Grand Rounds XXII
Welcome to Catallarchy, home of this week's Grand Rounds. This is the first time that the Rounds is being hosted by a blog not solely dedicated to medical topics. However, I am a fourth-year medical student preparing to enter pathology, and my co-blogger Jonathan Wilde is a resident in the Northeast. It is an honor to take part in the growing medical blogosphere's weekly gala.
If this is the first time you have visited this site, make yourselves comfortable, read our bios, and take a look at our "popular entries" on the right sidebar. We have a wonderful mix of writers here - people from many professional backgrounds, including medicine, engineering, economics, law, computer technology, and even private space tourism, not to mention a future seasteader.
While a unanimous point of view among us might be hard to pin down, we all share a belief in the virtues of the market process and the benefits of decentralized decision making. Though these views are in the minority among health care professionals, we believe that it is vital that they receive their fair hearing and hope to foster more discussion among our colleagues in the future. With that in my mind, I present the case for free market electronic medical records. Jonathan looks at the problems behind the current state of medicine and proposes some solutions.
Medical science is ruled by the expert. While nobody would argue with the efforts of said experts in defining the direction of medical care, one should not overlook the contributions of non-experts and complete outsiders.
The Medical Blogosphere would be wise to listen to patient stories out there in cyberspace. This can be a valuable tool for guaging some of the problems, both real and perceived, patients find with the state of care today. Glenn Reynolds, aka Instapundit, has been hospital-blogging during his wife's admission with cardiac problems. You can read about them here, here, here, here, here, and here. In this post, he makes the observation that a hospital isn't necessarily a place for rest:
We just spoke on the phone today and she sounded good -- except that the hospital routine is wearing her down with the constant sleep interruptions. They really do come in every couple of hours, and while some of the stuff makes some sense, I guess -- like checking temperature or even EKG -- they came in yesterday, and today, at about 5 AM to check her weight. Er, why not a couple of hours later?
Shrinkette offers a response to why this might be:
Glenn Reynolds posts about his wife's medical ordeal, and wonders why hospitalization itself must be so arduous (interrupted sleep, bad food, etc.). I wonder how many nurses and doctors will e-mail a response. I think hospitalization has become more difficult for inpatients, for a host of reasons: staffing shortages, increased severity and complexity of illnesses and treatments, and the pressure for shorter hospital stays. Inpatient treatment has become much more focused and intensive, and the patients are feeling it. (Staff feel it, too!)
He asks why his wife must be awakened at 5:00 AM to be weighed. It makes no sense to him. Weight is one of the more critical parameters for a heart patient (if his wife's heart is having trouble, a weight change will send a signal. And all those IV fluids that have been going in...what if they decide not to come out? Sick hearts, lungs, and kidneys can make that happen. You'll see it in the weight.) It has to be measured at the same time daily, and the results entered in the computer in time for morning rounds. It will be assessed with other measures of heart function and fluid balance for the preceding 24 hours.
Grunt Doc adds his thoughts.
This seems a good place where communication could be improved. Glenn and his wife are not the first patients to make this complaint - indeed, if they didn't, they may be in the minority. However, there are real reasons why most things are done in the hospital the way they are. While it may not be the patients' job to know these reasons, they should raise their concerns when they believe they should receive better care. The doctors and the hosptial staff should respond to these concerns, or offer satisfactory explanation as to the reasons why certain processes exist. Where intra-care communication is limited, these blog discussions between patient and doctor can help fill the void.
I was lying in the Intensive Care unit, lines running into various parts of my body, the ventilator blowing air into my lungs through the hole cut in my windpipe. My legs were bloated from over 2 gallons of intravenous fluids pumped into my body when my blood pressure dropped like a stone while in the middle of my scheduled angioplasty. My face and neck were so swollen I looked more like a pumpkin than the handsome guy I am used to looking at as I shave. Somehow I was still alive and through the one eye that could open I could see my wonderful wife as she held my hand.
Then I felt myself waking. It was all a nightmare from hell. Certainly the most vivid nightmare I had ever experienced. The relief started flooding through my body. Oh my beautiful God…..and then I really woke up and realized it was all true.
That’s at least six weeks at the wrong dose. It may have been four and a half months, if the previous prescription-plus-refills was written to the same strength. My life is lived on narrow margins at the best of times, and I’ve been on a half-dose of my medications. No wonder it’s taken forever to catch up after that round of the flu. No wonder everything’s been taking forever. No (emphatically unrepeatable) wonder.
…If I allowed myself to think about how much of my life has been eaten up by crap like this, I’d become unmanageably angry, and there’s those narrow margins again: I can’t afford it.
Andy Stedman of No Treason talks about his adventures all over the emergency room:
Of course, I can only guess how this experience would have been different in a free market for health care, but I can make educated guesses based on industries that are similar in some way but are less regulated.
Restaurants and tire stores, like emergency rooms, never really know how much business to expect. However, it is unusual to have to wait hours for a meal or new tires, whereas in emergency rooms it seems to be the norm to wait hours for treatment. They’re not full, either, they’re just woefully understaffed.
Pearls and Dreams makes the point that doctors, indeed professionals of all stripes, are only as good as their staff:
What I don't understand is this ...my doctor has no choice in who works in her office, she works in a clinic and her staff is assigned to her ... so why do hospitals and clinics put up with people like this who continually risk not only the doctor's reputations, but the health and wellbeing of the patient? When are the doctor's going to be given the autonomy to be the best doctor's they can be?
Josh Cohen shares some of his tribulations in trying to change his behaviors to become a healthier person and lose weight in the first of a three-part series:
So what’s the point? Good question. I haven’t really figured it out yet, but I think it’s this: I have a problem with personal inertia. My body is conspiring against me to keep me from doing something that it knows is healthy. Mentally I know that I need to dump at least one hundred pounds – even more would be great – and that going to the gym and eating healthier is the only way to do it. But I’m so used to eating only marginally-healthy foods and living a sedentary lifestyle that my body is fighting me every step of the way. It gets aches and pains. It tells the stomach to quake and rebel. It orders my subconscious to get so bored that I won’t stay on the elliptical as long as I should. It attacks my reasoning, making it more faulty than usual. And, worst of all, it makes me hungry about half an hour (or less) after I eat a healthy snack. I mean, who knew that a couple of cups of chopped carrots would make you hungrier than ever before your stomach has even started to send said carrots on to the intestines?
Shifting gears slightly, George Mason legal scholar Todd Zywicki recently testified at a senate hearing about bankruptcy reform. While there, he got to hear and respond to testimoney given by Elizabeth Warren, who made a splash with the medical world and others recently by publishing a study maintaining that 50% of all bankrupcies are due to medical bills and health problems. Dr. Zywicki claims the study is extremely faulty and does not show what the authors claim:
Let me emphasize--I do not deny that many bankruptcies are caused by health problems. This is why the bankrutpcy reform bill carves out several specific exceptions for treatment of health expenses and health insurance. In theory, the number may be as high as some now say, although as noted, the overwhelming number of studies fail to find anything approximating such a high number. But if it is true, that conclusion cannot be based on this article that is published in Health Affairs that got so much press last week and so much interest in the United States Senate. The statistical classification and methods are just too questionable to support that conclusion.
What we have now is expensive to administer, riddled with perverse incentives, and manifestly fails to provide families with protection from health-driven shocks. National health insurance would be even worse, sending our health care system into a downward spiral of inefficiency, shortages, rationing, and corruption.
The conventional wisdom is that the problem with health insurance in this country is that not enough people have it. However, the bankruptcy study shows that it is the conventional wisdom that is bankrupt. The insurance approach that uses cost reimbursement should be curtailed, not expanded. Instead, among all of the flawed systems from which we might choose, event-based insurance would be the best approach.
Economist Glen Whitman discusses the problems of requiring individuals to purchase health insurance.
Radley Balko discusses the recent trial and conviction of Virginia pain doc William Hurwitz. He includes the text of a letter from eight former presidents of the American Pain Society. The gentlemen take exception to the testimony, for the prosecution, given by recent president Michael Ashburn; in his testimoney, it appears that Dr. Ashburn made several materially false statements:
In the past, each of us perceived Dr. Ashburn as a respected colleague and his selection as an expert by the government as understandable. We are stunned by his testimony. As leaders in this field, we feel compelled to correct the errors in his testimony, lest it be used in the future in a manner that worsens the national tragedy of untreated pain. We will try to correct the public record after the trial concludes and sincerely hope that the government and the court will consider this information now.
If these criticisms are accurate (and appears to me that several of them are), there needs to be more outrage from the medical community. A doctor is losing his license, and probably going to prison, because of a zealous but impossible government effort to stop drug use everywhere. On top of that, it appears that the trial saw false testimoney and possible violation of due process. It is a disgrace.
Finally, Randall Parker posts about a study that suggests that estrogen becomes a vasoconstrictor in old age.
You'll have to excuse my childishness, but I couldn't pass up the opportunity to give the residents and attendings second billing. A small act of vengence for two years of torture at there hands. With no further ado: Dr. Tony leads off with his frustrations of the ER. Specifically, it doesn't give you the proper environment and amount of time to communicate meaningfully with the patient; and it wouldn't matter if you did because there is not the level of trust seen in a longer-term care relationship:
I know that if I don't write that 4 year old with a URI a prescription, his mother will take him to his local doc the next day and there is a better than even chance he will get one there. Guess who is wrong? That ER doc that you don't even know or the doc you purposely chose who has cared for your kid for 4 years?
I imagine that in some way, being an ER doc is like being a perpetual medical student. I enjoyed many of my clinic and primary care rotations, but I didn't get to experience the joy of caring for a person over time and becoming a part of their life. Not once. That, of course, isn't everything, but it is something that even the most hard-hearted of us can appreciate - and ER physicians never truly get that experience.
Madhouse Mad Man is not afraid to say what we all (or at least half of us) are afraid to say: it's uncomfortable for male physicians to care for young attractive females:
The physical exam becomes a torture of anxiety and all hell breaks loose in my head. "Touch there or don't? But I have to touch there, but will she think I have to touch there or not? Oh god. Need bag, h y p e r ve n t i l a t i n g, vision fading b l a c k.
Maria of Intueri discusses my single biggest problem in medical school: how to talk to a patient. They (med schools) fill you up with so much standardized patient practice and canned responses, you run the risk of forgetting to talk to a human being like a human being. Maria reads my mind:
“So how did that make you feel?”
Sometimes, I can’t believe what I say. I am about 45 to 50 days into my psychiatry training and sometimes, I am completely convinced that I am a puppet. Or that another voice has been dubbed over mine.
I feel like a fraud.
I hear myself saying things like
“We hope that you will learn more effective behaviors to help deal with these stresses in your life.”
Who says that?
The Cheerful Oncologist reminds us to be critical of how we write our own orders:
All one has to do to keep on top of medical orders is to visualize them being carried out and then ask, accompanied by a cartoonish shrug, "What could possibly go wrong?" By taking the time to answer this question, the doctor may prevent any bloopers or frustrating gaps in data collection from occurring.
Orac Knows reminds us that patients aren't room numbers. let me add that neither are patient diseases, annoying habits, or physical characteristics.
Grunt Doc passes along his letter from a patient who, thanks to medblogs, was more aware of symptoms of chest pain, and this knowledge led him to go to the ER. I say we mark this as the first data point in the inevitable study: "Are Patients Who Read Medical Blogs Healthier Than Patients Who Don't - A Randomized Controlled Clinical Trial."
Robert Klassen remembers how infection control used to be, and wonders if we may need to re-adopt some of those practices with the emergence of resistant bugs:
In order to enter an infected patient’s space, a person (even family) was required to put on a gown, gloves, mask, hat, and booties, and then walk across a mat saturated with a disinfectant. Upon emerging from the patient’s space, a person had to remove the all the protective gear, put it in a bag labeled "contaminated," walk across the mat again, and then wash hands in a basin of disinfectant. The procedure was time-consuming, annoying, expensive, and hard on the hands, but it worked.
...The things that vanished, around the time of the first Medicare financial crisis in the eighties, were the saturated mats and the basins of disinfectant. When I asked the infection control nurse why they were missing, she said they cost too much to maintain, and they weren’t necessary anyway. So that meant that the legions of nursing personnel and ancillary technicians can step in infected material in one patient’s room, and take it to another patient’s room, or to the neonatal intensive care unit, or to the cafeteria, or take it home on their shoes.
Dr. Maurice Bernstein discusses the ethics of "bedside rationing."
Dr. Charles encounters a patient suffering from panic attacks.
Parallel Universe, a blog from a Filipino physician, has a news release from a government operation that uncovered $5 million (P) of counterfeit medicines. I am interested to learn more about the regulatory structure of medicines in the Phillipines. I would think the best way to combat this is for undercover agents to buy medicines to be analyzed. Statistically, it would take a small sample to find counterfeiting pharmacists and manufacturers (where these parties would have to sell large quantities of fakes to make it profitable). This would likely cost less than some sort of government intervention or regulation for the purpose of prevention.
Mike Pechar of Interested Participant points to an occurence of rabies being transmitted through organ donation. This may certainly raise the volume of voices that call for wider screening of blood and organs for infectious disease. However, when one looks at the costs and benefits of preventing these diseases and the need for organ donation, it seems to me that any actions might exacerbate the organ shortage that currently exists.
As an aside, this is one of my favorite topics. I get in to occasional debates with my colleagues about views that there should be an open market for organs. They are frequently distressed to hear someone speak of organs as commodities - but that is precisely how they need to be viewed to alleviate the shortage. Regardless of how you feel about that, I think many of us could agree that there is a lack of a debate about the subject. It is one I would like to start.
Dr. Parker sends along two this week: a contoversial end-of-life family-doctor struggle at Mass. General, and a controversial doctor-doctor struggle over medical specialty proprietorship. In the latter he makes this statement:
Should we let any Tom, Dick, or Harriet perform any procedures they wish? The public already is critical of our ability to police ourselves and at the same time when we try to improve the quality of our product we are attacked as "monopolists".
I think Dr. Parker assumes too much when he claims that medical boards and licensure "improve[s] the quality of our product." There is a decent amount of literature out that concludes that such is not the case. This may or may not be true, but it is a purely empirical question and cannot simply be assumed. I recommend to everyone David Young's The Rule of Experts. It's a quick, interesting, and persuasive read.
From the "this will never go away department," more Cox-2 and FDA blogging: from Matthew Holt, who is afraid that this mess will keep necessary drugs from making it to market quickly enough; Medrants, who ponders what it will be like now that Vioxx is back on the market; and Chiisai Tokoro, who discusses the basic science of COX inhibition and the two types of enzymes.
I believe the COX-2 controversy has brought out the worst in everyone. Between doctors, insurers, lawyers, drug companies, medical journals, and the FDA, there is a never-ending supply of finger-pointing and ass-covering. Two things. 1) Patients need to take a little responsibiltiy in this. At the end of the day, we're the ones popping the pills, we're the ones who want the drugs cheap, and we're the ones who want to see the doctor for free. We have to accept the risks of putting any substance in our bodies, and we have to accept the consequences when we demand, both implicitly and explicitly, that our health care system be run in a way that invites the power-grabbing and flame-throwing that we have seen here. 2) It seems to me that the government, who is blamed for not doing enough to "protect us" from disease and bad medicine, should be blamed for doing too much and sowing the seeds for this whole mess. Of course what does everyone seem to want from this? Another government agency to do what was expected of the last agency to do. Fool me once...
Street Doc from Far From Perfect sends a link to this tool from the American Cancer Society:
...that will be of much use for those it was designed for - ER Physicians and Primary Care Providers. "C-Tools 2.0 is an innovative Personal Digital Assistant (PDA) software package that has been developed to help doctors and their staff prevent, diagnose and treat cancer." This is not a tool for oncologists, but for other providers to help diagnose and guide patients to the proper treatments and diagnoses.
Craig Bradley,one of the several contributors at Medgadgets, talks about medical lasers, an umbilical clamp "designed to decrease blood spray and thus retard the spread of AIDS in the third world", and gloves to prevent Xbox players from suffering burns due to overheated cords. I just found Medgadgets this week, but I think it's great. If this is your first exposure to it, stop by and check it out to see the future of medical technology.
Tales of and MD/PhD Student highlights the difference between the worlds of basic science and clinical medicine.
I'm thrilled that some of the medical blogging community has gotten this opportunity to see what this blog has to offer, and I hope that our regular readers have enjoyed their introduction to Grand Rounds. I encourage you to submit to other Grand Rounds in the future to bring an outside flavor to the festivities and conversations. I thank all those for their submission, suggestions, and kind words. Tune in next Tuesday at Intueri for week #23. Send your submissions to maria at intueri dot org.
Thanks to Nick Genes at Blogborygmi for all his work in getting Grand Rounds up and running, and for allowing us to host. Contact Nick (or, Dr. Genes, in just a few months) if you would like to host GR - there are open spots starting next month. Everyone, have a great week.
This post is dedicated to Kentucky native and one-of-a-kind writer Hunter S. Thompson, who tragically killed himself Monday. You can read "The Kentucky Derby Is Decadent and Depraved" here. No more fear and loathing.
Update: Follow-up here