember the fifth of November
The Gunpowder Treason and plot;
I know of no reason why Gunpowder Treason
Should ever be forgot

Wednesday, November 4th 2009

Serum Ethanol Levels: Predictor of Survival

Anyone who has spent any time at a major trauma center knows the nearly comical tragedy of alcohol associated motor vehicle accidents where the inebriated driver survives and the fourteen-year-old in the other car somehow doesn’t. It tugs at our sense of fairness. I have a particular interest in trauma and while going through a feed of major trauma and neurosurgical journals came across this paper from a mixed group out of Los Angeles.

Salim, Ali, Pedro Teixeira, Eric Ley, Joseph DuBose, Kenji Inaba, and Daniel Marguiles. “Serum Ethanol Levels: Predictor of Survival After Severe Traumatic Brain Injury.” Journal of Trauma 67.4 (2009): 697-703.

It’s a retrospective study from a single institution mining the SICU/trauma database from one of the nation’s larger trauma centers, LAC+USC, for severe traumatic brain injury whose EtOH level at the time of admission was documented. Severe TBI was defined as a head AIS >= 3. Their question focused on outcome differences between those with serum ethanol levels at the time of their accidents and those without; their primary outcome being in-hospital mortality.

Over a five year period they found 482 patients with head AIS >= 3 and EtOH serum levels drawn on admission. That’s from nearly 3,000 in the trauma database over the five year range the group was searching.

The question was certainly answered in the affirmative. Any EtOH on board seemed to convey an in-hospital survival benefit.

Indeed the serum EtOH level correlated with survival.

The mean serum ETOH level was significantly higher for survivors than for nonsurvivors (0.11 +/- 0.21 g/dL vs. 0.05 +/- 0.10 g/dL, p = 0.001). The serum ETOH levels
significantly correlated with the probability of survival (r = 0.21, p = 0.001), but this correlation was not strong as shown by the low r-value.

As can be imagined with that primary outcome, in hospital complication rates were pretty much lower across the board for those with positive EtOH levels on admission.

These findings aren’t shocking, merely confirmatory. Studies by Tien [1] and O’Phelan [2] and Kraus [3] and Tate [4], as cited by the authors of this paper had documented better outcomes for those who are inebriated at the time of their head injury as compared to those who aren’t. And indeed this isn’t even Dr. Salim’s only publication from this data mining effort. He is lead author of another broader retrospective study recently in the Archives of Surgery looking at the NTDB.

Salim, Ali, Eric Ley, H. Gill Cyer, Daniel Marguiles, Emily Ramicone, and Areti Tillou. “Positive Serum Ethanol Level and Mortality in Moderate to Severe Traumatic Brain Injury.” Archives of Surgery 144.9 (2009): 865-71. Print.

There are obvious limitations to this study. It is retrospective, as likely all in vivo studies of alcohol and trauma are likely to be. As well there were a limited number of TBIs presenting to LAC+USC who actually had serum EtOH levels tested. Formal serum EtOH testing of all trauma patients as a standard is becoming more and more frequent but likely wouldn’t have changed the findings of this study seeing as there weren’t major demographic discrepancies between those who had their serum EtOH drawn and those who didn’t (as the paper goes over). It was a single institution as well, but of course I feel safe in assuming that LAC+USC has a pretty heterogeneous population as might be seen elsewhere in the United States and most of the world.

These well documented results seem to be one of those sad, ironic, situations in life if I can prognosticate. Obviously these studies have limited clinical value at present, but perhaps if there’s some true protective pathophysiology in EtOH consumption before trauma then future bench top work may elucidate that and open some doors on acute measures that might be taken for those with traumatic brain injury early following injury.

Read More »

Wednesday, November 4th 2009

Healthcare Fighting

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Mildly amusing. Get your fill of health care reform humor today.