Archive for July, 2012

Sunday, July 29th 2012

Wages As Part of Healthcare Expenses

American physicians earn more than physicians anywhere else in the world. Even the most primary care of specialties still, on average (see here and here for example) exist amongst the top 90% of all American earners. And despite the mythos of the physician work ethic per hour earnings compares well to individuals with similar years of education and training. It’s true, physicians are also saddled with larger education debt and other burdens but even considering such, in adjusted terms, American physicians are doing better financially than doctors anywhere else in the world. And they’re doing better than the vast, vast majority of American workers.

Conceded, that espeiclaly amongst primary care phsyicians, there are examples of careers physicians could’ve chosen that would’ve been better for their wallets. In my experience many a physician points out what they think they could’ve earned in business, with far less lost earnings to education, had they chosen that career path. Those are anecdotal dreams usually but in a recent piece, Drs. Kenneth Chen and Judith Chavlier argue that female physicians planning for a career in primary care would be better off financially becoming a physician assistance instead.

I take that as a lone scenario and despite that recent publication the situation remains that doctors are in a pretty good place.

You hear much about tying reimbursement to performance or leveling the playing field between primary care and specialists, but rarely is the argument made outright that physicians simply earn too much. So this article in The Weekly Standard (h/t Andrew Sullivan) is novel in that regard.
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Saturday, July 28th 2012

Doctor As Drug Trafficker

Being a physician who focuses solely on pain is a dangerous occupation apparently just see here or here or any other examples.

‘Pill mills’ are a real problem (and not just in Florida) which routinely make the news. So the following story is remarkable only in the example of brazenness that actually got reported.

The deputy…showed ["Dr."] Atiga the dog X-ray [and] told the doctor she was in a car accident several weeks before her visit and needed “something way stronger” than the Tylenol she claimed to be taking, according to an audio recording of the visit reviewed by The Times.

The doctor asked few questions before listing the drugs he could prescribe.

“Do you want to try Vicodin ES?” he asked. “Or do you want to try others? … Roxicodone? Or oxycodone? … Or whatever you want….Maybe some Valium or Xanax.”

The deputy chose Roxicodone and pulled out two X-rays of the dog. Atiga examined them and referred to specific bones, explaining what they were to the agent, according to the recording.

“That’s the hip joint right there,” the doctor said, apparently indicating one of the dog’s bones.

Glendora police had received complaints “that for the right amount of cash” the doctor would “write prescriptions for you” and pocket the cash, Police Capt. Timothy Staab said.

“He was well-known among drug addicts and prescription medication addicts,” Staab said. “He was the doctor to go to.”

The doctor is believed to have asked patients, who paid hundreds of dollars for prescriptions, to give his receptionist a $50 tip “for her time and troubles,” Staab said.

Atiga has a prior felony conviction for taking illegal kickbacks in return for referring Medicare patients for home health services, according to state medical board records.

Indeed, the x-ray above is one of the images the undercover deputy showed the physician.

This kind’ve activity is apparently far too common and a real stain on the physician as a brand. I know there are times when there is reasonable disagreement about the appropriateness of certain actions by doctors, especially as it relates to prescribing opiates and other higher class pharmaceuticals; cases where aggressive government action is worthy of criticism. But cases such as the one above, so blatant are real problems and need to be routed out and dealt with.

Monday, July 23rd 2012

Research At Your Peril

A physician can’t employ novel, potentially dangerous, treatments on you, even with your permission, without crossing off Institutional Review Board approval. The IRB critique process is designed to weight the risk/benefit of the proposed study and assure appropriate informed consent of the subjects. And in the case of new drugs or devices, the physician can’t do it without running through the Food & Drug Administration.

And so the confusion out at UC-Davis right now, involving the chair of neurosurgery, is likely to grab some attention.

In 2008, [UC-Davis neurosurgery chair Dr. J. Paul Muizelaar and his colleague Dr. Rudolph J. Schrot] proposed treating a glioblastoma patient with bacteria applied to an open wound to “attack the tumor,” then later withholding antibiotics and letting the bacteria do its work.

Schrot contacted the FDA but ultimately was cautioned that animal studies were needed first.

Back at UC Davis, IRB chairman [Dr. John] Anderson…was also skeptical. Anderson told Schrot in an email that denying this patient the treatment would be “likely devastating to this family,” but that he believed the FDA and UC Davis “won’t allow this product to be used in humans without further testing,” internal documents reveal.

Despite the initial roadblock, Muizelaar and Schrot “strongly believed that the intervention with intentional wound infection was promising for patients who otherwise faced certain death,” according to [a letter from Harris A. Lewin UC-Davis' vice chancellor of research]

[...]

Between October 2010 and March 2011, the physicians went forward with three procedures on humans with malignant brain tumors, surgically introducing probiotics into their open head wounds.

[...]

Schrot got IRB permission to move forward on Patient No. 1 with a “one-time procedure” that was “not associated with any research aim,” the letter states.

University documents show that the physicians believed they had been given the go-ahead for all three surgeries, but officials later determined that they had been misinformed or were misunderstood by the doctors.

Muizelaar and Schrot stressed to The Bee that all three patients, in consultation with their families, gave their consent.

[...]

In the case of Patient No. 1, the investigation found, Schrot had made an “incorrect statement” about restrictions on the bacteria’s use, leading IRB staff to incorrectly conclude that such review was not necessary, Lewin told the FDA.

As for Patients 2 and 3, the university found that treating them with an “unapproved biologic” amounted to human-subjects research – and thus required prior review and approval.

The idea of infections stemming cancer progression is hardly unprecedented and is reported in the literature for everything from lung cancer to bone cancers. Indeed, even intentional infections in cancer patients have a history. And, although two recent relatively large retrospective studies from 2009 and 2011 failed to show post operative infections improved survival in GBM, the issue remains equivocal with more anecdotal reports supporting the idea that infections may promote an immunologic response against the tumor itself.

Much of the issue seems to center on the idea of these bacteria as a ‘biologic’. If what Drs. Muizelaar and Schort did constituted ‘research’ of a biologic then there is likely real trouble ahead and much, if not all, of UC-Davis’ federal research funds, from all sources, could be at risk. It probably bodes well that if the University thought there was something wrong going on here that they self reported it and potentially did so in a relatively timely fashion.

I’m not going to jump to conclusions here. Although two patients seems to have had poor outcomes, potentially related to the treatment, it seems very plausible that this is a matter of bureaucratic misunderstanding. I understand the idea behind IRBs and the reasoning of a level of paternalism that most bioethicists feel patients need,

Arthur Caplan, director of medical ethics at New York University’s Langone Medical Center, said that desperate people are especially vulnerable and need added protections.

“If you’re dying, you’re kind of like reaching out to anything that anybody throws in front of you,” said Caplan, who recently left the University of Pennsylvania’s Center for Bioethics to assume the New York post.

“That’s why so many people over the years are pursuing quack cures in Mexico and all kinds of questionable treatments,” he said, speaking in general terms. “They’re not able to think straight because they’re at death’s door.”

Caplan said that institutional review boards are often misunderstood, with many people believing that such strenuous oversight is “a lot of bureaucracy to get in the way of trying something to save lives.”

In reality, he said, the committees are an essential safeguard for research subjects, who may not get an unbiased view on a researcher’s consent form of the study’s risks vs. benefits.

Maybe the informed consent portion should be the sole purview of the IRB. It is true that the ‘informed’ in informed consent can be a matter of contention, there is very often a wide discrepancy in information between a provider and patient. However, if Drs. Murzelaar and Schort, provided a reasonable view of the risks versus very potential benefits to these patients, even if the use of the bacteria actually under law fell to the FDA for permission, I would be inclined to step back, take a very libertarian view and think much unnecessarily is being made of the situation.

I’m sure fuller details are to follow. It is unfortunate that this is playing out so publicly at present.

Thursday, July 19th 2012

I Love My Pager

As long as I’m a resident and I’m not serviced by a call center I will love my pager. I say this despite my love of all things tech.

And apparently I’m becoming slightly anachronistic.

Doctors don’t want to carry a pager anymore. They want to carry their iPhone or their Android device.

The quote above comes from Brian Edds, for Ancome Software, in an NPR story titled ‘Are Pagers Obsolete?’. So many I’m out in the minority, but I want my pager. I’ll be brutally honest about why but I don’t want people to be able to reach me on a whim. At least not while I’m a resident. I’ve written before about the abuse of communication with resident physicians. About how matters are triaged ineffectively at academic centers, partly I suspect, because it seems as less of a faux pas to call a resident, as say, a ‘real’ doctor out in the private world.

As such, I don’t want my phone ringing while on call. I return my pages timely but I want that barrier wherein I have to return the call. That barrier where I can triage the calls myself. A text page about a missing home medication can wait until I’m done with a procedure, a page from the ER may need more immediate scrutiny. A phone call takes away some of that discretion. And until the amount of frivolity goes down, until I’m out in the world practicing and deciding the systems in which I’ll practice, I want my pager.

Tuesday, July 17th 2012

Asleep At The Scalpel

I once saw a surgeon tell a family that they should delay their child’s brain tumor surgery a day because the surgeon had been on call the night before and up all night with an emergency and was not at his best. It was an impressive admission and raised my level of respect for him. The family as well seemed encouraged, not skeptical, of the admission, and so the surgeon moved his cases around for the next day and pushed the brain tumor surgery back a day.

Surgeon fatigue is a difficult thing to demonstrate for publication but anecdotally is a real issue. Even with the duty hours I’ve suffered nearly the exact same story as Dr. Youn, writing on CNN.com,

Heaviness returns to my eyelids. I’m dancing on the edge of sleep. Five minutes later, I lose the battle. My head briefly bobs down, then back up.

I immediately look around. Has anyone noticed? Apparently not the surgeon.

I look at the scrub technician, sitting to my right. She nods her head at me, knowingly. Then she digs her heel into my foot. Hard.

I suppress a yelp.

I’m awake now.

Minus the heel to the foot.

Indeed, when I was a medical student, after less than 24 hours awake I suffered a microsleep while I was suppose to be driving the camera for a lap appendectomy. The scope was out of the body at the time, but the chief resident had to reach over and punch me in the shoulder and demand, “Wake up!”

But for all that, I’m not sure regulation of resident work hours are the solution. The fact of the matter is we need to know when our limits have been reached. And especially for non-urgent care we need to be honest with patients on those very rare occasions when those limits have been reached. I’ve seen it happen at least once and it is how I want to model my future practice.

Monday, July 2nd 2012

International Care From Socialized Medicine

An interesting piece on ‘rationing care’ in single payer systems. The piece in The Guardian focuses on British patients who are sent overseas for specialized therapies not available in the United Kingdom, with the trips funded by the NHS. And how that compares to the current U.S. system.

Ethan [who has an ependymoma] is in the US because the NHS as yet does not have proton therapy machines, although the UK government has just agreed to fund two of them, in London and Manchester.

Pay for service models will obviously be inefficient and provide a plethora of potentially unnecessary care. There are probably strategies to mitigate the inefficiency of over use in a fee for service system, but they will never be as effective as the central control afforded in a single payer system.

The scary thing about such overt rationing, as in the NHS, is it removes some control from the patient and their personal physician and puts the control in the hands of committees of amorphous physician ‘experts’ and bureaucrats who deem what is appropriate and available care and what is not. The great fear is that such a system will deny effective or questionably effective care as a matter of cost.

The reality is that the U.S. system already does this. Private insurers already deny payment for treatments as being unproven. Centralizing this rationing and making it more transparent and overt may be an answer. Certainly it seems the case with the NHS and proton therapy.