tag:blogger.com,1999:blog-109651362024-03-23T11:26:28.569-07:00California Medicine ManDevoted to furthering the dialogue about <br> healthcare delivery and medical issues on the World Wide Web.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.comBlogger250125tag:blogger.com,1999:blog-10965136.post-84679581941649830672010-03-14T08:54:00.000-07:002010-03-14T09:06:25.947-07:00Trouble at Domino's PizzaVia the <a href="http://pajamasmedia.com/instapundit/95629/">Instapundit</a>, people are <a href="http://dailycaller.com/2010/03/12/an-uncompromising-look-at-the-dominos-pizza-tracker/">complaining</a> about Domino's online "Pizza Tracker". I for am appalled about the possibility that one of our most stalwart institutions may be attempting to deceive us. My 7-year-old loves keeping tabs of it when we order a pizza. How am I ever going to explain to her that maybe, <span style="font-style: italic;">maybe</span>, this example of modern technology may be a fraud?<br /><br />Well, at least I can console her that unlike big business, government would never engage in such duplicity.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com3tag:blogger.com,1999:blog-10965136.post-73185662448033511532009-05-05T12:06:00.000-07:002009-05-05T12:06:35.829-07:00Protecting the Lowly Pedestrian<a href="http://www.wired.com/autopia/2009/05/external-airbag-protects-pedestrians/">This article</a> mentioned by <a href="http://pajamasmedia.com/instapundit/78014/">the instapundit</a> caught my eye. Apparently, Cranfield University in England has prototyped a novel airbag technology to protect <em>pedestrians</em> hit by cars. <br /><br />From the photograph, it looks to have a somewhat Rube Goldberg flavor to it. To my unpracticed eye, it also looks to be somewhat expensive although a spokesman for the project reassures us that, "it would add little to the cost of the vehicle." Why does this seem unlikely to me?<br /><br />There is essentially no limit to the features that can be added to automobiles to make them safer. The problem is of course figuring out how to pay for them. There is also obviously a difference between technologies designed to protect innocent third parties (e.g. pedestrians or people driving other cars) and the cars' occupants. This is why all cars must have brakes but not bulletproof windshields.<br /><br />It's one thing for a consumer to be willing (or not) to pay for things that will directly benefit that consumer. On the other hand, it seems unlikely that he or she would be interested in voluntarily paying extra for something that will only be of <em>very</em> remote benefit to oneself. External airbags as described in the article seem destined to be a marketing and pricing nightmare. <br /><br />I wonder though, in our current atmosphere of government regulation, how far might the White House and Congress might go in mandating technologies such as this one? I also wonder what actual public health benefits might be realized. I can easily imagine such a device having only a marginal benefit in terms of morbidity and mortality. We will study this in a meaningful manner before broadly demanding its application?<br /><br />As an aside, I think it's ironic that this device was first tested on a Fiat Stilo. Fiat is of course a company soon to own 20% of Chrysler which is in the process of becoming nationalized by the U.S. How long before the powers that be declare that all Chryslers (and or Fiats) are required to have it installed?The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com3tag:blogger.com,1999:blog-10965136.post-17145328103144057752009-03-22T00:05:00.000-07:002009-03-22T00:05:30.746-07:00Natasha Richardson and Problems with Canadian Health CareWhen any young person dies of an intracranial hemorrhage, it's obviously a very sad thing. However, many people were uniquely touched by the death of Natasha Richardson owing to her popularity. There are now <a href="http://www.mercurynews.com/celebrities/ci_11968458">questions</a> being raised regarding the promptness of her care particularly regarding the lack of a Medevac helicopter system in Quebec. <br /><br />Will we be able to count on the mainstream media to investigate such possible inadequacies in the Canadian health care system? Wouldn't such debate be apropos given the Obama administration's commitment to implementing Universal Health Care, a system remarkably similar to Canada's?The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com3tag:blogger.com,1999:blog-10965136.post-85563338914440180442009-02-04T00:53:00.000-08:002009-02-04T00:57:24.378-08:00Taking Trust With a Grain of SodiumI was rather intrigued when a drug company representative showed up at my institution with some literature on a medication called Vaprisol manufactured by Astellas Pharma. This drug is one of a class of drugs called vasopressin receptor antagonists (VRA's) and is used to treat low blood sodium levels (also called hyponatremia).<br /><br />I may be the worst philistine in academia but to me, Vaprisol is a so-so solution in search of a problem. Hyponatremia is typically treated by first identifying its underlying cause. Once that cause is determined, treating it generally makes the hyponatremia go away or at least improve. And guess what? Even if the problem can't be cured, the chronically low sodium that results rarely causes serious problems by itself.<br /><br />That said, I can imagine rare scenarios whereby drugs such as Vaprisol may be useful. Obviously, attempting to be helpful, the rep left a reprint of <a href="http://www.ncbi.nlm.nih.gov/pubmed/17981159">a paper</a> from the reputable <i>American Journal of Medicine</i>. It summarized some expert panel recommendations regarding the diagnosis and treatment of this condition.<br /><br />I was surprised however to find that of the articles eight pages of text regarding the actual treatment of hyponatremia, <i>half</i> were devoted to VRA's. This may have been appropriate for a review of developments in the field but this was ostensibly a guideline for current management practice.<br /><br />I encounter hyponatremia frequently but I've never seen nor known of a physician using this drug or any drugs in its class. I hardly think that the use of VRA's is generally accepted by the medical community. Which brings me to the title of my reportage. Are the recommendations of this guideline really trustworthy? Curious, I immediately flipped through the reprint to find the authors' financial relationships disclosure which had been dutifully reported.<br /><br />I wasn't the least bit surprised that of the five authors, <i>all five</i> had financial ties to one or more of the companies selling VRA's:<br /><blockquote>Joseph G. Verbalis, MD, has served as a consultant and member of advisory boards and Speakers’ Bureau for Astellas Pharma US, Inc.; as a consultant and member of advisory boards for sanofi-aventis, and as a consultant to Otsuka.<br /><br />Stephen R. Goldsmith, MD, has served as a consultant and member of advisory boards for Astellas Pharma US, Inc.<br /><br />Arthur Greenberg, MD, has served as a member of advisory boards and Speakers’ Bureau for Astellas Pharma US, Inc., and as a consultant to sanofi-aventis.<br /><br />Robert W. Schrier, MD, has served as a consultant to Otsuka.<br /><br />Richard H. Sterns, MD, has served as a member of advisory boards and Speakers’ Bureau for Astellas Pharma US, Inc.</blockquote>Now don't get me wrong. I myself haven't done an exhaustive search of the literature to determine whether or not these drugs are in fact any good. For all I know, they're magic bullets that should be put in the water supply to treat and prevent all current and future cases of hyponatremia.<br /><br />But that's not my point. The problem is that even before checking out this particular drug's usefulness, I'm already starting from a position of mistrust. With such an undeniable "appearance of impropriety" how can I truly rely on these experts to give me the unvarnished truth? It's one thing to report hard facts. It's something entirely different to render an opinion which is what a guideline is.<br /><br />Surveys of physicians have shown that most believe that the clinical judgment of other physicians can be influenced by financial encumbrances. However, those same doctors also believe that they themselves wouldn't be. What does this tell us?<br /><br />Should any of us in medicine have unerring faith in the fairness and objectivity of our profession's opinion leaders and can we as patients trust that our doctors have access to the best information available? Perhaps we all need to read Dr. Daniel Carlat's 2007 <a href="http://www.nytimes.com/2007/11/25/magazine/25memoir-t.html"><i>New York Times</i> article</a> on his transformation from honest clinician to drug company shill (and back again).<br /><br />It seems to me that we're getting to the point where we have to get away from the very concept of having clinical guidelines (not to mention FDA Advisory Committee reports) formulated by opinion leaders altogether. It may be far better to simply convene skilled but generic clinicians, epidemiologists, and statisticians with no ties to the pharmaceutical industry to create recommendations based only on a nonbiased, critical reading of the existing medical literature.<br /><br />As drug reps are being increasingly isolated from prescribing physicians due to practice group and academic institution policies, pharmaceutical companies are shifting more of their advertising budgets towards cultivating (financial) relationships with academia's clinical gurus. No one can deny the moral hazard associated with this trend.<br /><br />Understand that I am not impugning the integrity of the authors of the above-mentioned guideline but truthfully, I have no <i>a priori</i> reason to trust them either.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com2tag:blogger.com,1999:blog-10965136.post-3972298535825336512009-01-23T21:43:00.000-08:002009-01-23T21:43:40.340-08:00A Fresh Look at the US Airways CrashIf you're at all like me, you may be a bit exhausted by the US Airways crash news coverage. OK. By now, I finally get that Chesley Sullenberger is a true hero. <br /><br />Well if you still have the stomach for yet another fresh view of this oh-so-close air disaster, may I recommend <a href="http://www.the-hospitalist.org/blogs/wachters_world/archive/2009/01/17/patient-safety-and-a-tale-of-two-pilots-usairway-s-sullenberger-and-klm-s-van-zanten.aspx">Robert Wachter's take on it</a>?<br /><br />His observations are newsworthy because Wachter raises more far-reaching implications about the nature of Sullenberger's training and the important innovations made in commercial aviation since the tragic 1977 crash at Tenerife. He describes some of the well-known corollaries between this industry and that of health care delivery.<br /><br />Well worth the time.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-85935034707099192412008-12-24T10:18:00.000-08:002008-12-24T12:07:34.846-08:00ER Docs Feel the Police Use Excessive ForceTo me, <a href="http://www.reuters.com/article/healthNews/idUSTRE4BN39F20081224?feedType=RSS&feedName=healthNews">this story</a> should be filed under the category of "There's less to this than meets the eye". Apparently a survey of emergency medicine physicians demonstrated their almost universal opinion that the police engage in excessive force.<br /><br />While this result is interesting, it may lead to conclusions that, while appearing important and plausible, are not really informative. I can easily imagine this data being used to support the position of "criminal rights" activists appalled at low performance levels of the police and high levels of police brutality.<br /><br />The opinions of ER docs would certainly be expected to carry great weight in discussions regarding health care as they should. However, the question of excessive use of force is most assuredly <span style="font-style: italic;">not</span> a health care issue rather, it falls under the purview of criminal justice.<br /><br />I don't recall a <span style="font-style: italic;">single</span> course in either medical school or residency that addressed the issue of appropriate use of force by law enforcement. Guess what. It's not part of the medical education curriculum (93.7% even admitted not receiving such training). I don't care if every ER doc does feel this way. The fact is, such physicians are in no more of a position to assess appropriate force usage than are social workers or New York Times reporters. It's OK to have an opinion and maybe such testimony might be relevant in specific cases (more as witnesses to a possible crime) but they weren't there and cannot possibly have much insight to the actual events leading to a suspect's observed injuries.<br /><br />In fact, the police have an extraordinarily difficult job dealing with some very dangerous people on a day-to-day basis.<br /><br />Medical personnel do receive coursework regarding child, spousal, and elder abuse which does tend to qualify many of them to assess such cases. However, this is mainly to learn whether or not physical trauma actually occurred. In caring for an injured criminal suspect, there is little or no question that their condition is the result of violence. The question is whether such violence was justifiable and this is not something physicians having no knowledge of the events leading to it are in a position to assess.<br /><br />The researchers apparently concluded that their results:<br /><blockquote>"suggest that national emergency medicine organizations in the USA should become involved, jointly developing and advocating for guidelines to manage this complex issue."</blockquote>A nice inference but saying so doesn't make it true...or even logical.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com8tag:blogger.com,1999:blog-10965136.post-39499183184052332762008-06-10T10:53:00.000-07:002008-06-10T22:37:32.749-07:00Interesting Case of "Co-rumination"I haven't written much about actual medical cases I see here at my hospital but this one intrigued me. Some details have been altered of course.<br /><br />A 30ish female showed up in our emergency department complaining of a sharp, stabbing pain in her left neck (10 out of 10 in intensity) for several days along with a palpable mass over the area. The pain had been present for two to three months but not nearly this intense nor had the mass been as large. She also complained of fatigue, shortness of breath, tactile fevers (felt hot but hadn't actually checked her temperature), and a range of other symptoms. The intern who presented this case to me found absolutely nothing on physical exam: normal vital signs, no mass, lungs clear, etc.<br /><br />My impression just from the presentation was that this was unadulterated BS (medicalese for "move along, nothing to see here"). How wrong I was.<br /><br />When I walked into the exam room there were two healthy-appearing women sitting, both with the same look of overwhelming dread. Usually I'm fairly insightful but in this case, it took several seconds to determine which one was the patient. Seeing an "older" attending, the patient's friend whom I'll call "Patient #2" immediately unloaded Patient #1's symptoms upon me.<br /><br />Patient #2 related in great detail every ache, every sensation, every pain, every bowel movement, indeed every agonized breath of her friends over the past three months. Certainly, it is not unusual for a patient's friend or family to function as an advocate and relate observations about the patient that may be helpful to clinicians.<br /><br />It's rare however for such advocates to give detailed subjective descriptions of how the patient is actually <span style="font-style: italic;">feeling</span> (at least when the patient herself is articulate, not shy or embarrassed, and for whom English is her native language). Between Patient #1 and Patient #2, I was barraged with with a torrent of imagined symptoms.<br /><br />In examining Patient #1, I agreed with my intern that there was no mass, nor any other physical findings of note. In my most professorial and reassuring manner and despite the fact that my skin was crawling in much the same way as when I walk into a room with a patient believed to have scabies, I told her her symptoms were nothing to worry about, that medical science can't always explain what patients are feeling, that her problems would undoubtedly resolve shortly, and that we were always here in case she didn't get better...<br /><br />Our <span style="font-style: italic;">patients</span> were greatly reassured and they both thanked me profusely. I walked out of the room feeling I'd done some good.<br /><br />The diagnosis? This woman (and her friend) turned out to have a severe case of <span style="font-style: italic;">co-rumination</span>, a topic I've written about <a href="http://califmedicineman.blogspot.com/2007/07/hazards-of-talking-about-your-problems.html">before</a>. The problem was that, like many females, they tend to "share" far too much. By doing so, their anxieties spiral upwards out of control as happened here. Men seem much less likely to engage in this maladaptive behavior. Certainly, we'll see more of this with men as society continues to encourage us to explore our "feminine side".<br /><br />Perhaps if I had been more upfront with my convictions, I would have also recommended they stop co-ruminating regarding each other's maladies.<br /><br />But that might not have been cool.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com2tag:blogger.com,1999:blog-10965136.post-24522250410661902162008-05-26T04:06:00.000-07:002008-05-26T09:51:38.102-07:00Google Commemorates Memorial DayGoogle generally makes special holiday modifications to their homepage logo. Here's Google's celebratory logo for Memorial Day:<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxpHSdqMKbkW57RTkw0UN3QQMFmkP1JhY-g1xSLG3fpiYVBBON2yI7-e664EW2PzxYtXdSifAH4WF8TjFDx5QQSr9SEum1boY48QTrUQTf7CFftQhkJZXbo2YqGYejEujaWgU9/s1600-h/logo.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxpHSdqMKbkW57RTkw0UN3QQMFmkP1JhY-g1xSLG3fpiYVBBON2yI7-e664EW2PzxYtXdSifAH4WF8TjFDx5QQSr9SEum1boY48QTrUQTf7CFftQhkJZXbo2YqGYejEujaWgU9/s400/logo.JPG" alt="" id="BLOGGER_PHOTO_ID_5204636039196675090" border="0" /></a>What kind of statement are they making here? It seems that I'm <a href="http://www.google.com/search?hl=en&q=google+%22memorial+day%22&btnG=Google+Search">far from the only one</a> who's noticed the extent to which they honor the deaths of our nation's fallen warriors; the same dead who gave Google the ability to freely gather and disseminate information in a free society.<br /><br />Google may be ignoring this day but at 10:30AM, my 5-year-old daughter, my wife, and I will be at the <a href="http://www.cem.va.gov/CEMs/nchp/losangeles.asp">Los Angeles National Cemetery</a> where we go every year...to remember.<br /><br /><br /><span style="font-weight: bold;">Update:</span><br />In case anyone wants to send a message to Google telling them how they feel about this, <a href="http://www.google.com/support/contact/bin/request.py?press=1">here's how</a>. My message to them: <br /><br />"One of the ways I'll be celebrating Memorial Day is by not accessing your website for a week. <br /><br />"Maybe next year you'll consider the pernicious effect of your decision to pointedly ignore one the United States' most solemn days."The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com1tag:blogger.com,1999:blog-10965136.post-14031017923665049112008-05-20T21:27:00.000-07:002008-05-20T21:37:06.928-07:00A Practical Suggestion for President Bush and CongressI rarely write about non-medical issues but I have an important policy recommendation that I think will help the country.<br /><br />Several days ago, the media lampooned <a href="http://www.iht.com/articles/2008/05/16/africa/mideast.php">President Bush</a> for being "snubbed" by the Saudi's for refusing his request to significantly increase oil production. Bush's request was part of his plan to to ameliorate the problem of seriously rising oil prices. I wasn't there but I imagine that his plea was met with an admonition to "go pound sand".<br /><br />Today, it was announced that the House of Representatives passed a bill allowing the U.S. to <a href="http://www.boston.com/news/nation/washington/articles/2008/05/20/us_house_passes_bill_to_sue_opec_over_oil_prices/"><span style="font-style: italic;">sue</span> OPEC</a> for their antitrust activity in arbitrarily limiting oil production. I may be wrong on this but I kind of doubt that the idea of being sued in an American federal court has the OPEC nations shaking in their boots right now.<br /><br />So to these two Solomonesque solutions, I've decided to add one of my own: Let's have a bipartisan committee from Congress travel, along with the president, to India and China and ask them to stop buying so much oil. Most economists believe that their dramatically increased consumption (due to rising industrialization) is a principle reason for our current high prices at the pump.<br /><br />Who could doubt that these two countries would willingly curtail their own drive for progress so that we Yanks can shave off a buck or two a gallon here in the states?<br /><br />See? This policy stuff isn't so hard.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com2tag:blogger.com,1999:blog-10965136.post-53114894394055029552008-05-10T10:03:00.000-07:002008-05-10T10:04:55.722-07:00Those Crazy Politicians and University Endowments<a href="http://online.wsj.com/article/SB121028579569979023.html">The Wall Street Journal</a> is reporting that Massachusetts is contemplating a 2.5% state tax on university endowments in excess of $1 billion per university (via <a href="http://gregmankiw.blogspot.com/2008/05/time-for-harvard-to-move.html">Greg Mankiw's Blog</a>). Now personally, I could care less about Harvard's financial concerns. It's hard to worry about a school with a $34 billion endowment. I'd be happy if my net worth was <span style="font-style: italic;">half</span> that amount.<br /><br />Here's an idea that would take some of the wind out of these legislative proponents' sails. Harvard could take 2% of their endowment each year and give it to their 19,000 undergraduates and graduate students. This is surely a fraction of the annual interest Harvard makes on its investments each year.<br /><br />This would amount to over $35,000 per year per student and would essentially give them free tuition. Of course the B-school students would still have to cough up about $7,000 more per year but well...they're B-school students. They'll be able to pay that off after their first few weeks of gainful employment.<br /><br />Massachusetts would have an awfully hard time taxing such "good" citizens as the Harvard administrators for providing a world class education for free.<br /><br />I don't know. 2.5% going to taxes vs. 2.0% going to their own students? Seems like a no brainer to me. Maybe the legislature is threatening the universities with this tax just to achieve this end. Either way, it seems like an abuse of their authority to me.<br /><br />More on my thinking about government meddling in the affairs of private universities (non profit organizations) <a href="http://califmedicineman.blogspot.com/2008/02/universities-endowment-funds-and.html">here</a>.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com1tag:blogger.com,1999:blog-10965136.post-16413807417407223582008-05-09T14:54:00.000-07:002008-05-10T10:02:39.199-07:00The EMTALA and Inintended Consequences<a href="http://edwinleap.com/blog/?p=151">Edwin Leap</a> wrote a revealing post about one of my personal pet peeves: the EMTALA laws (<a href="http://www.kevinmd.com/blog/2008/05/unintended-consequences-of-emtala.html">h/t KevinMD</a>). Read the whole thing.<br /><br />The EMTALA (Emergency Medical and Active Labor Act) mandates that essentially all patients must be seen regardless of ability to pay. Admittedly, this federal law states that people can be sent away without treatment after they've been properly evaluated. However, the penalties for being wrong are so severe that few hospitals are willing to take the chance. In effect, hospitals see and treat almost <em>all</em> E.R. patients even if they know that they won't be payed for doing so. <br /><br />People will of course argue that some patients might die after having been mistriaged to home. Unfortunately, it is the nature of things that this is so. Triage nurses <em>will</em> always make mistakes on occasion and as sure as the sun rises in the east, some patients or their families will pay a tragic price.<br /><br />Inevitably, such cases will become front page headlines, but rare as they may be, the victims will be "named" and therefore worthy of our sympathy and compassion. Consider though, that in California alone, at least <a href="http://www.signonsandiego.com/news/state/20060111-9999-1n11medcare.html">65 E.D.'s have closed</a> in the last decade. Unreimbursed care is at the root of most or all of these closures.<br /><br />How many <em>more</em> patients will die, however, because of a lack of nearby or conveniently located E.D.'s? Moreover, these patients will <em>not</em> be named but will instead be mere statistics in some as-yet-unperformed observational study.<br /><br />Again, read Leap's article for more reasons why the EMTALA is a bad idea (as it's currently written).The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-73911795110322044302008-03-29T23:55:00.000-07:002008-03-29T23:59:25.047-07:00From Dr. Jill Bolte Taylor: The Most Electrifying Lecture You'll Ever HearI've heard a lot of lectures in my life but <span style="font-style: italic;">never</span> one like this. This is neuroanatomist Dr. Jill Bolte Taylor giving a talk on the functional differences between the right and left hemispheres of the brain. She's passionate about her subject as she actually suffered a massive intracranial hemorrhage that trashed her left brain. Dr. Taylor brilliantly describes the experience and sensations both as a stroke victim and as a scientist.<br /><br />Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.<br /><br />It makes me never want to step up to a podium again.<br /><br /><object height="355" width="425"><param name="movie" value="http://www.youtube.com/v/UyyjU8fzEYU&hl=en"><param name="wmode" value="transparent"><embed src="http://www.youtube.com/v/UyyjU8fzEYU&hl=en" type="application/x-shockwave-flash" wmode="transparent" height="355" width="425"></embed></object>The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com7tag:blogger.com,1999:blog-10965136.post-71945474857183402132008-02-07T10:29:00.000-08:002008-02-07T10:34:29.707-08:00Universities' Endowment Funds and the Federal Government<a href="http://chronicle.com/news/article/3890/regulation-of-college-endowments-has-support-in-house">Here's</a> an idea I hate (via the <a href="http://instapundit.com/archives2/015038.php">instapundit</a>). Congress is considering regulating the amount of university endowments that schools may keep for themselves and how much they have to pass on to students (in the form of tuition cuts, financial aid, or scholarships). Do these guys really have this much time on their hands?<br /><br />Laws such as those being proposed give our legislature <a href="http://ap.google.com/article/ALeqM5jR80ylRipRFz_BSPltSUJ06-lMegD8U36DCG0">the bad name that it has</a>. Why a private, non-profit organization such as a university endowment "needs" to be controlled by the federal government eludes me. Don't get me wrong. When I read that elite schools such as Harvard could pay the tuition of their entire student body on just the <em>interest</em> that their endowments earn, I find that reprehensible and a poor reflection of their governance. But that's their problem, not the fed's.<br /><br />Surely people will make the argument that as tax-exempt organizations, some limitations on their behavior is appropriate. Really? Is the federal government really so much the paragon of efficiency and insight that they should decide where the Red Cross or Harvard should allocate the contributions they collect? Is that what we want?<br /><br />Likewise, some will point out that many (most?) students receive some federal aid in the form of grants or federally insured student loans and as such, the government has an overriding interest. <em>To me, this just strengthens the position that the fed should get out of higher education completely.</em><br /><br />My guess is that such legislation will probably go nowhere (although some provision for more transparent reporting of where endowment money actually goes may pass). I think though, that the real intent of such debate is to put a chill in the minds of fund managers' minds. The mere <em>threat</em> of such laws may well be enough to "influence" behavior. In my opinion such saber rattling is an immoral use of federal power.<br /><br />Bad law. It's contagious.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com3tag:blogger.com,1999:blog-10965136.post-46572009209044147072008-02-02T10:22:00.000-08:002008-02-02T11:14:24.618-08:00Gonzo Medical BloggingPeriodically, I will add a new blog to my "blogroll". Unlike many bloggers that maintain such lists, I try to post only the ones I like to read frequently. Some bloggers maintain huge alphabetized lists of blogs, a practice I've never really understood. Perhaps these lists grow because of <span style="font-style: italic;">quid pro quo</span> (you link to me and I'll link to you, a practice I hate) or perhaps some people just like the look of really unwieldy, completely unfiltered lists.<br /><br />Personally, when I look at someone else's blog, I enjoy looking through their blogrolls to see just what they like to read. Being an avid reader, I'm always curious about such things. When my patients or their families have books with them in the hospital or exam room, I invariably ask what they're reading. Huge blogrolls don't really give me that kind of insight into the compiler's tastes.<br /><br />At any rate, this post is to announce an addition to <span style="font-style: italic;">my</span> blogroll. That we are judged by the company we keep concerns me as I add a link to <a href="http://pandabearmd.com/">Panda Bear MD</a> but what can I say? The guy is hysterically funny and says things that many of us think but are unwilling to express in polite company. Panda is a resident in emergency medicine. I'm sure he is a bit older than his fellow residents as he's described a wide variety of prior life experiences.<br /><br />This added age undoubtedly gives his writing a level of sophistication extremely unusual in someone the age of a typical resident. If I had to pigeonhole him, I guess I'd call him the Hunter S. Thompson of medical writing, an appellation I'm sure he'd understand as a compliment.<br /><br />I enjoy his observations, his insights, and his style very much and have pointed colleagues, nurses, and residents towards selected posts to much hilarity.<br /><br />Truthfully, I sometimes worry about Panda. My hope is that his posts are put-ons and that the darkness, even bitterness, imbued in his writing is more for shock value than anything else, sort of like Ann Coulter's subtle style. But I have my doubts. His writing is too authentic and fluid.<br /><br />I think that while most of us will occasionally laugh at the peccadilloes of our patients and their families, most of us don't <span style="font-style: italic;">define</span> such people by them. I hope he is happy in what he does and that if so, medicine continues to sustain him. Unfortunately, my suspicion is that his cynicism has been acquired at far too early a stage in his career. He has all the markings of someone headed for premature burn-out. Hopefully by turning others' attention to his writing, I'm not reaffirming his world view and somehow facilitating such burn-out.<br /><br />One last point Panda, if you're reading this. You should give some serious thought to posting your name and your institution. Not because I want to know who you are but instead, to protect yourself. While I don't recall reading anything you've written that's frankly libelous or in violation of HIPAA or terribly likely to get you into trouble, some of your posts definitely push the envelope. I think that writing <span style="font-style: italic;">without</span> the imagined security of anonymity helps ensure just enough caution to prevent saying things that can have tremendous legal or professional repercussions. Internet anonymity is fleeting. Just ask the <a href="http://boston.com/news/local/articles/2007/05/31/blogger_unmasked_court_case_upended/">Flea</a>.<br /><br />My two cents.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com1tag:blogger.com,1999:blog-10965136.post-60066188636689604572008-01-31T03:13:00.000-08:002008-01-31T03:14:28.571-08:00Service in Medicine, Has it become a quaint anachronism from a bygone era?<a href="http://the-hospitalist.org/blogs/wachters_world/archive/2008/01/31/unexpected-consequences-of-it-ii-the-disappearance-of-radiology-rounds.aspx">Bob Wachter</a> has posted some great points regarding the "service" of radiology.<br /><br />The last paragraphs are priceless:<blockquote>In my <i>NEJM</i> article on dis-location, I described the growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their “real work,” then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.<br /><br />Or the country.</blockquote>I feel the same way about so many aspects of modern medicine. If primary care physicians want better reimbursement, they need to "add value" to their interactions with patients. Otherwise, why <span style="font-style: italic;">not</span> have a nurse practitioner or physician assistant grab their business at a discount (e.g. at CVS Pharmacies)? If emergency medicine docs want more respect from their colleagues and to not render themselves useless, then they have to do much more than act as glorified triage nurses. In the same way, if radiologists want to avoid having their jobs outsourced, let them raise their standards of service.<br /><br />The list of examples could go on and on. Read Arnold Kling's <a href="http://tcsdaily.com/article.aspx?id=012908A">recent article</a> in tcsdaily to see one reason why quality has declined so frequently. Hint: imagine what happens to a service when the recipient pays for it rather than someone else like a third party payer.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-77673319452740392962008-01-22T08:35:00.000-08:002008-01-22T09:06:23.614-08:00Who says big government is inefficient?Courtesy of the <a href="http://insureblog.blogspot.com/">InsureBlog</a>: <a href="http://www.usatoday.com/printedition/life/20080121/d_hnb21.art0.htm">A little USA article</a> on your government at work. So it seems that the NIH can't keep track of the potential conflicts of interest between grant recipients and the companies they <del>shill</del> consult for.<br /><br />I was going to ask myself how the General Accounting Office (GAO) could allow this to happen and then I realized...The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-31550215683740789752008-01-17T21:42:00.000-08:002008-01-17T21:44:48.456-08:00Of Mice and Men<a href="http://news.yahoo.com/s/livescience/20080117/sc_livescience/humanscraveviolencejustlikesex">This</a> caught my eye. It's an article in Yahoo News entitled <span style="font-style: italic;">Humans Crave Violence Just Like Sex</span>. I'm thinking, <span style="font-style: italic;">this</span> has to be noteworthy. Imagine my disappointment in reading the first few lines:<blockquote>New research on mice shows the brain processes aggressive behavior as it does other rewards. Mice sought violence, in fact, picking fights for no apparent reason other than the rewarding feeling. <span style="font-style: italic;"><br /><br /><span style="font-style: italic;">The mouse brain is thought to be analogous</span> to the human brain</span> in this study...(my italics)</blockquote>Pardon me my skepticism.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com1tag:blogger.com,1999:blog-10965136.post-16179490100989533622008-01-17T21:24:00.000-08:002008-01-17T21:24:43.608-08:00From the Field to Angiogram.Here's an <a href="http://content.nejm.org/cgi/content/short/358/3/231">interesting study</a> in the <span style="font-style: italic;">New England Journal of Medicine</span>.<br /><br />There have been several studies that fairly conclusively demonstrated that reducing the time from the symptoms of a particularly dangerous type of heart attack (the so-called ST-segment elevation myocardial infarct or STEMI) to the time of balloon angioplasty saves lives. Getting this symptom-to-balloon time down is of course partly a function of physician skill. But the biggest determinant has to do with the nature of the system that's in place to move the patient from initial transportation to assessment to cath lab team mobilization.<br /><br />Getting this time down involves tremendous planning, resources, and careful thinking. This study looked at door-to-balloon time (the time the patient hits the hospital to the time the angioplasty balloon is inflated (thus opening a clogged artery). It seems to show that if paramedics in the field are taught and allowed to diagnose STEMI's, then patients can be transported directly from the street to the cath lab <span style="font-style: italic;">thus bypassing the emergency room</span>.<br /><br />Using this strategy, the door-to-balloon time was shaved from 123 to 69 minutes. Judging from morbidity/mortality results of previous studies, this is no small amount and probably has important clinical significance. In fact, inpatient mortality went from 5.7% down to 3.0% using direct transport.<br /><br />This study was not randomized nor blinded and numerous confounders can be assumed and postulated. It is noteworthy however that the baseline characteristics between the direct transport and emergency room transport groups are surprisingly similar which suggests that these clinical benefits may be real and not explainable by such confounding variables.<br /><br />These results are preliminary but definitely tantalizing. It seems unlikely to me however, that a randomized trial testing this approach will ever be done and this data may be the best that we get. <br /><br />Might it be enough?The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-15981155233188599182008-01-11T08:01:00.000-08:002008-01-11T08:03:42.949-08:00Physicians and Their Role in Executions<span class="summpost">The New England Journal of Medicine has published a provocative editorial on capital punishment and the physician's role in carrying it out.<br /><br /><a href="http://califmedicineman.blogspot.com/2008/01/physicians-and-their-role-in-executions.html">Read my thoughts on this important editorial here.</a></span><span class="fullpost">The New England Journal of Medicine has published a <a href="http://content.nejm.org/cgi/content/full/NEJMe0800032">provocative editorial</a> on capital punishment and the physician's role in carrying it out. In truth, the position taken, that no physician should agree to facilitate an execution is old and has been endorsed by many medical societies. However, in over 1,000 words, the closest thing to an argument in support of this are these words: "A profession<sup> </sup>dedicated to healing the sick has no place in the process of<sup> </sup>execution."<br /><br />Yet even this statement is offered without proof or justification and is merely a recapitulation of the authors' opinion. Cannot the exact opposite position also be offered, that in a nation that condones the death penalty through its laws and courts (and incidentally in <a href="http://www.gallup.com/poll/1606/Death-Penalty.aspx">public opinion</a>), medical science should be brought to bear to insure that all executions are administered with compassion and decency?<br /><br />If that is the case, who <span style="font-style: italic;">better</span> to supervise an execution than a physician; preferably one expert in pain management, anesthesiology, or critical care medicine? After all, the article cites several instances of botched executions that almost certainly increased the pain and suffering of the criminal.<br /><br />The position that this editorial takes, that the medical community's canon of ethics forbids it from participating in executions may well be heartfelt. Yet consider revealing words such as these:<blockquote>Injected drugs, now used in all but 1 of<sup> </sup>the 37 states in which capital punishment is legal, have been<sup> </sup>part of the increasing medicalization of executions and the enlistment of medical personnel to <span style="font-style: italic;">lend them apparent moral</span><sup style="font-style: italic;"> </sup><span style="font-style: italic;">legitimacy</span>" (my emphasis).<br /></blockquote>I can't help but think that something else is going on here. Could it be that these authors are simply <span style="font-style: italic;">opposed</span> to capital punishment and that by promoting a policy forbidding physicians from facilitating it, they in effect render it an impossibility?<br /><br />If that is truly their agenda then that should have been their thesis and they should be forthright about it. Pardon me for finding it intellectually dishonest however, to hide behind some vague, poorly established interpretation of the Hippocratic Oath (which they also cited). The Oath was never understood to forbid the palliating of pain and suffering when death was imminent due to disease. Why should it be any different here?<br /><br />By the way, unless you know me well, don't presume to know where <span style="font-style: italic;">I</span> stand on the death penalty. This post is more about being upfront than about capital punishment.</span>The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com3tag:blogger.com,1999:blog-10965136.post-34120471486139428842008-01-10T08:38:00.000-08:002008-01-10T08:40:52.195-08:00medGadget Posts a Cool One<a href="http://www.medgadget.com/archives/2008/01/tank_chair.html">This</a> is one cool post by medGadget!The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-45219984739063906252008-01-10T08:06:00.000-08:002008-01-10T08:06:48.589-08:00Outsourcing the Day to Day Stressors of LifeHere's <a href="http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/01/06/wcall106.xml">some insight</a> regarding life on the other side of those monuments to outsourcing, Indian call centers. It seems that operators in India are succumbing to the stress of dealing with European and American ire:<blockquote>Miss Aggarwal, an English graduate, said she planned to quit, tired of wishing customers a good morning only to hear: "Oh, I'm through to India am I? Put me through to someone who can understand English, you f****** cow."</blockquote>Yikes. These people are apparently suffering from various medical problems real and imagined from this sort of work.<br /><br />I'm reminded of a patient I saw in my office many years ago, a young woman with a "positive review of systems" which is medicalese for having every complaint under the sun. After getting a detailed medical history and examining her thoroughly finding nothing wrong, I asked her if anything in her personal life was bothering her.<br /><br />"Well gee doc, I hate my job. It's kind of...you know, stressful."<br /><br />I asked her what she did (which I should have done in the first place). Her answer convinced me that she did in fact have one of the worst, most stressful jobs in the history of mankind.<br /><br />She worked as a cashier at an impound garage. She had to take rather large payments from less than cheerful "clients" to retrieve their cars which had been towed. My advice: find another line of work.<br /><br />Who says medicine has to be complex and arcane?The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-83984439171429468912008-01-09T08:14:00.000-08:002008-01-10T08:20:41.859-08:00Disaster Preparedness and Emergency Out-Of-State Physician LicensingDuring Hurricane Katrina, I called our local Red Cross chapter to offer my services in Louisiana. I attended their training course to do just that but was then told that I wouldn't be able to volunteer as a <span style="font-style: italic;">physician</span>. Louisiana was unwilling to temporarily grant licensing reciprocity to out-of-state doctors even though it had experienced a massive disaster.<br /><br />Any such physician assisting there would be practicing without a license and I surely don't need to review the medicolegal implications of that. Their state legislature is obviously filled with a group of rocket scientists!<br /><br />I instead opted to be placed on a list of physicians willing to respond to in-state disasters (California in case you missed the title of this blog).<br /><br />An interesting <a href="http://jama.ama-assn.org/cgi/reprint/299/2/169.pdf">letter</a> was published in the latest issue of JAMA. Lori A. Boyajian-O'Neill et. al. surveyed each state in the U.S. to find out what their policies were regarding the licensing of physicians in the event of a disaster. The chart they compiled lists three possibilities: an "expedited" licensing procedure, waiver of licensing altogether in the event the physician has a license in another state (reciprocity), or my favorite -- none.<br /><br />Louisiana belongs to the expedited procedure group. During Katrina, their governor wrote an executive order suspending the usual licensing procedures. Apparently this wasn't in place at the time I considered going with the Red Cross (who would only send docs with a valid Louisiana license).<br /><br />I was surprised to see that <span style="font-style: italic;">18 states opted for no emergency licensing at all</span>. Talk about protecting your turf!<br /><br />Maybe every states' lawmakers should be reviewing their own laws. To me, emergency reciprocity seems like the way to go. For most state medical boards, a physician's licensing status can be checked reliably and instantly on the internet. Why wouldn't a state want a physician in good standing in his home state to volunteer in the event of an emergency?The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-69745726884178408532008-01-08T01:17:00.000-08:002008-01-08T01:20:51.887-08:00Are Medical Device Manufacturers About to Get a Truly Free Ride?<span class="summpost">If my reading of an article in the latest <span style="font-style: italic;">New England Journal of Medicine</span> is accurate, then the Supreme Court is about to rule on a case of momentous implications.<br /><br />The case is <span style="font-style: italic;">Riegel v. Medtronic</span> and it's a big one. Charles Riegel is suing Medtronic over a balloon angioplasty device that malfunctioned necessitating emergency care and ultimately coronary bypass surgery. Medronic is arguing that because their product received premarketing approval by the FDA, it has effectively been "immunized" against lawsuits in any state court arising from the failure of that product and that the suit should be thrown out.<br /><br /><a href="http://califmedicineman.blogspot.com/2008/01/are-medical-device-manufacturers-about.html">Read more about this extremely important case here.</a></span><span class="fullpost">I'm not a attorney and I don't play one on TV. But unless I'm facing the wrong end of a lawsuit (which has happened more than once), I do find the law fascinating and engaging. Every once in a while though, I encounter a legal case that truly cuts at the heart of our day-to-day lives. One such case was <span style="font-style: italic;">Kelo v. City of New London</span>. This case ruled in 2005 by the U.S. Supreme Court gave local municipalities incredibly broad power in exercising eminent domain over private property owners.<br /><br /><span style="font-style: italic;">Kelo</span> sent shockwaves through society when a previously assumed fundamental right to be secure in one's property suddenly vaporized. A town could now take your home and give it to a real estate developer who could then commercialize it in such a way as to increase tax revenues to that town. People across the country (even people who were not owners but hoped one day to be) instantly felt less secure about their homes and their lives.<br /><br />If my reading of <a href="http://www.ncbi.nlm.nih.gov/pubmed/18172178?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">this article</a> in the latest <span style="font-style: italic;">New England Journal of Medicine</span> is accurate, then the Supreme Court is about to rule on a case with similarly momentous implications.<br /><br />The case is <span style="font-style: italic;">Riegel v. Medtronic</span> and it's a big one. Charles Riegel is suing Medtronic over a balloon angioplasty device that malfunctioned necessitating emergency care and ultimately coronary bypass surgery. Medronic is arguing that because their product received premarketing approval by the FDA, it has effectively been "immunized" against lawsuits in any state court arising from the failure of that product and that the suit should be thrown out.<br /><br />Their argument is based on an amendment to the FDA charter voted by Congress in 1976. This amendment granted authority to the FDA to certify the safety of medical devices, a power that had not previously been extended to them. In order to ensure that this new FDA mandate wasn't usurped by laws that individual states might create, a clause (360k(a)) was inserted in the amendment guaranteeing that FDA guidelines would supersede any such state laws.<br /><br />It is this clause that Medtronic is attempting to exploit in this case. They are arguing that 360k(a) gives the FDA priority over state laws and that <span style="font-style: italic;">this includes state provisions allowing lawsuits against device manufacturers if the FDA certified a product before it went to market</span>. Medtronic's argument then, is that Riegel's lawsuit against them should be completely thrown out.<br /><br />If the Supreme Court rules for Medtronic, this would open the door to immunizing all medical device manufacturers from lawsuits. The article in the <span style="font-style: italic;">NEJM</span> does an excellent job of describing the implications of such a ruling.<br /><br />I hate lawsuits as much as the next guy but I'm not so militant that I don't recognize the important social good that they can serve. While lawsuits are a blunt, often misused weapon, they clearly help promote better medical product reliability and safety. To simply eliminate the public's right to sue a company making a faulty device would be extremely damaging to society.<br /><br />I love medical device companies. I think the products they develop help incredible numbers of people. It is naive to think however, that getting FDA premarket approval is all that's necessary to insure product safety. It is the sword of Damocles in the form of a lawsuit that truly stimulates device manufacturers to "do the right thing".<br /><br />I differ with the authors in one respect. They claim that the most compelling argument the Supreme Court should be guided by is whether a ruling for Medronic will truly benefit or hurt society. My understanding is that the role of the Supreme Court is simply to adjudicate the law and determine whether or not it conforms with the U.S. Constitution. It is not the Court's job to decide whether a law is stupid or not or whether it does or doesn't achieve a particular objective<br /><br />In this case, I think that the Court needs to determine whether Congress ever <span style="font-style: italic;">intended</span> clause 360k(a) to prevent product liability lawsuits against device manufacturers. For me, it's inconceivable that that was the case.<br /><br />I can only hope that for my patients and for society as a whole, nine justices think long and hard about this one.<br /><br />Any lawyers have an opinion on this?</span>The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com0tag:blogger.com,1999:blog-10965136.post-51613098912185945642008-01-07T14:08:00.000-08:002008-01-07T20:03:52.040-08:00Project Steve and Its DetractorsA few days ago, I <a href="http://califmedicineman.blogspot.com/2007/01/project-steve-and-evolution.html">blogged about Project Steve</a>. Predictably, I ruffled some pro-creationist feathers, particularly those of M. Mitchell who commented.<br /><br />So M., I'm sorry if I've offended you but this is not a "petty squabble". The reason for Project Steve is to show that a larger and much more prestigious group of scientists can be compiled that discount rather than support creationism--even while limiting themselves to those named Steve. It's a whimsical idea but as a rhetorical tool, it also sheds light on exactly what's happening here.<br /><br />Creationists compile lists of scientists to cause the illusion that there is scientific merit to their positions when in fact, the opposite is true. One of the most important features of a scientific theory is that it has to be testable, i.e. it has to lead to conclusions that can be disproven. Creationism does not meet that standard as attributing the known world to God (or some other "intelligent" designer) can NEVER be tested nor proven wrong.<br /><br />People have looked at the fossil record and carbon dating evidence for evolution and simply said 'God created that these findings thus giving the "illusion" that evolution is a viable conclusion.' How can a scientist possibly respond to this? Such an idea is impervious to refutation.<br /><br />For this reason, the vast majority of scientists refuse to endorse creationism as science. I have no problem with including such theories in classes on religion...just not in science class.<br /><br />Even one like myself who unashamedly believes in God can recognize the difference. This is no petty squabble.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com1tag:blogger.com,1999:blog-10965136.post-56404391467413216572008-01-07T01:57:00.000-08:002008-01-07T01:57:45.595-08:00John Edwards Disgraces Himself With Regards to Nataline SarkisyanThe <span style="font-style: italic;">Wall Street Journal</span> just published <a href="http://online.wsj.com/article/SB119967240787671395.html?mod=googlenews_wsj">an article</a> on the Nataline Sarkisyan case and how it has been exploited by presidential candidate John Edwards. I have never endorsed nor rejected a political candidate in this blog. Today, I'm making an exception. I think that Edwards' actions regarding this case are despicable. It is clear that by giving Sarkisyan's family voice at his political rallies, he has accepted the preposterous notion that CIGNA systematically killed their daughter for profit (which they claim).<br /><br />It's bad enough when this family's lawyer makes such statements to the press. Malpractice attorneys have a rich and colorful history of trying their cases in the media. In law, this is thought of as mounting a "vigorous" advocacy for one's client. Edwards however wishes to be President of the United States.<br /><br />In my eye, his actions have firmly established his status as a lightweight. Policy differences aside, I for one would never wish for a president with such a simplified world view.<br /><br />By the way, I was quoted in this article but my title was mangled a bit. I'm sure that UCLA, my employer was quite surprised to find that I was promoted from assistant to associate professor.The Medicine Manhttp://www.blogger.com/profile/15083169360549914400noreply@blogger.com3