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    Friday, July 02, 2004

    More Notes: On the other hand, this 1940's surgical note is so extensive, it even includes the surgeon's anxieties.
     

    posted by sydney on 7/02/2004 08:14:00 AM 0 comments

    Generic AIDS Drugs: Looks like an Indian-produced generic AIDS drug may be just as good as a brand name drug:

    A cheap three-in-one generic AIDS pill from India is just as good as more expensive branded medicines and should be widely used in developing countries, researchers said Friday.

    Lack of scientific evidence about the clinical effectiveness of such generic fixed-dose combinations has until now caused some international AIDS donors to refuse to fund their use.

    But a team from the French national agency for AIDS research and Swiss charity Medecins sans Frontieres said Cipla's Triomune performed as well as brand drugs in the first open clinical study in a developing country.


    The study only lasted six months, but the generic pill made the HIV viral load undetectable in 80% of patients. The researchers say that that's the same sort of performance you see with the brand name drug. If so, that represents a tremendous savings potential, since the generic is $15 less a month than the brand name. The generic still hasn't been tested for safety, but if you're living with AIDS in a part of the world where clean drinking water is a challenge, a generic drug would certainly be better than nothing.
     
    posted by sydney on 7/02/2004 07:54:00 AM 0 comments

    Evolution of a Note: I've got documentation fatigue. Having not yet brought my office completely into the electronic age, the endless grind of writing down everything that passes between me and my patients day after day is getting to me. What was once brief enough to be called a "note" has evolved into a short story.

    Once, doctors' notes were just that - brief notes to jog the doctor's memory. I have a patient whose previous doctor died at the age of 90. When she transferred to me after his death, his office notes transferred to me, too. She's a young woman in her twenties and had been his patient since her infancy. His medical record from those twenty-some years fits entirely on a 3x5 card. He didn't have chart racks, he had card file boxes. A typical entry looks like this: "7/1/88- ROM -Amox." That's it. The thing is, I know what that means. And so would every other primary care physician. She was treated for an infection in her right ear with amoxicillin.

    Contrast that with the "properly done" modern note:

    Subjective: Eight year old white female complaining of right earache for three days. No fever. Preceded by one week of runny nose, cough. No headache, no shortness of breath, no sore throat. No change in her past, family, or social history. (If she's a new patient that would have to be fleshed out. It would need to include who she lives with and their smoking habits, whether or not she's ever been hospitalized or had surgery, and if so why, and the medcial history of her immediate family members.)

    Physical Exam: Temp- 99.9 Pulse - 98 BP 100/60 Respirations 18

    Alert, pleasant, no acute distress
    HEENT: R TM red, bulging. L TM normal. Nasal mucosa edematous and boggy. Pharynx benign. Conjunctiva without injection.
    NECK: Supple. Shotty right anterior cervical nodes. No masses. No thyromegaly. No nodules.
    LUNGS: Clear, with good air movement bilaterally.

    Assessment: 1. ROM

    Plan: Amoxicillin 250 mg po TID x 10 days. Disp: 30 Refill x zero.
    Discussed expected course of illness, mother to call if deviates.
    Discussed possible side effects of medication.


    Even using all of those abbreviations, it still took me about five minutes to type that. And that's a brief and easy note. A note for a diabetic with hypertension and heart disease can easily run two pages. And yet, if I died tomorrow and my note passed on to the patient's next doctor, he wouldn't get any more useful information out of it than "ROM - Amox."

    Why did the note change so much? Well, the obvious answer is that it changed for legal defense reasons. The most oft-repeated phrase I heard in my clinical rotations in medical school was "if it isn't written down, it didn't happen." Some time in the 1970's the doctor's note stopped being a document intended for himself and other doctors and became one intended for attorneys and juries. That's when the note expanded to its modern form. But it's taken another step forward in the past ten years. It's now also a document for third party payers who review the doctor's work. And the problem with that is, they neither like nor understand the abbreviations, which makes it an even longer writing process.

    Our hospital pays people to go through all the patient charts (while they're still in the hospital), looking for documentation glitches that may be used as excuses by third party payers to shirk their duty. They leave post-it notes on the chart with suggestions for better documentation. Sometimes it's a reminder to include a minor diagnosis in the progress note. (Like a headache for which the patient was given Tylenol the night before.) But, sometimes, it's a note requesting that physician short-hand not be used. For example, hypernatremia, which means a high sodium, is often expressed in doctors' notes as upward pointing arrow next to the chemical symbol for sodium, "Na". But, according to the reviewer, "upward arrow Na" is not a Medicare-recognized diagnosis. Of course it is. It's shorthand for hypernatremia. And a commonly used, unambiguous shorthand, too. But, we have to march to the tune of he who pays, so my notes just get longer and longer.

    Someday soon, I'll buy an electronic medical record, if my malpractice insurance premium allows it. I hope my hands can last.
     
    posted by sydney on 7/02/2004 07:39:00 AM 0 comments

    Organ Hazards: Add another disease to the list of illnesses that can be transmitted through organ donations - rabies:

    The lungs, kidneys and liver of an Arkansas man who died in May were donated to four patients in Texas, Oklahoma and Alabama, the Centers for Disease Control and Prevention said Thursday. Three of them died of rabies; the fourth, in Alabama, died of complications during surgery, the CDC said.

    The donor had shown no symptoms of rabies before his death from a brain hemorrhage, said Dr. Mitchell Cohen, director of the CDC coordinating center for infectious diseases.

    'We are learning as we go this has never happened before,' Cohen said.

    While these are the first known cases of rabies being spread through donated organs, at least eight people have contracted the virus through cornea transplants, the CDC said.


    Rabies is extremely rare, at least in humans. There are only zero to two cases a year in the United States, thanks to the friendly dog warden and rabies shots for pets. (And the fact that most of us don't live in close proximity to our wild animal friends.) It isn't so suprising that it's taken this long to find out it can be transmitted from organ transplants.
     
    posted by sydney on 7/02/2004 06:43:00 AM 0 comments

    Thursday, July 01, 2004

    Payola: Pharmaceutical industry employee Derek Lowe says that the practice of paying doctors to prescribe drugs is worse than payola. It certainly is, for all the reasons he states.

    Given human nature, it's almost possible to understand how this comes about on the drug company's side. The sales force hears every day that it's imperative they increase sales. They have goals to meet to keep their jobs or to make their pay. A salesman with a widely used product, like antibiotics or ulcer medication tries make it up in volume. He'll visit more doctors more frequently and give out more samples to try to persuade them his product is best. But a salesman with a more limited market - cancer drugs, hepatitis drugs, etc. - has a much harder job. There are only so many specialists in any given area and they can't really give out samples. So, they give in to the temptation of the payola scheme.

    But what on earth motivates these doctors to except it? Beyond greed? Sure, some of them are also employees and under pressure to "produce more" by their employers, but it's doubtful that drug company money gets counted as part of their productivity. And certainly, they don't need it to pay the bills. Especially in specialties like gastroenterology where endoscopies are a very lucrative business. It's hard to explain it beyond pure greed.

    It's a practice that should never be condoned. It gives both the pharmaceutical industry and medicine a black eye.

    UPDATE: But according to one of Derek's commentors, payola is even more pervasive in Europe:

    I have a relative who is a doctor in Europe, working for a government hospital and isn't paid much. Several times a year drug companies pay for her and her family to go to "conferences" at resorts around the world. The companies monitor what drugs she prescribes and reward her with more conference vacations. This is Europe where they get at least two months vacation to fill up. Of course she prescribes what they tell her to. Otherwise her family could never go on vacation on her offical salary. And it's not just her, that's the way the system works there.

    Drug companies keep track of what we prescribe here in the U.S., too, a practice I find deplorable since it lets them target the underprescribers for more intensive marketing. On the other hand, nobody's ever come to me offering rewards for being a big prescriber of anything. Maybe may prescribing patterns are too varied.
     

    posted by sydney on 7/01/2004 10:06:00 AM 0 comments

    Wednesday, June 30, 2004

    Stranger than Fiction: A new therapy for heart failure?

    It sounds like the brainchild of a mad scientist: Draw blood from the arm, heat it up, pump it with oxygen and bombard it with ultraviolet light and then re-inject it into the patient's butt.

    But as strangely unorthodox as it may seem, the process -- called immune modulation therapy -- may well be a legitimate and effective means of treating heart failure.

    ...The key scientific notion here is that inflammation plays a pivotal role in the development and progression of heart failure.

    The new blood-zapping procedure "targets inflammation by kick-starting the immune system's anti-inflammatory response," Dr. Isaac said.

    Immune modulation therapy, a patented therapy developed by Toronto-based Vasogen Inc., involves taking about 10 cubic centimetres of blood (two teaspoons), then putting it into a machine that "stresses" the blood by subjecting it to heat, oxidation, and UV light.

    Those stresses are designed to induce apoptosis (cell death) in white blood cells, those that influence the body's immune response.

    When this zapped blood is re-injected into the patient, the dying cells trigger a powerful immune response.


    Seems about as sound as chelation therapy. And in fact, it is completely experimental. Or, more appropriately, theoretical. It hasn't undergone any sort of trial to test its effectiveness or its safety. But it's cutting edge, so it must be worth a write-up in the paper!

    UPDATE: A reader points out that this is old hat in other ways, too:

    You might be interested to know that the re-injection of a patient's own blood has been popular in Germany for many years. It is used, as you might surmise, for exactly the sort of remitting/exacerbating conditions for which no good therapy exists, such as osteoarthritis. It is called in German "Eigenbluttherapie" or "Own-blood-therapy."

    About thirty years ago or so, I remember meeting a fellow who had been instructed to inject himself, intravenously, with his own urine. Equally faddish, but probably more palatable than the time-honored Vedic practice of amaroli, the oral ingestion of the morning's first urine. That's something they don't teach in the yoga classes at the YWCA.


     

    posted by sydney on 6/30/2004 08:49:00 AM 0 comments

    Sued Again, Naturally: George Harrison's doctor is being sued again. The ex-Beatle's estate sued him for taking advantage of Harrison's celebrity. That suit was settled out of court. Now, a Florida woman, whose husband died of pancreatic cancer, is suing him for misleading advertising (via the same attorney):

    In January 2002, Mr. and Mrs. Ryan received a marketing kit from Drs. Lederman and Silverman which touted body radiosurgery as having a success rate of more than 90 percent, the lawsuit said.

    In a video sent to the Florida couple, the lawsuit claims, Dr. Lederman said, 'We're seeing tremendous results; results in many hopeless cases.'

    The media kit video included patient testimonials, which are illegal under New York law, said Matthew Lifflander, an attorney representing Mrs. Ryan.


    That does seem beyond the pale - direct marketing to desperate cancer patients. George Harrison and celebrity play a role, too:

    The Florida couple decided to move to Staten Island to pursue the treatment in April 2002. When they arrived in Dr. Lederman's office, they saw autographed photographs of George Harrison, who had been treated by Dr. Lederman, which made them believe they were seeking the best possible treatment, the lawsuit says.

    Is it really the doctor's fault that they were so easily star-struck? No, but institutions do like to brag about the celebrities who come to them, knowing full well that a certain segment of the population will be impressed.

    But here's the meat of the matter. The over-selling of what is in actuality an experimental therapy:

    When Ryan's son asked Dr. Silverman whether body radiosurgery would prolong Ryan's life, Dr. Silverman said he could live one to 10 years longer and would have a 'good quality of life' after the procedure, court records say. The doctors told Ryan's family members that radiosurgery is a 'non-invasive technology that is highly successful in treating selected primary or metastatic cancers,' records state.

    Body radiosurgery is a highly directed form of radiation therapy. Its advantage is that it concentrates the radiation in the area of the tumor, hopefully sparing adjacent healthy tissue. Who knows what the doctor actually said to the patient. There's often a marked difference between what is said and what is heard. Desperate hope has a way of filtering out the bad and only letting in the good. But here's how

    Stanford describes their radiosurgery:

    In a recently completed study at Stanford University Medical Center, patients were treated with radiosurgery at a "low," "middle," and "high" dose.  In 100% of patients treated at the "high" dose, all patients had their pancreatic tumors controlled for the rest of their life. 
     
    But, if you have the stamina to slog through the study, you find that the "rest of their life" was a median of eight months. Their tumors may have not gotten any bigger, but they all died anyway. No doubt to a radiation oncologist this is success. The therapy worked. The tumor didn't grow. But, of course, to the patient it's a dismal failure.
     
    posted by sydney on 6/30/2004 08:43:00 AM 0 comments

    Hyped Thyroid: The other day one of my patients asked me to check her for that "disease you doctors always over look." Which one would that be? We're accused of so many. But I knew which one she meant. Hypothyroidism. You can't pick up an issue of a popular women's magazine without finding an article about it. They always go on in a vague sort of way about how doctors misinterpret the tests or overlook the symptoms. These are irritating because the diagnosis is fairly straight-forward. You just do a blood test. Either it's normal or it isn't. And quite honestly, it's the first test most doctors reach for when someone complains about those vague symptoms of fatigue and weight gain.

    But now I know why there's been so much press given to the issue. The American Association of Clinical Endocrinologists has a public awareness campaign about thyroid disease, which evidently has been a smashing success. Unfortunately, the AACE promotes definitions of thyroid disease that run contrary to all evidence-based definitions. Why would they promote something of such marginal worth so widely ? Could it be because their corporate sponsor for Thyroid Awareness Month is Abbott Laboratories, maker of Synthroid? Or is it the combined influence of many of their corporate sponsors?

    Adopting the recommendations of the AACE for the screening and treatment of hypothyroidism would increase the numbers of Synthroid users by millions, according to their website. That would be tens of millions of extra dollars a month going to the association's sponsors. Doesn't quite seem kosher, does it?
     
    posted by sydney on 6/30/2004 06:45:00 AM 0 comments

    Tuesday, June 29, 2004

    Preparedness: Is the bioterror preparedness program a boondoggle? One microbiologist says "yes":

    In the end, Dr. Ebright says, it is simple greed, not science or national security, that lies behind some of the Level 4 offensive.

    "It's the easiest way to bring $100 million to your university," he said. "Perhaps the only way."

     

    posted by sydney on 6/29/2004 02:48:00 PM 0 comments

    More "Cooked Up Crisis": A physician from Missouri explains the "drop" in malpractice insurance claims there, which New York Times columnist Bob Herbert used to prove the medical malpractice crisis was cooked up:

    I can reply to the issue he raises from Missouri. The data was skewed by NOT including any payouts from large self insured health care organizations (which apparently had been included in the past). The jury is out on whether it was a deliberate white wash (as our chief executive [the governor - ed.] really was in need of data to support his decision to veto tort reform at the behest of some of his best contributors).

    However, I would posit that what the payouts have been between 2002 and 2003 (or even 2001 and 2003) is the wrong number to look at. Every time there is a "crisis" and it gets media play, juries get tighter. What we should be looking at is what payouts have done between 1990 and 2002 (and it was a phenomenal jump). We were spared the increased premiums as long as the insurance companies were doing well in the stock market, but as our "roaring 90's" came to a close suddenly premiums had to play catch up to both match payouts and replenish reserves.


    UPDATE: Chris Rangel has more thoughts on medicine and malpractice, as usual.

    AND YET MORE: A Tort et a Travers explains that the cost of defending suits, not the cost of losing suits, is one prime driver behind malpractice insurance rates:

    What is even worse is the medmal industry incurred 25.63 percent of direct premiums written in incurred defense costs while the overall industry incurred 5.56 percent of direct premiums written on defense costs.  Thus, the medmal industry has a different defense cost structure than the industry as a whole and this is just one of a number of reasons med mal premiums are so high!

    And he's got tables of data to prove it.

     
    posted by sydney on 6/29/2004 01:21:00 PM 0 comments

    Museum Tour: Cardiology through the ages.
     
    posted by sydney on 6/29/2004 08:05:00 AM 0 comments

    Particulate Matters: Michael Fumento wonders how small is small enough when it comes to particles, air pollution and health.
     
    posted by sydney on 6/29/2004 07:54:00 AM 0 comments

    Fitness vs. Fatness: The BMI debate.
     
    posted by sydney on 6/29/2004 07:48:00 AM 0 comments

    Strike's Over: The nurses' union ratified the new contract. There was jubiliation on the picket-lines. Even jubiliation from the administration which sent out an email announcement brimming with joy, in contrast to their usual staid and reserved updates.

    Even I feel relieved, and my practice wasn't touched much by the strike. I had three patients who needed to be admitted to the hospital during the strike, and although all three balked, citing the strike as reason, only one absolutely refused to go. (She's doing OK, but making a slower recovery than she would have if she had been admitted.) Trying to get things done with replacement nurses was a strain. They just weren't familiar with the routines of the hospital so everything took a little longer. This past week must have been a trial for the surgeons and other proceduralists who have to do most of their work at the hospital.

    And I'm sure the other hospitals in town are relieved, too. They were staggering under increased patient loads. So much so, that one of them sent out letters to physicians asking them to try to manage as many problems in the office as possible rather than sending them to the hospital or the emergency room.

    The entire community will be happy to get back to business as usual. Not to mention grateful that the hospital didn't have to relocate.

     
    posted by sydney on 6/29/2004 07:25:00 AM 0 comments

    Monday, June 28, 2004

    Stemming the Flow: One of the most tragic illnesses that can befall a person is a sudden bleed into the brain, usually when an aneursym bursts or from trauma to the head. Reports from a stroke conference suggest that there might be new hope in a drug that's used for hemophilia:

    An international study involving 400 patients found that a single infusion of the drug, a synthetic version of a naturally occurring protein, given within three hours after onset cut by about one-third the risk of death or severe disability among patients in the midst of a bleeding stroke."

    ..."The results we've seen are just so eye-popping that I have no doubt that eventually this is going to become the standard treatment for stroke around the world," said Mayer, who unveiled his findings at the World Stroke Congress in Vancouver. "The results are so clear, so consistent and so robust it is truly remarkable."

    ....In the study, designed primarily to test the drug's safety and potential for reducing bleeding, patients received an intravenous infusion of either the drug, given in one of three different doses, or a placebo. A CAT scan 24 hours after receiving the treatment showed that any of the three doses reduced by about half the amount of bleeding in the brain, Mayer said.

    But when the researchers followed the patients for three months, they found that those receiving the drug were approximately 30 percent less likely to die or be left severely disabled -- paralyzed or in a coma. About 70 percent of those who received the placebo either died or were left severely disabled, compared with about 50 percent of those receiving the drug, Mayer said.

    "On average, for every six patients you treat, you are going to eliminate one death or severe devastation," he said.

    ....The study was funded by the drug's maker, Novo Nordisk of Denmark, but Mayer said he has no financial interest in the company or the drug.


    Dr. Mayer's eyes are popping, but the rest of the attendees interviewed in the story seemed cautious:

    Some researchers, while praising the findings, cautioned that the drug carries risks. More testing was needed to gauge the relative risks and benefits, especially because the trial was not specifically designed to prove effectiveness, they said.


    And since, the data were shared at a meeting rather than in a journal, we in newspaper-reader-land can't evaluate them. (Although 50% morbidity compared to 70% for placebo sure seems promising.)

    The drug is NovoSeven, a recombinant version of Coagulation Factor VIIa, a protein that's critical in the chain reaction that causes clotting.

    Actually, there are two chain reactions in the clotting mechanism, the intrinsic pathway, which gets kicked off when a blood cell comes into contact with a damaged cell surface (such as it would find in an injured blood vessel wall), and the much faster extrinsic pathway, which gets its kick-start from a protein on cell surfaces called tissue factor. Coagulation Factor VIIa is crucial to both pathways, so it isn't inconceivable that it could prove of immense benefit against hemorrhage.

    The drawback is that it induced clotting elsewhere in the body, too, so it has the potential to increase the risk of heart attacks or even strokes caused by clots. And that's why there's a lot more work to be done before it makes it to the bedside.
     

    posted by sydney on 6/28/2004 10:41:00 PM 0 comments

    Backlog: The FDA finally catches up with its backlogged cases and gives the stamp of approval to leeches.
     
    posted by sydney on 6/28/2004 10:34:00 PM 0 comments

    Solicitation Hormone: Researchers are testing a hormone that makes rats prone to soliciting:

    The drug, a synthetic hormone called PT-141, appears to work within the brain to fan the flames of sexual desire, says James Pfaus of Concordia University in Montreal, who began testing PT-141 on laboratory rats in 2001.

    ...Female rats injected with PT-141, which mimics a naturally occurring hormone in the body, increased solicitation behaviour around males, which includes hopping and darting, as well as running away, then coming back - a female rat's way of sending flirtatious "come-hither" messages, he said.

    "Think of solicitation as an indication that the animal wants sex - now," said Pfaus, whose study appears this week in the Proceedings of the National Academy of Sciences.


    What do you suppose the street value for this will be among pimps if it ever gets FDA approval?

    UPDATE: Proving that it's oh-so-easy to offend, comes this email:

    The fact that you choose to link increased female libido to prostitution -- not so subtly -- is quite revealing about your attitude toward sexuality.

    What my mind linked to prostitution was the word "solicitation" which is repeated throughout the description of the experiment.
     
    posted by sydney on 6/28/2004 10:32:00 PM 0 comments

    Laboratory Hangovers: How's this for a study?

    The researchers tested 55 men and women aged 21 to 35 by simulating a night out under laboratory conditions.
    Five hours before the study participants started drinking, the researchers gave them two capsules of prickly pear fruit extract (1600 IU in total) or a placebo. The people in the study then ate a junk-food meal and were told to start drinking.

    They could choose from vodka, gin, rum, bourbon, scotch or tequila. But they couldn't mix their drinks.

    Over the next four hours they drank 1.75 grams of alcohol per kilogram of body weight, which earlier research had shown was enough to induce a hangover. Limousines took them home at the end of the night.


    Brought to you by Extracts Plus, the Californian supplier of the prickly pear extract capsules, which the study claims is a good preventive for hangovers.
     
    posted by sydney on 6/28/2004 10:25:00 PM 0 comments

    Bouncing Baby: 4D ultrasound video of a 12 week old fetus bouncing in the womb, from the BBC.
     
    posted by sydney on 6/28/2004 09:30:00 PM 0 comments

    Trust Me, I'm a Doctor: The scary case of one expert witness, who lied with impunity and got away with it. If you can't trust the guy to be who he says he is, how can you trust his testimony?
     
    posted by sydney on 6/28/2004 02:37:00 PM 0 comments

    Medical Marijuana: Will gets it day in court, the Supreme Court:

    The marijuana case came to the Supreme Court after the San Francisco-based 9th U.S. Circuit Court of Appeals ruled in December that a federal law outlawing marijuana does not apply to California patients whose doctors have prescribed the drug.

    In its 2-1 decision, the appeals court said prosecuting medical marijuana users under the federal Controlled Substances Act is unconstitutional if the marijuana is not sold, transported across state lines or used for non-medicinal purposes.

    Judge Harry Pregerson wrote for the appeals court majority that smoking pot on the advice of a doctor is "different in kind from drug trafficking." The court added that "this limited use is clearly distinct from the broader illicit drug market."

    In its appeal to the justices, the government argued that state laws making exceptions for "medical marijuana" are trumped by federal drug laws.


    Look for the Supreme Court to uphold the decision. You can debate the merits of using marijuana medicinally (the evidence is weak that it does much good), but once a state has made it a legal prescription medication it doesn't seem that the federal law about illegal drugs applies. We prescribe plenty of controlled substances that are illegal to have without a prescription. I doesn't make sense that marijuana would be treated any differently than morphine, at least in states where it's legal to prescribe it.

     
    posted by sydney on 6/28/2004 01:09:00 PM 0 comments

    Bigotry: My take on the trend among some doctors to avoid treating trial lawyers, over at Tech Central Station.
     
    posted by sydney on 6/28/2004 08:53:00 AM 0 comments

    Misperceptions: The study that scared women off hormone replacement therapy is being accused of fatal flaws:

    But a report in the June issue of the journal Fertility and Sterility says women recruited for the study were not representative of those taking the drug and the results were wrongly interpreted.

    Most subjects were in their 60s, some were in the early 70s and almost all had long since gone through the menopause, the authors say. Because the study was set up to test the effects of HRT on heart disease, most had heart problems when it started, the report said.

    'It's a very sad outcome from a very important study. But this was a study on aging women who very likely already had some level of cardiovascular disease when they started,' said lead author Dr. Frederick Naftolin of Yale University. 'People interpreted them as having implications for younger women, that was the real tragedy.


    The study is no longer available on-line in its entirety, only the abstract, but I seem to remember that the two groups were the same as far as age distribution goes. However, the differences in stroke and heart disease and breast cancer were so small (less than one percentage point), that it's quite possible small differences in age distribution would play a role. Why didn't these guys speak out two years ago?
     
    posted by sydney on 6/28/2004 08:50:00 AM 0 comments

    Sunday, June 27, 2004

    Spitzer Analysis: Research chemist Derek Lowe explains what's wrong with New York Attorney General Elliot Spitzer's fraud case against GlaxoSmithKline.
     

    posted by sydney on 6/27/2004 11:19:00 AM 0 comments

    Strike Over? The hospital and nurses have reached a tentative agreement. Details aren't available, but it sounds as if the nurses got pretty much what they wanted - "raises and other improvements." Now we'll have to wait and see what services the hospital will have to cut to pay for them. Fewer new hires? Probably. Which means that there will be more reliance on nurses' aides and poorer patient care.

    UPDATE: Nurse Alwin at Code: the WebSocket says I'm wrong:

    I know that' the conventional wisdom is that with wage and benefit increases come poorer care and more aides. However, my experience has been just the opposite at my House of Pain.

    With a better wage and benefit package we were able to attract more RN's to apply and be pickier about whom we hired. As attrition took it's usual toll, we retained more of the 'solid' nurses and were able to lose the ones that flitted from hospital to hospital looking for Nirvana. It was a real issue, with 5 major and numerous smaller community hospitals competing for bodies in the Portland metro area.

    What are your nursing vacancy rates ? It could well be that you are using nursing aides because you can't hire enough RNs and they are filling slots to put bodies at the bedside. We run an almost completely RN staff at our joint, in a part of the country that has some of the lowest Medicare reimbursement rates due to competition from the Kaiser Permanente HMO network (which has been in the area
    since WWII). With some of the highest benefit/pay packages in the area we are turning out some of the highest budget surpluses, patient, and physician satisfaction numbers in the area.

    It could get better now, rather than worse. I'll be interested in hearing how things resolve; it usually takes about a year for feathers to settle locally before any real team-building re-occurs.


    I'm not sure what the philosophy is behind the over-reliance on nurses' aides in the hospital. But, having once been in a practice owned by them, I suspect it's because the administration believes its a cost-saver. They were very gung-ho on hiring physician's assistants and nurse practitioners in the doctor's offices they owned so that the doctors could "see more patients" at lower costs to the hospital. Of course, the doctors don't really see the patients, the physician-extenders do. They made it clear that they would rather do this than hire new doctors. I suspect that the same thing applies with the nurses' aides. But the problem with that approach, at least in the hospital setting, is that the nurse doesn't get to know the patient at all and the nurse's aides don't necessarily have the knowledge to know when something isn't right with the patient. We'll see how things go, but I'm not optimistic.
     
    posted by sydney on 6/27/2004 08:22:00 AM 0 comments

    Herbert Strikes Again: New York Times columnist Bob Herbert fires another salvo against the medical tort reform movment. In Friday's column he accuses the AMA of manufacturing the crisis:

    Just last January the nonpartisan Congressional Budget Office said this about the link between high malpractice premiums and the availability of physicians in various specialties:

    The General Accounting Office "investigated the situations in five states with reported access problems and found mixed evidence. On the one hand, G.A.O. confirmed instances of reduced access to emergency surgery and newborn delivery, albeit `in scattered, often rural, areas where providers identified other long-standing factors that affect the availability of services.' On the other hand, it found that many reported reductions in supply by health care providers could not be substantiated or `did not widely affect access to health care.'


    But Mr. Herbert has left out a critical statement from the GAO's report:

    Multiple factors, including falling investment income and rising reinsurance costs, have contributed to recent increases in premium rates in our sample states. However, GAO found that losses on medical malpractice claims - which make up the largest part of insurers' costs - apppear to be the primary driver of rate increases in the long run. (emphasis mine)

    And here's the House Joint Economic Committee:

    Between 1994 and 2001, the typical medical malpractice award increased 176 percent to $1 million.

    And the American Academy of Actuaries. (All of these sources are from the excellent Point of Law.) Look at those graphs from the actuaries and tell me there isn't a problem with the tort system.

    Herbert then goes on to look at malpractice claims in a few selected states:

    Moreover, in several states specifically characterized by the A.M.A. as in "crisis," the evidence is rolling in that malpractice claims and awards are not appreciably increasing, and in some instances are declining.

    The A.M.A. has its crisis states marked in red on a map of the U.S. on its Web site. One of the red states is Missouri. But a press release in April from the Missouri Department of Insurance said, "Missouri medical malpractice claims, filed and paid, fell to all-time lows in 2003 while insurers enjoyed a cash-flow windfall."

    Another red state on the A.M.A. map is New Jersey. Earlier this month, over the furious objections of physicians' representatives, a judge ordered the release of data showing how much was being paid out to satisfy malpractice claims. The judge's order was in response to a suit by The Bergen Record.

    The newspaper reported that an analysis of the data showed that malpractice payments in New Jersey had declined by 21 percent from 2001 to 2003. But malpractice insurance premiums surged over the same period. A.M.A. officials told me yesterday that they thought the New Jersey data was "incomplete," but they did not dispute the 21 percent figure.


    The Missouri Medical Association noted that the state's Department of Insurance report on medical malpractice claims was heavy on the political spin. It wouldn't be surprising if the same sort of spin is behind the newspaper's reporting of the malpractice numbers. The numbers from New Jersey come from an editorial in the Bergen Record (registration required), which makes them impossible to analyze or to verify. Then there's Florida:

    Last summer a legislative committee in Florida, another red state, put insurance executives, lawyers and medical lobbyists under oath in an effort to get to the truth about malpractice costs. When questions about frivolous lawsuits arose, Sandra Mortham, the chief executive of the Florida Medical Association, told the panel, "I don't feel that I have the information to say whether or not there are frivolous lawsuits in the state of Florida."

    The definition of "frivolous" is one that is difficult to agree on, so Ms. Mortham was understandbly reluctant to make a statement. A lawyer may say that any outcome which is less than the outcome the patient expected is a justifiable reason for a suit. But a doctor may say that if an outcome is a complication that is known to happen as a result of the disease or a procedure, even if it isn't the perfect outcome the patient expected, is not a justifiable reason to sue.

    Bob Herbert has selectively presented one side of the issue, as he so often does.

    But at least one letter writer to the Times points out that
    reform is what we need:

    What's needed is a new system of medical justice that can make deliberate, predictable choices on standards of care. Specialized health courts — like those that exist for tax issues and workers' compensation — could begin to restore the reliability needed to heal American health care.

    That's not a bad idea. Although, workers' comp cases often drag on forever.
     
    posted by sydney on 6/27/2004 06:27:00 AM 0 comments

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