"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Home Movies: From the New England Journal of Medicine - a vivid illustration of Prinzmetal angina in action. (Prinzmetal angina is when a coronary artery goes into a spontaneous spasm and deprives the heart of oxygen, in contrast to plain old angina which is caused by a clot in the artery.)
Video A shows the electrical conduction changes that occur during an attack as recorded on the patient's heart monitor. Normally there's a small bump, followed by a thin vertical line, followed by a larger bump. But, when the artery is in a spasm and the heart is deprived of blood in a region, the second bump melds with the vertical line and disappears into a hump. Video B shows the actual coronary artery going into a spasm during a catheritization. posted by Sydney on
7/05/2003 09:11:00 AM
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The 26-year-old special service agent for Virgin at Heathrow is still shaken and recovering at her west Reading home after the lightning bolt zeroed in on her lip and tongue piercings.
The drama began when she and a friend were forced to flee the beach at Kavos by an approaching storm and Becky was crossing the courtyard of their hotel.
She said: "When it hit me all I could see was lightning. It was a bright blue and I couldn't see anything else. My body was shaking for 10 minutes." posted by Sydney on
7/05/2003 09:09:00 AM
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Charity: It's tough being a charitable institution in today's healthcare climate. High malpractice insurance premiums, the cost of meeting government quality assurance regulations, and the stock market dip make it difficult to remain solvent. Now the Shriner's hospitals are announcing that they may have to close some of their hospitals. No money, no mission. posted by Sydney on
7/05/2003 09:06:00 AM
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Bias: The British pathologist at Oxford who rejected an Israeli grad student’s application simply because he was Israeli, has apologized, sort of:
"My act was out of conscience about the war and I was completely open about my reasons. It was totally out of order I agree but it was done honestly.
"I am deeply sorry for this and realise that I took the wrong action. In addition an official apology has been issued by Oxford University and the student’s case will be taken forward. I retract what I said, which was caused by too personal and emotional a response to the terrible situation in Israel. I hope you can forgive me."
Sign Me Up: Why would anyone complain about a job like this?
McSweegan said he struggles to fill his eight-hour workdays by reading, exercising and writing fiction. He has self-published a bioterrorism thriller and a science fiction novel, and is working on a third book.
But he says his six-page job description is the ultimate work of creative writing and describes his position as "a bizarre, surreal situation -- part Orwell, part Kafka and part Dilbert."
Down Under Torts: Kraft is planning to make its products healthier - including vegemite. (Who knew Kraft was responsible for that?) But, when it comes to Australia at least, the motivation apparently isn't fear of lawsuits, but concern for public relations. Good luck making that Vegemite stuff healthier. It's vegetable paste, after all. posted by Sydney on
7/05/2003 08:42:00 AM
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Missive from the Front Lines: Another reader shared his experience with doctor lectures about weight loss:
A few weeks ago you mentioned several people who had been berated by their doctors for being overweight. I used to have that problem. I had a doctor who was, or at least looked like, a marathon runner. One time I went to see him, and his first comment was "Why haven't you lost weight?". I switched doctors shortly after that. Now, I have found the ultimate solution to the problem of being harassed about my weight by my doctor: my current doctor is fatter than I am. He does mention that I should lose weight, exercise and so on, but he doesn't lecture me.
I realize that this is not an ideal solution, and not everyone can use it (for example, does my doctor have a doctor who is heavier than he is? If so, what about that doctor, and so on.) However, I have realized that, at age 55, I will never again be thin, and stressing about it won't help. My doctor does not lecture me about losing weight. He mentions it, and I know that it is a good idea, and he leaves it at that.
Even thin and fit doctors can follow this model for counseling. I learned long ago that gentle reminders work much better than harangues for issues like smoking cessation and alocohol abuse. The same goes for obesity and weight loss. You can only help someone when they're ready to be helped. posted by Sydney on
7/03/2003 08:48:00 AM
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Purgative Purge: That old stand-by for home first-aid in case of poisonings, ipecac, may no longer be available over the counter:
On June 12, a US Food and Drug Administration subcommittee voted, 6 to 4, in favor of removing ipecac from over-the-counter status. Simply, investigators could not offer clear evidence that the syrup treats accidental poisonings all that effectively. And there are safety concerns as well.
....It's true that ipecac does cause retching. Studies show within 20 minutes of swallowing the syrup, roughly 90 percent of individuals will eliminate anywhere from 28 to 83 percent of their stomach contents. But that percentage, which varies drastically from person to person, doesn't translate to better health. No one could produce any clear evidence to the subcommittee that patients given the syrup became less sick, stayed in the hospital less time or survived a severe poisoning episode any better than patients who hadn't been given a couple of teaspoonfuls.
Shoe Poisoning: One of my elderly patients told me last week that she had “shoe poisoning” a couple of years ago and hasn’t been the same since. It seems she bought a pair of irresistable red Italian leather shoes to go with a new suit she planned to wear to a Christmas party. She decided to break them in gently by wearing them while she wrote her Christmas cards. By the time she finished the cards, her feet and legs were red and swollen. The ER doctor told her she had “shoe poisoning,” She says that the poison went through her entire body and she’s never been the same since.
I confess, I couldn’t help thinking of magical shoes with an evil charm cast on them to poison the wearer. Or the poisoned dress that was once supposedly sent to Elizabeth I by her enemies. I thought she probably had an allergic reaction to the dye or something and was exaggerating her case. But, I spoke with her daughter yesterday about something unrelated and it turns out she did have shoe poisoning. Chromium is used to tan leather, and if there's too much of it left in the final product - especially if the leather is in contact with sweaty skin - it can be toxic. Her daughter said she later saw a neurologist who confirmed the diagnosis and told them that he had seen a similar case with a man who wore cowboy boots all the time without socks (and who had very sweaty feet.)
In Memoriam: I posted some thoughts on renowned children's author Robert McCloskey at blogcritics. He was one of my oldest son's favorite authors. Blueberries for Sal was one of the first books he read by himself, and Homer Price was the first chapter book he read alone. My personal favorite, though, is Burt Dow, Deep-Waterman, about a crusty old seaman who survives storms and sea creatures in his leaky old tub. posted by Sydney on
7/03/2003 08:22:00 AM
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Wednesday, July 02, 2003
Driven to Distraction: Too many demands this morning to blog, especially since it takes me longer to post with the new blogger. Posting will resume later this evening. posted by Sydney on
7/02/2003 10:31:00 AM
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Tuesday, July 01, 2003
Silly Pills: Medicinal chemist Derek Lowe also thinks the polypill is a silly idea, as do many readers of the BMJ. (If the archives were working properly, my take on this would be here, but if you scroll up to the next post you'll find it.) posted by Sydney on
7/01/2003 08:22:00 AM
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The comprehensive reforms contained in the Patients First Act of 2003 include:
* Ensuring patients receive 100 percent compensation for their economic losses, including medical expenses, rehabilitation costs, lost wages and more, if harmed by a physician’s negligence;
* Maximizing the amount of money juries award for patients—not trial lawyers;
* Implementing expert-witness requirements; and
* Enabling patients to receive up to $250,000 in additional, non-economic damages, while also allowing states the flexibility to establish different caps.
Trial lawyers everywhere will say "Patients First" is a misnomer - but the intent is to prevent a decline in access of care caused by the malpractice crisis, and to insure that the bulk of monetary awards go to the plaintiff - not his attorney. Fitting name. posted by Sydney on
7/01/2003 08:12:00 AM
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The Backlash Begins: Private insurers are concerned about the new Medicare drug benefit:
"But if Congress does not improve payments to H.M.O.'s in 2004 and 2005," she said, "more of them will withdraw from Medicare, and that instability will undermine confidence in the private sector as an alternative to traditional Medicare. It's very difficult to build a new program around a private sector that doesn't exist."
Which is a problem now with Medicare HMO's - the insurance companies can't afford to care for Medicare patients at Medicare rates. (And neither can some doctors)
There are other problems with the plan:
Under the legislation that the Senate and House passed on Friday, Medicare would sign contracts with up to three preferred provider plans in each region of the country. Those plans would provide drug benefits along with a full range of medical services. The Bush administration has indicated it might designate 10 regions.
....The House and Senate bills would create an option for Medicare beneficiaries, encouraging them to enroll in preferred provider organizations like those that serve millions of working-age Americans. Contracts between Medicare and the plans would normally run for two years, too short a term to guarantee stable markets, the insurers said.
"To establish a network of doctors and hospitals, to compile all the data needed for a bid, to hire a sales force and to advertise a new product to Medicare beneficiaries requires a huge investment," Ms. Lehnhard said. "Health plans would be hesitant to make that investment if they could be excluded from the Medicare program in two years. You don't want to put a new product on the market, entice people into it, tell them it's a great deal and then leave the market in two years."
.....Insurers say they are also nervous about Washington's plan to award contracts for large multistate regions. A health plan that does business in Massachusetts and New Hampshire may not have a network of doctors and hospitals to care for Medicare patients in Maine or Vermont, the companies said. Moreover, they added, in a big state like New York or California, it will be difficult to establish a statewide network of providers.
The Senate bill says, "There shall be at least 10 regions," and, "Each region must include at least one state," with all parts of a state assigned to the same region
First of July: Well, this is it. The first day of work as a full-fledged doctor for first year residents across the nation. It’s a day that inspires dread in a lot of people:
In the United States, doctors often mention the July Phenomenon. In England its counterpart is called the "killing season" -- the time in high summer when turning up in a teaching hospital is said to be dangerous. July is when medical school graduates are assigned to teaching hospitals and begin to practice. Some people figure that these interns, or first-year residents, will never know less than during their first month on the job and that if they are going to make huge mistakes, this is the likeliest time.
But the reality, at least for patients, is much different:
The only problem is, only a few studies have investigated the July Phenomenon. And not a single one that I can find has established a link between bad outcomes for patients and the time of year the patient was treated. Death rates were not shown to be higher in July than at other times. The same held true in England, where it's not in July but in August that residents begin to practice.
It is a nerve-wracking time if you’re a new resident. New job, new routine, new responsibilities - and, oh, what responsibilities. But, it’s also a time when senior residents and attendings are on their guard. They don’t yet have a feel for the competency of the new residents, so they put in longer hours and are more likely to double check the interns’ work. Like anyone would with a new employee. posted by Sydney on
7/01/2003 07:40:00 AM
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Eye of the Beholder: Dinesh D'Souza explains how America's obesity epidemic looks to someone from a less prosperous place:
....an acquaintance of mine from Bombay who has been unsuccessfully trying to move to the United States. I asked him, "Why are you so eager to come to America?" He replied, "I really want to live in a country where the poor people are fat."
MedMal in the Keystone State: A Pennsylvania woman who smuggled drugs into her hospital room is suing the hospital because she over-dosed:
In early May 1999, Hagan was going through drug withdrawal and was involuntarily committed to Norristown State Hospital. According to court records, she had been admitted there before.
On May 6, the 18-year-old son of Hagan's roommate visited his mother at the hospital and slipped to Hagan and his mother cocaine, heroin and needles.....
That night, both Hagan and the roommate injected themselves with cocaine and heroin. While injecting the drugs, the needle broke off in Hagan's arm.
Around 10 p.m., a nurse gave out medications to Hagan that included an antidepressant.
About two hours later, another roommate heard Hagan gasping for air. She noted that Hagan appeared ''very gray'' and tried to awaken her, according to the suit. When she couldn't, she called for help and Hagan was taken to the emergency room of Montgomery Hospital in Norristown.
Hagan says that the nurse should have known she had a broken needle stuck in her arm when she gave her that anti-depressant. Surely, Hagan wasn't so stupid as to do something illegal without trying to hide it. So, it's the nurses fault that Hagan is such a successful sneak?
Meanwhile, the courts say that Pennsylvania's law to restrict venue-shopping by trial lawyers has been - surprise! - struck down. The decision has economic consequences, and not just for doctors:
Although the state law was designed to reduce the number of cases filed in Philadelphia, where verdicts are about twice the state average, the plaintiffs in the Commonwealth Court case were more concerned about avoiding trial in Montour or Bradford counties.
A significant portion of jurors in those areas work at or have some connection to Geisinger Medical Center and Robert Packer Hospital.
Since the new Supreme Court rules were established in January, medical-malpractice filings in Montour County have more or less doubled, according to county Prothonotary Susan M. Kauwell.
Surely, the cases worthy of pursuit didn't double with the new rules, just the likelihood of success at trial.
And here's a thought. Has anyone ever done a study to see if venue shopping occurs at the same rate in states with non-economic damage caps as those without caps? Bet it doesn't. posted by Sydney on
6/30/2003 08:24:00 AM
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Soulful Matters: Researchers say that music is a window to your soul, and they have the studies to prove it:
According to Gosling, the students categorized music into the following classifications: Blues, jazz, classical and folk music was collectively seen as "reflective and complex"; heavy metal and alternative was viewed as "intense and rebellious"; country music, sound tracks, religious and general pop song were labeled as "upbeat and conventional," and rap/hip-hop, soul/funk and electronic dance music was called "energetic and rhythmic." The students then indicated which types of these music styles appealed to them.
In a separate study, they were asked to identify their personality types and how they would describe themselves.
...Across the board, the way in which students viewed themselves meshed intricately with their musical choices.
For example, says Gosling, students who were extroverted commonly preferred cheerful music with vocals, while those who considered themselves open to new experiences preferred more intricately composed music.
Likewise, he says, those who preferred "esoteric" or complex music viewed themselves as being sophisticated, while those who enjoyed conventional music styles described themselves as having conservative life views.
For the students who looked at themselves as physically fit and athletic, the choice was upbeat, rhythmic, even vigorous music.
What's more, you can predict somone else's personality by the music they keep:
Finally, the researchers say cruising your partner's CD collection may also tell you a little something about their verbal and analytical skills. In still another of the six studies, those students who scored highest on tests measuring these functions frequently said they preferred far more complex music, compared to those who scored lower on these same tests.
When you remember that "complex music" was defined as "blues, jazz, classical and folk music," it becomes obvious that there was an inherent bias in this study. Obviously, it was conducted by NPR fans.
Useful Illnesses:The Weekly Standard’s Jonathon Last has an interesting piece about a New Jersey high school girl whose unexplained medical illness has allowed her to reach the peaks of academic success. posted by Sydney on
6/30/2003 06:31:00 AM
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Life’s Lessons: The launching of my independent practice has been teaching me a lot of lessons these past few weeks. I’ve learned just how difficult it is to work with a passive-aggressive personality. I’ve learned that a Medicare provider number is the key that opens all medical reimbursement doors. That it costs more to knock down walls than to build them. That the banker is my friend. And most of all, I’ve learned that a supportive spouse is an asset not to be underestimated.
I used to sneer at the idea that a spouse could make or break a career. That those old notions of wives being responsible for their husband’s business or political successes were nonsense. Hype put out by divorce attorneys to get their clients good settlements. I even once bought a young doctor manual from the early 1950’s called The Physician and His Practice, in anticipation of a good laugh at the expense of the chapter called “The Doctor’s Wife” . It did not disappoint. Among its gems are these closing lines:
Physicians are by inclination and training discerning men, wise in human relations and keen in judgement. It would seem logical that such men should make their lifelong alliance with partners of comparable astuteness and wisdom.
But now I’ve learned that there’s wisdom in that chapter, too, and that I was an arrogant young woman to scoff at the important role of the doctor’s spouse. I’ve learned how important it is to have someone who doesn’t mind handling all the home finances, and yet can resist meddling in office decisions that affect those finances. Someone who doesn’t mind interruptions by phone calls. Who doesn’t mind unexpected delays at the office. Who understands that sometimes you have to make short term sacrifices for long term gains. Who will let you come home and cry on his shoulder, no questions asked. Who can say in all seriousness,“We’ll be OK if we have to sell pencils in the street.” But most of all I’ve learned how important it is to have the kind of spouse who makes statements like that true. And for that, I’ll always be grateful. posted by Sydney on
6/30/2003 06:19:00 AM
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Sunday, June 29, 2003
How Stupid is Your Doctor? Meant to blog on the news last week that doctors are stupid but ran out of time. Now I have the time, and the story is one that deserves some scrutiny:
Americans have a slightly better than 50-50 chance their medical problems will be addressed in an optimal way when they visit a doctor's office or enter a hospital, according to a new survey.
The failure to do the right thing -- or, more precisely, all the right things -- extends across the spectrum of activities physicians are expected to perform
...The study built on a previous survey that asked 20,000 randomly chosen adults in 12 metropolitan areas where and how they received medical care. In this study, they were asked to name their physicians and consent to the release of their medical records for the previous two years. A brief medical history was also taken over the phone. Ultimately, copies of hospital charts and clinic notes from about 40 percent of the people surveyed were sent to Rand researchers.
Twenty nurses then reviewed the records, looking for evidence that specific interventions were done -- or, in some cases, avoided -- in people with particular medical histories, conditions, symptoms, findings on physical exam, habits or laboratory results.
There’s the first problem. Chart reviews are dependent on the diligence of the reviewer and on the quality of the notes kept by the doctor. Sometimes, interventions don’t get documented, especially interventions that involve counseling. So, the doctor may tell the patient to quit smoking and explain why he should quit, and offer to help, but if the patient says, “no thanks,” it isn’t likely to get documented. Especially if there are other more acute problems to be documented at that visit. (The same goes for other substance abuse issues, and for recommendations for preventive screening.) And in fact, the breakdown of results shows that the largest deficiencies were in just those sorts of areas:
The researchers also looked at performance based on general type of intervention. Medication choices followed recommended practices 69 percent of the time; immunizations, 66 percent; physical examination, 63 percent; and lab testing, 62 percent. However, physicians asked key questions while getting the medical history for the patient 43 percent of the time. Adequate counseling and teaching were done 18 percent of the time.
Another factor in these chart review studies is the diligence of the person doing the reviewing. The information often isn’t easy to find, unless you’re the doctor or nurse who uses those charts all of the time. Immunizations, for example, may be within the progress notes rather than in a separate immunization chart. A doctor’s writing may be difficult to read, affecting the assessment of history and physical exam findings documented. Get a lazy, or fatigued, or distracted reviewer, and the results will tend toward the negative. (although the study says that agreement between reviewers in selected samples was “substantial to practically perfect” - a claim that sounds too Mary Poppinish to be believable.)
The other problem is that the survey doesn’t take into account patient compliance. The indicators for high cholesterol treatment all rely on the presence or absence of laboratory results in the chart. Getting those results requires some incovenience and effort on the part of the patient - fasting and usually a separate visit to collect the blood. But there’s no indication that the authors even considered compliance in their review.
And then, there are the indicators themselves:
The recommended interventions were chosen by experts, based on strong evidence of value or harm found in scientific studies. In the case of some conditions, there were many -- 37 for coronary artery disease, 27 for high blood pressure, 25 for asthma. In others there were few -- 5 for alcohol dependence, 5 for pneumonia, 3 for arthritis. In all, there were 439 on the list.
The percentage of the time that patients got the recommended treatment for a selection of conditions was: cataracts, 79 percent; breast cancer, 76 percent; prenatal care, 73 percent; low back pain, 69 percent; coronary artery disease, 68 percent; hypertension, 65 percent; congestive heart failure; 64 percent; depression, 58 percent.
The full list of indicators is here (in pdf and it may require money to access), and they are extensive. Of the 36 indicators for congestive heart failure, the first 29 are matters of documentation (documented history and documented physical findings). The indicators for the treatment of menopause rely entirely on documentation of counseling. And as mentioned before, absence of documentation isn’t necessarily the same as absence of treatment.
In addition, although the indicators of quality of care were “chosen by experts, based on strong evidence of value or harm found in scientific studies,” the actual process consisted of:
The indicators of quality used in the study were derived from RAND's Quality Assessment Tools system. RAND staff members selected acute and chronic conditions that represented the leading causes of illness, death, and utilization of health care in each age group, as well as preventive care related to these causes. For each condition, staff physicians reviewed established national guidelines and the medical literature and proposed indicators of quality for all phases of care or medical functions (screening, diagnosis, treatment, and follow-up)....
....Four nine-member, multispecialty expert panels were convened to assess the validity of the indicators proposed by the staff, using the RAND–UCLA modified Delphi method. The members of the panels, nominated by the appropriate specialty societies, were diverse with respect to geography, practice setting, and sex. Indicators were rated on a 9-point scale (with 1 denoting not valid and 9 very valid). Only indicators with a median validity score of 7 or higher were included in the Quality Assessment Tools system.
So, a bunch of physicians at RAND looked at the guidelines available in the literature, and chose what they thought represented good care, then a panel of other doctors got together and looked them over and said whether they sounded good to them or not.
The problem with this approach is that all guidelines are not created equally. Guidelines are, well, guides, to care, but they are not written in stone, or the last word on treatment approaches. Consider the experience of a group of Danish physicians in implementing an alcohol screening guideline:
Most doctors found that the screening conflicted with establishing rapport (especially among middle aged and elderly patients), because it set an agenda in advance. They were generally surprised at how difficult it was to generate rapport and to ensure compliance with interventions to address risky drinking behaviour or to reduce harm and to arrange follow up consultations.
....Some doctors said that a few patients may have been encouraged to take steps to modify their drinking behaviour, but in general the doctors were deeply sceptical about the effect of the intervention on patients' drinking behaviour. The patients' lack of interest in the follow up consultations seemed to confirm this scepticism....
...Firstly, the screening and brief intervention programme was seen as awkward to implement in the normal flow of a consultation. It disturbed the agenda, and patients seemed to be distracted from the subject that made them seek health care in the first place. Secondly, doctors could not work in their usual patient centred way because of the agenda setting imposed by the screening. Thirdly, the extra workload was too high, taking resources from other functions of general practice and in general disrupting the pattern of working together in the practice: "To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me"
And there, in a nutshell, you have the problem with judging quality of care by adherence to guidelines. We practice in the real world, where time is limited and patients come to us with problems that they want solved. The way we spend our time is, correctly, directed at helping them solve those problems. Sometimes, many times, screening interventions get put on the back burner, documentation of peripheral issues is neglected, although attention to them may not be. Drugs that may be recommended by the guidelines turn out not to be suitable for the patient due to side effects or financial considerations. Ditto for certain surgical interventions. The practice of medicine can never be reduced to cookbook therapy. Or at least it shouldn’t be. posted by Sydney on
6/29/2003 03:46:00 PM
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