"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
Apologies: Sorry blogging's been light. Parenting and professional duties are getting in the way. One of those duties last night involved writing a letter of necessity for Synagis®, a vaccine to combat a respiratory virus in premature babies. My patient meets the criteria, yet, as I wrote the letter I couldn't help wondering if the vaccine was really worth the cost. It's given once a month at the hefty sum of $1100 a dose. It does reduce hospitalizations due to the virus it targets, but only from 12.8% to 7.9% in babies like my patient. And last year I had two patients (twins) who were hospitalized for the virus despite getting the immunization. But, I suppose the insurance companies must feel they'll save more in prevented hospitalizations than they'll pay for vaccine, otherwise they wouldn't cover it. posted by Sydney on
1/07/2004 08:23:00 AM
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Monday, January 05, 2004
Gallery of Nostrums: Some old potions from the FDA. Note the "Obesity Cream." Evidently it's not a purely modern affliction. posted by Sydney on
1/05/2004 12:50:00 AM
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Can't Get No Satisfaction: The New England Journal of Medicine last week also ran an interesting essay on physician dissatisfaction. It's nothing new:
Earlier generations of physicians had experience with much of the anxiety that we sometimes assume is unique to modern medical practice. "A doctor's life is made up of moments of terrible nervous tension," wrote one physician in the early 20th century. "A sudden turn for the worse in a convalescent patient, an incurable who cries for relief, the impending death of a patient, the ever present possibility of an untoward accident or mistake. . . . There are times when the powers to continue such a life are entirely exhausted and you are seized with such depression that only one thought remains — to turn your back on all and flee."
Add to that inherent tension the escalating malpractice premiums, dwindling reimbursement, and paperwork hassles of today, and you have to wonder why anyone would go into medicine. Well, it's actually not so bad. You get to meet interesting people. Once in a while you get to make a difference in someone's life. And you can't be outsourced. (Unless you're a radiologist.) posted by Sydney on
1/05/2004 12:42:00 AM
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Anatomy of a Practice: The sad story of a young cardiologist and his struggle to stay afloat:
Lewis didn't take home a paycheck in June, July, September or October. He worked 10- to 12-hour days, six days a week, and estimates that he averaged around $30 an hour this year for his efforts. (Lewis declined to specify his income, but using the figures he provided for this story, it would appear he made about $100,000 during his best years.)
...At 44, Lewis has been able to save little money for retirement. He still pays $320 a month to cover medical school loans. His wife's job provides health insurance for them both.
..."I think we're running a really tight ship right now," says Katherine Lewis, who managed to trim about $4,200 in monthly costs by reducing the phone bill, bringing in another doctor to share the office space and laying off the office manager.
"Even if you're an excellent businessman, it isn't going to cut it," she says. "There's always something, and the medical system doesn't give you enough cushion."
In 2000, the office flooded, causing more than $20,000 in damage. In 2001, an office theft cost the practice $14,000 before it was discovered. Both incidents left the practice cash-poor for several weeks until insurance payments came in. Then, earlier this year the practice moved into a new space, which cost more than $40,000 to outfit.
This year, Lewis's malpractice insurance increased from $12,000 to $18,000. Lewis has never been sued, and has no complaints on file with medical boards in Maryland or the District.
...."During the first year, I was just really, really frustrated, because I'd install a pacemaker and have no hope of getting that to my bottom line," he said.
On Aug. 7, Lewis handles a case that seems unlikely to get bogged down in the reimbursement process: an hour of patient consultation that he values at $195, even though Medicare's set rate for the service is $127.68. Lewis collects the patient's co-payment of $25.54 on the day of the visit, and, if all goes without a hitch, he will collect $102.14 about six weeks later.
Meanwhile, in the adjoining room, Lewis's secretary grapples with a worst-case scenario: She's trying to figure out how $3,460 worth of services billed a week ago has become a $345 item in the practice's computer system. She can't log into the online bill-monitoring system the practice pays $150 a month to use. The billing agent who collects 8 percent of every bill paid by insurance companies is unresponsive, so she spends up to five hours a day auditing the bills.
Lewis looks over her shoulder and shrugs helplessly. Collecting 45 percent of billed charges is the best anyone can hope for, he says, because collecting more than that requires too much effort.
...In a typical month, Lewis said, the practice took in $18,000 to $25,000 in gross revenue. From that figure he had to pay rent, phone bills, loan payments, malpractice insurance, the lawyer, the accountant, the billing agent, the secretary, the copier lease, office supplies, staff health insurance and computer support. This left him with about half the gross to pay himself. Some months, there was nothing to take home after the bills were paid.
"We looked very hard at the trends, and they are only going down," Lewis said. That was the last straw. "We all value taking home a paycheck as a sign of respect."
Dr. Lewis closed his practice and took a job with the FDA testing pacemakers. Poor guy. I feel his pain. posted by Sydney on
1/05/2004 12:13:00 AM
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Mystery Case: The New England Journal of Medicine has another mystery case up this week. We're supposed to guess what's in this guy's stomach. Whatever it is, it's heavy, because it's pulled his stomach all the way down into his pelvis. Looks like paper clips to me, but I always get these mystery cases wrong. No answer until February. posted by Sydney on
1/05/2004 12:09:00 AM
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The Doctor Factor: The Washington Post has a withering analysis of Howard Dean as a stereotypical doctor:
The man is a doctor. This is the least-examined chapter of his career. But suddenly it all makes sense: Where else but in medicine do you find men and women who never admit a mistake? Who talk more than they listen, and feel entitled to withhold crucial information? Whose lack of tact in matters of life and death might disqualify them for any other field?
As much as I hate to admit it, there's a lot of truth in this essay. Anyone who has worked even peripherally in the medical field knows doctors who fit the profile. Although some would argue that beneath the arrogance and haughtiness lies a fear of being wrong or out of control, the closer truth is that during our medical educations we're exposed to an inordinate amount of arrogance and haughtiness in our role models.
Someone once described medical education as being akin to living the life of an abused child. And that's not too far from the truth. When we're medical students and residents, we get lambasted and yelled at for the simplest of mistakes or errors or lack of knowledge. We're ridiculed in front of our peers and our superiors at morning presentations, after sleepless nights spent doing work no one else wanted to do. Sometimes we're ridiculed in front of patients during morning rounds. At least, that's the way it was twenty years ago, and it's a good bet that's the way it was thirty years ago when Dr. Dean went through his training.
The result is, that we grow up professionally incapable of admitting when we're wrong, and we grow up thinking that the correct response to other's faults is the same scorn and contempt we got as students - even when those faults live more in our own perceptions than in reality. It certainly isn't any way to manage people effectively, let alone lead them.
Admittedly, not all physicians turn out this way, just as not all children from abused homes grow up to be hopelessly messed up. But a goodly proportion of us do.
UPDATE: The excellent Galen's Log, by a practicing internist, has another take on this. While RangelMD thinks I'm harming our profession by admitting that we have more than our fair share of pompous jerks. (To be fair, we probably have the same share of pompous jerks as academia.) Note to Rangel: Self-examination is a good thing. Without it, there can never be any self-improvement.
While I Was Away: So much happened while I was napping. A trial lawyer managed to temporarily halt the military's anthrax vaccine program on the technicality that the vaccine was never approved for inhalation anthrax. That's a charge that isn't entirely true. This week the FDA announced that the vaccine is safe and effective, regardless of the route of exposure. The trial lawyer who initiated the case accuses the FDA of "gamesmanship" in the ruling, but truthfully, the vaccine is effective, and the FDA has the data to prove it, to the best of anyone's ability. (See the first link above for more on that.)
The truth is, that since the approval of the vaccine in 1970, and it's use in high risk groups, the incidence of inhalational anthrax in this country dropped to zero. It wasn't until the bioterrorist attacks of 2001 that cases of inhalational anthrax emerged again. All the more reason why military personnel stationed in high risk areas should be vaccinated.
And then, of course, there was the case of the mad cow. It didn't seem to bother too many people outside the media, at least not in this country. I got zero calls at the office about it. (People were more concerned about the flu, and rightfully so.) And according to this story sales of meat at fast food restaurants and stores is staying stable.
The risk seems to be small, since there are already regulations in place to avoid the kind of mad cow epidemic (which was really relegated to cows only) that occurred in Britain. Even so, the slaughter industry is also getting a new set of regulations, to minimize the risk even further.
It's amazing that so much fuss can be caused by a simple protein that manages to get itself folded differently. The diseases caused by these prions are very rare, even the variant Cruetzfeldt-Jakob disease that comes from mad cows. Over 200,000 English cows were infected with the bovine version of it, yet there have been only 124 human cases linked to that outbreak. Therefore, the presence of one mad cow does not a crisis make.
And in lesser news, Howard Dean announced he was going down South to witness for the Lord. He didn't say whether it would be the bike path Jesus or the angry Jesus he would witness for, but one thing for sure, it won't be this Jesus.
Don't you think Jerry Falwell reminds you a lot more of the Pharisees than he does of the teachings of Jesus?' he added. 'And don't you think this campaign ought to be about evicting the money-changers from the temple?
Actually, neither politicians nor government should be ejecting anyone from temples.
posted by Sydney on
1/02/2004 08:15:00 AM
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Every Man a Poet: Last week's New England Journal of Medicine had reviews of two books that are worth a look. First, the intriguingly titled, The Healing Art: A Doctor's Black Bag of Poetry by poet/psychiatrist Rafael Campos. According to the review, the book is a compilation of case histories interwoven with an anthology of poetry that illustrates Campos's (and his patients') use of poetry as a healing art. But the importance of the personal narrative in healing goes far beyond poetry:
... "curing and healing are not the same, and it is possible to achieve the latter without succeeding in the former."
...Narrative provides more than a bridge between patient and doctor; it is also a diagnostic and therapeutic tool. Carried in the black bag, it is part of the physical examination, an internal ultrasound. Campo writes that "poetry locates us inside the experience of illness, demanding that we consider it from within, as attentively as we do from without."
It's part of the art of medicine to listen and, more importantly, to hear, our patient's stories. Not everyone is able to write down their stories or express themselves through poetry, but everyone has a story to tell if we only take the time to hear it. Many times that story is the most important part of the medical encounter. Unfortunately, it's often the first to fall by the wayside in the press of time. (For more on Campos's approach to mixing poetry and medicine, click here.)
The other book is an example of the practical application of Dr. Campos's approach. Breathing for a Living: A Memoir, is the very personal story of a young woman's life with cystic fibrosis. (See NEJM review here.) The author explicitly acknowledges the role of poetry in dealing with her illness, citing her physician father's habit of reading poetry to her when she lay sick in the hospital. She opens with one of those poems:
I wake to sleep, and take my waking slow.
I feel my fate in what I cannot fear.
I learn by going where I have to go.
Cystic fibrosis shortens young lives. It robs its victims of that illusion of immortality that makes young adulthood so exhilirating. And judging from the samples of the book available at Amazon.com, this book successfully conveys what it's like to come to terms with that mortality.
posted by Sydney on
1/02/2004 07:50:00 AM
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Happy New Year: I really meant to begin posting again on New Year's Day, but Blogger was supremely bloggered. Just one of many in a long series of things beyond my control. Maybe that's why I'm waxing romantic about Saint Joseph. posted by Sydney on
1/02/2004 07:48:00 AM
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The Picture Below: For those of you who might be interested, it's Rest on the Flight to Egypt by Luc Olivier Merson. A Frenchman born in the middle of the 19th century to an art critic, Merson gained fame and success as a champion of classicism. His paintings always told a story in the grand tradition of the artists from a generation before him, in marked contrast to the avant garde work of his contemporaries, Manet, Monet, Van Gogh, et. al.
Take a look at the full painting of Flight on the Rest to Egypt, with Joseph collapsed at the foot of the Sphynx while his wife and stepson sleep serenely in its embrace. It says more about Saint Joseph than it says about the other two members of his little family. Joseph bore a lot of burdens through no fault of his own. But bore them he did and without complaint. A wife pregnant with someone else's child, a long trip at the height of his wife's pregnancy. (And who do you suppose delivered that baby in the stable?) Then, a much harder trip to a foreign land, all for the sake of that very baby who had already caused him so much grief and who was very pointedly not his. That image of him collapsed on the desert floor speaks volumes. There he is, in all his human weakness, but nonetheless able to love with the purest love. The kind of love that his wife's baby grew up to preach.. The kind that "suffers long, and is kind; envies not; vaunts not itself, is not puffed up,does not behave itself unseemly, seeks not her own, is not easily provoked, thinks no evil." that "bears all things, believes all things, hopes all things, endures all things." All so beautifully expressed in the exhausted Joseph.
Merson was fiercely committed to his old school style. So much so, that he resigned his position at the Beaux Arts school to protest the rise of the modernist tradition. In the end, modernism won. The names of the impressionists live on while Merson remains a slight figure, not even mentioned in the sweeping coffee table histories of art. Not withstanding the fact that some of his work received much widercirculation. posted by Sydney on
1/02/2004 07:41:00 AM
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