Welcome Back: RangelMD is back after a long absence, with lots of good posts, including this one on managed care:
Two decades later the HMOs and insurance companies have found to their horror that the massive cash flow that they initially saw in this industry is not going to change course and flow into their coffers. To make matters worse, the massively expensive bureaucracies these businesses brought with them are simply adding to the expenses as they consume up to 30 cents of every health care dollar.
Lancet On-Line: The British medical journal, The Lancet, is now available online in its entirety - all 180 years of past issues. For a price, of course. Hopefully, this will catch on. posted by sydney on
10/07/2003 08:22:00 AM
Many people have asked me how I was able to do a successful daily three hour show while loaded up on pain meds,' Mr. Limbaugh said. 'I'm going to love telling them about the low incidence of side-effects I enjoy while gulping dozens of OxyContin each morning. When I say I do this show with half my brain tied behind my back, I'm not kidding.'
Sleep Safe: New research in the journal Pediatrics, suggests that babies who sleep in their parents' beds are at greater risk for sudden death:
The study drew on data collected by the federal Consumer Products Safety Commission about suffocation deaths in sleeping children 11 months old or younger and compared the figures for 1980 to 1983 with those from 1995 to 1998.
The number of deaths rose from 513 to 883. Deaths in beds, chairs or sofas rose from 152 to 391, and deaths in cribs fell from 192 to 107, the study found. Most deaths outside cribs occurred when children became trapped between mattresses and walls or headboards or when the children were covered by soft bedding that cut off their air supply.
The number of reported suffocation deaths in cribs fell from 192 to 107, the number of reported deaths in adult beds increased from 152 to 391, and the number of reported deaths on sofas or chairs increased from 33 to 110.
The findings are rather dramatic and should give a heads up to anyone who shares their bed with their children to use extra caution when doing so. It will, however, be sure to draw controversy, as in this online response:
Only breastfeeding infants are recommended to share the mother's bed as bottle feeding mothers have been found to treat the infant as another adult in the bed and turn their backs on them in their sleep (amongst other things).
Those mean old bottle-feeding mothers. The rest of the response, however, makes valid points about exercising appropriate precaution when sleeping with babies. But the caution should be heeded by both breast-feeding and bottle-feeding mothers. No one can control their movements in sleep, no matter how devoted a mother they are, or what feeding method they choose.
Power of Myth: A disconcertingly high number of patients believe that contact with air makes lung cancer worse. As a result, many refuse to have their lung cancers resected:
Thirty-eight percent of patients who responded to a survey in five urban clinics believed the myth that cancer spreads when exposed to air during surgery.
....Of the 38 percent who said they believed that cancer spreads when exposed to air, 24 percent said they would reject lung cancer surgery based on that belief. Nineteen percent said they would reject surgery even if their doctor told them the belief had no scientific basis.
Sense Breaks Out in the Senate: Unbelievable as it may seem, there's bipartisan support in the Senate for needs-testing Medicare:
With unexpected support from some Democrats, Republican negotiators from the House and the Senate say they are seriously considering a change in Medicare that would require elderly people with high incomes to pay higher premiums than other beneficiaries.
....In the past, Democrats have vehemently opposed the idea. But some of the social policy experts most respected by liberal Democrats now say they are receptive to it, as a way to avert cuts in Medicare and other domestic programs. Pressure for such cuts will increase, they say, as budget deficits grow and baby boomers cash in their claims to Medicare and Social Security.
Most of the 40 million Medicare beneficiaries now pay the same premium, $58.70 a month, or about $704 a year, for doctors' services and other outpatient care.
Under one proposal being discussed by House and Senate negotiators, premiums would rise gradually with a beneficiary's income. The change would affect only people with annual incomes above a certain level, perhaps $75,000 or $100,000. Individuals with incomes exceeding $200,000 could see their premiums triple, to about $2,100 a year.
And that's still a bargain compared to what working people with much lower incomes pay for health insurance. Still, there are those who object, predictably:
AARP, the lobbying group for older Americans; labor unions like the United Automobile Workers; and some liberal Democrats, including Senator Edward M. Kennedy of Massachusetts, say levying an extra charge on affluent beneficiaries would undermine the universal nature of Medicare. Such a change, they say, would be a dangerous first step in turning Medicare from a universal social insurance program into a welfare program.
Nobels: The Nobel Prize in medicine went to two researchers whose work led to MRI's. MRI has been a godsend to medicine. Before MRIs patients had to undergo painful, invasive procedures to determine if they had a herniated disc or a spinal tumor. And as functional MRI's evolve, they have even greater potential to revolutionize the diagnosis of disease. posted by sydney on
10/06/2003 07:36:00 AM
Mississippi Justice: The feds are wondering just why it was that one impoverished county in Mississippi had so many unusually large jury awards:
Perhaps the most notable jury award in Jefferson County — a poor black county of less than 10,000 residents — was $150 million given to five plaintiffs in 1999 against the makers of the diet drug fen-phen. The case was eventually settled with more than 800 other fen-phen cases for a reported $400 million.
In nearby Claiborne County, jurors in 2001 returned a $100-million award against Johnson & Johnson stemming from the heartburn drug Propulsid.
... At least two drugstores in the area have been subpoenaed by a federal grand jury looking for patient information and possibly forged prescription records.
Investigators from the state Attorney General's Office reportedly contacted former jurors who sued the CBS newsmagazine "60 Minutes" after it aired a segment last November called "Jackpot Justice." It featured former Fayette florist Beau Strittman, the recipient of an undisclosed settlement from the makers of the obesity drug Redux, who said juries had "awarded these people this money because they felt as if they were going to get a cut off of it."
... More than a half-dozen lawsuits have been filed against several of the lawyers who went after the drug maker. The lawyers being sued — Michael Gallagher of Houston and Dennis Sweet, Shane Langston, Richard Freese and Richard Schwartz — led the fen-phen litigation.
Two of the lawsuits contend Mr. Schwartz signed up fake clients to increase the lawyer's portion from the settlements. Ben Skipper, Mr. Schwartz's attorney, called the accusations "completely baseless."
A Jackson State University employee, Kenneth Kennedy, claims he referred 70 users of the drugs fen-phen, Propulsid and Rezulin to Mr. Sweet for $150,000, plus expenses. Mr. Kennedy said he was never paid.
With regard to biological warfare activities, which has been one of our two initial areas of focus, ISG teams are uncovering significant information - including research and development of BW-applicable organisms, the involvement of Iraqi Intelligence Service (IIS) in possible BW activities, and deliberate concealment activities. All of this suggests Iraq after 1996 further compartmentalized its program and focused on maintaining smaller, covert capabilities that could be activated quickly to surge the production of BW agents.
Debriefings of IIS officials and site visits have begun to unravel a clandestine network of laboratories and facilities within the security service apparatus. This network was never declared to the UN and was previously unknown. We are still working on determining the extent to which this network was tied to large-scale military efforts or BW terror weapons, but this clandestine capability was suitable for preserving BW expertise, BW capable facilities and continuing R&D - all key elements for maintaining a capability for resuming BW production. The IIS also played a prominent role in sponsoring students for overseas graduate studies in the biological sciences, according to Iraqi scientists and IIS sources, providing an important avenue for furthering BW-applicable research. This was the only area of graduate work that the IIS appeared to sponsor.
Discussions with Iraqi scientists uncovered agent R&D work that paired overt work with nonpathogenic organisms serving as surrogates for prohibited investigation with pathogenic agents. Examples include: B. Thurengiensis (Bt) with B. anthracis (anthrax), and medicinal plants with ricin. In a similar vein, two key former BW scientists, confirmed that Iraq under the guise of legitimate activity developed refinements of processes and products relevant to BW agents. The scientists discussed the development of improved, simplified fermentation and spray drying capabilities for the simulant Bt that would have been directly applicable to anthrax, and one scientist confirmed that the production line for Bt could be switched to produce anthrax in one week if the seed stock were available.
A very large body of information has been developed through debriefings, site visits, and exploitation of captured Iraqi documents that confirms that Iraq concealed equipment and materials from UN inspectors when they returned in 2002. One noteworthy example is a collection of reference strains that ought to have been declared to the UN. Among them was a vial of live C. botulinum Okra B. from which a biological agent can be produced. This discovery - hidden in the home of a BW scientist - illustrates the point I made earlier about the difficulty of locating small stocks of material that can be used to covertly surge production of deadly weapons. The scientist who concealed the vials containing this agent has identified a large cache of agents that he was asked, but refused, to conceal. ISG is actively searching for this second cache.
Additional information is beginning to corroborate reporting since 1996 about human testing activities using chemical and biological substances, but progress in this area is slow given the concern of knowledgeable Iraqi personnel about their being prosecuted for crimes against humanity. posted by sydney on
10/04/2003 12:29:00 AM
California, for example, seems determined to keep itself stuck firmly in the 20th century by trying to require further costly health insurance mandates on employers. If California employers who pay wages of, say, $25,000 per year, are required to purchase $8,000 health insurance plans to cover their workers' families, the result will be that companies will have to fire people in order to cover the workers they still have. The unintended but unavoidable consequence of trying to extend the state's old-fashioned employer-centered health insurance system will be higher unemployment and fewer business startups.
The fact is that fewer and fewer Americans are following the career paths of their parents and grandparents—i.e., graduating from high school, going to work for one big company that provides health insurance for the worker's family, and retiring at 65 with a company pension. In the 2lst century, workers change jobs more frequently, more people are working for smaller companies that offer fewer benefits, and one in 12 Americans will start her own business. What is needed is a more flexible health insurance system to meet the needs of the modern world. So why not let workers decide how to handle their own health insurance needs?
Yeah. Why not? There's an opportunity here for a forward-looking health insurance company. If there is such a thing. My husband and I have spent much of the past month looking for a health insurance policy for our family, and it's no easy thing to find. Most of the big insurance companies don't offer individual policies, but prefer only to deal with employers. There's a market void out there that's just waiting to be filled. posted by sydney on
10/03/2003 11:19:00 PM
A Miami physician, Marco Vitiello, has come up with a device he said will be able to prove whether people are telling the truth about neck, back and carpal tunnel injuries.
If -- and it's a huge if -- the device, called the Comprehensive Neuro-Muscular Profiler (CNMP), could prove to be all he claims, it could make a big difference in many ``soft-tissue'' personal liability and workers' compensation cases in which doctors have a hard time determining the extent of an injury.
``This is a very, very elusive type thing, and anything that can put objective detail to it is valuable,'' said Ron Bellows, a risk management specialist with AIG Consultants.
Bellows said there are several devices trying to make such objective measurements, and he's not endorsing any single product, but ``it's become more and more into vogue.... . . The question is can they persuade the medical community by... . . doing trials and showing results.''
The technology, Vitiello acknowledges, is not new, but ``the problem has always been that reading their results has been subjective, varying from doctor to doctor. But with our software, we've solved those dilemmas. We're absolutely objective.''
The device consists of sensors that are applied to the body parts in question, such as the neck, arm, and hand for carpal tunnel syndrome. The sensors then pick up the electrical signal that travels from the brain to the hand along the nerve that runs down the arm. If someone is faking an injury, presumably there’s no nerve signal because there’s no intent to move the limb. It’s not at all clear if this actually works. It may be fairly effective for sorting out false claims of weakness, but what about people whose functional limitations are caused by pain? The pain may cause them to stop trying to move the affected limb, resulting in no nerve activity. That means they would get the same reading as a malingerer. The technology just isn’t there yet to measure pain objectively.
However, in the future, functional brain imaging, as detailed in The New Brain, may be used for just this sort of thing. Pain centers in the brain would light up on a functional MRI or PET scan when a person tries to move an injured limb. They wouldn’t light up in a malingerer. Unfortunately, this, too, lies in the future since researchers haven't come to any clear agreement on which functional signals are real and which are "noise."
UPDATE: A pain physician who has had some experience with these devices emails:
As a pain physicain I have seen a lot of gadgets like that. They all
claim to show if someone is actually injured. All seem to be variations of the same type of technology. None has ever been documented to actually be useful. Interestingly they tend to be used by physicians who treat MVAs and by chiropracters. The report is used tp "prove" the injury, not to disprove the reported injury. posted by sydney on
10/03/2003 08:47:00 AM
Thursday, October 02, 2003
Yet More on Going Bare: Grunt Doc points out the folly of practicing without malpractice insurance:
This is stupid for several reasons, and I'm not a shark plaintiffs' attorney, I'm sure they'd be glad to explain more reasons. First, from a purely practical aspect, most hospitals won't let you be on staff unless you're insured for at least a minimum amount. They aren't interested in being the deepest pocket, and as we're (mostly) not their employees they don't want the multi-mil$ liability.
Second, as was explained to me when I was but a pup, "yeah, you have nothing now, but you will someday, so I'd get a judgement and then renew it every 7 years". Because your net worth is negative today doesn't mean it'll stay that way. Just remember that bankruptcy doesn't wipe out many jury verdicts.
Third, the nail that sticks up is the one that gets hammered down. This doc is deliberately making himself a target, and might get sued just to scare others into not going bare.
Lastly, say he gets sued. All his legal expenses are out of pocket (mine are covered in my policy), billed at huge numbers per hour (more than an FP collects by far), and there's no settling for more than you have in savings, because you don't have it.
The doctor who goes without malpractice insurance is taking a substantial risk. It’s one that I wouldn’t be comfortable taking, either, unless I had no other choice. But, it isn’t complete folly. What we have today is a system that’s being gamed far too much by trial lawyers. Think about people you know who have been in auto accidents. How many times have you seen them shrug their shoulders and say they have to pay their own repair expenses because the other driver didn’t have insurance? Why can’t they just sue him for the repairs? Because they can’t find a lawyer willing to take the case. BUT, add in insurance, and not only will a lawyer gladly take the case, he’ll find ways to ask for more money.
The same thing happens in malpractice. A few years ago there was a case that got prominent play in the front pages of the New York Times. There was an abortion clinic in the city that was run by a doctor who had no malpractice insurance. One of his patients died from a hemorrhage after an abortion. The main angle of their stories was not that abortions have risks, but how horrible it was that this guy had no malpractice insurance because no one could sue him. Of course they could sue him, they just wouldn’t. (He ended up losing his license, by the way, so justice was done.)
The doctor from Chicago who’s going bare explains everything on his website (Thanks to fellow physician blogger Veshland for the link). This is how he explains it to his patients:
They have to know that bad things happen. Being alive carries a risk of dying, being healthy carries a risk of being sick, and the best medical care in the world can't always prevent it.
They have to know that I am human, and although I am very, very good at what I do, I can err. Just last week I locked my keys in my car (although that was the first time I have ever done that).
They have to know that I am not my own insurance policy. I own a Tercel, a large mortgage, $150,000 in student loans, as well as 7 years of post-graduate education, and 6 years of clinical experience.
And if you think that the trial lawyers are only in it to keep medicine safe for the patients think again:
Over the course of three years, my malpractice insurance went from to $2500, to $4000, to $10,000, and this year I was told it would be $40,000. If I had decided to continue delivering babies, it would cost me $150,000. If I quit my practice, and move to a different county, my insurance would only cost me $5000.
There is no reason that moving to the next county would improve a doctor’s performance enough to cut his malpractice premium by $35,000. The only reason the next county is that much cheaper is that it’s too hard for big city law firms to gather up clients from there.
And as for patients, their motive isn’t too far from the lawyers’:
My experience with my patients has been that their concern is that a disaster will befall them, not that I will commit malpractice. If disaster struck, they could find themselves in the position of needing to sue me, just to cover their medical costs, or lost earnings. What these patients really need is disaster or disability coverage. Imagine spreading the risk of two-thousand patients over two-thousand policies as an alternative to traditional malpractice. Imagine people filing claims instead of suits...no court costs, no attorney fees. (emphasis mine)
If we’ve come to regard our tort system as the equivalent of an insurance policy, then there’s no doubt the system is broken.
(His website has a link to the attorney who is helping him make this possible. Not all lawyers are blind to the faults of the system.)
UPDATE: A lawyer/doctor reader point out:
The tort systems only real justification is as insurance. It was originally set up as a way to shift costs to the one responsible. Torts predate actual insurance. A whole area of research called law and economics explores the justification of tort law. Essentially torts can only be justified as either a cost shifting mechanism, ie placing the costs on the party responsible, or as private vengence, ie I want to hurt the person who I think hurt me. A subset of private vengence is the deterrance function. This might be viewed as "Its not really venegance I'm after, its just to prevent this from happening to others."
No one has shown to a level of proof that would be accepted in medicine that the deterrance function works in tort. The insurance justification is known to be so inefficient that it is a theortic basis but not an best practice basis. It is more efficient to allow patients to insure themselves against malpractice through policies or price differentials. (Price differential would be an OV costs x if you agree you can not sue for anything or x plus y if you want to be able to sue). Private vengence is an interesting justifiaction but do we really want to allow private vengence in our society.
Lawyers/judges/patient advocates assume torts are good for society but have never actually proven why. Since law rejects the scientific hypothesis/enlightenment and hews to a Platonic theory of proof discussion of tort reform tends to break down. I would suggest that until society decides what exactly is the function of tort law and how that is best accomplished all tort reform does is rearrange the deck chairs on the Titanic.
Beware of Experts: Especially if they're getting paid for their trial testimony. Here's a gynecologist who's being sued for sexual harassment for what the expert witness for the plaintiff says is unorthodox medical care:
Tugging a woman's nipple during a breast exam is "like milking a cow," a doctor testified Monday in the continuing sex-abuse trial of Phoenix gynecologist Brian Finkel.
"It's never done," testified Dr. Sidney Weschler of South Dakota during the eighth week of Finkel's trial.
But something similar to that is done during a breast exam to check for nipple discharge.
Finkel also is accused of performing unnecessary rectal examinations on two patients.
Weschler acknowledged under cross examination that he taught students that no "pelvic examination is complete without a rectal examination." However, he said it is a "teaching standard that is rarely applied" in practice. Rectal exams are typically done only on women age 40 and older to check for diseases, he said.
If rectal exams are a "teaching standard rarely applied" at the expert witness's medical school then those medical students aren't getting their money's worth. Rectal exams are done during pelvic exams to palpate the back of the uterine wall and other masses that may be lurking behind the uterus. Under different circumstances and in the hands of a different attorney, not doing a rectal exam could be construed as negligent.
He also testified that touching certain parts of the vaginal area during an examination is unnecessary because most abnormalities are obvious. Some women have testified that Finkel manipulated their vaginas during exams.
It may be true that "most abnormalities" are obvious, but there are also plenty of abnormalities that are only detectable by touch. In addition, a thorough visual inspection of the external genitalia requires that flaps of skin be moved out of the way.
Context is everything, of course, and maybe the doctor did some inappropriate touching, but on the basis of this story it looks as if he's guilty of nothing more than doing a more comprehensive examination than most of his colleagues take the time to do.
You fail to mention that the doctor has 60 counts of assault and abuse charged against him by 35 different patients. That's a pretty important piece of information. Your post makes it seem as if this was a one-time misunderstanding. Apparently, this guy has frequent misunderstandings with his patients.
Had the physician had a better "bedside manner," explaining thoroughly to the patient prior to conducting the exam what exactly he was going to do and why he was going to do it, and documenting that such a conversation took place in the medical record, he likely could have avoided such a situation. Also, it's unclear whether the physician had an opposite-sex assistant in the room at the same time (which also tends to reduce lawsuits). These types of harassment-oriented cases (inappropriate touching) tend to arise only in two situations:
(1) when the physician and patient are on different pages about what is/should be done (meaning: a poor informed consent discussion - and even then they don't tend to come up unless the doctor comes across as a little creepy); and
(2) when the doc is really trying to get away with stuff he shouldn't be doing.
He has more on his blog, just scroll down since the archive links are, of course, bloggered. Although he makes good points about the importance of communication during sensitive examinations, he misses the point of my post. It isn't about whether or not the doctor is guilty. It's about the quality of the expert witness testimony. "It's never done" (regarding manipulating nipples during a breast exam), rectal exams are "teaching standards that are rarely applied," and that touching the genitalia is "unnecessary because most abnormalities are obvious," are all statements that are simply not true. And the expert knows it, as does anyone who paid attention in medical school.
Based on that testimony, anyone doing a thorough exam would be accused of harassment. Think it doesn't matter because it was only part of a court case? Think again. Plenty of women have now read the testimony in their local newspaper. And just what are they going to think when their physician performs an appropriate breast and pelvic exam? Chances are, after reading that expert's perceived wisdom, they're going to be suspicious - even if their doctor does the appropriate explaining.
Absence: Apologies for the absence these past few days. I moved into my new office Saturday, and it took every last minute of my days to get it up and running so that it would pass any unannounced inspections from insurers and government bureaucracies. I felt like a captain getting his ship ready to sail and pass inspection by the admiralty. We had our first full day of patients yesterday and I'm happy to report that my ship is yare. (And thanks to all of you who emailed with concerns about my unexplained absence.) posted by sydney on
10/02/2003 07:07:00 AM