Links to analysis of socialized medicine and how the government currently increases the cost of medicine:

1. How even charitable hospitals take advantage of lack of competition

2. Reasoned analysis of Canadian system's quality and cost. (If it's so great why are there Canadians in my waiting room begging me not to send them back there for their heart care? Why do my patients who go there for work or education get horrible management of their anti-coagulation and other critical cardiac issues?)

3. Outstanding and well researched analysis of implications of socialized medicine in particular and Obamacare in particular from the Heritage Foundation.

Their line by line analysis of President Obama's statements are well reasoned and accurate. If you don't agree with their politics, attack the facts (if you can) but do not attack the messenger. One summary document in particular elaborates on some themes similar to mine below; health care reform must look at the foolish unintended consequences of government meddling.


4. An example of a highly successful, cost-effective locally led and run program for the uninsured poor. I participate in the this program, as do thousands of physicians around the country.

Our practice alone has given hundred's of thousands worth of high-quality, timely health care to the poor and the uninsured over the years. Before you criticize "rich doctors" I want to hear how much charity YOU give away every year.

Local initiatives are always more cost effective. When your money takes a trip to Washington, it feeds a thousand leeches along the way there and back.

5. Look up some of the financials on hospitals and local health care organizations buying up physician practices.

Surprise! The productivity plummets when docs no longer work for themselves. As these organizations wax and wane in their enthusiasm for "owning" the doctors, they try ever more complex contractual schemes to try to hold up productivity. Ultimately, behind closed doors, they have to decide whether eating the cost of less productive physicians is worth the financial incentive of controlling the referrals the doctors make.

That's right . . .when you hear that Hospital General of your town is "buying" physician practices, what they want to do is control the physician's referral and practice patterns. They tell the doctors that all insured patients must be referred to them . . . and usually find ways of discouraging physician patient communication about expensive less covered services.

The hospitals also raise charges from these practices to Medicare/Medicaid because they can pretend in some instances that these were "hospital based" services. The Inspector General caught onto this in the late 1990's.

It's hard to find good journalistic effort on this topic, because the contracts and the implications of these contracts are so hush, hush. Every honest doc knows what is going on behind the scenes, however.

One mentor from my training, who had disagreeable (to me) politics but good personal ethics earned my eternal respect. A heavy-handed financial negotiator with our University Hospital demanded that a particular list of expensive treatments be "off limits" to physician patient dialog, unless, of course, the patient brought up the topic first.

He replied that the only way they would ever limit the dialog between him and his patients was "if you put a bullet between my eyes."

Again . . .when you walk in the room and shut the door with your physician, you want to be sure that he is your servant. It's your body. It's your life. It your family's financial well-being. He should by all rights be your servant.


I could sit here all day and provide a thousand more links. The answers to maintaining the best while averting the worst in health care are going to be more complex and require more maturity than "Let the federal government do it."

Gubmint health care - come and get it!

The sign in the post below would have been much more appropriate for a post about government-run health care.

I've been fascinated with how our country seems to be scared silly into plans to spend more than we make in a decade on a variety of schemes to increase the size, power, intrusiveness and inefficiency of our federal government. WTF?!

I would refer anyone in the U.S. to some helpful sites that give a clearer picture of bureaucratic health care. If you think that you are going to get anything near the current level of innovation, competition, thoroughness, access to and timeliness of care with a one-payer system, you must be smoking crack.

Don't send me a sob story; I didn't say our system is perfect. I said it is better than government run care. There is a difference between those positions.

If you want cheaper and more accessible care, why don't we consider some of the initiatives that actually restore competition to the marketplace and that reduce unnecessary cost:

Competition among health care providers
Recent stories in WSJ show how even "charitable" hospitals dramatically raise their prices and cut more burdensome services the minute they drive their competition out of town. The government often fosters "one hospital towns" unintentionally by reducing and restricting normal healthy competition.

Doctors too tend to work harder when they know that they have competitors. This is a fact of human behaviour. When I am contemplating whether I will work in that worried new patient on my lunch hour, the fact that there are several other cardiology groups in the area always tempers my enthusiasm for lunch. The family who says "Thank you for getting my husband in on such short notice! We were so worried after that ER visit last night" becomes a group of very loyal customers.

If I were the only game in town, well . . . I like lunch. I'm only human.

A single payer system becomes a noncompetitive system. The government can never create the kind of competition that fosters good service. The free market is just too complex and the government is just too beholden to politically correct interests.

We all know this is true if we only think about the other areas in which the governement has free rein. Why does the military, after all these years of weapons experience, still buy its innovations from the private sector. Conformity trumps innovation.

Why did my daughter's school, reeling from budget cuts, fire the young teacher good at mainstreaming and retain a old embittered teacher who is terrible at her job in that particular topic? Tenure trumps competence.

Why do the workers in the IRS, DMV and city hall feel so perfectly comfortable being rude and dissmissive? I've had enough experiences with these kind of agencies to know that the people who work for them do not think that I pay their salary. They know that the beaurocracy is their boss and that they are the only game in town.

Choice and competition in health insurance:
States that have legislatures deeply involved in mandating what kind of policies an insurance company can offer (i.e. it is illegal to offer health insurance in many states that does not cover chiropractor or massage or other atypical therapy services) end up causing reduction in number and increase in cost of policies available to their citizens.

Why can I not decide whether I want just preventative and catastrophic care, and whether I think I would rather pay out of my pocket for say, acupuncture and back massage? The end result of the heavy lobbying by these alternative health and other health care interests is abuse of the system that is costly for the average person.

Why do you think so many trial attorneys send their auto accident victims off to a loooooong course of chiropractic? The ultimate "award" in their case is affected by the "medical costs," which are allowed to include excessive trips to the chiropractor. By mandating that your insurance covers this, your state government is complicit in assisting this scam. If you could chose a policy that does not cover services that you reasonably want, you could have more insurance options and competition.

Medical malpractice patterns:
States with high awards and numbers of law suits against physicians lose physicians. Period. The end. The data are clear. If your state allows a John Edwards to sue OBs for their undesirable outcomes (funny, I thought my handicapped daughter was a human being not "an undesirable outcome") then your state will lose OB docs. Ditto for cancer, orthopedic surgeons and neurosurgeons.

The only ones your state won't lose is incompetents supported by the government. They never go away and never seem to be shamed by the errors of their ways. True story, an acquaintance of mine is in medical mal defence work. Has FMG client docs who have repeated been sued for things like failing to refer a woman with a new breast lump for biopsy. Repeatedly. They don't get sued out of business in general. They just continue to do the same things the same way.

And while I have great respect for many of the VA doctors who are truly healers, educators and researchers, there are still swarms of lazy incompetents who work for the VA and, for that matter for many of the federally supported programs in local low income clinics. I hear an appalling story about one of the these losers every week or two.

The worst doctors cannot make it in a private situation where your reputation is everything and where you must please and serve the patient. They slide down to the level of a fixed salary and wait there like the bottom feeders they are.

Do you really want a system that rewards the lazy and the arrogant with a fixed salary and fixed hours? Doctors are absolutely no different that other human beings. We work harder, try harder and are nicer when we have more at stake and more to gain. The last rounder week in the hospital, I worked 88 hours. I started rounds at 4 am and did not finish until late at night. I had many patients who wanted to be seen by me and I did everything in my power to get people seen and set up with a plan acceptable to them as quickly as possible.

I am telling you right now, if the government becomes my boss I will never work that hard. If I have to click a bunch of stupid boxes in a computer to satisfy my high-school educated overseer (Did you educate the patient about seat belt use? About using a condom? About smoking?) then I may lose the will to work this hard at being a great cardiologist.

I have worked for the government before and would grieve to see my entire profession usurped by any government, including the current one.

I'm a smart person and know how to make a living. I will survive and make a living at something. It may not be medicine if we stay on this course. I believe that practicing medicine is noble, provided that when you go in the room with the patient and shut the door, you are the patient's servant and not the government's.

Ramblin'

Completely unrelated rambling observations:

*I get resident evaluation forms on residents I can barely remember. Do you really think you can show up on my service a few times for half a day, work up one patient, disappear for hours at a time and then, 6 months later, get an evaluation that justifies your cardiology credit? My residency cardiology rotation was a 6 am to 6 pm gruelling marathon in which I had to know the diagnosis, EKG findings, medications and relevant labs for every single patient on a telemetry monitor in any ward of the hospital.

Currently the rules seem to be so biased against "overwork" that it's impossible to give the residents a teaching rotation. I have trouble circumventing the "rules" enough to get our residents just to work up and follow a couple of patients. They behave as if it is way too much trouble for them even to know the medications that their 2 inpatients are taking.

They have a host of mandatory conferences, meetings and clinics outside of this rotation, and still disappear for much longer than these events are supposed to take. They disappear on rounds to make personal phone calls and socialize. I told one of the last residents to work with me, "I can't keep calling you to come and catch up with me. At least stay with me on rounds. If I look over my shoulder and you're gone again, you flunk this rotation."

Sigh.

I hate to be one of those attendings who says "When I was a resident . . ." But . . .whatever . . . when I was a resident you had to hustle. You presented in conference. You stayed around to see what happened to patients. You got a more complete picture of disease processes and how things presented and progressed. You felt responsible for your patient's outcome.

Our residency programs do not instill any confidence in me. If and when my family needs care, I don't want that care coming from the locally trained. Isn't that a terrible admission?

Maybe I'll start with a new strategy. On day one I'll tell the resident, "Your grade is a fail on this rotation. Now show me what you think you need to do to raise it to a pass."

*****

*Unrelated thought number 2: I just completed my IEP for my daughter. That's the "individual educational plan" for those of you unacquainted with the work of disability education. My daughter's teacher asked me where we saw my daughter in 3 or 4 years. The question really took me by surprise. When you are so ingrained with the business of childhood, school and so forth, you don't really picture the impending adulthood that is right around the corner.

I want her to work, of course. She has had dreams of different jobs just like any child without Down Syndrome would. She has wanted over the years to be everything from a restaurant hostess to artist, from grocery bagger to rock star. I not only think that work will give her life skills and a place to socialize, but dignity, independence and self-respect. I also think that everyone should do whatever they are able to do for their fellow man because it is immoral not to work. No one should have a free ride; do what it is that God gave you the ability to do.

You heard me: "It's immoral not to work." Unless you are so tragically ill that you can literally do nothing, it's a character flaw not to contribute to society. Can't do heavy lifting any more? Answer phones. Can't use your commercial license anymore? Get an office job. I don't believe that anyone was put here to make no contribution whatsoever. Sorry.

After her teacher and I discussed the various strategies, skills to be worked on and programs that help with work preparedness, we came up with a plan for my daughter's impending high school and work future.

Not too long after this IEP, I was sitting in clinic, where a very able bodied patient with extremely minimal cardiovascular disease and strong life-long aversion to work was trying to game me with some B.S. about his disability application.

Normally I would find such a such a clinic visit a real downer.

But today I couldn't help getting a chuckle out the contrast. I just returned from an IEP where we put an extensive plan in place to make sure my 90 lb. daughter with congenital heart disease and Down syndrome is able to work as many hours as possible and make a contribution to society, and here you are, sir, trying to get me to arrange some B.S. paperwork so you can suck off the system.

Dude, you are so in the wrong cardiologist's office today and you have no freaking idea!

*****

* Unrelated thought number 3: They say that doctors make the worst patients. Not true. Doctors' wives are the worst by a margin so far that it is not even funny.

News flash: Listening to your spouse tell war stories at the dinner table does not make you an expert is his field, let alone in medicine in general. No, I don't care that you were once a nurse or that you went to one of his conferences with him. Sorry, that just doesn't cut it.

Don't order studies on yourself, come into clinic with a high-fallutin' idea of your own diagnostic skills, treat yourself and then be mad that the studies and treatment weren't effective. I'm just sayin'. You had a fool for a patient all along.

What about doctors' husbands? I dunno. Mine pretty much does what he's told, but maybe that's why I married him in the first place. He has no illusion that listening to me bitch occasionally about echo reimbursement somehow makes him an expert on reading diagnostic studies. That's why I love him so much. His clue bag is extra full.

Despite the diatribe, we tend to be extra nice and extra diplomatic with the families of MDs. If nothing else, you did survive medical training and all those low-paid slave years with your spouse, and for that you do deserve some TLC.

*****

*Unrelated though number 4: I see so many fascinating cases, but always feel constrained when it comes to writing about them. It's hard to change the facts of some cases enough to hide the innocent (or guilty). I don't want to violate someone's privacy and I don't want to write about cases in ways that are misleading because of all the fact changing that had to go one.

Unfortunately that means that this blog really hasn't gone in the direction that I would like it to go. I tend toward general statements (Don't combine coumadin with antibiotics without proper supervision!) instead of specifics (You should have seen the completely appalling intracranial hemorrhage that I just saw!).

Some docs, like scalpel, Fat Doctor and urostream, have writing styles and case loads that get them around this problem. I still haven't found the proper voice to do that. Maybe, after a year of sporadic blogging, I never will.

Oh well, it's still a place to vent now and again. And for that I'm grateful.

photo credit: http://www.flickr.com/photos/riddle/219246833/sizes/m/

Coumadin and antibiotics - a recipe for disaster

The cooler weather is barely upon us and we are already getting our share of unnecessary coumadin bleeds. Patients receive an antibiotic, usually one that was not medically necessary, from a well-meaning urgent care or primary care doctor. Or sometimes the antibiotic was a spouse's or was left over from an unfinished prescription. Once a few days of antibiotics have been taken, the mischief begins. The INR (measurement of how thin the blood is) shoots to astronomical levels and the patient bleeds. Sometimes the patient bleeds from the nose or the urinary or GI tract and the bleed is obvious. Sometimes the patient bleeds internally, with the worst place of all being within or around the brain.

Antibiotics mess with blood coagulation and coumadin in so many ways that it is impossible to list them all. They can raise or lower the vitamin K producing bacteria of the gut, change the metabolism of coumadin or the production of coagulation factors by the liver or induce other problems that change your vitamin K levels, like diarrhea.

If you are on coumadin (warfarin) and are put on an antibiotic, make sure your anticoagulation clinic knows immediately. Get an extra protime-INR done within 2-3 days of starting the antibiotic and make sure the results of that test are followed up immediately.

You need to do this even if the well-meaning doctor, PA or ARNP giving you the antibiotic tells you that you don't need to do it.

And for heavens sake, don't be one of those fools who takes antibiotics for viral self-limited illnesses. A hemorrhagic stroke with brain damage is so infinitely worse than the possibility that your viral bronchitis will turn bacterial.

Multivitamins Do Not Reduce Risk for Lung Cancer, and Vitamin E May Raise It

From the March 1 issue of the American Journal of Respiratory and Critical Care Medicine via Medscape.com:

"Vitamin pills are widely used with the idea that supplementing our diet with extra vitamins must be a good thing," comments Tim Byers, MD, MPH, from the University of Colorado in Aurora, Colorado, in an accompanying editorial. "However, almost every time we take a hard look at objective evidence regarding nutritional supplements, the balance tips away from benefit and toward harm."

"Over the past two decades, we have been repeatedly disappointed in the ability of vitamin supplements to reduce risk for cancers at several sites, including the stomach, colorectum, breast, and lung. Foods that are rich in vitamins seem to be associated with a reduced risk of cancer, but vitamins packaged as pills clearly do not have the same effect," Dr. Byers writes.

A diet full of whole healthy foods - beneficial.

Popping a handful of vitamins/supplements extracted from the diet - harmful?

Again - there is so much we don't know about disease processes, diet and nutrition. Arbitrarily labelling one thing "natural" and being willing to take it in pill form, while refusing to take something that has been shown to have mortality and morbidity benefit because it is somehow "unnatural," is foolish in my opinion.

How could a beneficial effect of consuming fruits be consistent with an adverse effect of a nutrient that is derived in a large part from that same food group?" Dr. Byers asks. The likely answer is that "processes involved in biologic systems end up being far more complex than we had previously thought. Fruits contain not only vitamins but also many hundreds of other phytochemical compounds whose functions are not well understood."

Mother Nature does not love you

I've had about my umpteenth discussion with someone who has life-threatening heart disease and only wants to do something "natural" for it. While I'm all for those natural things that reduce disease, such as healthier diet and exercise, the idea that things you have arbitrarily labelled "natural," somehow are better for any given problem is really quite silly. For the most resistant to reason, I think that this is basically a religion.

This is a PSA for folks who think that mother nature loves them:

The most natural thing to do when you have heart failure is to die.

Historical controls and older studies of heart failure tell us that it has a worse prognosis than most cancers, that most people with it who do not take some form of current therapy will be dead within 5 years. In some early heart failure studies, 60% were dead within 3 years. Those who were untreated also had serious loss of function and discomfort as they basically drowned in their own fluids.

Mother Nature Adherents: Let's back up and have a little paradigm shift, shall we?

According to epidemiologists, the most common cause of death throughout human history is dehydration, most often due to dysentery. Diarrhea has killed more children than all the wars and other childhood diseases put together. Dehydration and its sister diseases, bleeding and sepsis, have killed more adults than all the wars, wild animals, volcanoes, earthquakes, tsunamis and hurricanes put together. Mother nature (speaking teleological now) cannot outfit us to avoid all our predators, but she has outfitted us to evade as best as possible a fall in perfusion to our tissues due to low blood volume due to dehydration, bleeding or infection. Many of our neuroendocrine systems are devoted to springing into action when you have one of these problems.

Therefore, when your perfusion falls, even when it is due to a bad heart pump, your body turns on all those wonderful neuroendocrine mechanisms that have helped young (and still reproduction-worthy) people survive dehydration.

These mechanisms may ensure your survival if you are 12 and have diarrhea. They may buy you time if you are 17 and have lost a moderate amount of blood. They may get you through a severe infection with SIRS (early sepsis-like features) when you are 22.

And they will ultimately kill you if you are a 50 year old with heart failure. Because you don't have low perfusion due to dehydration. You have a lousy pump. But since you are very sick and unlikely to ever reproduce in this setting, Mother Nature is not going to return your calls. She is done with you. She is a disinterested and dispassionate goddess. She has 5 billion more similar to you and she ultimately will love (and pass on the survival gear) of the ones that reproduce. Since that has never in human history included to any significant degree those who, for example, have survived a massive myocardial infarction, she's really not that interested in you anymore.

She has not outfitted you to meet this challenge for more than a few weeks or months. The stress hormones that are raging through your system in response to the stress of a failing heart include beta-adrenergic agents, angiotensin, renin, cytokines and other inflammatory proteins. They induce fluid retention, adversely effect remodeling of the heart muscle and of the blood vessel walls, increase stress upon the already dying heart and ultimately speed along a process called apoptosis.

Apoptosis is programmed cell death. Cells that are sick commit suicide, presumably to make room and save energy for the remaining "healthy cells." If your heart if full of sick cells and you have already loss a critical amount of heart muscle, however, apoptosis is the way that you lose what little you have left.

Wear a crystal, grind a herb and chant at the moon if it helps you to feel better.

But if you want to get better, then please take you heart failure regimen.

And if you plan on continuing to worship Mother Nature, please do not hold your breath waiting for her to climb up on a cross and die for your sins. Not gonna' happen . . . .

John Ritter case

I wanted to write a bit about the Ritter case - but Movin' Meat beat me to it and I don't think there is anything I could add to his incisive analysis or to the comments that follow: http://allbleedingstops.blogspot.com/2008/02/malpractice-and-john-ritter.html

Aortic disease, as I've said before, is a sneaky bastard. Aortic dissection with dissection into the coronaries is highly lethal under the very best of circumstances.

Ritter was a talented actor who died too young.

Tragic. Sad. But malpractice? I doubt it. Every cardiologist in North America is thinking "Thank God it wasn't me on call for that one."