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Schadenfreude: Florida Leads The US In Primary Care Physician Shortages

I can’t help my feelings of schadenfreude when I happened to see a graph at the Kaiser Family Foundation noting that Florida has the largest shortage of primary care physicians in the United States. Only 42% of Florida’s overall need for primary care physicians has been met. Runner up California was a distant second. Why do I continue to get satisfaction from Florida’s troubles? It goes to show that states reap what they sow when they create policies to attack medical providers. When Florida’s Senator Bill Nelson whines that Florida “desperately needs more doctors“, maybe he should discuss with Governor Rick Scott why Florida has chosen to implement so many unfriendly policies toward physicians. I’ve been keeping a separate page with some of the reasons why physicians should avoid going to Florida to practice medicine. Here are a few reasons: Florida voters changed the Florida Constitution so that if a physician loses three malpractice cases, the physician’s license is automatically revoked. Florida used to cap non-economic damages in malpractice cases. Not any more. Florida’s Supreme Court recently struck them down (.pdf file). News article from the Tampa Bay Times here. Florida voters also created a Constitutional Amendment that makes peer-review documents related to adverse events discoverable in lawsuits. Florida is perennially on the list of Judicial Hellholes. When medical providers begin searching for the best places and worst places to practice medicine, Florida definitely is one of the worst. Don’t practice medicine in Florida.

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Louis Caplan, Maureen Dowd, and Lack of Professional Ethics

With the flurry of Twitter posts about Maureen Dowd’s article “Stroke of Fate” in the New York Times, it almost seems as if the subject is already stale. Maureen Dowd is the Pulitzer prize-winning op-ed columnist for the New York Times who tells a compelling story about a young patient who suffered from a stroke. The patient was a healthy triathlete and she initially attributed the symptoms of her stroke to a migraine headache. Ms. Dowd’s article also touched upon the frustration and fear that patients feel after the diagnosis of a stroke which was an important part of the article. However, somewhere in the middle of the article, Ms. Dowd does a journalistic faceplant that probably had Joseph Pulitzer doing a few backflips in his grave. Ms. Dowd accompanied the subject of her story – her niece – to Boston in order to be evaluated by a national stroke expert. There they met 78-year-old Dr. Louis Caplan, a Harvard professor of neurology. Dr. Caplan made several inflammatory quotes regarding emergency departments which Ms. Dowd was only too happy to publish. She doesn’t appear to have fact checked the statements, she doesn’t appear to have asked the professor for the basis behind his statements, nor does she appear to have asked other experts in the field for their comments on the topic. Of course, Ms. Dowd may argue that her failure to check her sources was an innocent mistake or that was part of her journalistic expression, but in either case, she was irresponsible and unethical. She used one of the largest forums in the United States to provide misinformation about emergency medical care. As I read through Dr. Caplan’s quotes and the comments to the article, I can’t help but wonder whether or not Ms. Dowd’s actions were intentional. It doesn’t take much insight to realize that comments from a medical “expert” who denigrated another medical specialty would result in an avalanche of clicks to the New York Times web site. The problem is, Ms. Dowd, your article generated interest not because it was good journalism, but rather because it was hack reporting. You could have used your niece’s misfortune to provide information to your readers about the signs and symptoms of vertebral artery dissection, the treatment, and the outcomes. Instead you threw your integrity out the window to create just another piece of clickbait. Shame on you. It isn’t just Ms. Dowd who failed at the New York Times. The New York Times editors failed. Again. Ms. Dowd’s article is eerily similar to a sepsis article written by Jim Dwyer in the New York Times several years ago. Mr. Dwyer told the story of his nephew, Rory Staunton, who, in the midst of influenza season, went to the emergency department with fever and vomiting. Rory received treatment in the emergency department, his symptoms improved, and he was discharged, but he later died from sepsis. Mr. Dwyer went on a crusade against the hospital and the emergency medical providers. In the process, Mr. Dwyer failed to note many of the circumstances regarding Rory’s care, made many inappropriate comments, misapplied sepsis guidelines that were not designed for children, and then tried to hide the fact that those guidelines were not designed for use in children. When called out on his selective reporting of the facts, Mr. Dwyer made excuses such as Rory may have been a child, but he “was the size of an adult.” That episode of drive-by journalism didn’t work so well, either. So the New York Times editors allowed yet another poorly researched and inflammatory article to be published in ...

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Google Glass in the Emergency Department

Google Glass is trying to make inroads into the medical field and there have been several stories about how it is being used in the emergency department. One story begins with how Boston’s Beth Israel Deaconess Medical Center is the first hospital in the world to use the glasses for direct patient care. The benefits are reportedly legion: “Information like the patient’s name, their past medical history, even X-rays can all come up with Google Glass and could be life-saving, especially if a patient can’t communicate or doesn’t know their allergies and medications.” Yawwwwn … er, um … WHOA! The physician who is spearheading the Google Glass program at Beth Israel says that “I can say, ‘Page nurse,’ and say, ‘Nurse, can you get me some more sedation, thanks!’ And it will page them automatically all through voice commands and voice dictation.” That’s great. But there are other products out there that do the same thing. Think Vocera. And in Dr. Horng’s example, the nurse would then page the doctor back and say” “Doctor, I’ll get you some more sedation as soon as you put the order in the computer. Administration doesn’t let us take verbal orders, remember?” Then the doctor would have to walk out of the patient’s room, with Google Glass flashing e-mails and cat videos into his peripheral vision, so that he could enter the sedation order into the computer, then re-page the nurse and tell her that the order has been entered, which she’ll probably already know about and will only serve to piss her off because of the needless interruptions from the doctor playing with his new toy. Either that, or the doctor will sit in front of the patient having the following argument with an inanimate object … OK Glass … OK GLASS! Open patient John Smith chart. No, not that one. Close patient John Smith chart. Open patient John … what’s your middle name, sir? … Open patient John Francis Smith chart. Close patient Francis Smith chart. Open patient JOHN Francis Smith chart. Open orders. No, I don’t want hors d’oeuvres. O-PEN OR-DERS. By now, the patient is either annoyed or laughing. In either case, Google Glass probably cost more time than it saved. No sooner did the pixels dim on the first story than another story pops up about how not only did Google Glass just *work* at Beth Israel Deaconess Medical Center, but how Google Glass SAVED A LIFE! It turns out that the same Dr. Horng was treating a patient with a “severe brain bleed” and that the priority in brain bleed patients is to lower the blood pressure. However … dun dun dun duuuuuhhhhhh … the patient was *allergic* to some unknown blood pressure medication and … dun dun dun duuuuuhhhhhh … the patient was also taking an unknown blood thinner. Dr. Horng was able to find the answers “almost instantly” using Google Glass and “was able to administer the right medications to slow the bleeding and save the man’s life.” I call bullshit. Let’s walk through a typical patient experiencing a “severe brain bleed.” First, the patient doesn’t walk up to the registration window saying “Pardon me, ma’am, but I happen to be having a severe brain bleed – left hemisphere, temporal region.” The patient walks up to the registration window (or is brought in by ambulance) saying “I have a headache.” Perhaps the patient has “weakness.” Or maybe the patient is brought in by ambulance unconscious. But a “severe brain bleed” is a diagnosis made after workup, not a presenting symptom. So even with the help of Google Glass, a ...

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Contaminated Stethoscopes COULD Be Harmless

An interesting study is making the rounds in the mainstream media. Instapundit, Scientific American, NBC News, Healthcare Business Tech Blog, MedPage Today, CBS Atlanta, and Consumer Reports have all reported on the study. Unfortunately, the study draws questionable conclusions. A group of scientists at the University of Geneva Hospitals (Switzerland) and affiliated with the World Health Organization recently published a study demonstrating that physicians’ stethoscopes harbor many bacteria. The study was titled “Contamination of Stethoscopes and Physicians’ Hands After a Physical Examination” and was published in this months’ Mayo Clinic Proceedings. First, the researchers note that physician stethoscopes can be contaminated after a physical examination. Agreed. The amount of contamination can be as much as that contained on the palm of the hand (but not the fingertips). OK wonderful. The number of colonies causing the level of contamination is “substantial” after a single physical exam. For fingertips, the average number of colony forming units transferred was 467. For stethoscopes, the average number of colony forming units transferred was 89. Not so sure that is “substantial,” but we’ll go with it. For MRSA carriers, the average number of CFUs transferred was 12 for the fingertips and 7 for the stethoscope. However … no transfer of any MRSA bacteria occurred in 24% of patients and the researchers just discarded the data from those patients for the final analysis. (“Because MRSA was not recovered from the physicians’ dominant hand or the stethoscope after the examination of 12 of 50 patients colonized with MRSA (24%), these patients were excluded from the final analysis”). Averaging in a bunch of data that don’t fit with their conclusions would only dilute their message. Then come the “scientific” conclusions: “By considering that stethoscopes are used repeatedly over the course of a day, come directly into contact with patients’ skin, and may harbor several thousands of bacteria (including MRSA) collected during a previous physical examination, we consider them as potentially significant vectors of transmission. Thus, failing to disinfect stethoscopes could constitute a serious patient safety issue akin to omitting hand hygiene.” Note the hypothetical pseudoscience contained in just these two sentences. Stethoscopes “MAY harbor several thousands of bacteria” – meaning that stethoscopes also “may NOT harbor” several thousands of bacteria and you haven’t proven anything. “WE consider them as potentially significant” – ah, the logical fallacy of an appeal to authority. WE are published in a national journal and are getting national media attention. No one else might consider them as potentially significant, but those who do not agree with US are obviously unqualified to make such decisions. Oh, and by the way, WE still haven’t shown any literature proving this point, so just believe our pseudoscience and move along. “THUS …” – a haughty prelude showing that you are trying to use your unfounded conclusions to get everyone to believe your ultimate point that … “failing to disinfect stethoscopes COULD constitute a serious patient safety issue” – BRILLIANT! Oh, and by the way, the moon COULD be made out of green cheese, the government COULD be putting nanobots in our vaccines, Juan Pablo COULD marry any woman he wanted on the Bachelor, and I COULD win the lottery. Without better research, there is no way to determine whether any of these possibilities is more likely to occur than any other of the possibilities. A scientific statement that something “COULD” occur is close to being meaningless, showing only the absence of an impossibility. The likelihood of that event occurring is anywhere between 0.0000000000000000001% and 100%. There are multiple parallel studies which also make leaps in logic about the possibility ...

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“Illegal” Limits on Emergency Department Use

According to an article in the Miami Herald, Florida is “illegally” limiting Medicaid patients to six emergency department visits per year. Federal officials call such arbitrary limits illegal and says that the limits would not be in a patient’s best interests. CMS intends to withhold a portion of Florida’s Medicaid funding as a result. Another article on ThinkProgress.org comments on how unfair and inappropriate the limits would be, especially since only a “sliver of the poorest Florida residents” are eligible for Medicaid. The total population in Floirda is 19.5 million. The number of Florida residents eligible for Medicaid is 3.3 million. That’s 17% of Florida residents eligible for Medicaid. Add to that another 3.1 million Florida residents who have Medicare benefits (although there is likely some overlap with patients who have both Medicare and Medicaid) and you’re looking at one third of Florida’s population that receive medical care from the government. Some fricking “sliver.” Aside from the misinformation that reporter Sy Mukherjee is perpetuating, the story raised several additional issues with me. First, if acts that are not in a patient’s “best interests” violate the Social Security Act, then how did Obamacare pass muster? Not enough doctors in the system: not in a patient’s best interests. Outlawing established insurance plans: not in a patient’s best interests. Byzantine registration process: not in a patient’s best interests. Inappropriate Healthcare.gov web site security: not in a patient’s best interests. Second, I was surprised by the number of people commenting on the articles who deemed Gov. Rick Scott’s attempts to limit excessive emergency department use as: intended to harm poor people “DEATH PANELS,” a form of fascism a form of criminal Naziism preventing “Medicaid patients from receiving legitimate treatment” There were also multiple ad hominem attacks tossed at Gov. Rick Scott for taking steps to shore up the state’s budget. Want a couple of easy ways to solve this problem? Get rid of the rationing. All it will do is incite people whose services may be rationed. Change must come from within. First, publish the names (pictures?) of the top 50 ED users each month/each quarter/each year in the newspapers and on websites throughout the state. Announce that this list will be published in advance so patients are given fair notice. Don’t have to publish any medical data or the hospitals involved – just publish the number of visits the patient made and the costs involved in providing care for each patient. Post the lists in the waiting rooms of the hospital emergency departments. If the public is paying for the care of these individuals, the public has a right to know who is receiving the public’s money. Sunlight is the best disinfectant. Then, require mandatory co-pays for all emergency department visits … regardless of the medical problem … regardless of the urgency. Other patients don’t get free health care just because they’re having an emergency. Why should we create a privileged class of patients who receive all their medical care at no cost? Everyone should pay something for their medical care. Non-urgent cases still pay a co-pay, receive a screening exam and then must be discharged to a federal health clinic for follow up care. Not enough federal health clinics? That’s not in a patient’s best interests. The federal government is violating the Social Security Act. If the patient doesn’t have money for the co-pay, deduct the costs of the copay from any future forms of government assistance that the patient may obtain each month. Controversial? Sure. Effective? Absolutely. If you don’t agree with me, give me some better ideas on how to ...

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Cardiologists are Causing Patients to Get CANCER

It’s true. Cardiologists routinely perform angiograms on patients who have no heart disease whatsoever. As shown in this Harvard newsletter, each angiogram exposes the patients to about 7 mSv of radiation. Add in the myocardial perfusion imaging at another 25 mSv of radiation and you have enough radiation to cause cancer in an otherwise healthy individual. And cardiologists ROUTINELY subject patients with normal coronary arteries to this dangerous testing … as can clearly be seen by all of the normal angiogram results. Not only does this type of wasteful testing line the pockets of the cardiologists who order, perform, and interpret the tests, but it is dangerous to the patients and can lead to many types of cancer in the patients that the cardiologists are supposed to be helping. In fact, Dr. Rita Redberg could personally be responsible for multiple cancer deaths due to radiation from angiograms she has recommended on patients with normal coronary arteries throughout her career. Fortunately, we can reduce the rate of medical imaging by simply avoiding unnecessary scans on patients with normal coronary arteries and minimizing the radiation from appropriate testing. Practices such as performing angiograms on patients with normal coronary arteries, for which there is little or no evidence of benefit, should be eliminated. Wait. Did I hear some cardiologists objecting? Cursing my name? What’s that, you say? There’s no evidence for the allegations I’m making? They’re preposterous? Yeah, you’re probably right. But it’s interesting because the last paragraph parroted the assertions that a troll of a colleague of yours made while discussing emergency physicians in the New York Times. In her diatribe, Dr. Rita Redberg stated Fortunately, we can reduce the rate of medical imaging by simply avoiding unnecessary scans and minimizing the radiation from appropriate ones. For example, emergency room physicians routinely order multiple CT scans even before meeting a patient. Such practices, for which there is little or no evidence of benefit, should be eliminated. No basis for her statements. No scientific evidence. Just some cheapshot about emergency medical care that she obviously knows little or nothing about. This type of statement should seriously draw into question any of the other statements of scientific “fact” that Dr. Redberg makes. And if the cardiologists and the American College of Cardiology are outraged by the unsubstantiated assertions in this post but don’t take issue with Dr. Redberg’s New York Times misstatements, then they are just as dishonest and misinformed as Dr. Redberg.

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