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    Thursday, January 20, 2005

    Drug Relief: For Ohioans who need help with prescription drugs.

    posted by Sydney on 1/20/2005 09:18:00 PM 1 comments

    Tsunami Scourge: Not malaria or cholera or typhoid, but lockjaw.
    posted by Sydney on 1/20/2005 09:14:00 PM 0 comments

    Daily Stress: Remember this post the next time your doctor seems a little short with you.
    posted by Sydney on 1/20/2005 09:09:00 PM 0 comments

    Simple Tests: The Disintegrator notes a new, simple diagnostic test for ADHD based on eye movements and wonders how reliable it could be. I'd say it needs to be tested in much larger sample sizes before making any definitive conclusions.
    posted by Sydney on 1/20/2005 09:05:00 PM 0 comments

    Think They Would Know Better Department: Watch out for smoking drivers:

    East of Toronto -- where a 43-year-old woman was arrested last week for driving while puffing pot with her two grandchildren in the car -- police are also taking the training course.

    Sgt. John Givelas of Durham Regional Police's traffic services said he thinks the problem can be helped by letting both drivers and police know about the effects of driving under the influence of drugs.
    posted by Sydney on 1/20/2005 08:55:00 PM 0 comments

    Rubenesque Ballet: A ballet company with grace and size:

    Cuban ballet dancers in white glide across the floor, executing an airy blend of pirouettes and back stretches. Within seconds, spectators are captivated, quickly forgetting what at first they couldn't overlook - most of the dancers weigh more than 200 pounds.

    Six dancers between the ages of 23 and 41 make up the island's Voluminous Dance group, which has presented about 20 works and is preparing its current show, Una muerte dulce, or A Sweet Death, for the spring.

    'It's incredible how they utilize their roundness,' Mirta Castro, a tourist from Costa Rica, said as she watched the dancers rehearsing in Havana. 'It breaks free of the belief that dance is only for slender people.'
    posted by Sydney on 1/20/2005 09:23:00 AM 0 comments

    So That's My Problem: I'm not drinking enough.
    posted by Sydney on 1/20/2005 09:12:00 AM 0 comments

    Wednesday, January 19, 2005

    They're Coming to Take Us Away: Some people see conspiracy everywhere, even in the government food guidelines.

    posted by Sydney on 1/19/2005 09:23:00 AM 0 comments

    Tuesday, January 18, 2005

    Best of the Med Blogs: EchoJournal's 2004 medical weblog awards have been announced.

    posted by Sydney on 1/18/2005 04:10:00 PM 0 comments

    Monday, January 17, 2005

    Medical Blog Alert: Welcome to new med blog Medviews.

    posted by Sydney on 1/17/2005 11:34:00 PM 0 comments

    Novocaine Riche: While medical reimbursement declines, dentistry is booming. Which makes doctors the poor relations of dentists:

    The turnabout in fortunes has made some dentists pity their physician colleagues. Robert H. Gregg, a dentist in Cerritos, Calif., says he had an operation for a snapped Achilles tendon a few years ago, which required him to go under general anesthesia for more than an hour. He was amazed his insurer paid just $2,000 to his orthopedic surgeon for the procedure. 'I get about $3,000 for a three-unit bridge,' Dr. Gregg says. 'He's getting pennies on the dollar to what his skill level was.'

    Dr. Gregg says he offered to pay more out of his own pocket. The surgeon's office manager, he adds, 'told me I was the first person' to ever make such a request.

    UPDATE:To this reader, dentists are head and shoulders above medical doctors:

    I've got quite a few dentists who are clients. In my professional capacity I have found them personable,respectful, grateful for services rendered, not technology-averse,and extremely hard-working in improving their businesses as businesses. For dentists the greatest business challenge is finding and retaining good staff.

    I've had medical doctors as clients, too. They've been smart, peremptory, technology-averse, knew more than I did about my own specialty (or gave that impression at any rate), jealous of their prerogatives, and slow to pay. I'm not sure what the greatest business challenge for medical doctors is today. It may be reimbursement.

    That having been said I think that there are other reasons for the change in fortunes of dentists.

    First, dentists don't seem to be quite as beholden to insurance companies as medical doctors are. Quite a few of my dentist clients don't accept insurance at all.

    Second, dentistry is structured quite a bit differently than medicine. The really successful dentists of my acquaintance are not just billing their own time but have quite a team of hygienists, etc. whose time they're billing.

    Have I mentioned that most dentists' offices (scores) I've been in are cleaner than the doctors' offices (also scores) I've been in?

    Are they really cleaner, or are they just more dazzling?
    posted by Sydney on 1/17/2005 11:31:00 PM 0 comments

    More Tales from the North: Almost unbelievable.
    posted by Sydney on 1/17/2005 09:09:00 PM 0 comments

    Childhood Obesity: Michael Fumento blames television.
    posted by Sydney on 1/17/2005 09:05:00 PM 0 comments

    Close to Home: A medical researcher enters his own research trial.
    posted by Sydney on 1/17/2005 08:45:00 PM 0 comments

    Unfortunate Son: Jonathon Drummond-Webb, a prominent pediatric cardiothoracic surgeon had everything going for him:

    The son of two well-to-do liberal intellectuals, whose surnames form his hyphenated name, Dr. Drummond-Webb attended boarding school and earned a medical degree at the University of the Witwatersrand in Johannesburg. After two years service in the South African army, he completed a residency in cardiothoracic surgery at Johannesburg Hospital.

    Encouraged by his wife, Dr. Lorraine E. de Blanche, Dr. Drummond-Webb emigrated to escape South African government restrictions on medical practice. In 1993, he became a fellow in cardiovascular and thoracic surgery at the University of Utah LDS Hospital in Salt Lake City.

    Two years later, he moved to the Cleveland Clinic Foundation, one of the most prominent centers in the United States for heart surgery.

    He was lured to the Little Rock hospital by what he saw as a state of the art operating room, an enthusiastic surgical staff, and unlimited potential. He was determined to build the hospital into a nationally dominant pediatric cardiac center.

    Dr. Drummond-Webb, who said he competed in triathlons merely to keep himself in shape for surgery, also became an associate professor of surgery in the College of Medicine at the University of Arkansas for Medical Sciences. He conducted research and set a frenetic pace performing surgeries -- nearly three times the normal annual tally of 200.

    And yet, it wasn't enough, or maybe it was too much:

    Drummond-Webb killed himself on Dec. 26, authorities say; he reportedly overdosed on painkillers and bourbon, three days after what seemed like another miracle: the successful use of a miniature heart pump that kept a 14-year-old boy alive until an organ became available for transplant.

    The 45-year-old surgeon left a profanity-laced suicide note, officials say. In it he indicated he felt that his work was underappreciated, and he ranted about colleagues at Arkansas Children's Hospital and at the Cleveland Clinic, where he had worked.

    'Every day my living hell!!' the note read. 'These people don't care. I have a gift to save babies. The world is not ready for me.'

    ....Colleagues said Drummond-Webb was his toughest critic.

    'Some would say they saved 98 out of 100,' said the Arkansas Children's Hospital's chief executive, Dr. Jonathan Bates. 'He looked at it and said, 'I lost two out of 100.'

    Working at triple the normal pace has its price.
    posted by Sydney on 1/17/2005 08:42:00 PM 0 comments

    Department of Corrections: A correction has been added to this post about a "Seattle-area" doctor.
    posted by Sydney on 1/17/2005 07:57:00 PM 0 comments

    Frequent Check-Ins: New research suggests that blood pressure can be controlled better, faster by phoning in the numbers instead of coming in for blood pressure check-ups:

    The team developed their new approach in hopes of reducing the inconvenience and cost related to blood pressure monitoring.

    The study included 106 patients who first attended the Hypertension Care Clinic for several days in a row. A drug treatment plan was drawn up for each of the patients, and they were educated about hypertension and cardiovascular disease preventive measures.

    The subjects were then instructed to measure their blood pressure twice daily at home for a 7-day period at 1, 3, 6, 9, and 12 months. The results were sent to the clinic nurse and drug treatment was intensified if blood pressure readings were not less than 135/85.

    With this strategy, the percentage of patients who achieved this target level of blood pressure control increased from 0 percent at the start of the study to 63 percent after one year.

    'This model should reduce both cost and inconvenience associated with the treatment of hypertension,' Canzanello's group suggests.

    'Too often, patients with hypertension are 'fit into' the course of a busy practitioner's day through a series of visits over weeks to months, and patients never receive the focused attention necessary at the outset of care,' Dr. Andrew B. Covit, at UMDNJ-Robert Wood Johnson Medical School in South River, New Jersey, maintains in an accompanying editorial.

    The only problem with the approach is that it misses a chance to check for side-effects and to answer questions. Most doctors offices are overwhelmed by the phones as it is, so a patient is likely to get less attention via phone than in a face-to-face encounter. In that sense, the study is somewhat of an artificial environment. Unlike lawyers, we don't charge for phone calls, though, so there's no denying that it's a cheaper alternative.
    posted by Sydney on 1/17/2005 01:29:00 PM 0 comments

    Simpsons on Drugs: Last night's episode of the The Simpsons was one of the best in memory, with Homer becoming a Canadian drug mule when the everyone in town loses their prescription drug benefits. It was so rich in jokes it bears watching again to catch the ones you missed the first time.
    posted by Sydney on 1/17/2005 01:18:00 PM 0 comments

    EMR Saga: A physician reader asked me to elaborate on the saga of my electronic medical record. There's a lot of pressure for physicians to forsake their old dead tree based record systems and adopt computerized electronic medical records. The use of a computerized record would, theoretically, cut down on errors as a result of bad documentation and bad hand writing. Even the President is pushing for them. (Although his dream of one universal record that can be accessed anywhere by anyone is a little daunting, and more than a little scary in its implications for patient privacy.) And yet, few of us have made the move.

    Frankly, we fear them. They're expensive - very expensive. To those of us who have only ever known a paper system, they seem intuitively less secure. There's the fear that an errant touch of a button or a computer malfunction could evaporate thousands of patient charts. Or that someone could walk away with all of the charts by stealing the hardware. Or that an employee could download a virus or worm that destroys the whole system. And there's just the general fear of the unfamiliar. I count myself among the fearful, but in the end decided to move to an electronic medical record because I hate paperwork. A hate so strong it finally overpowered my fear.

    I ended up choosing a system called SOAPware, largely because it's one of the more affordable, if not the most affordable, programs available. Most companies make you go through the process of talking to and meeting with a sales rep before you can learn how much the system is going to cost, but SOAPware had all of their prices on their website, along with an online demo. In addition, I had heard good things about it from a few other doctors on a family medicine email listserve, and I had a chance to see it in action a few years ago at a conference. The biggest selling point, though, was the ability to buy it in modules. This let me purchase the most basic features I needed at a price I could afford. (I spending about $1500, a far cry from the $23,000 quote from another company.)

    I'm looking forward to being able to write prescriptions and referral letters with the click of a button. I'll even be able to fax prescriptions to pharmacies. I'll be able to do that in less time than it now takes me to give my staff the OK to call in a prescription. And my staff will no longer waste time on hold with the pharmacies. A click of a button and orders for tests will be written, complete with diagnosis codes and patient demographic information. Ditto authorization requests for insurance companies. And when a test result comes in or another physician calls about a patient, I won't have to ask for the chart to be pulled, I can pull it myself. With the click of a button. Charts won't get lost or misfiled, and my staff won't have to go through the office searching for through "call-back" and "to be done" stacks. We won't have to copy charts for patients who are leaving. Instead we can download them to a CD-ROM or print them out. With the click of a couple of buttons. I'll even be able to dowload selected parts of a patient chart to my Palm for easy transport to the hospital. (Password secured, of course.)

    There are some drawbacks, however. SOAPware isn't very attuned to pediatric patients. Documenting immunizations in the standard form that most practices use on paper is difficult, but not insurmountable. And there are no growth charts, although the flow chart module can automatically calculate height, weight, and head circumference percentiles. I miss the graphic data, though, and will probably continue to do those on paper.

    Perhaps the biggest drawback is the lack of tech support, although this could be an advantage to those who are more computer literate than I am. When it came to buying the appropriate hardware and putting the software on the computers, I was on my own. The SOAPware people provide a list of hardware vendors and consultants who can help with these matters, but that's more money and a degree of trust in strangers that I just don't have. It's also a little more work to look them up and contact them and interview them than it would be if all of that support came with the package. (Of course, that's one of the reasons it was affordable.)

    My relationship to computers is akin to the one I have with cars. I can use them very well, but I don't know how they work. Luckily, I have a husband who is very computer savvy. By that I mean that he has experience with programming and problem-solving. Doubly luckily, he can also read my mind. That may seem beside the point, but as a computer illiterate, I often have trouble communicating with tech support people. I just don't use the right phrases and words to get my point across, or I don't use them correctly. My husband understands my limitations and was able to help me choose the networks and hardware I needed and set them up with a minimum of confusion. He also installed the program for me, a process he describes as "easy." I'm sure it was for him. It would have been impossible for me.

    ADDENDUM: For those beginning the process of looking for an EMR, the American Academy of Family Physicians has a comprehensive collection of useful links. Some are restricted to members only, but there's also a lot of useful information available to non-members. The Family Practice Management journal has many helpful articles. And although it's a little dated, I found this article a good place to start my search for a vendor.

    UPDATE: Here, in a nut shell, is why electronic medical records haven't been widely adopted:

    Buying an EMR system with adequate overall technical support is still very expensive, and the declining economics of primary care along with higher malpractice insurance and other expenses just do not allow the average small practice physician to make the investment. A lot of us look at this as just another potential unfunded mandate. If somehow I could project another 25K in income this year, I would be happy to invest it in an EMR. That's not going to happen.

    Maybe we could leverage tort reform and medmal insurance premium reduction into an EMR-subsidy. Just dreaming.

    And from someone with experience in medical systems design:

    Some things I've seen may explain your experience. The reason that it's hard to find medical applications that perform a reasonable task at a reasonable price is that too many docs want Ferraris, Maseratis, and Mercedes-Benzes. Not the cars--the computer applications equivalents.

    It's not enough to bring a product to the market that performs the required task effectively. The product has to make your breakfast in the morning, fly to Mars, and solve Fermat's Last Theorem as well.

    Especially breakfast in the morning. And coffee in the office, too.

    posted by Sydney on 1/17/2005 08:49:00 AM 0 comments

    Sunday, January 16, 2005

    Proof in the Pudding: In November, the RAND Institute released a study that looked at California's experience with tort reform. What they found is that it works:

    After evaluating the outcome of plaintiff wins in 257 medical liability trials that took place between 1995 and 1999, the study found that payments were 30% less than they would have been without the cap. The total payout would have been $421 million before the cap was applied but came to $295 million after judges reduced excess awards.

    'It gives us proof that MICRA is working extremely well,' said Richard Anderson, MD, chair of The Doctors Company, a physician-owned national medical liability insurer based in California. 'We have always said MICRA is worth 20% to 30% when all of the provisions of MICRA are used.'

    The study also showed that patients weren't seeing a 30% reduction in their awards.

    MICRA limits the amount that attorneys can collect, and the study showed that the combination of award caps and attorney's fee limits reduced the amount that plaintiffs' attorneys collected by 60%.

    Consequently, plaintiffs saw 15% less then they would have without the cap or attorney fee limits -- not the full 30% less. And after MICRA reductions, the total awards in most of the cases were still more than $1 million.

    But malpractice attorneys say that the study proves tort reform disproportionately punishes the weak:

    "It disproportionately affects seniors, stay-at-home moms and children," said Ken Sigelman, MD, a lawyer who is chair of the medical malpractice committee for the Consumer Attorneys of California.

    For example, the study showed that the plaintiffs who were younger than 1 year old most often saw reductions in their total awards when the ages of plaintiffs were considered: 71% of that age group experienced reductions. The median reduction was $1.5 million, according to the study. Other plaintiffs saw a median reduction of $268,000.

    The report also showed that women often have a larger cut to their overall verdict. Overall awards that women received had a median change of 34%when their noneconomic damages were adjusted. Men saw a 25% median reduction in their overall when caps were factored in.

    Last, trial lawyers point to the study's conclusion that plaintiffs who are 65 or older see 67% of their cases reduced by the cap. The median dollar reduction is smaller than any other age group because their awards are often close to the $250,000 cap.

    Women, children, and the elderly. Those would be plaintiffs who are more likely to get big awards based on pity rather than justice. Don't we want a system based on jurisprudence rather than on emotions? It isn't surprising that the attorneys find this disturbing. Emotionally manipulating juries in personal injury cases is what they do best.

    But here's another look at the same data by a lawyer who is also a physician:

    One observation from my study of the RAND report: If you omit the jury verdicts in the seven highest awards as "outlier" cases (that is, omit the top 3% of the cases, ranging from $4.7 million to $31.3 million), the conclusions of the study would change significantly. Rather than characterizing MICRA as penalizing "seniors, stay-at-home moms and children," the data clearly point out that the major savings occur in the area of attorney fees.

    The "little secret" of MICRA is not that it forces a significant limit on the awards of deserving, injured patients, but rather that it limits the amount of money received by the law firms representing those patients. Based on my calculations, the average net capped award received by 97% of the patients reported was reduced by only 7.5%, and in most cases even less than that. Over 80% of the savings of those cases occurred as a result of fee limits.

    In simple terms: The party who suffers most under MICRA is the plaintiff's attorney, not the plaintiff.

    MICRA's limits on unreasonable awards made by "juries gone wild" hurt the attorneys who encourage them, not the patients and families who need help.


    posted by Sydney on 1/16/2005 12:19:00 AM 0 comments

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