"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
Deliveries Up the Highway: The hospital in the small Ohio town of Conneaut will no longer deliver babies:
Beginning next month, UHHS Brown Memorial Hospital will close down its inpatient obstetrics unit and will no longer provide inpatient obstetrics services, hospital officials said Tuesday.
The OB unit will close Oct. 3, according to a BMH statement. After that date, no babies will be born in the city, ending a tradition of maternity care that has spanned decades of maternity tradition at BMH.
...The announcement means Ashtabula County Medical Center will become the only medical facility in the county where babies can be delivered. Patients at BMH have been referred to ACMC or hospitals based in Erie, according to the statement.
The hospital's problem is that it can't find enough anesthesiologists and obstetricians to man the labor and delivery suite for emergencies. For patient safety, they need the ability to perform cesarean sections within thirty minutes notice. Now why do you suppose they're having trouble recruiting?
Malpractice insurance costs have made it difficult for BMH to find certified personnel to provide necessary services, officials said.
“We’re in a real difficult situation regarding malpractice insurance,” Kraus said. “OB units are traditionally the hardest hit.” posted by Sydney on
9/18/2004 05:52:00 PM
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On Tuesday, the House of Representatives passed H.R. 4571 by a vote of 229 to 174, sending it on to the Senate. Supporters say the measure will curb unnecessary litigation by re-enforcing rules already on the books, and by creating a new requirement preventing plaintiffs' attorneys from shopping around for friendly legal venues.
....Specific provisions include:
- Making monetary sanctions against attorneys who file frivolous lawsuits mandatory rather than discretionary, and removing an earlier 'safe harbor' provision that allows attorneys who file frivolous lawsuits to avoid sanctions by withdrawing their suit after a motion for sanctions has been filed.
-Allowing sanctions for frivolous or harassing conduct during discovery.
-Allowing a plaintiff to sue only where he or she lives or was injured, or where the defendant's principal place of business is located.
The first two provisions may be difficult to meet since the meaning of "frivolous" is so liquid. The average doctor thinks that most malpractice lawsuits are frivolous. Malpractice no longer means willful negligence, but the inability to avoid known complications or to diagnose with 100% certainty. Lawyers, on the other hand, think that complications are negligence and that we should be able to diagnose everything as certainly in real time as we can in retrospect.
But the last provision, limiting the venue of suits makes sense. There's no reason lawyers should be able to shop around for the most profitable jury venue.
It remains to be seen whether this one will pass the Senate. All those going before it haven't. Will constituent pressure make some Senators think twice before voting against it? posted by Sydney on
9/18/2004 01:20:00 PM
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Going Private: As some American politicians seek to move American medicine closer to a Canadian model, some Canadian doctors are trying to move the Canadian system closer to the U.S. system:
Three doctors who have opted out of medicare are set to open Quebec's first-ever private emergency clinic.
Dr. Luc Bessette, a former emergency room doctor at St. Luc Hospital, says he knows first-hand how long people have to wait to get treatment.
His experience has prompted him and two colleagues to go private.
"We have three kinds of services we are offering. One will be for people who want emergency attention, like minor surgery. The other service will be for people who want to have a medical [checkup]," says Dr. Bessette. "And the third service is for people who are looking for a family physician."
A 20-minute consultation will cost patients a minimum of $100, he says, and claims the price is less expensive than visiting a veterinarian.
I wonder if they'll have any trouble getting people to pay? My patients gripe about $10 co-pays.
Meanwhile, the Canadian government's idea of reform is to throw more money at the system:
Given the premiers' fixation on extracting as much money as possible from Ottawa, our expectations for the first ministers conference were fairly low. But it still came as a disappointment that no one was willing to discuss the one innovation that could put Canadian health care on a sound basis in the long run: the introduction of more private delivery options. In this sense, the meetings in Ottawa this past week were a replay of the recent election campaign, in which none of the party leaders dared speak of health care reform in any terms except those pre-approved by Roy Romanow.
What makes all of this so surreal is that -- as the leaders themselves know -- the all-public health care world they describe in their joint communiques no longer exists: Even as the premiers were shaking hands in Ottawa, an announcement was being made of plans for Canada's first private emergency room in Quebec.
It is a shame that our leaders refuse to publicly acknowledge this shift. Canadians want to see improvements in the speed and quality of their health care. They are not particularly interested in which level of government is wasting their hard-earned dollars on it.
Remember that the next time you hear the Kerry/Edwards talking points about expanding government-subsidized healthcare. posted by Sydney on
9/18/2004 10:49:00 AM
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In a survey believed to be the first of its kind, 217 in vitro fertilization clinics across the country described the variety of methods they use to dispose of the frozen clusters of cells, which are the size of a dot and incapable of living outside a womb.
The reverence that some clinics gave to the task surprised researchers at the University of Pennsylvania and Rutgers University.
Seven clinics said they performed a quasi-religious ceremony, including a prayer, for each embryo they destroyed.
....Seven clinics, or about three percent of all that participated in the study, said that because of religious or ethical concerns, they would not create more embryos than they intended to implant, and thus had no cells to freeze or destroy.
Dr. Vincent A. Pellegrini, a fertility doctor in West Reading, Pa., said he wrestled with the issue for two years before deciding that destroying surplus embryos would be akin to "throwing away human life."
"It just wasn't an option," Pellegrini said. "Once we have a dividing embryo, it is human material I can't discard."
Is it really surprising to learn that fertility clinics think of their charges as life? They're in the business of making baby-dreams come true. How could they not think of their embryos as life?
This is kind of weird, though:
Seven others took the technically unnecessary step of culturing the cells in a lab dish, then allowing them to multiply on their own, briefly, before they perish.
I guess that's the embryonic version of a natural death.
Screens-R-Us: The March of Dimes is pushing to screen every newborn for 30 rare diseases in all fifty states. According to the article, the tests only cost about $50, a drop in the bucket compared to the overall hospital bill for a newborn baby. The catch is, the machine to run the tests costs close to half a million dollars.
States already test for hidden diseases in newborns, notably phenylketonuria and hypothyroidism, although the number of tests done depends on the state. (For a list of what tests your state does, see Genes-R-Us.) These are the
heel stick blood draws that every newborn gets after the first twenty-four hours of life. The tests do save lives, no doubt about it. posted by Sydney on
9/17/2004 09:17:00 PM
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Thursday, September 16, 2004
Unintended(?) Consequences: Not surprisingly, the FDA decision to place "severe warnings" on the newer anti-depressants regarding the risk for suicide, is discouraging their use - even among doctors. Most of the doctors in the article say that they'll be hesitant to treat any depression in adolescents, and plan instead to refer them to psychiatrists.
The problem is, there aren't enough psychiatrists to see them all in a timely fashion. The wait for a pediatric or adolescent psychiatrist in my area is two to three months. I've had kids end up in the hospital for suicidal gestures while waiting to get in with the psychiatrist. And yes, that's because I, too, am afraid to prescribe drugs for them while they're waiting for that appointment. These kids act impulsively. Unless someone's overtly suicidal, it's impossible to predict who's going to act out in the near future, and who will be just fine until the psychiatrist has time for them. But, even though the studies did not find any increase in suicide, only suicidal thoughts and behaviors, the language the FDA and the media have used in describing the warnings are so strong that it would be medicolegal suicide for a primary care doctor to prescribe them.
Decreasing the rate of prescribing was the implicit goal of the warnings , however. The FDA even extended the warnings to all anti-depressants so physicians won't be tempted to use any of them:
The advisory committee decided that the suicide warning should also be placed on the physician prescribing sheets for an older set of antidepressants called tricyclics. These medicines have largely fallen out of favor because of the damage they can do to patients' hearts and the risks that result from overdoses.
The warning was extended to them in part because of the "great risk in scaring clinicians back to the tricyclics," said Dr. Thomas Laughren, a top agency official.
Until we have drugs with zero risks and zero side effects, looks like depressed teenagers are just going to have to suck it up.
posted by Sydney on
9/16/2004 10:15:00 PM
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Having studied 36 of those rather unforgiving self-portraits, a neuroscientist suggests that Rembrandt was stereoblind - that is, because his eyes did not align correctly, his brain automatically used one eye for many visual tasks. This may have allowed him to flatten images automatically as he observed the world, and then transfer that perspective onto the two-dimensional canvas, says Margaret S. Livingstone, a professor of neurobiology at Harvard Medical School.
Click on the collage of Rembrandt's eyes in the upper right hand of the New York Times article to enlarge it. It certainly looks like he had exotropia. Or is it pseudostrabismus? Look at the eyes again, concentrating on the light reflex in the iris and pupil. Although it's difficult to tell in half of them because the left eye is often portrayed in shadow, the reflex is in the same spot in both eyes in five of them. That suggests the gaze is convergent rather than divergent.
Scanning for Tumors: Another study says that MRI's are superior to mammograms for detecting early breast cancer in very high risk women (women with known gene mutations that predispose them to breast cancer):
For five years, the researchers studied 236 women between the ages of 25 and 65 who had either mutation.
For women with the mutations who don't have a prophylactic mastectomy, the lifetime risk of breast cancer is up to 85 per cent.
Dr. Ellen Warner, a medical oncologist at Sunnybrook and her colleagues compared four screening methods:
Of the 22 cancers that were detected in the study, 17 were found by MRI (77 per cent), compared to eight through mammograms (36 per cent), seven by ultrasound (33 per cent) and two (9.1 per cent) from clinical breast exams.
The study is here, at least in the abstract, but the CBC news story provides more details than the abstract.
It shouldn't really be a surprise that MRI's can detect tumors earlier than other screening methods. They have a much better resolution and image quality. Compare this MRI with a mammogram and an ultrasound, and you'll see what I mean. Questions, however, remain. Does finding early breast cancer make any difference in terms of survival? How many false positives did MRI find, even in these high risk women? Only time, and more research, will tell.
posted by Sydney on
9/15/2004 07:20:00 AM
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In the clearest signal yet of nanotechnology's ascendancy in the realm of medicine, the National Cancer Institute will announce a major nano-research program today.
The institute will spend $144 million over the next five years to fund cancer-related nanotechnology research.
The commitment represents the first major foray into nanotechnology by the National Institutes of Health, which funds the majority of biomedical research in the United States.
They will be funding research into things like nanoshells and quantum dots. A complete nanocancer tutorial is available here. Fascinating, and exciting, stuff.
Pulse of the People: It's been almost two months since I last did a "Pulse of the People," and oh, my how things have changed. The conventions, the Swiftvets, and now the CBS Guard memos have all added new twists to the race. Polls now show Bush ahead in Ohio. But in my office, he's still got a fight ahead of him.
This is the third Presidential election since I began practicing in this area, in this practice. Most of my patients have been with me for all of those years. And this is the first time that I've ever seen so much political activism among them. A lot of them come in now wearing Kerry/Edwards buttons. Some of them preach to me about the evilness of Bush, running down what can only be described as Michael Moore Talking Points. The most memorable, was from a man who's surely old enough to remember Johnson and Nixon describing Bush as "the most corrupt President in my memory." One woman asked that I avoid giving her any medications that could make her drowsy - she had a Kerry rally to attend. And another patient told me he had to get better by the weekend so he could canvass for Kerry. This, even though, according to this data base, my area is heavily pro-Bush.
The one thing all of these patients have in common is that they're union members. And the unions see this as a fight for their life:
According to an AFL-CIO lobbyist, Clinton was told two weeks ago that this election was not about his reputation but rather the survival of organized labor in the United States.
'Clinton was told -- and it's something that he knew anyway, we think -- that four more years of Republican control on Capitol Hill and in the White House could weaken organized labor to the point where we wouldn't be able to help Democrats the way are now,' says the AFL-CIO lobbyist.
"This isn't some ``namby-pamby'' mission to get out the vote no matter what," she told the volunteers.
``It's about getting the vote out for (Democratic candidate John) Kerry. We're not screwing around. We want them to know what Bush has done to working families. This is war.''
And like war, apparently everything's fair. The activists are so vocal, it makes it hard to tell which way the wind's blowing. Even the Democratic mayor of a Democratic stronghold is hedging his bets:
"In a sense, we have both bets covered,'' Mayor George M. McKelvey said. "The Democrats, you know, they're going to deliver probably their traditional 60 percent of the vote. So, if Kerry's elected, he's sure going to deliver something to them, right? If Kerry's not elected and Bush is elected, I guess I'm the go-to guy."
It's all very confusing, but I'm going to modify my original prediction that Ohio will go to Kerry and predict it will be as close as Florida 2000 (and maybe just as contentious), unless RatherGate has an impact. (So far, everyone seems very unaware, but that could change as more mainstream media investigate CBS's apparent malfeascence.)
The Columbia experts were asked by the FDA to determine whether instances of self-harm that occurred during clinical trials were truly suicide attempts. No child had actually killed himself during the trials — a detail often overlooked in the media coverage — but there were incidents ranging in seriousness from a hanging attempt to lightly scratching one's arm to a girl who slapped herself in the face.
When the Columbia experts parsed these events into various categories they found relatively little cause for alarm. Within the 15 clinical trials of pediatric depression they examined, youngsters on SSRIs were no more likely to experience an "emergence of suicidality" than those on placebo, nor was there any discrepancy between the two groups with respect to the "worsening of suicidality."
And it turns out there's at least some evidence that SSRI's may reduce suicide in cases of true depression:
....Along these lines, a study in the Archives of General Psychiatry last year looked at the numbers of anti-depressant prescriptions written for youths according to zip codes across the country and compared them with census data on youth suicide. The greater the increase in the prescriptions in particular geographic areas, the sharper the reduction in the teen-suicide rates in those locations over the last decade. Though an intriguing finding, the study did not control for potential risk factors such as substance use and so cannot be said to constitute definitive proof.
Bottom line? I wouldn't be afraid of the newer anti-depressants if your child is truly depressed.
Medical Blog News: Another new medical blog (as always, to me, anyways) - the excellent Shrinkette, a psychiatrist in the Northwest. (She makes a particularly good point in one of her posts about psychiatric conditions and politicians. To determine how well they're handling their problems, we should examine how well they react to stress now. Judging by not so well in some cases.) posted by Sydney on
9/13/2004 01:17:00 PM
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Presidential Diets: You have to feel sorry for Bill Clinton, the way his diet habits have been picked apart since his bypass surgery. But this is just too funny:
Surveying flood damage in North Dakota, the president's empathy turns to wonder at the whims of nature:
High in his helicopter, President Clinton was staring forlornly at Red River when something caught his eye.
"The McDonald's is dry!" he told fellow Marine One passengers as a smile spread across his face. "The Pizza Hut is, too, but you can't get to it."
End of an Era? More evidence that prostate cancer screening isn't all it's cracked up to be:
"The PSA era is over," said researchers at Stanford University school of medicine in their paper in the Journal of Urology.
The team studied prostate tissues collected over 20 years, from the time it first became standard to remove prostates in response to high PSA levels. Thomas Stamey, who led the research, said they concluded that the test indicated nothing more than the size of the prostate gland. "Our study raises a very serious question of whether a man should even use the PSA test for prostate cancer screening any more," he said.
The original research isn't available on line (at least not for free), but Stanford University gives some details in its press release:
To figure out the PSA test’s usefulness in determining which cancers warrant radiation or surgery, Stamey and his team from Stanford’s Department of Urology set out to document what was actually found following prostate removal, such as the volume and the grade of the cancer – two indications of the cancer’s severity. They then compared those findings to aspects that could be determined prior to surgery, such as how many of the cancers could be felt by rectal examination and the patient’s blood PSA level.
For the study, they used prostate tissue samples collected by professor John McNeal, MD, who has examined more than 1,300 prostates removed by different urologists at Stanford in the last 20 years. The researchers divided McNeal’s data into four five-year periods between 1983 and 2004 and looked at the characteristics of each cancer. They found that over time, there was a substantial decrease in the correlation between PSA levels and the amount of prostate cancer – from 43 percent predictive ability in the first five-year group down to 2 percent in the most recent one.
However, the Stanford researchers concluded that the PSA test is quite accurate at indicating the size of the prostate gland, meaning that it is a direct measure of benign prostatic hyperplasia. And Stamey pointed out that it is still very useful for monitoring patients following prostate removal as an indicator of residual prostate cancer that has spread to other parts of the body.
In other words, the test's predictive value was higher years ago when prostate cancers were much larger. But now, we intervene so early in prostate cancer that the PSA has very little correlation between the severity of the cancer (which is not necessarily related to its size) that it isn't useful at all in predicting who will have invasive cancer and who will not. We knew this, but it's nice to have the proof. Now, where can this guy go to get back his idealism? posted by Sydney on
9/13/2004 08:11:00 AM
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Embryo-Centrism: There's a new charge against the Kass bioethics council - that they're embryo-centric. But that isn't necessarily the insult that critics think it is:
Finally, the charge of embryo-centrism assumes that microscopic embryos are too narrow and trivial a topic for a national debate on bioethics. On a practical level, this is quickly refuted. One of the facts uncovered by the council is that the in vitro fertilization business in the United States has swollen from nothing into a $4 billion industry in 25 years. The financial potential for embryonic stem cells is largely speculative, but it could be far greater. The future of embryos touches every home in America.
According to another council member, William B. Hurlbut, a medical doctor and instructor at Stanford, belittling the importance of the embryo ignores the commercial potential of human body parts at all stages of development. "Anyone who denigrates our council work as 'embryo-centric' and therefore an overfocus on obscure concerns is not seeing clearly where science is heading," he says. "Sometimes the smallest things carry the largest meaning. This is not 'microethics' but a crucial hinge in the history of our understanding of human embodiment and human dignity."
....What has emerged from the quarrel over the council is evidence of the fracture between the "bio" substance and the "ethics" process. Critics like Annas and Caplan focus on the ethics--the codes, protocols, and declarations created by their new discipline. In their eyes, the destiny of bioethicists is to sit on bioethics committees and set public policy. As council member Gilbert Meilaender pointed out in an email, "It's exactly that view that has been responsible for a loss of much of the depth of reflection in bioethics in recent years."
Kass's fundamental concern, however, and one that is reflected in the unusually thoughtful tone of the council's reports, is to examine the "bio"--the nature of life and what it means to be a human person. As the 2002 report, Human Cloning and Human Dignity, says, "On the surface, discussion has focused on the safety of cloning techniques, the hoped-for medical benefits of cloning research, and the morality of experimenting on human embryos. But driving the conversations are deeper concerns about where biotechnology may be taking us and what it might mean for human freedom, equality, and dignity."
A variety of public policy issues merit careful study by bioethicists, but few affect a fraction of the people whose lives are touched by the rapidly changing context of human reproduction. On that score alone, the council's deliberations deserve praise, not censure, for placing far-reaching technologies at the center of national debate--not closeted away in company boardrooms. posted by Sydney on
9/13/2004 08:05:00 AM
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Dutch Slippery Slope: Euthanasia is legal in Holland, as long as the patient has requested it. But Dutch physicians act against those who can't speak for themselves with shocking frequency:
Research suggests that in about 100 cases each year paediatricians make decisions that result in the death of babies with severe multiple handicaps. Most decisions involve instituting palliative care only, or withholding treatment, but in about 20 of these cases the paediatrician will, after consultation with both parents, choose to end the child’s life with a fatal injection.
Only two or three cases are reported each year to a local coroner, even though the current law requires all such cases to be reported. In 10 years, only two cases have reached the courts.
First they came for the old people, then they came for the children.....
Euthanasia consciousness is catching. The Netherlands' neighbor Belgium decided to jump off the same cliff as the Dutch only two years ago. But already, they have caught up with the Dutch in their freefall into the moral abyss. The very first Belgian euthanasia of a person with multiple sclerosis violated the law; and just as occurs routinely in the Netherlands, the doctor involved faced no consequences. Now Belgium is set to legalize neo-pediatric euthanasia. Two Belgian legislators justify their plan to permit children to ask for their own mercy killing on the basis that young people "have as much right to choose" euthanasia as anyone else. Yet, these same children who are supposedly mature enough to decide to die would be ineligible to obtain a driver's license.
He explains why they're going down that slippery slope, too.
UPDATE II: Michael Fumento looked at euthanasia in the Netherlands in 1991. It's fair to say they've journeyed even further down the slope these days. This quote from an anti-euthanasia Dutch general practioner is well worth remembering:
"...[I]t is enormously dangerous to think that doctors, who aren't the most conscientious people in the world, should have the right to kill – and kill unchallenged."
Class Matters: This didn't get much attention last week in the media, but the New England Journal of Medicine ran an opinion piece suggesting that class is more important than race (subscription required) when it comes to healthcare disparaties:
In a study of white American men (which therefore eliminated the variable of race), when smoking and other risk factors were taken into account, men earning less than $10,000 a year (on the basis of data from the 1980 Census) were 1.5 times as likely to die prematurely as were those earning $34,000 or more. Similar results were obtained in Great Britain, where the Whitehall study of British civil servants showed that when smoking and other risk factors were controlled for, those in the lowest employment category were still more than twice as likely to die prematurely of cardiovascular disease as were those in the highest category.
When I think of my practice, it's undeniably true that the poorest are the least healthy. But it's also true that many times the reason they're poor is because they're in poor health. I have some patients who are poor because they have low-paying jobs. Their health is pretty good. But my sickest patients are those on Medicaid who are on Medicaid because they're too sick to hold a job. They have very bad congenital problems (spina bifida, cerebral palsy) or they have had major trauma that caused severe disabilities, or they have severe psychiatric illnesses that make holding a job difficult. It isn't their poverty that makes them ill, it's their illness that makes them poor.
I can't say with any certainty whether that holds true for the nation, but it's the way it is in my little corner of the world. posted by Sydney on
9/13/2004 08:00:00 AM
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Insults Get You Nowhere: Dr. Franklin Price is mad as hell and he isn't going to take it anymore. Unfortunately, he put that anger into a nasty letter to the judge in his malpractice case, who in turn took it the newspaper and to the American Board of Internal Medicine. From the parts of it quoted in the paper, it does seem a particularly nasty letter. To make a long story short, the doctor thinks he was the victim of reverse discrimination:
Six black jurors outvoted two white colleagues in August 2002 in finding that Price failed to diagnose the coronary-artery disease in Lawrence Smith, a black 54-year-old LTV Corp. worker who died of a heart attack in 1999. With court-ordered interest, the Smith heirs' award topped $5 million.
That case sounded familiar, and sure enough, here it is. The plaintiff's attorneys argued that the doctor didn't do enough to prevent the patient's heart disease. The crux of their case rested on EKG findings which were interpreted in hindsight as "abnormal." EKG's, although very good at detecting heart attacks in progress, are extremely poor predictors of future heart attacks or of latent coronary artery disease, for that matter. I never realized that the jury's decision was divided along racial lines. It could be just a coincidence. Or maybe not. After all, there was an awful lot of media attention to the racist quality of American medicine at the time. (Which has since been debunked. It's more a matter of demographics and economics than inherent racism.)
Euthanasia: A local reader asked me to comment on this story from a couple of months ago. It's the story of a local emergency room physician who gave an elderly woman succinylcholine. It's a sad story, and one that I avoided before because I know the doctor involved, at least professionally.
An elderly, "comfort care only" patient was transferred from her nursing home to the ER in the middle of the night because the nursing home didn't know what to do when she developed abdominal pain. She was much too frail to withstand surgery, and since she was "comfort care only," that wasn't an option anyways. The emergency room doctor who drew her case just happened to have a mother who was in the last stages of terminal cancer himself. The patient's pain didn't respond to morphine or to other pain medication. At some point, the doctor made the decision to give her a drug that wouldn't stop her pain, but would stop her breathing. And it worked. She stopped moaning.
There were so many other ways this could have been handled. Hospice could have been consulted. Morphine could have been increased to alleviate her pain, even if it depressed her breathing and eventually resulted in her death. That would have been passive euthanasia, and perfectly acceptable. The intent would have been to keep her comfortable, as per her wishes. Death would have been a side effect, not the primary intention. But in this case, the use of succinylcholine made it active euthanasia. Succinylcholine does nothing for pain. Its only use is in anesthesia to paralyze the diaphragm so the patient doesn't breath against the ventilator. The only intent possible in this case was to end the life of the patient. (That is assuming it wasn't given in error.)
Everyone understood this. The doctor's colleagues understood it. They turned reported him to the hospital adminstration and confronted him about it. The hospital administration understood it. They reported it to the police,to the coroner, and to the state medical board. And the coroner understood it. She ruled the cause of death a homicide after she learned of the cirucmstances.
Everyone understood it except the county prosecutor who declined to press charges, and the state medical board which, according to their website, still hasn't taken any action. (As of the newspaper story, he was still practicing in Ohio.) The only logical conclusion is that the prosecutor believes euthanasia is OK, and so does the state medical board.
The most disturbing aspect of the case is that the doctor chose to silence the patient, not to treat her pain. She still felt pain until her dying breath. She just couldn't vocalize it. Succinylcholine is the ideal drug for ending the suffering of the caretaker, but not the patient. Which is, after all, the problem with active euthanasia in general. It's never quite clear exactly whose suffering is being relieved. (The same thing happened in an Oregon ER in 1997, before they approved assisted suicide. The prosecutor's office also declined to press charges, stating that they would never be able to find a sympathetic jury.) posted by Sydney on
9/12/2004 01:11:00 PM
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Manifest: A reader asks if I have a manifesto for healthcare. Not really. If I did, I'd be running for office. But, I do believe that the ownership plan that President Bush put forth in his convention speech is superior to Kerry's stewardship plan. How could I not? Every day in my practice brings further confirmation of the simple truth that it's human nature to disregard cost when your spending someone else's money. Whether it's my staff ordering supplies or my patients asking for the latest drug they saw advertised on television. And the current "woes of the uninsured" is due entirely to the fact that our health insurance is tied so strongly to employment. Breaking that bond would do much to improve the situation. There's no reason health insurance shouldn't be like auto insurance. posted by Sydney on
9/12/2004 09:18:00 AM
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New Blog: Well, new to me, anyways, but not to DB. Check out Personal Touch, a blog about the trials and tribulations of starting your own solo practice. Good luck to him (or her?).
And elsewhere, Dr. Bradley has left urgent care work and returned to solo practice, which has provided him with much blog fodder. He must have gotten tired of working for "the Man." posted by Sydney on
9/12/2004 09:14:00 AM
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"If you are not bleeding all over the place, you are put on the back burner," Ms. Pacione said, "unless of course you have money or know somebody."
Despite what politicians and academics say, I'm convinced that we have a superior system to Canada's. Very few people are unable to find a doctor here in the States, and our waiting times to see one for an acute problem are much lower - usually one or two days. When people complain about the uninsured, what they're really complaining about is the fact that they have to pay for their healthcare, not that they can't get an appointment with a doctor. The Canadians pay for their healthcare in spades through higher taxes, but they still can't get an appointment.
UPDATE: From a reader:
Let's be clear, Americans are paying in spades--the highest per capita expenditure in the world --whether you are paying in the form of taxes, employee contributions, reduced employer/corporate profits or lower wages we are paying--in some parts of the country the cost of a family plan now substantially exceeds one's gross earnings at the minimum wage. Let's not even discuss the lack of a correlation between our high per capita expenditure and health outcome/status (and on many independent polls we are not more satisfied than other industrialized countries).
And for many of the uninsured it isn't just a complaint that now they have to pay for health care--it is a complaint that it is either unaffordable or unobtainable. Realistically, tell me how a single mom or couple with one child affords health insurance when there is no employer contribution or they are self employed and make $13.00 per hour (not an unrealistic wage for many jobs). Imaging trying to squeeze it out at $6-10.00 per hour or if you only work part time, are an emancipated student, recently unemployed, etc.. Do the math after taxes, housing, food, transportation, and utilities--And remember, not every one lives in Ohio--how about Boston or SF where housing may well be double this.
Estimates
Gross wages 26,000
Less taxes 4-6000 (state. local, sales, fica, federal, etc)
Housing + Utilities 6000-7,200
Transportation (for work) 4,000
Food 4-5,000
Medical insurance 6,000 to 9,000
Yes, we do pay in spades - for health insurance. That's because there aren't many catastrophic plans out there, and because it's extremely difficult to get insurance as an individual. Things would be better if the risk were distributed more evenly across the population rather than through employment pools. For one, it would increase the competition for different health plans. People would be much more willing to purchase catastrophic plans and pay out of pocket for the simple things (an office visit with a primary care doctor is generally around $50-$60, cheaper for cash-only practices that don't have to process insurance claims.) But when an employer is paying the bill for the insurance, which is the case for most people, there's no incentive to purchase catastrophic plans. Everyone wants comprehensive plans that cover as much as possible. Unions demand them. Employees of small businesses expect them, or they'll find work with larger employers. As a result, few insurance companies offer catastrohpic coverage, but they all offer comprehensive coverage - at very hefty prices, of course.
As I said in the original post, divorcing health insurance from employment would be a major step forward in correcting this, and in making health insurance more affordable. Of course, that means giving up some benefits for the majority of people, which never sits well.
posted by Sydney on
9/12/2004 08:29:00 AM
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