Awesome

Jon Stewart with a dead-on Glenn Beck.
The 11/3 Project

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(h/t Little Green Footballs)

Annals of Wasted Resources

I performed an uneventful laparoscopic right colectomy on gentlemen a few weeks ago that went quite well. The following morning he was started on clear liquids and he was ambulated to the hallways. He looked great. His vitals were pristine. His abdominal exam was benign. He had excellent bowel sounds (I know, unreliable but I like hearing them nonetheless) and was even passing gas. His CBC, however, showed a WBC count of 15.7. Reactive white blood cell counts 18 hours after surgery are pretty much par for the course and they don't really bother us as long as the patient is doing well clinically.

When I saw him later that afternoon, he was tolerating his liquid diet and was making laps around the nursing station with his IV pole. But he asked me, "doc, why did I have to get all those needle sticks and tests today?" I had no idea what he was talking about. So I checked the chart.

The primary care doctor saw the WBC count that morning on rounds and was obviously much more concerned than I was. Eminently concerned. Freaked out would be another way of putting it. So this was what was ordered: blood cultures x 2, urinalysis and culture, CXR PA and lateral views, sputum cultures, an ID consult, and a CT of the abdomen and pelvis!!!!

I was able to get the CT scan cancelled but the rest of the orders were carried out as written. The ID consultant's note was two sentences. None of the cultures grew out anything. The CXR was negative. The patient went home two days later...

That doesn't belong there...

This elderly (mid nineties) lady presented with nausea and profuse vomiting for a couple of days. An NG tube was placed and the above scan was obtained. What you're looking at is an incarcerated paraesophageal hernia complicated by a gastric volvulus. She was taken semi-emergently to the OR where the stomach was reduced from the thorax, the sac taken down, the hiatal crura reapproximated, and a gastropexy was performed. She actually recovered quite well...

NFL Head Trauma

Malcolm Gladwell has an illuminating article in last week's New Yorker about an entity known as Chronic Traumatic Encephalopathy (CTE) which is a variant of cognitive dementia that develops in people who are subjected to repeated blows to the head (pugilists and football players especially). The article is debased slightly by the usual Gladwellian attempt to make a forced correlation between two seemingly unrelated topics (in this case dogfighting and NFL linemen), but it's a decent read nonetheless.

A recent study from Boston University delineates the pathophysiology of CTE as relating to abnormal deposition of the tau protein (whatever that is). Another study from the University of Michigan reports that former NFL football players develop early onset dementia or memory loss at a rate 19 times higher than the general male population between the ages of 30-49. There was even a sample from a teenage football player whose brain showed abnormal levels of the tau protein.

The bottom line is that football is an extremely dangerous activity. The dog fighter analogy is a stretch but these guys who play professional football for a living are indeed the gladiators of our age. Especially the interior linemen. And none of their contracts are guaranteed, that's the best part. These billionaire owners can cut a guy at any time, for any reason. Injury prone? Too many concussions? Out the door. So these guys play through it. They lace up their pads until they can't physically do it anymore. And too many of them are ending up like Mike Webster after their playing days have ended, sleeping under highway bypasses with all the other bums....

Cool Tune for the Weekend

Edward Sharpe and the Magnetic Zeroes. If you're feeling the least bit broken down, sad-souled, cornered and depressed...this tune will make you happy.

The Doctor Fix

I haven't read much in the med blogosphere about the so-called doctor fix. Last week, word leaked out that a version of the Democratic health care plan included a provision that would eliminate planned Medicare cuts to physicians as mandated by a 1997 federal law. This law used a complex formula, known as the sustainable growth rate (SGR), to limit federal spending on health care. The idea was to prevent spending on health care from growing faster than the economy. The problem is that spiralling health care costs have in fact grown exponentially faster than the economy. Therefore, as demanded by the SGR formula, doctors should have seen reimbursement cuts of 20-40% over the past few years. Given the tight balance between profitability and bankruptcy that most primary care docs negotiate, such drastic cuts would lead to a near collapse of private practice as a business model. So every year, Congress passes a one time bill that defers those cuts until the next fiscal year. In the most recent iteration of Obamacare 2009, the plan was to completely do away with any future Medicare cuts for the next ten years by subsidizing the cuts with $240 billion of federal money. The problem is that this subsidy was completely unfunded (sort of like GW Bush's prescription benefit bill) and more moderate congressmen went nuts. The idea is now dead in the water.

The whole thing is amusing to me in this respect. Remember when J. James Rohack (President of the AMA) wrote a guest post on Kevin MD enthusiastically supporting Obamacare back in August, mainly because of promises to do away with any future SGR cuts? I can't wait to read his follow up piece. Tort reform gets taken off the table early in the game and our AMA President is ok with it. Because, you see, our noble politicians in Washington promised him that the SGR issue would be "fixed". And this bad faith effort to effect reform by slapping together an absurd plan to simply write off the SGR cuts as unfunded debt for ten years represents an ingenius form of cynicism, even for our wily DC politicos. Of course the plan was going to get panned. Of course public backlash would make passage of the bill impossible. So it's out. And now we're back to square one. Obamacare has moved on, closer than ever to becoming a reality. And it still carries an endorsement from the AMA, even though the giant carrot that warranted that endorsement has been disregarded....


UPDATE:
The WSJ Health Blog reports that the doctor fix is still in play, unfunded as before. Only now it's going to be implemented via a separate bill. That way there, Obamacare isn't contaminated by the stigma of having anything in it that will increase the federal debt. I hope Dr Rohack is pleased...

Mammology

A NY Times op ed from October 10 makes the case that the management of breast cancer ought to be coordinated and run entirely by fellowship trained specialists hereafter to be known as "mammologists". The article was written by an OB/Gyn who runs the breast fellowship program at the University of Rich Rod. Basically, it's another barely camouflaged attempt by a sub-sub specialist to corner the surgical market on a type of operation that is about as straight forward and simple as it gets. (Surgical training programs assign junior residents and interns to all the breast lumpectomies). The decision-making in breast oncology is certainly complex and patients benefit from a multi-disciplinarian approach but the actual surgical procedures are not exactly enigmatic. The idea that you need to have your mastectomy done by an expert, i.e. a "breast surgeon" is rather absurd.

But the article does raise an interesting point. Specifically, why don't OB/Gynes do breast surgery? They do pap smears and pelvic exams and formal breast exams and usually are the ones who order yearly mammograms on their patients. It has always struck me as odd that once breast pathology is identified, the patient is all of a sudden shunted off to a general surgeon.

The super-specialization of surgery is an apparent inevitability. The paradigm of practicing "general surgery" is a dying ideal. I can read the writing on the wall. But these specialists are going to have to do a better job in coming up with new appellations. I mean, "mammologist"? That sounds terrible. It sounds zoologic. Just call yourself a breast surgeon, dammit.