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1209717_19610439The focus of this web site is medicine. In this blog, you’ll read about patient stories. The situations have been changed to be HIPAA compliant. You’ll also read a lot about health care policy. I may throw in posts about life lessons, computers, and will even throw in family stories once in a while. If you’re looking for articles about politics, sports, or celebrities, you’re in the wrong place – unless the topics have some relationship to medicine.
If you want to add a guest post or to cross-post something from your blog, or if you have a patient story you want me to write about, e-mail me. See more information in the “About Me” page.

Pressure to Admit

We were away for the weekend, but in a restaurant, I caught glimpses of this segment on 60 Minutes called “The Cost of Admission.” Couldn’t hear the conversations in the restaurant, but luckily CBS posted the entire report online. If you didn’t see it, you really need to watch the video and/or read the transcript. In summary, 60 Minutes spent a year investigating irregularities in hospital admissions. Administrators at Health Management Associates and at EMCARE (one of the national emergency medicine contract groups) were accused of putting pressure on emergency physicians to admit at least 20% of patients that came to hospital emergency departments.  For Medicare patients, the “benchmark” for admissions at one hospital was allegedly 50%. The 60 Minutes expose also included spreadsheets showing comparisons of different physicians’ admission practices and text from e-mails saying such things as “I have been told to replace you if your numbers do not improve.” HMA held a conference call disputing the allegations and stating that they “take all allegations regarding compliance very seriously.” HMA allegedly had outside experts review the data (not the medical records?) and the experts determined that “the data simply do not support the allegations.” Now HMA is being investigated by the US Department of Justice for Medicare fraud. I predict that HMA will make a large settlement with the government to drop all charges (without admitting wrongdoing, of course) and that things will return to business as usual shortly thereafter. With things like this, I can’t really blame patients for thinking that medical care is “all about the Benjamins.” Patient satisfaction metrics are creating quite similar incentives with physicians. How long will it be before people wake up and see how much fraud that the satisfaction scores are causing?

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Dear Diary

Dear Diary Some things just don’t make sense to me. Why do dogs just like to eat random objects? Lately, it’s been a case of “guess what the dog ate today” around our house. Eraser. Hairbrush. Tube of toothpaste (she loves toothpaste). Martial arts training knife. Our other dog just walks around with his tail between his legs when he sees something chewed up on the floor because he thinks the other dog will blame him for it. Then we get the great idea to lock spazzy boxer pup in the bathroom so she won’t have to sit in her cage for 12 hours while the family drives to a football game and back this past weekend. No, that was Ms. WhiteCoat’s idea. I had nothing to do with it. We returned to find the door broken, the stripping ripped up from the door jamb, and a bathroom that looked like it was being renovated. Our vet calls it separation anxiety. I call it something else. Then the dog gives us the big googly eyes when we get home as if to say if only we had provided her with a doggie counsellor to help control her impulses, none of this would have happened. Where do all the damn headphones in the world go? I have this pet peeve. I hate it when people take my things and don’t put them back. With six people in the house, no one will own up to losing whatever it is that’s missing. So if things go missing more than a couple of times, I buy 10 of them. Kids kept stealing my combs out of the bathroom, I bought a 20-pack and threw a few in each kid’s room. Kids were taking all of my pens, I got a 100 pack of the pens I like from Staples for like $20 and bring up handfuls from the storage room when they go missing. Tennis balls to play with the dog go missing – I bought 50 used ones off of eBay. Of course, half the missing balls were in the gutter, but now we have extras. Also have a half dozen nail clippers laying all over the house. But mine are left alone. One thing that just doesn’t reach the saturation point of missingness is headphones. I had a couple of good pairs of ear buds that went missing. So I went online and bought 10 pairs of them for $4 apiece. Within a week, they had all vanished. Not a trace. I bought 10 more. Gone within another couple of weeks. WTF? So I said to hell with it and I jog listening to music from the speaker on my phone now. I checked on eBay and no one from this house is selling them. And I looked through the doggie doo and didn’t see any wires, so it isn’t spazzy boxer pup, either. Maybe we got ourselves a gremlin. What is it with our family and insects? First, it’s the ants. Then I leave for work last week for an overnight shift. I get an urgent call from home telling the secretary to pull me out of a room with a patient. Mrs. WhiteCoat is on the other end of the line and is freaking out because our basement has turned into the set for some horror flick. She says there are like 200 flies on the ceiling of the basement buzzing all around. I made the mistake of telling her that maybe there was a mouse dead in the ceiling or something. She calls around to every exterminator in ...

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Too Heavy to Fly

Medical care for the morbidly obese is back on the radar. Today this blog got several inbound clicks from a site where a bunch of apparent doctor haters have used one of my blog posts and the comments to the post as an example of how much the medical profession allegedly likes to bestow shame upon others. It seems that the discussion we had regarding whether it is ever acceptable to refuse medical care to morbidly obese patients was something that Ms. Marianne’s readers were cautioned that they may not be able to “stomach.” The author and most of the people who commented to her article seem to believe that they have the right to demand that any doctor at any time must provide any type of services to them that they demand. Whether or not the doctor is comfortable providing those services or whether the doctor even has the knowledge and training to provide those services is irrelevant. Any doctor who doesn’t agree to their demands is hated and publicly shamed. This doctor who chose not to treat patients weighing more than 200 pounds was one example of their wrath. I left a comment to Marianne’s rant back when she first posted it. I don’t remember the comment verbatim, but the gist of my comment was that there are specialists for a plethora of conditions who provide care to patients when other providers are uncomfortable caring for those conditions – HIV, diabetes, organ transplants, ophthalmology, etc. Why shouldn’t doctors be able to refer obese patients to other physicians more experienced in caring for obese patients? In addition, there is no “right” to force any person to provide you with any services against their will. The Thirteenth Amendment to the Constitution addressed that. Finally, I noted that when there is a bad outcome related to a patient’s obesity, one of the first things that a plaintiff’s attorney will allege is that the patient should have been referred somewhere else. My comment was never approved. Non-conforming, I suppose. Today there also happened to be an article in the NY Post – linked by the Drudge Report – about how a morbidly obese woman with multiple health problems traveled to Hungary for a month-long stay in their family vacation home. When she tried to board a flight back to New York to resume her medical treatment, the airline refused her because she had gained water weight and could not be safely strapped into three seats. The airline tried to make alternate arrangements for the patient’s travel back to the US, but those plans also fell through due to the patient’s size. There was no mention that the woman ever went to a hospital for care of her medical problems while trying to secure travel back to the US. Both the patient and her husband were quoted as saying that they “didn’t trust” doctors in Hungary. Nine days after first attempting to return to the US, the woman died. Difficult situation. Comments to the article were mixed. Some people blamed the patient for allowing herself to become so obese. Others blamed the airline because it was able to get the patient to Hungary and then left her stranded there. This case illustrates the point that I was trying to make in my previous post about providing medical care to morbidly obese patients. At some point, the safety and well-being of the patient and of others must be taken into account when deciding whether to provide care. These decisions are made all the time in medicine. A patient with severe lung disease may be ...

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Healthcare Update — 11-26-2012

Whatever the hospital is paying this person … it’s not enough. After Hurricane Sandy hit, ED tech Marsha Hedgepeth swam down the flooded road from her apartment to a major highway and then hitchhiked ride with out-of-state utility truck to get to work so she could help other hurricane victims. Amazing dedication. Note to criminals, if you get injured committing a crime, one of the first places that police look for you is … in the emergency department. Five kids beat up one kid and steal his belongings. When victim goes to the ED for treatment, guess who shows up? Now 18-year-old Joseph Scott is charged with several felonies and will take a nice vacation in the Greybar Motel. http://murrieta.patch.com/articles/robbery-suspect-arrested-in-hospital-emergency-room New Hampshire jury awards plaintiff $5 million after radiologist mis-reads CT scan of 25 year old headache patient showing evidence of a stroke. Later, allegedly due to the delay, the patient suffered brain hemorrhage and permanent disabilities. Excellent review article on the accuracy of the Broselow Tape. You may recall that not too long ago Dr. Broselow wrote an interesting article in EP Monthly about how he came up with the idea for his invention. Now it seems as if the weight estimations on the Broselow tape are too low in almost 50% of the cases – which would result in underdosing of medications during a pediatric code. Best estimate of how much a child weighs? Ask the child’s parent. Woman who remained alive in coma for more than 40 years passes away. Quite a remarkable story of family love and devotion. What are the most common reasons that patients come to the emergency department for Thanksgiving? Here’s one doctor’s list. My experience differs somewhat. Who comes to the emergency department because they ate too much? Family member issues involve more patients whose children haven’t visited them in the past 12 months who return to find that mom or dad aren’t as spry as they were a year ago and want to make sure that there’s nothing wrong with them. By the way, am I the only one wondering why this guy brought his kid with him on camera? First the kid flops over like he just went unresponsive and then by the end of the segment, the doc literally had to put his kid in a wrestling hold to get him to sit still. Ironic, isn’t it? The same people who voted for Obamacare are now the ones asking physicians to break the law so that the patients don’t have to abide by Obamacare’s mandates. Oh, and that “free” exam that Obamacare promises you every year … ya get what ya pay for. A good example of why correlation and causation aren’t necessarily the same thing: Selena Gomez rushes to the emergency department after date with Justin Bieber. The date with the Beebs didn’t cause her to go to the emergency department (at least I think that’s the case) … Selena’s “emergency” was a sore throat that had been troubling her for “some time.” Next on the FDA’s hit list … 5 hour energy shots. The supplement may have been involved in as many as 13 deaths in the past 4 years. May … have been involved with … Quick, let’s ban this stuff before it may be involved with another death. To save almost £3 billion in costs, the UK is planning to implement “virtual clinics” where patients connect with doctors through iPads and Skype. Don’t have an iPad? Can’t afford broadband internet access? Unable to connect? Not sure of the credentials of the person on the other ...

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Accepting Our New Normal and Finding New Opportunities

by Birdstrike M.D. It Is Here To Stay The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes. In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.” Comparing and Contrasting With Other Industries In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors? Are we special? Are we different? In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations. What Government Will (or Will Not) Do Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of….nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure? There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ...

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Healthcare Update — 11-19-2012

Can you imagine your kids on this stuff? Two ounces of Cracker Jack’d will have 70 mg of caffeine – as much caffeine as a cup of coffee. Frito-Lay reports that the snack won’t be marketed to children and will be labeled different from the traditional Cracker Jack boxes. Not sure how I feel about this. On one hand, I think that companies should be able to market any legal product that they want. How is taking Cracker Jack’d any different than using energy drinks or No-Doz caffeine pills? On the other hand, I don’t think that changing the labeling and marketing the product only to adults is going to prevent children from eating the Jack’d version. Kids still smoke a lot of cigarettes. In addition, unless Frito-Lay colors the popcorn differently – such as red popcorn for Jack’d version and traditional caramel color for the regular version – I foresee a lot of unintentional ingestions/overdoses. If there’s no way to differentiate caramel corn outside of the box, how can someone tell if their snack has been Jack’d? One way to bring down medical costs. GruntDoc mentioned this group of docs on his blog as well. Oklahoma surgery center publishes list of prices for pretty much all-inclusive surgical care, and the prices are one-fifth of what the nearby Integris Health hospital system charges. For example, a bilateral sinus procedure costs $33,000 at the hospital – not including surgeon or anesthesiologist fees. The same procedure at the surgery center – including all doctors’ fees – is $5,885. A plane trip and hotel plus surgical fees would cost a lot less than what most local hospitals charge. Domestic medical tourism – what a concept. Hoping this care model expands. VA Medical Center sued for prescribing four month supply of Seqoquel to patient who abused prescription drugs and previously attempted suicide by overdose. The patient was successful in her fourth suicide attempt when she took most or all of the pills and was found dead in her apartment. When the shoe is on the other foot, now government attorneys argue that Seroquel is not particularly lethal (good thing for that or else the patient may have died from her overdose) and was “effective in treating [the patient’s] psychosis when taken as directed” (it was also effective in killing the patient when she took too much of it). Despite the risk of overdose, the attorneys argue that the greater risk to the patient was that she would run out of Seroquel, which seemed to help her. But one of the documented side effects of Seroquel is “suicide attempts.” Obviously, we need to charge all the government employees involved in the patient’s care with murder. After all, how is this case that much different from all the cases where the government is charging doctors with murder when patients overdose from using narcotic prescriptions inappropriately? Making pediatric patients happy to wait. All rooms in Stanford’s Packard Children’s Hospital emergency department have iPads included. “One iPad is worth 10 milligrams of morphine,” says the department director. Until the iPad is dropped on the floor, that is. I also wonder whether the idea will have unintended consequences. What if more than one kid is in the room? How do the hospitals manage “inventory control”? Will kids who don’t have iPads at home feign illness to go back to the emergency room? Any issues with privacy if parents look things up on the internet or take pictures using the iPad? Will patients/families become upset if there are not enough iPads to go around? How will hospitals deal with those ...

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Open Mic Weekend

It’s time for another episode of Open Mic Weekend and our special guest is … you. All weekend everyone is welcome to post any medically-related comments, questions, or observations in the comments section. I’ll try to answer any questions on Monday. As usual, the only rules for comments are that there are no personal attacks and that the comments/questions have to be medically-related. Have a safe and enjoyable weekend. Oh, and Go Irish!

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Flu Alert

Influenza has arrived. Some Georgia emergency departments are seeing a 25-30% increase in volumes due to people seeking care for influenza or influenza-like illness. According to the CDC web site, there is good match between vaccines and the circulating virus strains this year. H1N1 virus strain not being seen much. H3N2 is the predominant Influenza A strain while “Yamagata lineage” is the predominant Influenza B strain in circulation. Note that there is one Influenza B strain circulating that was NOT contained in the vaccine – the “Victoria lineage” which accounts for about 15% of the total samples tested. For an interesting look into how influenza vaccines are created each year, see this link. It’s not too late to get vaccinated, but realize that vaccination takes about 1-2 weeks to generate an immune response in your system before it becomes effective. One side note, there are some medications which may shorten the course of influenza when taken early in the course of the disease. One 2012 Cochrane review questioned the effectiveness of neuraminidase inhibitors (Tamiflu and Relenza) because “60% of patient data from phase III treatment trials of [Tamiflu] have never been published” and because the company that produces Tamiflu – Roche – reportedly ignored five different requests from the researchers to release the information in those studies. According to the CDC site above, so far there is no resistance to the neuraminidase inhibitors with any of the influenza strains. There is high resistance to the less expensive amantadines in all influenza A samples (influenza B is not sensitive to amantadines). In other words, if you get the flu, taking amantadine (Symmetrel) or rimantadine (Flumadine) would be just as effective as taking a “ZeePack” (Azithromycin) or as taking red jelly beans in making you feel better. I’m personally not a big fan of Tamiflu and Relenza. I’ll discuss the above with patients who have influenza, and afterwards if people want to pay $50-$120 for medications that may make them feel better and may shorten the course of the disease by 12-24 hours, I’ll write them the prescription. PT Barnum philosophy in my book. In our state, Tamiflu and Relenza aren’t on the Medicaid formulary – only amantadine. You’d be surprised how many people demand amantadine prescriptions so that they can take something to help with their symptoms – even though it has little or no effectiveness against the circulating virus strains. Seems that no one cares about amantadine’s side effects. They just want a pill. I’d prescribe red jelly beans instead, but those aren’t on Medicaid’s formulary, either. Good thing those folks have insurance, though. Finally, if you want an interesting influenza anecdote to start up a conversation at parties, this year scientists discovered a new influenza virus that is entirely different from all known influenza A viruses. The hemagglutinin portion of the virus (the “H” part of the influenza designation in “H1N1”, for example) was dubbed H17. The neuraminidase portion of the virus (the “N” in the H1N1 designation) hasn’t been determined. Researchers weren’t able to grow the new influenza virus in any of the traditional methods and believe that the virus would require significant mutations before it is able to infect humans. Just to be safe, though, stay away from Guatemalan fruit bats – which were the reservoir for the new virus.

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