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    Saturday, February 05, 2005

    When Similes are Too Much: I'm on call this weekend and just had a conversation with another doctor's patient about whether or not I can give him a note to go back to work. I was trying to explain why there was no way I could make that judgement over the telephone. I wasn't getting through, so I told him it was like calling me up to ask me if he was dressed appropriately for work. His answer? "My clothes look OK." Sometimes, you just have to say "No," and hang up.
     

    posted by sydney on 2/05/2005 02:41:00 PM 4 comments

    Medicaid Solutions: Florida's plan for revamping Medicaid:

    Florida's Medicaid is more comprehensive than many private plans. Such generosity comes at a price. For the past six years, Medicaid spending has climbed 13 percent annually and now soaks up about a quarter of the state budget. And the worst is yet to come, with costs expected to rise to 35 percent of state revenue in the next four years. As a result, Governor Bush proposes something innovative: getting his state out of the business of micromanaging Medicaid.

    Under his plan, those eligible for Medicaid would qualify for a set, need-based amount of money. With this money, recipients could pick a plan among competing insurance company offerings--from more comprehensive coverage to less comprehensive but at a lower premium, with part of the money saved going to a recipient's flexible spending account for out-of-pocket medical expenses. In addition, the state would offer incentives in the form of better benefits to those who live healthier lives.

    The contrast between Florida's approach and that of other states couldn't be starker. At a time when state governments are developing more and more elaborate ways of controlling Medicaid, Jeb Bush envisions Tallahassee doing relatively little. Besides funding, Florida would ensure transparency of the private plans and counsel Medicaid recipients about their choices.

    Governor Bush's plan offers a way out, overcoming the federal-state divide. It allows governors to give recipients more choice, yet rein in spending by increasing competition among insurance plans. It's an innovative approach that controls costs, particularly since it involves recipients more in their health decisions. Notes Frogue, 'It's fiscally wise and pro-patient.


    The usual approach to cutting Medicaid costs is to cut back on reimbursements to hospitals, doctors, and pharmacies, who then turn around and decline to participate. The result is less access for Medicaid patients. As the article points out, in one study in California, only 2 out 50 orthopedists were willing to see Medicaid patients.
     
    posted by sydney on 2/05/2005 02:03:00 PM 0 comments

    Friday, February 04, 2005

    Suffering the Children: More bad news for anti-depressants. Babies whose mothers took Paxil during pregnancy withdrawl:

    Sanz and his team searched the World Health Organization (WHO) database on adverse drug reactions for convulsions and withdrawal symptoms in newborns associated with the use of SSRIs in 72 countries.

    Ninety-three cases had been reported by November 2003, which they said suggested a causal relationship.

    'Nearly two-thirds of reported cases of suspected SSRI-induced neonatal withdrawal syndrome were associated with paroxetine,' Sanz said.

    All of cases reported in the study recovered after a few hours or a day.

    Vladislav Ruchkin and Andres Martin, of Yale University School of Medicine in the United States, said the research raises the question of how concerned we should be about exposing the youngest patients to SSRIs.

    'It remains to be seen whether ... (the) report ultimately reflects a minor problem for a particular antidepressant, or further evidence of a larger set of serious problems for SSRI use in young people,' they said in a commentary.

    In the meantime, they suggested doctors use non-drug therapies and review prescription thresholds, particularly during pregnancy.


    OOPS: That should be "withdrawal."
     

    posted by sydney on 2/04/2005 07:59:00 AM 0 comments

    EMR Saga: Yesterday was the one week mark of our computerized medical record. It's nearly brought one staff member to tears at times because she's fallen behind on her paperwork, and I've been up past midnight most nights entering patient histories in the summary page for future reference. (Truthfully, that's because I come home for dinner, kid extracurricular events, and sometimes a nap before resuming the job.) But yesterday, everyone seemed to find their rhythm with the process. I was able to see 27 patients and finish on time instead of 22 and running 40 minutes behind. I noticed the pile of paperwork was gone from the stressed-out employee's desk, and I have no pile of paperwork waiting for me on my desk at work. Everyone's prescriptions have been called in or faxed, everyone's cholesterol letters have been sent, everyone's lab results have been filed. The staff still tends to think in terms of paper charts, though. Yesterday I heard the receptionist tell the medical assistant that she could have the chart in just a few minutes because she still had to enter the demographic data. They haven't yet grasped that more than one person can use an electronic chart at the same time. Nevertheless, we've made enormous progress in just one week.
     
    posted by sydney on 2/04/2005 07:42:00 AM 0 comments

    EMR Saga: Yesterday was the one week mark of our computerized medical record. It's nearly brought one staff member to tears at times because she's fallen behind on her paperwork, and I've been up past midnight most nights entering patient histories in the summary page for future reference. (Truthfully, that's because I come home for dinner, kid extracurricular events, and sometimes a nap before resuming the job.) But yesterday, everyone seemed to find their rhythm with the process. I was able to see 27 patients and finish on time instead of 22 and running 40 minutes behind. I noticed the pile of paperwork was gone from the stressed-out employee's desk, and I have no pile of paperwork waiting for me on my desk at work. Everyone's prescriptions have been called in or faxed, everyone's cholesterol letters have been sent, everyone's lab results have been filed. The staff still tends to think in terms of paper charts, though. Yesterday I heard the receptionist tell the medical assistant that she could have the chart in just a few minutes because she still had to enter the demographic data. They haven't yet grasped that more than one person can use an electronic chart at the same time. Nevertheless, we've made enormous progress in just one week.

    UPDATE: Today the system will be put to the test. The Hellboys are coming. They're two brothers of preschool age who wreak havoc in the office every time they come in. No matter where I am, I know when they've arrived. The last time they were in the office they pulled a drawer out of its cabinet, dropped it on the floor and sent all of its contents sprawling. The time before that, they left the water cooler spigot turned on and flooded the waiting room. I've instructed the staff to keep their computers away from the little hellions. They're not even to take them in the same room with them. Maybe we'll have to stick with paper charts just for them.
     
    posted by sydney on 2/04/2005 07:42:00 AM 2 comments

    Wednesday, February 02, 2005

    Brain Surgery: On video.
     

    posted by sydney on 2/02/2005 08:21:00 AM 0 comments

    Timothy Leary Redux: The days of psychedelic research are here again.
     
    posted by sydney on 2/02/2005 08:19:00 AM 0 comments

    Smoking Bans: Blogger and Pioneer Press columnist Craig Westover has some thoughts on his state's efforts to ban smoking and the science behind it.
     
    posted by sydney on 2/02/2005 08:16:00 AM 0 comments

    Tort Reform Agenda: The House is trying once again to act on tort reform:

    The Lawsuit Abuse Reduction Act, which Rep. Lamar Smith, R-Texas, introduced Wednesday, would also require that plaintiffs in civil tort actions could only be permitted to sue in the jurisdiction in which they live or suffer their injury, or where the defendant maintains its principal place of business. Tort reform advocates claim that such a requirement is needed to reduce so-called “forum-shopping.” That occurs when plaintiffs in interstate class actions seek out the most plaintiff-friendly state jurisdictions in which to file their actions.

    “This common sense civil justice reform would help solve one of the worst problems small businesses and many others face: frivolous claims,” said Sherman Joyce, president of the American Tort Reform Assn., in a statement released Wednesday morning. “Far too often, the system allows, in effect, legal extortion.”


    Maybe they'll have more luck this time around.
     
    posted by sydney on 2/02/2005 08:13:00 AM 0 comments

    Tuesday, February 01, 2005

    More on Sex and Intellect: An interesting observation on sex and career choice from a reader:

    I have been wondering for some time about women in medicine.
    I graduated from med school in 1971 in a class of 120 men and 7 women.
    My father-in-law graduated from the same school in 1929 in a class that
    had no women. I'm sure that in his day the admissions committee members
    would have been quite candid about expressing their opinions that women
    were innately unfit to be physicians. In may era, the committee members
    would have told you that women were fit to be physicians but they were
    likely to be less productive.

    By 1975, med school classes were 20-30% women ( by my recollection .)
    Now there is parity.I don't remember much external pressure. Do you know how these changes came about? I think the same thing happened in law schools over a similar time frame. Will it really be a surprise if we see it happen in math and engineering? When I was in grade and high school, there were some real smart girls in my arithmatic classes.


    Yeah, how did that happen? When I was a teenager in the late 1970's, and I began to dream of going into medicine, my father tried his best to discourage me. I seem to recall him saying, "Who would want to go to a woman doctor?" But, by the time I entered medical school in 1984, women made up almost 50% of medical school classes nationwide. What happened in those years between 1976 and 1984? Well, the women from the medical school classes of 1975 had come into professional maturity. Just by being there they made it possible for other, younger women to realize they, too, could become physicians.

    There's no reason a similar phenomenon can't happen in the hard sciences. We've got Dr. Barbie. Will we have mathematician Barbie? (Oh, she's already here!)
     

    posted by sydney on 2/01/2005 10:25:00 PM 0 comments

    So, How is That EMR Going? Not too bad. Although at this point it does slow down things - a lot. I usually run on time. I pride myself on it. But since going electronic I've been routinely running 30 to 45 minutes late. It's taking a couple of minutes longer to check patients in, a couple of minutes longer to put people in a room, and couple of minutes longer for me to see them. All those couple of minutes add up to 30 to 45 by the time ten to twelve patients have passed through. I'm hoping this will get better as we get used to it. I live in fear of prescriptoin typos, and find that I make more of them the more behind I am.

    As for my staff, they're having trouble breaking old habits, and that's slowing things down, too. Instead of checking to see if a patient has a computerized record, they automatically go to the paper charts and start searching if there's an abnormal lab result. They still bring me phone messages written on paper and attached to the paper chart instead of entering the message in the computer chart. In the paper system, when I had to write a letter to a patient, I would type it out on the computer, print it, sign it, and give it to the staff. They would make a copy for the chart and mail off the original to the patient. The computerized record prints and saves the letter to the patient's file. All the staff has to do is put it in an addressed envelope. And yet, this afternoon, I found a copy of an electronic-record-generated letter in the "to-be-filed" folder, waiting to be filed away in the old paper chart. No wonder we're always running behind.

    And yet, there are definite advantages. Today, I received some lab results on a patient who is a transplant recipient. The results were not good, and needed immediate attention. This particular patient usually goes to a tertiary care center about an hour from here for her care, so I had no idea whether or not these results were far from her baseline. And as often happens, I couldn't reach the patient during office hours. It was late tonight before I made any contact. Thanks to the EMR, I was able to talk to the transplant fellow on the phone, with her chart and lab results in front of me - from home. But it was nice to be able to pull up the details of her visit last week, too, to accurately fill in the background for the other doctor.

    I'm still optimistic that in the long run having computerized records will be better and more efficient than paper records. They certainly take up less storage, at any rate.
     
    posted by sydney on 2/01/2005 10:00:00 PM 0 comments

    Healthcare Blog Collective: I've been too busy these past couple of weeks to do much blogging, but there's plenty of good stuff at Grand Rounds XIX.
     
    posted by sydney on 2/01/2005 03:03:00 PM 0 comments

    Sunday, January 30, 2005

    Nature vs. Nurture: A mathematician looks at math and the sexes.

    P.S. I happen to be blogging next to my daughter who is busily taking apart an old radio for her "Discover Technology" girl scout badge. I don't know much about electronics, but my husband is pointing out all the parts and what they do, and she's listening as intently as she would to a Sponge-Bob cartoon. I've got to think that the testing differences are due more to nurture than nature.
     

    posted by sydney on 1/30/2005 01:51:00 PM 0 comments

    Beyond Google: Ohio's online library.
     
    posted by sydney on 1/30/2005 01:15:00 PM 0 comments

    Good News for Babies: Infant deaths from HIV have decreased dramatically:

    The New York Times reported 2,000 babies were born infected with HIV in 1990, but now the number has declined to just over 200 a year. In New York City, health officials said 321 babies were born with the virus, but the number was reduced to just five in 2003.

    The reason is two-fold: Better drugs for infected pregnant women and automatic HIV screening in all pregnancies. When I was a resident in the late '80s and early'90s it, HIV testing of pregnant women was still not routine. Testing people for HIV was shrouded in secrecy. It required a special consent form and a special procedures that insured the patient's name wasn't connected with the test. The blood specimen even had to be transported in a special plain cardboard tube. Tests for other sexually transmitted diseases, however, were done routinely so that they could be treated. HIV is done pretty much like that now, although it still requires a consent form. You can't treat something if you can't diagnose it.
     
    posted by sydney on 1/30/2005 12:45:00 PM 0 comments

    Left Behind: When technology goes wrong. (Bigger image here. Video here and here.)
     
    posted by sydney on 1/30/2005 12:22:00 PM 0 comments

    Senator Tomorrow: Here's Bill Frist, in his Shattuck Lecture (audio here) which was published two weeks ago in the New England Journal of Medicine, on the wonderful world of future medicine:

    I would like you to meet a patient from the year 2015. He lives in a world in which years ago America's leaders made tough but wise decisions. They built on the best aspects of American health care and unleashed the creative power of the competitively driven marketplace. These changes resulted in dramatic improvements to the U.S. health care system — lower costs, higher quality, greater efficiency, and better access to care.

    The patient, Rodney Rogers, is a 44-year-old man from the small town of Woodbury, Tennessee. He has several chronic illnesses, including diabetes, hypercholesterolemia, and hypertension. He is overweight. He quit smoking about eight years ago. His father died in his early 50s from a massive myocardial infarction. In 2005, Rodney chose a health savings account in combination with a high-deductible insurance policy for health coverage.

    Rodney selected his primary medical team from a variety of providers by comparing on-line their credentials, performance rankings, and pricing. Because of the widespread availability and use of reliable information, which has generated increased provider-level competition, the cost of health care has stabilized and in some cases has actually fallen, whereas quality and efficiency have risen. Rodney periodically accesses his multidisciplinary primary medical team using e-mail, video conferencing, and home blood monitoring. He owns his privacy-protected, electronic medical record. He also chose to have a tiny, radio-frequency computer chip implanted in his abdomen that monitors his blood chemistries and blood pressure.

    Rodney does an excellent job with his self-care. He takes a single pill each day that is a combination of a low dose of aspirin, an angiotensin-converting–enzyme (ACE) inhibitor, a cholesterol-lowering medication, and a medication to manage his blood sugar. That's one pill daily, not eight. He gets his routine care at his local clinic. He can usually make a same-day appointment by e-mail.

    Unfortunately, chest pain develops one day while Rodney is on a weekend trip several hundred miles from home. The emergency room physician quickly accesses all of Rodney's up-to-date medical information. Thanks to interoperability standards adopted by the federal government in 2008, nearly every emergency room in the United States can access Rodney's health history, with his permission. The physician diagnoses an evolving myocardial infarction by commanding Rodney's implanted computer to perform a series of rapid diagnostic tests. The cardiologist in the "nanocath" lab injects nanorobots intravenously, and remotely delivers the robots to Rodney's coronary arteries. The tiny machines locate a 90 percent lesion in the left anterior descending coronary artery and repair it.

    The hospital transmits the computerized information about Rodney's treatment, seamlessly and paperlessly, to Rodney's insurer for billing and payment. The insurer pays the hospital and physicians before Rodney returns home. Payments are slightly higher to this hospital than to its competitors because of its recognized high quality and performance. Rodney's hospital deductible and co-insurance are automatically withdrawn from his health savings account. Because Rodney has met all his self-management goals this year, he gets a 10 percent discount on the hospital deductible.


    Chances are, living in a small town in Tennessee, Rodney still has only one hospital to choose from for emergency care. There's no reason to assume that reduced prices and computerization will mean that the number of hospitals increase out of proportion to the population they serve. Ditto his "providers." One of the draw backs to living in a small town is that there's less choice - from grocery stores to lawyers to doctors. The cost of healthcare will likely have skyrocketed, not fallen, to cover the cost of the new nanotechnology and the computer systems. His single pill is expensive and when he feels nauseous or achey, or tired after taking it or he develops serious complications from it, he can't tell which of its components are causing the symptoms. It improves his chances of living longer by about 2 to 3% over ten years.

    Whenever Rodney gets upset or anxious or drinks too much coffee or has sex, the little implant in his abdomen sends off an alarm signal that his blood pressure and pulse are too high. Rodney can't make a same-day appointment at his local doctor's office by email because the doctor doesn't get a chance to read his email until after office hours have finished, and doctors still have to examine and treat patients one at a time, so his schedule is no more open than it ever was in the past.

    It's nice that Rodney's medical record is so easily at hand, however it's hard to imagine that having it will make diagnosing a myocardial infarction any faster than doing an EKG. Maybe that implant can diagnose a heart attack and send out a signal. And will the nanobots be faster and deliver a better outcome than coronary angiography and angioplasty?

    The last part is the most laughable:

    The hospital transmits the computerized information about Rodney's treatment, seamlessly and paperlessly, to Rodney's insurer for billing and payment. The insurer pays the hospital and physicians before Rodney returns home.

    Yeah, and pigs will fly. Here's what will happen. Because Rodney had his heart attack at an out-of-network hospital in a distant city, his insurance company refuses to pay, leaving Rodney or the hospital to eat the cost of all that fancy technology. Or, since Rodney has catastrophic health insurance and therefore may not be limited to a network, the insurance company reviews Rodneys freely-available health record which they are free to do without his permission, and find that he smoked until a few years ago, that he didn't always fill his prescriptions on time, meaning that he wasn't completely compliant with his blood pressure medication, and that his implanted chip recorded occasional high blood pressure readings. They deny the claim because Rodney didn't hold up his end of the bargain in keeping himself healthy.

    Payments are slightly higher to this hospital than to its competitors because of its recognized high quality and performance.

    The insurance company sets their standards for quality higher than hospitals can realistically meet and still treat real people. Insurance companies aren't in the business to give money away, and that's not going to change in the future.

    Rodney's hospital deductible and co-insurance are automatically withdrawn from his health savings account. Because Rodney has met all his self-management goals this year, he gets a 10 percent discount on the hospital deductible.

    Rodney just cost the insurance company a bundle for that nanobot procedure. What's more, he's now at higher risk for future cardiac events. Rodney's premium goes up by 20%.

    Having this seamless universal system of health records sounds on the surface like it would be a wonderful thing, but the two groups who benefit the most from it are the insurance industry and the government. The insurance industry will benefit because they'll be better able to assign individuals to risk groups and to review records for denial of payment. The government will benefit because they'll have an easier time auditing charts for denial of payment or investigating fraud. But when it comes to treating a patient for illnesses - especially emergency ones like trauma, strokes and heart attacks - having a complete history is just icing on the cake, not an essential of care.
     
    posted by sydney on 1/30/2005 12:10:00 PM 0 comments

    Medical Electronic Errors: A reader on the article about data entry errors:

    Aside from the content, I found these two amusing things in the article:

    1. One of the patient safety experts who was quoted said she was surprised, shocked, and disturbed "that a new type of error is replacing handwriting". Really? As surprised, shocked, and disturbed, let us suppose, as were experts in the early 20th century to discover that injuries from automobiles were overtaking injuries from horses?

    2. There is actualy a glaring error in the report - in the second table that accompanies the report titled "Most errors don't cause harm". The 6th entry down should be 0.24% - NOT 24.0%. Ah, well, entry errors are truly feisty things, good that this one caused no harm!
     

    The article is an important one and warrants a closer look as the push towards electronic medical records continues:

    'Computer entry' was the fourth-leading cause of errors, accounting for 13% (27,711) of the medication errors reported in 2003. In contrast, illegible or unclear handwriting was the 15th-leading cause, and accounted for 2.9% (6,134) of reported errors.

    It would be very useful to know what percentage of medical errors were due to illegible hand-writing before computerized systems were adopted. For that matter, it would be interesting to know if medical errors have actually increased with the adoption of computerized systems. When a pharmacist or a nurse sees illegible hand-writing, they know they can't read it, and the responsible thing to do is to take the time to ask the doctor what it says. When they see a typed number they have know way of knowing it's wrong until it's too late. And it's much easier to type in a wrong number than it is to write a wrong number.

    Although this study was in an inpatient setting, where the computer entries are usually done away from the bedside, I've found in just the two days I've been using electronic medical records in my office, that patient's are less respectful of the time it takes to enter the information. For example, when I'm writing a prescription by hand or a lab order, my patient's will often start to tell me something else they've thought of, but stop themselves and say "I'll wait 'til you're finished writing." They don't do that when I'm entering their prescription into the computer, and it actually takes a little more concentration for me to do the electronic one, because I'm trying to make sure there aren't any typographical errors in it -that the quantity and the dosage are correct. But they keep right on talking. I have to admit, I don't hear what they're saying, and I appear distracted when I look up from my task and ask them to repeat it. The irony is, I can write prescriptions by hand and listen at the same time, but I can't proofread and listen at the same time.

    And this, I have trouble believing:

    Cousins said the good news was that errors related to electronic prescribing are less likely to lead to patient harm.

    Defined as an error caused by incomplete or incorrect entry of a medication by a licensed prescriber, USP added "computerized prescriber order entry" to its list of "cause of error variables" in May of 2003. It received more than 7,000 reports of this type, but only 0.1% of these led to patient harm. In comparison, the percentage of patient harm associated with all errors reported in 2003 was 1.51%.


    Typing the wrong dosage or giving the wrong medication to the patient in the wrong room due to a typing error would have a great deal of potential for harm.
     
    posted by sydney on 1/30/2005 08:45:00 AM 0 comments

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