tag:blogger.com,1999:blog-30499448.post4206310844673689087..comments2024-02-18T13:53:30.168-08:00Comments on Surgeonsblog: Spendtacular SurgerySid Schwabhttp://www.blogger.com/profile/14182853083503404098noreply@blogger.comBlogger30125tag:blogger.com,1999:blog-30499448.post-28778719051300842542008-03-27T11:17:00.000-07:002008-03-27T11:17:00.000-07:00Under the umbrella of research, does this surgery ...Under the umbrella of research, does this surgery lend itself to innovations in medicine (perhaps ones that may ultimately one day save resources)?JPhttps://www.blogger.com/profile/12023875555959570250noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-27601058715797091482008-03-27T10:57:00.000-07:002008-03-27T10:57:00.000-07:00It's a shame that the government doesn't fund medi...It's a shame that the government doesn't fund medical research more liberally. I'm sure many commonplace operations that the public takes for granted today were initially considered "heroic" or cutting edge, and very costly, at the time.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-2180917238614467602008-03-27T10:08:00.000-07:002008-03-27T10:08:00.000-07:00i see my comment strikes a chord... Apperantly, we...i see my comment strikes a chord... Apperantly, we (collectively) only think certain measures is a waste of money, if we/people we know, don't have the disease. I apologize for the comment, did not mean to stir up such an emotional response.<BR/>Although, it really goes to show that nobody has any place to determine/judge what is proper/not proper, heroic/not heroic.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-80745824792251235622008-03-26T22:01:00.000-07:002008-03-26T22:01:00.000-07:00Good air in, bad air out. Is that all? Why are t...Good air in, bad air out. Is that all? Why are there 5 forms of idiopathic pulmonary fibrosis? My apologies I don't mean to whine it just seems odd that I need to learn this and we get absolutely no education on anything that is being discussed in this post. By that I mean rationing, health care financing, Medicare reimbursement etc.<BR/><BR/>AND<BR/><BR/>Thanks for the kind words and the phenomenal book. I read it when I started medical school/started reading this blogUnknownhttps://www.blogger.com/profile/04303016383746363456noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-35294189118286730692008-03-26T21:46:00.000-07:002008-03-26T21:46:00.000-07:00chris: well said and provocative. And all you need...chris: well said and provocative. And all you need to know about the lungs is "good air in, bad air out."Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-73994159928271329632008-03-26T21:22:00.000-07:002008-03-26T21:22:00.000-07:00It may be a stark opinion, but I do not believe th...It may be a stark opinion, but I do not believe the health care debate or rationing will be dealt with until politicians have absolutely no choice(IE when the Medicare trust funds go bankrupt in the next couple decades). Why solve a problem for the people who did not elect me(IE the 10-30year olds of today)? It really is no different than insurers who ignore preventative medicine savings because almost certainly the patient will be differently insured 20years later when the cost/medical loss of a myocardial infarction is incurred. Medicare was a gift to those who first received it in the late 1960s. They didn't pay a dime into it and received all the perks. When the pleurality of the voting population is over 60 and has paid into the medicare system for 40 years the story will be different. There will be an expectation of care. <BR/><BR/>My guess is in order to maintain the benefits they will "use democracy" to mandate coverage levels similar to that seen by today's Medicare. To future politicians, good luck getting elected on an issue like cutting health care spending when the AARP or equivalent runs the show. David Walker, the recently resigned Comptroller of the United States, puts it best in his bipartisan lectures. Here is a link to one: Page 10 is the most fascinating in my opinion.<BR/><BR/>http://www.gao.gov/cghome/d08524cg.pdf<BR/><BR/>In short, the underfunding of Medicare is roughly 50 Trillion dollars or $450,000 per household. At current estimates the Medicare burden is 90% of America’s total net worth. And this estimate includes a laughable 40% cut in physician reimbursement that cannot happen if the government expects doctors to keep seeing Medicare patients. The congress is currently unwilling to touch this issue and all 3 presidential candidates claim fiscal seriousness. However, Obama and Clinton's healthcare plans(if they can really be called such) expect to save $50Trillion by expanding individual coverage to the federal books. Disease management, administrative savings, and evidence based medicine may relieve some of the fiscal damage, but the resulting costs on my generation(I'm a 23 year old medical student)are not acceptable. Universal healthcare is a laudable goal, but I require candidates to “Show me the money” before I sign off on any of it. If the candidates want to be taken seriously on matters of Federal fiscal policy 3 things matter: Medicare, Defense Spending, and EVERYTHING else. More importantly, they matter in that order. <BR/><BR/>Although my opinion means little in the current debate, if I were in a position of influence a mighty axe would be wrought into medical spending. Starting with procedures like the ones mentioned above by Dr. Schwab and the commentators. To believe the costs of the mega-procedure are not passed on to other patients is naïve. And 3 livers are you kidding? At my institution each of those transplants runs over $200k(I forget the exact number Dr. Busittil presented) a piece. $200k on one probably forgone patient may be acceptable, but X 3 it is ludicrous. <BR/><BR/>Wow I just ranted my way out of 20 minutes of studying the lungs :PUnknownhttps://www.blogger.com/profile/04303016383746363456noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-68482868714885215562008-03-26T20:13:00.000-07:002008-03-26T20:13:00.000-07:00anonymous: I assume, because you were diagnosed so...anonymous: I assume, because you were diagnosed so young, you've been evaluated for such things as vascular anomalies in the kidney?Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-71894982358555664952008-03-26T18:08:00.000-07:002008-03-26T18:08:00.000-07:00Im trying to understand this poster who think peop...Im trying to understand this poster who think people with high blood pressure should not be given medication calling it a waste of effort. I also want to know how I caused my HBP?<BR/><BR/>I have literally had it since I was a kid. First diagnosed when I was about 17 years old. Still in school, very active, not overweight. The only reason the doctor started checking it was because of daily nose bleeds. At age 19, many years ago, was when I first went on medication. Back then we didn't really have the good meds for it that we have today. This was back in the early 70s. I was on lasix for years. Now, I take 4 different meds daily. My mother also had HBP for as long as I can remember as did both of her parents. My grandmother and mother both were about 4ft 11in tall and weighed usually less than 100 pounds, so I dont understand this thinking that it is caused by our behavior. What behavior? What was I doing at age 17 that caused me to have horrible nose bleeds and a lifetime battle with HBP? <BR/><BR/>Why is it easier to blame patients for their illnesses than to just treat them?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-72166094442720577132008-03-26T17:18:00.000-07:002008-03-26T17:18:00.000-07:00Sciencekid,I agree that rationing of health care b...Sciencekid,<BR/><BR/>I agree that rationing of health care based on the financial and personnel constraints of the healthcare system as well as the patient's likelihood of survival, is needed. However, I don't believe that health practitioners should be in a position of making decisions about care based on whether we believe the patients are responsible for their illness. <BR/><BR/>Taking your example of not spending money on people with hypertension (and I hope i am not misrepresenting you here). . I think that if a treatment is deemed not financially viable to control this, then it should not be provided through government subsidy (Im assuming this is how it works in the USA). <BR/><BR/>However, I don't believe we should not be able to withold medications based on whether a patient has hypertension/atherosclerosis because they have eaten too much fried food compared to if they have familial hypercholesterolaemia.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-46677530017484924732008-03-26T15:06:00.000-07:002008-03-26T15:06:00.000-07:00I think these heroic measures are sometimes needed...I think these heroic measures are sometimes needed, abstractly speaking. Just to know how far we can push the medicine frontier. I am opposed however to have these kinds of surgeries to be common practice. I also somehow opposed to giving 20 plus meds for people that has metabolic syndrome/CHF/HTN, etc etc, unless they can pay fully on their own. I think the money spent on this surgery is too high, but if we think about it, spending medicare/aid money on people with metabolic syndrome/CHF/HTN/drug addicts etc, etc is also waste of money.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-57280996585692201382008-03-26T14:42:00.000-07:002008-03-26T14:42:00.000-07:00There are studies which demonstrate that across cu...There are studies which demonstrate that across cultures, we exhibit higher rates of compassion and will donate at higher rates when a single person is observed to be in need. The rates of demonstrable compassion and offers of assistance go down as the population in need rises.<BR/><BR/>This seems somewhat counterintuitive, doesn't it?<BR/><BR/>But with a single person, we attach emotional identification, and with a group, that emotional attachment is diminished by its increasing abstract qualities. We still "think globally while acting locally".<BR/><BR/>If this woman's plight had been presented as representative of a group's situation and assistance with financing targeted for the group, I expect that the expressions of sympathy and affiliative/identification statements wouldn't have been as strong.<BR/><BR/>Some of our compassion is still very much rooted in the ability to self-identify. So the more "real" the person's experience is, the likelier we are to offer help and to "support the cause".<BR/><BR/>It's a major reason that community and public health initiatives are so difficult to garner enthusiastic and widespread support. Ditto preventive health initiatives. The need can only be imagined - can't see what has been prevented, and so, more difficult to perceive, to identify with,and to emotionally invest.<BR/><BR/>One related point - cases such as this one are heroic in investment and in "life saving". It's much sexier to join up and support something that "saves a life" instead of investing in a water treatment plant or in diesel exhaust emissions reductions, no?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-76288040422423297952008-03-26T12:46:00.000-07:002008-03-26T12:46:00.000-07:00My mother-in-law has a leiomyosarcoma, the same ty...My mother-in-law has a leiomyosarcoma, the same type as this woman, and hers is also in what we have been told is an inoperable spot. I love my MIL, but when it's gotten to that point, it's gotten to that point, and there is a time for putting fear aside and simply facing the fact squarely that each of us is given a life, and then it ends. The blessing of cancer is having and treasuring the time to make memories and to tell your loved ones you love them. You get a chance to say goodbye.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-30232248533716902912008-03-26T12:14:00.000-07:002008-03-26T12:14:00.000-07:00Dr S, your point is correct. I wasn't adequately a...Dr S, your point is correct. I wasn't adequately addressing the specific situation of a mega-operation like this, but rather just the general idea of whether there should be any consideration at all of willingness/ability to pay as a criterion for triaging any form of medical rationing.<BR/><BR/>The only way to extend that example to THIS particular case is if the patient consuming the resources for this 10-unit mega-operation comes up with funding to cover the costs of 11 or 12 procedures. I know that is far-fetched, but I trust you get the point :)IVF-MDhttps://www.blogger.com/profile/15278457522408272479noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-58551635055291991792008-03-26T11:57:00.000-07:002008-03-26T11:57:00.000-07:00IVF: unless I'm missing your point, it seems -- wh...IVF: unless I'm missing your point, it seems -- while true (the workforce) -- to be off point. In terms of what I was saying, it's more like this: what if there are resources for 100 operation "equivalents." Since resources are limited and finite, that makes sense. So then what if one person's operation is so extensive that it uses up, say, 10 equivalents. Then only 91 people get an operation. That is a more realistic scenario, at least in terms of the questions I think I was raising.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-40535471904148170852008-03-26T11:34:00.000-07:002008-03-26T11:34:00.000-07:00Consider this scenario.What if there are enough re...Consider this scenario.<BR/><BR/>What if there are enough resources / manpower / facilities etc to provide procedures for 100 people?<BR/><BR/>So the priority list is made, as determined by whatever triage criteria are set, irrespective of ability to pay, of course.<BR/><BR/>The fortunate 100 people get "saved". Person #101 is out of luck.<BR/><BR/>Now, what if person #101 saves up enough money to fund 3 additional procedures? So by allowing him to get the procedure, he and two additional patients get saved, thereby allowing three more people (counting himself)to derive benefit? Is that wrong?<BR/><BR/>I realize rarely is it that clearly defined, but it is true that those who contribute most to the workforce are the ones who are funding the original 100 procedures to begin with. Without the workforce, then nobody gets saved.<BR/><BR/>Bear in mind that the great prosperity achieved during the past 100 years was due in great part to a system where those who work hardest and contribute the most are motivated to so by the chance to derive proportional compensation and self-benefit.IVF-MDhttps://www.blogger.com/profile/15278457522408272479noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-5810598235975142012008-03-26T09:48:00.000-07:002008-03-26T09:48:00.000-07:00I agree with the poster who says that rationing is...I agree with the poster who says that rationing is necessary and that it has to be across the board - not dependent on whether you can pay or not. <BR/><BR/>I do not believe that Americans will accept it if it isn't pay-ability independent, and I don't think it would be right either.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-2706792712945254012008-03-26T08:33:00.001-07:002008-03-26T08:33:00.001-07:00Another intriging and excellent post. In today's ...Another intriging and excellent post. In today's Chicago Tribune, there was an article about when Medicare & SS going bankrupt, with more outgo than income. (I've already tossed the paper, as I read in on the train). We (as in humans, Americans in particular) have to get over this incredibly selfish notion of saving at all costs. The Catholic church helps to perpetuate this. <BR/>I especially appreciate webhill's comments. My previous dog had bladder cancer. I was provided with the option of giving her chemo. Taking the financials out of the picture, I could not put her through that, so I could selfishly have more time with her.<BR/>Yes, I know, a dog is not a human. But why do we insist on utilizing "heroic" measures (a misnomer if ever there was one) to extend existence. I call it existence, but it usually isn't living. I watched my cousins do that to their father with stage 4 esophogeal cancer. The last few months of his existence were miserable. The mostly ignored medical advice, and was provided paliative care. They weren't doing it for him. They were doing it for themselves. Even before this, I've made certain that people know, that I NEVER want to be in similar circumstances.<BR/>These aren't easy issues and decisions to grapple with. I don't mean to suggest otherwise. But these kinds of discussions need to be had with our loved ones while we're healthy.gay CME guyhttps://www.blogger.com/profile/05817474200268605557noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-83031905369523346872008-03-26T08:33:00.000-07:002008-03-26T08:33:00.000-07:00anonymous: going overseas for transplant is not so...anonymous: going overseas for transplant is not something I've heard much about; off the top of my head, the issues that come to mind are the ethics of "buying" organs and, by implication, facilitating the coercive selling of them. Of course that may or may not be the case every time. But given the waiting lists here, I'd guess that if one can go overseas and get an organ in less time, some shady dealings might be going on.<BR/><BR/>It's another matter entirely, that of getting care on return. Most doctors, and surgeons particularly, don't much like the idea of managing other doctors' problems; that's particularly true when someone has gone elsewhere "on the cheap" and then expects care back home. As to being "entitled" to such care: I'd say if they chose to circumvent the system, there'd be no entitlement, and it'd be their responsibility to work things out, presumably ahead of time. Just one man's opinion...Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-15499718671457148622008-03-26T07:56:00.000-07:002008-03-26T07:56:00.000-07:00dr. sid, how do you feel about people going to for...dr. sid, how do you feel about people going to foreign countries for transplants that they don't qualify for in the u.s.? <BR/>if they pay for it completely themselves, is that okay? should they be entitled to transplant level follow up here?<BR/>thanks for your thoughts.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-73181041355555249742008-03-26T07:47:00.000-07:002008-03-26T07:47:00.000-07:00aj: that's an excellent question, and one about wh...aj: that's an excellent question, and one about which I can only conjecture from the cheap seats in the ballpark. Since it may well have been considered "experimental," the surgeons may not have been paid at all. If they were, I doubt there's any code for it, so they'd have gotten a fee that would reflect a very much lesser operation. Most hospitals charge an hourly rate for operating rooms. I suppose it varies but I'd guess it's now around 2K/hr, not including the equipment used which would be considerable. Anesthesia fees. Intensive care fees, floor care fees. There are unpredictable downstream costs: directly related to post-surgical issues and possible complications, and then, costs related to predicted (but not certain) recurrence. I'd guess the initial hospital charges, excluding professional fees, were at least $100K. But I was also thinking of resource management: the commitment of so many people and so many hours of high-demand and high-skill services such as OR, recovery room, ICU for one person with such a long-shot, as opposed to have them available to many other people with much better odds. Which is, of course, the most difficult calculation, philosophically, given the fact that money and beds are finite.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-32293444031667724642008-03-26T04:03:00.000-07:002008-03-26T04:03:00.000-07:00a good insight into a surgeons mind!!:)a good insight into a surgeons mind!!:)broca's areahttps://www.blogger.com/profile/10978879187404578908noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-73413807967708213242008-03-26T03:56:00.000-07:002008-03-26T03:56:00.000-07:00Dr Schwab,Out of curiosity, how much would you est...Dr Schwab,<BR/><BR/>Out of curiosity, how much would you estimate a surgery like this to cost the healthcare system?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-24120325843008016322008-03-25T23:36:00.000-07:002008-03-25T23:36:00.000-07:00There are too many variables and every situation s...There are too many variables and every situation so different that no body of law would ever be able to create a blanket law governing these types of situations. It would be such a vaguely written law that it would, almost, certainly be ineffective as most laws on the books are. You can't tell a hard working, blue collar, unisured, American that he is unable to have a, potentially, life-saving operation because of his inability to pay. Even if the surgery only has a chance of extending his life for a few years, most people would want to live that extra time, as long as it wasn't an extreme quality of life depreciation. <BR/><BR/>Personally, I would much rather pass away than live an extra few years with severe quality of life depreciation. I wouldn't want to be a burden on my family.<BR/><BR/>I think the biggest problems, financially, for the medical field have potential solutions if something would be done. Malpractice suit caps, illegal immigrant health care (Bill their country of origin, then once they are better, send them back. Probably wouldn't get paid though). I think we need to lower health care costs by fixing these types of problems rather than denying health care, no matter how ridiculous.<BR/><BR/>Sorry for the long rant.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-81382006055332985702008-03-25T19:59:00.000-07:002008-03-25T19:59:00.000-07:00I also think we need rationing, but that it needs ...I also think we need rationing, but that it needs to be across the board. There needs to be set guidelines, and not one set of rules for rich people and another set for those less fortunate. It becomes very easy to say, "yes, we need to not provide care for those who can't pay" when you know darn well, that statement will not ever effect you or your family, medstudentgod.<BR/><BR/>I dont see rationing as a bad thing at all, if it is done in a moralistic and ethical manner. Also, there needs to be better advocates to inform people of the importance of medical directives. I think when grandma is laying in the ER, or even her own bed, many times people claim to want everything done to save her, becuase in reality, they dont know what her wishes are. They are afraid of making a mistake or of being accused of being heartless.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-54516239917189800962008-03-25T15:58:00.000-07:002008-03-25T15:58:00.000-07:00I believe rationing care is necessary. Unless cert...I believe rationing care is necessary. Unless certain patients can pay, up front, for these heroic measures I don't feel they should be done. Like you said, it seems like this was done for spectacle and not much else. Far too often that's the ego talking of doctors who fail to do the best of the patient or society.<BR/><BR/>BTW: I just received your novel and have already poured through the first 5 chapters. Interesting reading I must say.MedStudentGod (MSG)https://www.blogger.com/profile/02670042423377931696noreply@blogger.com