"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
"Civilizing" Therapy: Interesting history of the treatment of homosexuality in Great Britain in the mid-twentieth century, from the BMJ:
In electric shock aversion therapy, electrodes were attached to the wrist or lower leg and shocks were administered while the patient watched photographs of men and women in various stages of undress. The aim was to encourage avoidance of the shock by moving to photographs of the opposite sex. It was hoped that arousal to same sex photographs would reduce, while relief arising from shock avoidance would increase, interest in opposite sex images. Some patients reported undergoing detailed examination before treatment, while others were assessed more perfunctorily. Patients would recline on a bed or sit in a chair in a darkened room, either alone or with the professional behind a screen. Each treatment lasted about 30 minutes, with some participants given portable electric shock boxes to use at home while they induced sexual fantasies. Patients receiving apomorphine were often admitted to hospital due to side effects of nausea and dehydration and the need for repeated doses, while those receiving electric shock aversion therapy attended as outpatients for weeks or in some cases up to two years.
Oestrogen treatment to reduce libido (two participants in the 1950s), psychoanalysis (three private participants and one NHS participant in the 1970s), and religious counselling (two participants in the 1990s) were also reported. Other forms of treatment were electroconvulsive therapy, discussion of the evils of homosexuality, desensitisation of an assumed phobia of the opposite sex, hypnosis, psychodrama, and abreaction. Dating skills were sometimes taught, and occasionally men were encouraged to find a prostitute or female friend with whom to try sexual intercourse.
They didn't succeed in converting anyone.
COMMENTS: A reader comments on the significance of this treatment's failure:
What has perked my interest since I prefer the company of men is the idea that the infusion, inclusion, tepid acceptance and increased presence of the "homosexual lifestyle" in the mass media and in everyday life will sway (mostly young men) to become homosexual. That premise is illogical. I (and every other homosexual) are inundated with heterosexual images, and outright blatant heterosexual lifestyles everyday. Every conscious minute of my entire life the heterosexual mantra is broadcasted. There is no escaping from it. And yet I was not swayed to become heterosexual. Those that tout the idea that the specks of the gay lifestyle (usually stereotypical images) will "tip" someone to choose to be heterosexual is ridiculous. posted by Sydney on
2/20/2004 08:01:00 PM
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Dream Amnesia: A doctor in Dayton, Ohio, says one of his patients developed amnesia after an Iraq nightmare:
In his letter to the journal, Marinella, a clinical associate professor in the internal medicine department, said the 61-year-old patient came to the emergency room with his wife, who was alarmed because he could not remember what he did the night before. Also, he was unable to keep new memories for more than a few minutes.
Doctors ran a series of tests, including a brain scan, and could find no reason for the patient's amnesia. 'He repeatedly inquired, 'Did I have a stroke?' and stated, 'I can't remember anything,'' Marinella reported.
He said that on the second day at the hospital, he was able to remember his nightmare. He had dreamed that his son, who was contemplating joining the military in reality, went into the Marines and died in combat. In the dream, the father vividly saw his son in a casket draped with an American flag. The father woke up screaming.
Other doctors aren't so sure that the nightmare was the cause:
Other specialists were skeptical of the Ohio doctor's report. They said a tiny stroke or some other undetected physical event in the brain was a much more likely cause of the amnesia.
NOTE: One hypothesis of the cause of transient global amnesia is that something causes a backward flow of blood in the veins of the neck to the brain, causing some temporary brain congestion that stuns the neurons. That could be what happened in this case when the man woke up screaming.
posted by Sydney on
2/20/2004 08:47:00 AM
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Help for the Uninsured: The Department of Health and Human Services has clarified Medicare's position as a "favored nation" when it comes to doctors and hospitals. (That's the clause in Medicare contracts that says no one can be charged less than Medicare gets charged.):
"The Bush administration encouraged hospitals on Thursday to give discounts to uninsured patients and to financially needy Medicare beneficiaries.
Such discounts are permissible under federal fraud and abuse laws, the government said, in a clarification requested by the hospital industry.
...Tommy G. Thompson, the secretary of health and human services, explained the administration's position in a letter to the American Hospital Association.
'Hospitals can provide discounts to uninsured and underinsured patients who cannot afford their hospital bills and to Medicare beneficiaries who cannot afford their Medicare cost-sharing obligations,' Mr. Thompson said. 'Nothing in the Medicare rules or regulations prohibits such discounts.'
Difficulties: The morning newspaper had one of those my friend's bad medical experience columns, by an editor from Tribune Media Services. The theme is that sometimes you have to be obnoxious to get doctors to listen to you. That may be true - sometimes. But the column isn't an example of that. Instead, it's the chronicle of a difficult personality's sojourn through a medical crisis. To begin with there's the opening, which reads as if the truth is being stretched:
The first thing was the phone-in diagnosis -- yeah, it's malignant. ``You need to call your surgeon.''
The doctor's 2-year-old was screaming in the background. Sorry about that, the doc told Sheri over the phone. But, to Sheri while she gripped the receiver in disbelief, there was no disguising the doctor's distraction or, profoundly, her indifference. Sheri had just been told she had breast cancer.
We can't make the diagnosis of malignancy or of breast cancer by any other means than a biopsy. So, how is it that Sheri finds out she has breast cancer before she's ever contacted her surgeon?
The column goes on to explain how Sherri had to fight for respect:
But you may not guess the whole person matters when a dreaded diagnosis plunges you willy-nilly into the multibillion-dollar cancer industry, which is often clueless about how to deliver qualities as simple as compassion and respect. For that, patients have to fend for themselves.
As a "bad patient," Sheri did so doggedly, without embarrassment. And often enough she found it. As she went into surgery, for instance, she implored her doctors to operate with love, and one of them said, "We're the two loviest guys in the hospital.''
Going into a relationship - any relationship - expecting the worst of the other person, is a set up for disappointment. Expect someone to be misogynistic, and you'll find it in almost everything he says. Expect someone to be racist and you'll likely find it in his every word and action. Expect your doctor to be cold and heartless and he likely will seem that way. It may not be the reality, but in such emotionally laden geography, perception is everything. And unfortunately, expectations have a way of warping perception. Sheri was fortunate that one of her surgeons had a well-developed sense of humor and was able to diffuse a tense situation.
This reassuring conversation took place in the pre-surgery prep room, soon after Sheri had argued with the anesthesiologist.
Sheri, a musician and health-care professional, had programmed two CDs for her surgery -- Mahler (sad, heavy strings) for the mastectomy, and James Taylor for the reconstructive surgery that would be done immediately afterward. And she had wanted her friend, an allergist and doctor, to be in the operating room to work the CD player.
The two surgeons had no problem with the arrangement, but the anesthesiologist smelled irregularity and nixed the plan, refusing to consider Sheri's point of view or even look her in the eye.
...In the end, there was a compromise -- one of the surgeons agreed to work the CD. But after she took her stand (while lying prone on the gurney), she told me, ``His students were standing there with big grins on their faces because they couldn't talk to him the way I could.''
Or maybe they were grinning because they knew no one was going to be operating that CD player, and she would never know it.
Now, there are definitely times when patients need to be their own advocate. If a patient feels that his doctor isn't listening or providing the care he needs, then he should find a new doctor. But, this story just sounds like the story of a difficult person. Chances are, she's just as difficult for waiters and store clerks as she is for doctors.
ADDENDUM: Bard Parker reminds me that there is a way to get biopsy results without ever seeing a surgeon:
Concerning your question about a biopsy sans surgeon, if the patient had a lesion on her mammogram a stereotactic biopsy may have been performed by a radiologist. A practice I am not in favor of, by the way.
I had forgotten that radiologists do those. (In my practice, I send them to the surgeons.)
UPDATE: And another physician reader has this observation:
Oh brother. "Difficult" is a charitable assessment of this patient. I have no argument with a patient carefully selecting which doctor and which hospital she wants to go to, or which therapy among the available and appropriate choices she may want. But to insist on what kind of music (maybe the surgeon, who is the one doing the work here after all, would prefer not to have music playing while he is doing his work) would be played while in surgery is going a little too far. The writer, who seems a little fuzzy-headed with his pop-science reportage, implies that the operating room environment is just one more venue for the self-involved to tailor to their tastes, all under the wooly cover of compassionate care. It doesn't occur to him that there may be valid safety reasons for the anaesthesiologist wanting to set limits on CD playing. He should get a clue; this is the OR, not a garden party or a dance club.
UPDATE II: Another point of view:
I offer a polite disagreement with your assessment of the 'difficult patient'.
I don't deny that there are patients who are difficult -- demanding attention far beyond the norm. No one likes them -- not the doctor, not the staff, not even the people cringing in their chairs in the waiting room as they listen to her vocal demands.
Yet there are two reasons why that attitude should be understandable -- not desirable, not easily acceptable, but understandable.
First, most simply, she's a consumer. Someone has informed her of a major change to her life plans. She has a right to wring every iota of useful attention and information from them, whether it's convenient for them or not.
Second, she's in a tough position, and feels that she isn't getting the level of attention that that tough position deserves. Should she be a good patient and sit quietly? No more than she should meekly accept the word of the auto mechanic who's just blithely informed her 'that sound means you need a new transmission, lady'.
Neither of these gives her to right to be pushy or arrogant, demanding more than her service provider can reasonably give. Was she? Did she? Yes, I think so. Any professional relationship demands a level of civility and balance that was exceeded here. She was wrong to act in that way. But she wasn't wrong to believe that she needed extra attention, and to act on that belief.
Mystery Solved: Last month I linked to this medical mystery from the New England Journal of Medicine - a man whose stomach appears to be in his pelvis. If I recall, I thought it looked like he had eaten paper clips. Today, the Journal published the answer (requires subscription):
At laparotomy, the distended stomach was found to contain 5.5 kg of coins, necklaces, and needles.
Fighting Cancer: Researchers have used a vaccine to improve lung cancer outcomes. Although the trial was a very small one, it did show some success:
The vaccine uses cancer cells obtained from the patient's tumor to activate the immune system. In the trial, 43 patients with early and advanced-stage non-small cell lung cancer were treated with the vaccine. Half of the patients responded to the treatment.
For about 10 percent, the remission lasted more than eight months, and some patients have been cancer-free for three years, said Dr. John Nemunaitis, oncologist and researcher at the Mary Crowley Medical Research Center at Baylor.
People with non-small cell lung cancer typically survive four to six months.
...In the study, three patients with advanced-stage lung cancer experienced complete remission lasting six months, 18 months and ongoing at 22 months.
For two of these patients, treatment with chemotherapy had failed. One patient experienced a 30 percent decrease in the size of a lung nodule, and for seven patients, the disease did not progress for a period ranging from almost five months to more than 28 months.
One of the significant advantages is that the vaccine has virtually no side effects, Nemunaitis said.
According to the abstract, the only side effect was a little redness and irritation at the site of the injection. Here's the abstracted data from the study:
Three of 33 advanced-stage patients, two with bronchioloalveolar carcinoma, had durable complete tumor responses (lasting 6, 18, and 22 months). Longer survival was observed in patients receiving vaccines secreting GM-CSF at more than 40 ng/24 h per 106 cells (median survival = 17 months, 95% confidence interval [CI] = 6 to 23 months) than in patients receiving vaccines secreting less GM-CSF (median survival = 7 months, 95% CI = 4 to 10 months) (P = .028), suggesting a vaccine dose–related survival advantage.
(Editor's note: GM-CSF is a chemical put out by cells that stimulates the immune system.)
This does look promising, and has some interesting implications. Since the vaccine was produced from the patients' tumor cells, there is the possibility that it could also be effective against other types of cancer, as long as access to the tumor is possible. And it gains survival advantage without serious side effects, unlike so much of chemotherapy and radiation therapy. posted by Sydney on
2/19/2004 08:35:00 AM
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Flu Retrospective: This year's influenza season wasn't such a big deal after all. It just came earlier than expected:
Flu and pneumonia accounted for 10 percent of all deaths during influenza's peak in late December, said Ann Moen, an influenza specialist of the Centers for Disease Control and Prevention. That's just shy of the flu's death toll in 1999, the last time an H3N2 strain predominated. The CDC knows of 134 flu-associated deaths among children, 82 of them in youngsters under 5, Moen said. In the 1990s, there was an average of 92 deaths a year among children under 5.
That squares with my experience. We had a fast and furious stream of cases for 2 to 3 weeks, as usual for an average flu season, then it died its natural death, as it always does. It just came in December instead of January. posted by Sydney on
2/19/2004 08:28:00 AM
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Crystal Ball Medicine: Having a small, premature baby puts future pregnancies at risk, although there isn't much you can do about it:
Women who give birth to small babies -- whether prematurely or not -- are more likely to have stillborns during their next pregnancy, a study found.
The Swedish study, published in Thursday's New England Journal of Medicine, suggests that the same causes may underlie both stillbirths and stunted growth in fetuses.
However, because so little can be done about many growth problems, the study is not expected to bring about any big changes in obstetrics.
The risk is there, but it's a small one (and one that I would argue most obstetricians are already cognizant of, since they treat women with prior preterm, low birthweight babies as higher than average risks):
The researchers used a national registry with 410,021 women who had two consecutive pregnancies resulting in live or stillbirths.
....Preterm newborns raised the later risk of a stillbirth only if they were also small for their fetal age. The risk of a later stillbirth was five times higher if the newborn was both very small for its fetal age and very early in its delivery -- before 32 weeks.
...Though small newborns heightened the risk of later stillbirths, the overall rate of stillbirths for the second pregnancy was low at 2.6 per 1,000 births. Even in the highest-risk group, there were only 19 stillbirths per 1,000 births.
Nefarious Scientist Medical Watch: Dr. Khan finds opportunity yet again:
Abdul Qadeer Khan, who in recent weeks apologized to Pakistanis for running a black-market nuclear weapons proliferation network, suffered a cardiac arrest today as a result of the stress of being pardoned by President Musharraf rather than jailed as a traitor and terrorist.
'When I brought some flowers to A.Q. Khan today,' said Gen. Musharraf, 'I noticed that some of the government-provided medical equipment was missing from his room. He confessed that he had sold it to Kim Jong Il, and was very sorry. I immediately forgave him.' posted by Sydney on
2/17/2004 08:27:00 AM
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Antibiotic use in women is associated with an increased risk of breast cancer, according to a study released Monday that raises new questions about the underlying causes of the deadly disease.
.....The study, based on health data from more than 10,000 women in the Pacific Northwest, found that women who used the most antibiotics had twice the risk of breast cancer when compared with women who had not been given the drugs. That risk increased as the amount of antibiotics prescribed to a woman went up.
The study was led by researchers at Group Health Cooperative, a Seattle-based health care provider that sees patients in Washington and Idaho. Researchers started with health data from more than 2,200 women cared for by Group Health Cooperative who had been diagnosed with invasive breast cancer between 1993 and 2001.
They then compared the medical histories of the breast cancer patients with those of about 7,900 female patients who did not develop breast cancer, looking at everything from age to weight to the amount of antibiotics the women had been prescribed, over an average of 17 years.
The more antibiotics the women had been prescribed, the higher the risk of breast cancer, they found. Women who had been prescribed smaller amounts of antibiotics -- anywhere from one to 25 prescriptions -- were about 1 1/2 times more likely to get breast cancer than those who took no antibiotics. Women who had received more than 25 prescriptions had twice the risk of breast cancer.
This increased risk stayed constant regardless of the type of antibiotic the women had taken or the specific ailment the drugs had been prescribed for, the researchers said."
The study is available at JAMA's website, in PDF format (also at this direct link. Here's what they really found. Out of 7,989 women who did not have breast cancer, 18% never used antibiotics, 51% used them 1 to 10 times, 22% used them 11 to 25 times, 6% used them 26 to 50 times and 2% used them over 50 times. On the other hand, out of 2,266 women who did have breast cancer, 14% never used antibiotics, 51% used them 1 to 10 times, 22% used them 11 to 25 times, 9% used them 26 to 50 times, and 3% used them over fifty times. Looks like both groups used antibiotics at the same rates, and over the same distribution curve.
Of course, it's never a good idea to take antibiotics needlessly, but that's because of real side effects (bacterial resistance, allergies, diarrhea, etc.) not because they cause cancer.
posted by Sydney on
2/17/2004 07:59:00 AM
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Eye of the Storm Update: One of Ohio's state senators plans to go after the malpractice insurance companies:
A state senator is asking the Ohio Department of Insurance to launch an investigation into insurance company decisions to deny malpractice coverage to doctors who treat nursing home patients.
State Sen. Robert F. Hagan, D-Youngstown, a member of the Health, Human Services and Aging Committee, said he was ``overwhelmed'' and ``troubled'' by a story in Sunday's Akron Beacon Journal that chronicled how doctors are being denied malpractice coverage until they agree to no longer treat nursing home patients.
``We are losing care for some of the most precious individuals in our lives, at the end of their lives when they really need that care the most,'' Hagan said Monday.
.....In addition to asking the Department of Insurance to investigate, Hagan wants the Health, Human Services and Aging Committee to hold hearings, bringing individual insurance companies to the table to explain their policies for insuring doctors at nursing homes.
``If it's true that they're coercing doctors to leave nursing homes,'' he said, ``we need to take away their license to sell in this state, because they don't deserve it.''
Here's the problem. We only have five malpractice insurance companies writing policies in northeast Ohio. Only three of those have a financial rating of "A-" or higher, a prerequisite for doctors to maintain their hospital staff privileges. One of those three is planning to leave the market. That will leave two companies. Take away their license or their ability to maintain financial solvency in this state, and we'll be down to zero. We're headed that way as it is, but we'll just get there quicker with Senator Hagan's plan. posted by Sydney on
2/17/2004 07:48:00 AM
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Backpeddling: One of the researchers of the Women's Health Initiative, the study that emphasized the dangers of hormone replacement therapy, now says that many women were unwise to give it up:
Susan Johnson, a gynaecologist who took part in the Women's Health Initiative trial in the US, told the American Association for the Advancement of Science in Seattle that HRT was still the best treatment for most women. Professor Johnson said: "There are many women for whom HRT continues to be an excellent choice for the treatment of menopause-related symptoms. In my clinical practice I'm putting a lot of women back on HRT."
The study, you will remember, found a 0.08% increase in breast cancer, a 0.07% increase in cornary artery disease, and a 0.08% incraease in strokes in women who used hormone replacement therapy for five years. At the time of its release, its lead author was saying things like this:
"Considering that millions of American women might consider taking estrogen plus progestin . . . that could translate into tens of thousands of cases of breast cancer or cardiovascular disease over several years," said Jacques Rossouw, acting director of the WHI.
...Several said women who take the two hormones to relieve hot flashes and other symptoms of menopause should use the treatment as briefly as possible, and those wishing to prevent osteoporosis should probably choose alternatives to hormones.
The study found that breast cancer risk did not rise significantly until the fourth year of treatment, but that women's risk of heart attacks and blood clots increased as soon as they began taking hormones.
Lately, more of my patients have opted to suffer their hot flashes and forego hormone replacement therapy, even though I've gone over the data with them. All of them have cited ads they've seen from law firms: "If you've taken Prempro and have had a stroke, breast cancer, or heart attack, call this number!" They figure the drugs must be more dangerous than the data suggest if people are suing the manufacturer. And I have to admit, it makes me more than a little nervous about prescribing them. We truly do live under a tyranny of lawyers. posted by Sydney on
2/16/2004 07:42:00 AM
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Lame Excuses: The doctor who requested Dr. Atkins's medical examiner report says he wanted it for research purposes:
Fleming said his interest in the report was scientific and he wanted to gain insight into the health effects of the high-protein, low-carbohydrate diet Atkins promoted and millions now follow.
In recent weeks, Fleming received numerous calls from the Physicians Committee for Responsible Medicine asking for copies of the Atkins report, Fleming said in the statement. He said he never intended for the information to go public and felt "a sense of betrayal" because the report had been provided to the group "for research purposes only."
Eye of the Storm II: More news on the malpractice crisis here in my town. Doctors have to drop nursing home patients to keep their malpractice insurance coverage:
Dr. Waleed Nemer had a choice -- either stop treating a patient he had been seeing for nearly two decades, or lose his malpractice insurance, and with it, his Akron practice and his livelihood.
His elderly patient hadn't filed a lawsuit against Nemer. She hadn't complained about his care. The problem -- at least from the insurance company's point of view --was that she had moved to anursing home.
``The bottom line: The insurance company asked me to write a letter saying that I will never see another patient in a nursing home,'' Nemer said. ``Only under those circumstances, they will give me insurance.''
....But Dr. Robert Norman had nothing to fall back on when his insurance company made the same demand. A Summit County geriatrician specializing in Alzheimer's care, Norman had built his career on caring for the elderly, especially those in nursing homes.
In 2003, his malpractice premium jumped from $5,000 to $34,000. When he tried to renew his coverage for 2004, he ran into roadblocks from the insurer. Paperwork wasn't getting sent to him. Phone messages weren't being returned. Finally, someone at the insurance agency told him, ``Well, there's a problem.''
``I said, `A problem?' Well, the problem was, they didn't want to cover me if I stayed in nursing homes,'' Norman said.
.....Dr. Atul Goswami has cared for more than 300 patients in a dozen nursing homes over the last 15 years. But he, too, couldn't find insurance until he agreed to leave the nursing home patients behind.
``It was really scary for me when this all happened,'' said Goswami, who now focuses solely on his office practice in Akron. ``I wrote letters to all the families telling them that I would not be able to provide care for their loved ones. I got lots of calls and letters. The families cried. They'd say, `We don't want to lose you.' Many families said they would bring Mom to my office if I would continue to take care of them. I had to say, `No, I can't do that. The insurance company says I can't.'
Dr. Norman is angry at the insurance company and thinks the state should do more to regulate them. I can't blame him. They certainly didn't behave honorably toward him - giving him the run around, and only announcing their decision at the last minute. I suspect he has the same insurance company I have, and there have been rumors that they're looking to get out of Ohio completely. They tried to make my policy null and void last week by claiming they didn't get my premium check six months ago. I had to threaten to report them to the Ohio Department of Insurance to get them to correct their accounting error and reinstitute my policy. They are not consumer friendly.
But, the state does regulate them. The problem is, they're in financial trouble and are looking for anyway to reduce their costs. I suspect the rumors are true and they'll soon be exiting the market completely. And if the state restricts them too severely, even more companies will leave the market:
One of the more controversial proposals for dealing with the malpractice crisis is Senate Bill 112. This legislation, which has some bipartisan support, would place limits on how insurance companies set rates and require longer contracts for doctors.
State Sen. Eric Fingerhut, a Cleveland Democrat now running for the U.S. Senate, proposed the legislation as an amendment to last year's tort-reform bill, but it was tabled. State Rep. Scott Oelslager, a Canton Republican, has voiced support of the proposal.
The bill would require that medical malpractice policies last five years, while also restricting a company's ability to cancel policies and, for the most part, limiting the amount of premium increases to no more than 5 percent a year.
Ohio Insurance Director Ann Womer Benjamin has called the measure extreme.
``Were Ohio to take extreme action as suggested, companies would leave the Ohio market entirely or their financial situation would plummet... '' she said. ``Forcing medical malpractice companies into insolvency is not in the best interests of Ohio consumers.''
But, we do need at least a modest level of insurance regulation:
Maglione said the Ohio State Medical Association likes the idea behind the bill but favors a simpler solution.
In Ohio, insurers now can implement new rates while their rationale is reviewed by the Department of Insurance. A better way, Maglione said, would be to review the insurers' rationale for the rate increases before they take effect.
And they should have to give doctors ample notice before terminating their policies.
UPDATE: A reader emails:
What is going to happen to the nursing home patients without doctors? You know. They will be dumped on the local emergency rooms when they become acutely ill, on doctors who know very little about their histories and who will be compelled to sort out their problems or have the on-call internists do the same once they are admitted. If they are discharged (and that invites another issue as to where, since you know how problematic post-discharge planning for nursing home patients can be) there remains the question as to who will provide followup, since the very mechanism of outpatient followup and management is being thwarted here. And thus begins the cycle again.
Yes. It does nothing to improve care and everything to undermine it.
And then there's this take on the nursing home problem from another reader:
Families are automatically suing doctors when their parents die in a nursing home. They want to add to their inheritance at no risk to themselves.
Lawyers are finding these families by reviewing obituary pages. Then they pressure the families to sue. The insurance companies can’t be blamed for reacting to this scam.
I am very happy to see all of these malpractice insurance companies cancel policies and place limitations on doctors. This will create a national crisis that will force politicians to bring some sanity back to our destructive tort system.
I don't know if lawyers scan the obituaries for possible clients, but it wouldn't suprise me. But what worries me is that these nursing home doctors are just the beginning. First they came for the nursing home doctors, then they came for me..... How long will it be before no one in Ohio can find malpractice insurance coverage?
posted by Sydney on
2/15/2004 08:56:00 AM
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