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Showing posts from August, 2009

Toons

In a comment on my previous post, a series of slides is recommended. I like the cartoon above even better. In simplicity there can be great truths.

Retort

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Sooner or later, in any discussion of health care reform (to the extent that screaming and fear-mongering can be gotten past and actual thoughts exchanged), the issue of tort reform is raised. On that subject I'm of two or more minds. Neither a student of the various proposals nor particularly well-versed on the veracity of claims and counter claims about tortophobia adding to costs of medical care, I can only speak based on personal experience. Which is why I'm multi-minded. I've seen good and bad. I don't think I altered my practice style to avoid malpractice suits, but I can see why people would. The central issue is this: there's a difference between malpractice and adverse outcomes . Most certainly, the one leads to the other; but the other does not imply the one. Were that distinction properly made and encoded in the law, the rest of the issue would become moot. If malpractice suits were about bad care -- actual errors, poorly thought-out diagnoses or treatm

Grand Old Times

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Nice Grand Rounds up over at the resurrected Dr Charles . His balloon is on the rise again, even as the hot air leaks soundlessly out of mine. Dr Charles has always been one of the most lyrical of medical bloggers, and it's nice that he's rediscovered his muse.

Stupid

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Uuggggghhhhh. Sorry. I feel dirty, I need a shower, I may have to kill myself. Where are the death panels when you need them? So Jon Stewart interviewed Betsy McCaughey last night, on The Daily Show . She's the one credited with raising alarms about the dastardly implications in the health care bill regarding end of life counseling. "Death panels," evidently, wasn't her exact term. "Disgusting," is what she said she wrote in the margins when reading it. There was a point to which she kept returning (in between quite amazing dramatic gestures to the audience -- the kind when a stand-up comedian goes, "Am I right? Am I right? Huh? Huh?"). Medicare reimbursement is increasingly tied to performance standards, and it's an issue about which I've written a bit , and which, in its execution, is potentially problematic for all doctors. Nevertheless, her interpretation regarding end of life counseling was utterly, idiotically, cosmically ass b

Bureaucrats

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Among the many themes of dissent which have gained traction in the health care debate is the canard that we don't wont some government bureaucrat between us and our doctors . Funny thing about that: the only payer entity with which I never had a problem getting authorization for care was Medicare. Here's the sort betweenness I routinely encountered from private insurers: In the fine print of nearly every private plan are exclusions for "pre-existing conditions." Okay. You had breast cancer, now you can't get any insurance to cover issues related to it. Fair enough, right? Guy's gotta make a buck, right? I mean, it wasn't their fault you got it, right? But how about this: more than a couple of times I had patients with colon cancer who were denied coverage because of a previous history of.... hemorrhoids!! Yes. Hemorrhoids . Similarly, people who'd had, say, a rubber band placed for hemorrhoids -- a two minute, hundred buck outpatient procedure -- c

Death Panels

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Surprise! It's a Republican idea . .

One Small Step

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If anyone here reads Andrew Sullivan's blog, runs across this post , and finds anything familiar in the writing, there could be a reason... Anonymity doesn't do much for blog traffic, but any way to spread the word... The word, of course, is the extent to which health care reform is aimed at doing things that will be helpful. Even -- especially! -- for those very people who yell and weep and carry guns to meetings, spouting verbatim the insane ravings of Glenn Beck and Sarah Palin while having not the slightest idea what they're really talking about. "Keep government out of Medicare," they say. "Socialism." The "socialism" trope may be the most laughable (were it actually funny): all of the proposals on the table fall over themselves to maintain the death-grip insurance companies have on us. (Talk about "death panels!" What is it when insurers deny coverage?) None talks about nationalizing the health care delivery system. Not ev

Local News

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Using local anesthesia, I always took care to do it gently, slowly, and thoroughly, and had reason to be proud of the results. Almost routinely, patients expressed their happiness and relief that the process was so... not unpleasant. I've written a bit about it before . So when I couldn't seem to make someone numb, it hurt. As it were. In addition to having a dissatisfied patient, it made me feel like a failure. It has always been my belief that there are some people who, for some unknown biological reason, process the drugs differently; that it's more than just a few 'fraidy cats or me having a bad day. Now, it seems, there's substantiation . It's those darn redheads. It never occurred to me to check. I wish I could play back the scenes in my head, in full color. Were the unhappy ones all rubro-capited? There's much I know now that I wish I'd known a few decades ago (and not all of it is surgery-related.) And there've been a few notable redheads

Advance Directive

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On those few occasions when a patient had an advance directive, it was terrifically helpful. To me as their surgeon, to other caregivers, to the family, and, of course, to the patient. Which is why the outrage over a plan to assist people in making them (and cover the cost of counseling) is as cynical as it is ill-founded. Cynical, because people are turning it into "they're coming to kill grandma." Unfounded, because it actually puts people in control , not caregivers or government. My parents serve as two examples. Like most people (or so I assume), my dad had always said he'd never want to be kept alive by machines, and had a directive that put it in writing. Yet when he entered the hospital for what turned out to be the final time, after months of physical decline that had made his life only about the rudiments of existence, when the chips were down he opted for the ventilator. Which is an important point: nothing in his directive prevented him from changing hi

Scam Alert

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For months I've been getting spam comments linking to a website called "Findrxonline." I finally took the time to look at it, and find that it requires a monthly subscription which supposedly pays them to find you low-price meds from other websites. As if you couldn't do it yourself. What a joke. I assume none of my readers is so dumb as to fall for it, but I thought I'd mention it anyway. An outfit that thinks leaving spam on blogs is a good business plan is surely one to avoid. There was another, recently, that responded to my complaint by apologizing. This one not only doesn't do that, but at least one of its email addresses bounces back. Sigh. For all the beauty of the internet, there must be, it seems, a little ugly too.

Head-Scratcher

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I simply don't get it. Quite aside from the fact that the plan to disrupt health-care town-meetings is overtly to stifle honest debate on a very difficult subject, and despite the fact that there isn't even a bill yet (only a House version and several Senate versions that need reconciling), and even imagining that the anger is real and not ginned up by the distortions and outright lies of the right wing media or fomented by interest groups with a long history of ripping off the health care system for legal profit -- not to mention being fined one point seven billion dollars for fraud -- overlooking all of that: what the hell are these people so mad about? As far as I can tell, the proposals out there -- the ones that are actually in writing as opposed to the absolutely insane claims of the Rush O'Beckly axis of a$$holery -- are fairly weak-kneed attempts at maintaining the status of most of the quo. Are people really that upset about a bill which aims to prevent their

Certifiable

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Think Slow

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Not too long after setting up shop in this town, I shared a tough case with one of my favorite intensivists. (By way of diversion, I'll add there were only two of them at the time, and they were both my favorites. Practical and canny, surgical-patient-wise, they were a pleasure to work with. Over the years we developed great mutual respect and affection; to the extent that caring for critically ill and deeply challenging patients can be fun, it was. It's unique to private practice, I think, that such relationships can be so positive and mutually supportive and satisfying. I know I have said that in the academic centers, there's too much turf war and defensiveness. Was, back in the day, anyway. The discovery of such collegiality was one of the pleasures of my entry into private practice.) To make a long and dimming story short and bright, the patient was an older woman, admitted in extremis to the intensive care unit. Dying, evidently, of infection of indeterminat