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    Monday, July 07, 2003

    Latest Innovation: What would Mayor Bloomberg make of this?

    posted by Sydney on 7/07/2003 08:10:00 AM 0 comments

    Public Service Announcement: Beating the heat, and preventing heat stroke.
    posted by Sydney on 7/07/2003 08:05:00 AM 0 comments

    Playing to Emotions: Today's installment on the medical malpractice crisis in my local paper concentrates on evil doctors:

    Ater 24 years, there are still nights when Rande McDaniel's mind wanders to what might have been.

    A healthy baby boy. A normal childhood filled with school plays, Little League baseball, girlfriends, dances and his first car. And in adulthood, a decent job, a loving wife and a family of his own.

    But her son, Christopher, now 24, never had any of those things. And he never will.

    McDaniel's doctor botched Christopher's delivery so badly that his life has been confined by severe mental retardation. He can't talk. He wasn't potty trained until he was 15 years old. He drools. He's teased, taunted and outright avoided.

    Quite simply, McDaniel says, Christopher's life was ruined by her doctor, who was shopping while Christopher was being asphyxiated in the womb, and by a hospital that didn't use a fetal monitor, which would have discovered the problem.

    McDaniel, who lives in Brimfield Township, sued for malpractice in Summit County Common Pleas Court. Five years later, her hospital and doctor agreed to a settlement worth $1.9 million.

    That was in 1984. But if the same lawsuit were settled today, the amount would be much lower.

    ...Tears come easily to McDaniel when she talks about what happened 24 years ago. But that sadness turns to anger when she talks about capping damages on pain and suffering.

    ``These people -- doctors who mess up kids -- it gives them the right to do what they do and not care,'' she says. ``They can say, `Oh, I screwed up a kid for life, but it'll only cost me $500,000. I can handle that. It's no big deal.' They don't have to answer to nobody. That's not right.”

    You would think they could have found a better case illustration for doctors who screw up than a case of cerebral palsy. Not knowing the details of the case, it's hard to judge, but from what's presented in the article, it sounds like McDaniel's son is a typical case of cerebral palsy - which is just as likely to happen during fetal development as it is during the birth process. Recent studies suggest that it's more likely to happen before birth. The fact that the hospital didn't use fetal monitors (which some argue don't do much to improve outcomes, but only increase cesearean section rates) only means that the trial lawyers had an easier time pinning the blame on the hospital and obstetrician. Cerebral palsy cases are malpractice lawyer's dream - no easily identifiable cause, and thus difficult for a doctor to defend. The fact that the case went five years before being settled suggests that the hospital caved in rather than continue to bear the cost of defending itself. If they had no case, they would have settled sooner.

    The other case in the article, a young girl who's spine was injured during surgery, is a better illustration. But the argument that she deserves millions of dollars to compensate for her loss is specious. Large monetary awards for pain and suffering are nothing more than blood money. It's a means to satiate the desire for revenge.

    posted by Sydney on 7/07/2003 07:45:00 AM 0 comments

    Crisis: How bad is the malpractice insurance crisis in West Virginia? This bad:

    Scene opens with a pair of binocular-toting border guards watching a remote stretch of river at dusk.

    First Border Guard: Here they come, just like clockwork.

    (Camera pans to a trio of middle-aged men, stripped to their shorts, walking stealthily to the edge of the river, looking around cautiously, then wading into the stream and swimming across, the handles of valises gripped in their teeth.)

    Second Border Guard: I’m surprised any of them are left, considering how many have already made it across the border. Why can’t they just go back where they’re coming from? It can’t be that bad.

    First Border Guard: I don’t know. Personally? I can’t help but feel sorry for them. They’ve been hounded by trial lawyers, abused by insurance companies and ignored by their elected officials. You can’t blame them for trying to make a better life for themselves and their families here.

    Second Border Guard: I suppose you’re right. And what good would it do to turn them back? Another batch will just take their place tomorrow, and the next day and the next, until things change in their homeland.

    First Border Guard: Well, it’s show time! (Flips on a searchlight and focuses it on the trio of swimmers, now emerging on the border guards’ side of the river) Gentlemen! Welcome to the state of Ohio! If you doctors will please surrender your West Virginia driver’s licenses, we’ll transport you to the nearest medical center for pre-employment processing. (Turns searchlight back to West Virginia shore, where another group of border-crossers is already approaching the river.) When’s it ever gonna end?

    Second Border Guard: Not until the last medical professional in West Virginia turns out the light.

    Sorry fellas, it's almost as bad in Ohio. At least it is if you're near a major city.
    posted by Sydney on 7/07/2003 07:33:00 AM 0 comments

    Life Imitates the Weekly World News: Thought that this sort of thing only happend in tabloid land:

    Gleicher and colleagues took cells from 3-day-old male embryos and inserted them into 21 female embryos at the same stage of development.

    The resulting embryo was part male, part female and could potentially have developed into an apparently healthy fetus, the London Telegraph reported Thursday.

    Gleicher said the research could lead treatment for genetic diseases but mainstream scientists said the research was pointless and could endanger the reputation of serious embryo research.

    And rightly so.
    posted by Sydney on 7/07/2003 07:32:00 AM 0 comments

    Sunday, July 06, 2003

    MedMal Update: Senator Frist plans to introduce the tort reform bill this week in the Senate, even though it has zero support from Democrats and no hope of overcoming a fillibuster. Their hope is to make it an issue in this election:

    Republicans made it clear that they intended to use the vote against Democrats.

    "Women are having trouble finding obstetricians to be able to deliver their babies," said Senator John Ensign, Republican of Nevada, the chief sponsor of the measure.

    "In states like Nevada, doctors are leaving in droves, and that kind of scenario is repeating itself over and over around the country," Mr. Ensign said. "As voters become aware of it, I think you're going to see the change of minds of senators who may now be against it. We bring it up for a vote now, and it may cost them in the next election."

    And it should. It's no coincidence that there's not one Democrat behind the bill. They recognize the hand that feeds them.

    Speaking of which, that same hand is busy feeding others to fight their battle:

    ...Both sides are lobbying hard. The medical association is starting an advertising campaign focused on senators opposed to the bill, and USAction, a consumer advocacy group backed by the trial lawyers, is spending more than $500,000 on a two-week advertising campaign featuring victims of medical malpractice.

    Notice that the AMA isn't hiding behind another group, but is making its own commercials. The trial lawyers, however, are hiding behind a "consumer advocacy group." An advocacy group that supports out of control asbestos litigation, and which describes those with whom it disagrees as "right-wing forces". (That echo of "vast right wing conspiracy" is no coincidence. Many of the group's executives have ties to the Democratic Party.)

    The Trial Lawyer Association, er, I mean, USAction, plans to hit back with stories of gross neglect and injury:

    "This Congress has a very bad track record of supporting powerful special interests at the expense of average Americans," said Jeff Blum, USAction's executive director. "We want to make sure that real stories of real people are in the debate on medical malpractice."

    Forget for a moment that USAction itself is supporting one of the most powerful special interests in Congress, and just consider "the real stories of real people." One could argue that more real people are suffering real harm from the current medical malpractice crisis than would be harmed by tort reform. Look what's happening in my town:

    Consider Dr. Robert Norman, a geriatrician in Cuyahoga Falls who specializes in treating people with Alzheimer's disease.

    His malpractice insurer raised his annual premium from $5,700 to $34,000 last year and warned him that it could jump to $100,000 this year if he continued treating patients in nursing homes.

    But when it came time to renew his policy in May, every insurer gave him an unexpected ultimatum: Either sign a paper agreeing to stop seeing nursing home patients or lose his malpractice coverage altogether.

    He had 150 nursing home patients who had to find another doctor. Then there's the high-risk woman who couldn't find a doctor to treat her:

    Before seeing him, she went to six other doctors seeking help for uncontrollable uterine bleeding.

    ``She was not a thin woman,'' Davis says. ``She was told right to her face, `If you were a thin woman, I'd operate on you.' ''

    Davis agreed to take over her care and tried hormonal treatments, which eventually stopped the bleeding without surgery. None of the other doctors she had seen offered any help, even nonsurgical options.

    ``That's what's bothering me,'' Davis says. ``People are starting to be stereotyped and doctors are saying, `I'm not going to treat this kind of patient because she's too high-risk.' ''

    There's more than just prejudice against the obese at work here. The hormone therapy in a morbidly obese woman is also riskier. Dr. Davis took a chance that his colleagues didn't want to take:

    Just having one jury verdict, one settlement or one unresolved lawsuit, he says, could make an Ohio doctor uninsurable.

    Davis says doctors have to make a decision:

    ``Should I risk my care of my 5,000 other patients for one patient?''

    And, of course, there's the problem of finding and keeping an obstetrician:

    Regardless of the cause of high cost of malpractice insurance, patients such as 24-year-old Carrie Mace, of Cuyahoga Falls, are getting an unwelcome lesson in the economics of medicine.

    Mace was five months' pregnant when her family doctor, Ross R. Black, decided he couldn't afford to deliver babies anymore.

    The Cuyahoga Falls physician was notified at the beginning of the year that his annual premium would jump from $45,000 to $75,000 if he continued to practice obstetrics.

    So he dropped that part of his practice in February, and his annual premium fell to about $17,000.

    And then there's the factor that often doesn't get noticed in the current debate. The effective of plummeting safety ratings of malpractice insurance companies on a doctor's ability to practice medicine:

    Adding to the problem is the fact that several major insurers still offering malpractice insurance have had their financial stability ratings downgraded below an A- in recent months.

    Most major hospitals require doctors to be insured by a company with a rating of A- or better to stay on staff.

    Phyllis Klein, a 73-year-old Akron resident, was caught in this insurance pitfall when she was hospitalized for intestinal problems.

    When she arrived at the emergency room, she found out her physician, Dr. Steven L. Cochran, was no longer allowed to take care of her at Akron General Medical Center.

    ``It's kind of hard when the doctor who walks in to discuss your case is a stranger,'' Klein says. ``It was kind of a shock to find that I would be dealing with doctors with whom I have no familiarity at all. Not that they weren't absolutely wonderful and certainly professional. But they still weren't my doctor.''

    Cochran is looking for another, higher-rated insurer that will offer him a policy so he can get his hospital privileges back.

    ``We receive daily phone calls from the patients: `Why aren't you here? Why aren't you seeing me? I want my doctor,' '' he says. ``It's been very stressful to a lot of the patients, particularly the geriatric patients.

    ``This (the malpractice crisis) has probably changed the nature of our practice more than anything that has happened in the last 10 to 20 years.''

    Yes, indeed, it has. And what happens when there are no more insurance companies with safety ratings of A- or higher in a state? (And believe me, they're dropping like flies.) Will hospitals be left without doctors? Probably not, since a hospital can't function without doctors. But before hospitals change their rules, there will be a lot more doctors - including those who depend on their hospital practices for their livelihood such as surgeons and cardiologists - who will be forced out of practice. And then who will care for their patients?

    posted by Sydney on 7/06/2003 08:04:00 AM 0 comments

    Saturday, July 05, 2003

    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 0 comments

    When Lightning Strikes: A hazard of body piercing:

    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 0 comments

    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 0 comments

    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."

    He's also facing a disciplinary hearing, and rightly so.
    posted by Sydney on 7/05/2003 09:00:00 AM 0 comments

    So Many Grommets Who knew there were so many types of grommets?
    posted by Sydney on 7/05/2003 08:51:00 AM 0 comments

    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."

    So why don't they just fire him?
    posted by Sydney on 7/05/2003 08:48:00 AM 0 comments

    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 0 comments

    Welcome: There's a new medical weblog up and running - Cut to Cure - the perspective of a surgeon. Check it out.
    posted by Sydney on 7/05/2003 08:39:00 AM 0 comments

    Friday, July 04, 2003

    Happy Fourth of July

    Have a safe celebration!

    posted by Sydney on 7/04/2003 07:15:00 AM 0 comments

    Thursday, July 03, 2003

    Workplace Hazards: Whatever you do, don't answer the phone.

    posted by Sydney on 7/03/2003 08:57:00 AM 0 comments

    Of Mice and Men: A reader shares his visual impressions of the headline "Scientists work to infect lab mice with HIV":

    1) Gay mice furiously having unprotected sex with each other in a bath house

    2) Mouse in hospital bed receiving IV with chart reading: hemophilia--transfuse as needed

    3) mice with a vacant stares--propped up in a filthy mouse hole, shooting up--while researchers stand outside slipping dirty syringes into the hole

    posted by Sydney on 7/03/2003 08:53:00 AM 0 comments

    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 0 comments

    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.

    posted by Sydney on 7/03/2003 08:44:00 AM 0 comments

    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.)

    That's what I love about this job. You learn something new everyday.
    posted by Sydney on 7/03/2003 08:33:00 AM 0 comments

    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 0 comments

    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 0 comments

    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 0 comments

    Patients First: A new bill has been introduced in the Senate for medical malpractice-specific tort reform:

    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 0 comments

    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

    It just grows more and more complicated every day.
    posted by Sydney on 7/01/2003 08:00:00 AM 0 comments

    Headline News: Maybe I'm twisted, but this story conjured some strange images in my mind:

    Scientists work to infect lab mice with HIV
    posted by Sydney on 7/01/2003 07:47:00 AM 0 comments

    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 0 comments

    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."

    (via Tim Blair)
    posted by Sydney on 7/01/2003 07:34:00 AM 0 comments

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