Thursday, May 9, 2013

Christie Gets a Band

I had blogged a while ago about New Jersey governor Chris Christie's angry response to a former White House physician's opinion that he needed to think about losing some weight.  Christie basically told the doc she needed to mind her own business.  My take was that, morbid obesity being a risk factor for coronary artery disease, stroke, and early death, Christie's weight would be a issue I considered if and when he decided to run for the Presidency in 2016.  In order to be reassured that he could withstand the stress and pressure of being the leader of the world's only superpower, I indicated that I would need to see recent stress test/cardiologist bill of good health records before I even considered casting him a vote.  The blog was cross posted at KevinMD and subsequently set off a firestorm of conflicting opinions.  Many commenters felt strongly that it was a form of bigotry to even mention his weight when considering him for higher office. 

Again, I have no doubt that an obese person could be an excellent US President.  But I would be more likely to vote for him if I knew he wasn't necessarily a ticking time bomb for a major heart attack.  And publicized stress test results (just as melanoma survivor John McCain published his records from his oncologist when he ran for office in 2008) would go a long way in setting my mind at ease.

And now we find out that Mr Christie recently underwent Lap-Band weight loss surgery.  Why would he do such a thing?  I thought obesity was irrelevant to the discussion of higher office?  According to the governor:
 “For me, this is about turning 50 and looking at my children and wanting to be there for them."
 
I see.  Sooooo, weight loss is.....good?  I don't want to be a bigot. 

But why did the dude get the Lap-Band?  Doesn't he have a coterie of advisers and lackeys?  The Lap-Band results in less long term weight loss than a gastric bypass and the complications/annoyances that develop over the long haul with the Bands often necessitate their eventual removal. 

Anyway, best of luck to the Governor in in weight loss endeavors.

Defensive Medicine and the Drone Wars

From my interview with Andrew Thompson the other day, the issue of a medical malpractice crisis was raised.  Mr Thompson averred that such a concept is pure myth, a spook story older docs tell young interns around the campfire at night.  And he may be right.  In a paper from the Journal of Healthcare Quality, researchers at Johns Hopkins demonstrated, using data from the National Practitioner Data Bank, that "catastrophic claims" (those awards in excess of $1 million) totalled about $1 billion per year, a figure that represents just 0.05% of total national healthcare spending in this country. 

Now one could retort that "catastrophic claims" account  for only 36% of total claims over the time period (unduly neglecting the effects of smaller claims up to $1 million) or that the study doesn't include the settlements made with hospitals and healthcare corporations, only individual physicians.  But the data are eye opening nonetheless.  Total number of med mal cases have been dropping precipitously over the past ten years.  The costs of waging a medical malpractice case are prohibitive for most law firms (discovery, expert witnesses, contingency based fees, physicians win 70% of cases that go to trial, etc).  So why is tort reform still the linchpin piece of alternative national healthcare reform plans?  Why do the GOP and physicians organizations continue to shout from the rooftops that medical malpractice represents the single biggest threat to American healthcare?  Why has the refutable become dogma in the minds of otherwise intelligent people?

Friday, May 3, 2013

World Class

This is what can happen when a private practice surgeon refers a complicated colon cancer patient to a medical oncologist affiliated with a certain multinational, gigantic world-famous non-profit health care system.

Let's say the surgeon is asked to see a patient with a large bowel obstruction.  Perhaps the colonoscopy demonstrated a high grade constricting lesion in the distal sigmoid/upper rectum and the CT scan revealed a massive, locally infiltrating mass invading into the bladder and a possible liver lesion.  Perhaps the patient has lost 30 lbs recently and has noted foul smelling material in her urine.  The surgeon is concerned about diffuse tenderness on exam, possibly due to impending cecal ischemia.  He books the case for the OR and curbsides a med oncologist on treatment options.  Should I just divert?  Would there be a role for neoadjuvant chemoradiation?  Or best to just try and resect now with possible pelvic exenteration?  The med onc guy isn't too certain.  Whether there is liver involvement or carcinomatosis is key.  But no time to determine that now given presence of an acute abdomen.  He thinks the case ought to be presented to the tumor board and perhaps a multidisciplinarian consensus could emerge.  The surgeon thinks this seems reasonable.  He performs a laparoscopic diverting colostomy and places a mediport.  CT guided liver biopsy is scheduled as an outpatient.  She recovers from the surgery and is discharged home.  Her instructions are to follow up with a med oncologist from the world-famous healthcare conglomerate close to her house, in addition to seeing the surgeon. Arrangements are made for the case to be presented at next week's tumor board.  Patient's parting words to surgeon are: whatever you guys decide, I want you to do the surgery.  I trust you

Thursday, May 2, 2013

Gitmo Force Feedings


In response to over a decade of indefinite detention without charges or trial, with no foreseeable hope of ever being repatriated home, with no hope of ever seeing wives and children again, over 100 inmates at the American Gulag in Cuba are now participating in a mass hunger strike.  Of the 100, our medical personnel in Guantanamo are now force feeding 21 of them using silastic nasogastric tubes.  (The above image is the chair at Gitmo used to restrain prisoners while the tubes are forcibly inserted.)

The American Medical Association (AMA) has again gone on the record condemning the practice of forced feedings.  In a letter to Defense Secretary Hagel, AMA President Dr. Jeremy Lazarus wrote:
  Every competent patient has the right to refuse medical intervention, including life-sustaining interventions,” Lazarus said, adding that the AMA took the same position on force-feeding Guantánamo prisoners in 2009 and 2005.

“The AMA has long endorsed the World Medical Association Declaration of Tokyo, which is unequivocal on the point: ‘Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially.’”

Wednesday, May 1, 2013

Interview with the Lawyer



My interview series continues, this time with local vampire litigation attorney Andrew Thompson, Esq.  The topic this time is medical malpractice.  I asked him a bunch of questions.  He answered.  See what you think. 

Background on Andrew Thompson:


I attended Syracuse University Newhouse School of Journalism, transferred to CWRU and received a BA in Political Science in 1996. I obtained my J.D. from CWRU School of Law in 1999 and passed the Ohio Bar Exam. In addition to Ohio, I have handled cases in courts in Pennsylvania, New Jersey, Florida, and West Virginia.


I was an Associate at Chattman, Gaines & Stern in Cleveland until that firm dissolved in 2001. I moved with a partner from CG&S to Stege & Michelson Co., LPA, and became a partner at that firm a few years later. In October 2010, I left that firm to start a litigation firm in Beachwood -- Dubyak Connick Sammon Thompson & Bloom, LLC. The firm has a focus on litigation, and my practice concentrates on railroad law, labor/employment and personal injury matters mostly from the plaintiff’s side, including medical malpractice. Every firm that I’ve worked at has handled medical malpractice cases.


#1: In your opinion, is there a medical malpractice crisis in this country?


No. This is not even a close issue. The concept of a “crisis” or dramatic increase in the number of medical malpractice cases is a fabrication created by the U.S. Chamber of Commerce and the insurance industry. High-priced public relations firms have been hired to disseminate this message to the general public to generate support for tort reform bills. For the most part, the effort has been successful. The average person firmly believes there is a crisis, and tort reform bills have been passed in many States, including Ohio in 2003.

Complications and Profits

This paper from JAMA had the health blogosphere in a tizzy recently.  The Boston Consulting Group reviewed surgical discharge data from a 12-hospital system in the southern US to see if there was a "relationship" between surgical complications and hospital profits.  Their findings were obvious and unsurprising:
When a privately insured patient experiences one or more complications -- such as blood clots, stroke, infection, septic shock, pneumonia or cardiac arrest -- hospitals' profit margins are 330% higher compared to a patient with no complications, the report found.

For Medicare patients with complications, hospitals' profit margins are 190% higher, according to the report...
 
So if a patient develops a medical condition that requires further medical treatment with utilization of resources and involvement of other specialists then we are supposed to be astounded that the resultant costs will be higher?  This may sound controversial but who cares?  Why is this an issue? The problem is being painted as one of doctors expecting to be paid for doing the hard work of managing a surgical complication.  Complications are part of medicine, especially surgery.  A major part of what makes a good general surgeon is his ability to manage a difficult case, including the judgment as to when to return a patient to the operating room.  Anastomotic leaks in Crohn's patients on steroids will happen.  Bile leaks from the liver bed will occur at a fairly regular statistical probability.  Old ladies who undergo major abdominal resections will develop post op pneumonias despite the best preventative measures.    Sometimes you have to try to make a chocolate cake out of mud and stones.  You do the best you can.  Success is not measured in terms of cost overlays but as to whether or not you can get the patient from the ICU to a rehab bed in a safe, timely fashion.      

Barry Rosenberg MD sort of tip toes around the implications:
Hospitals make more money the longer a privately insured or Medicare patient stays, said Rosenberg, a partner with BCG's health care practice. As a result, they may lack financial incentives to take steps to reduce surgical complications, he said. 
 "Insurers are rewarding hospitals when there are complications," he said. "This is not the type of incentive you want ... in the healthcare system for your family."
 
So what do you mean by that Barry? 

Saturday, March 23, 2013

MRCP: Stop Already.

A typical general surgery scenario plays out like this.  Patient comes into ER at 1AM with RUQ pain, gallstones on US, elevated WBC and mildly abnormal LFT's.  The patient is admitted, hydrated and started on antibiotics with the plan to re-assess in the morning.  I see my ICU patients, do a 7:30 case and then check the overnight admit's morning labs.  The WBC is now normal and the bilirubin is slightly improved (down to 1.4 from 1.9).  I go to see her but she's gone.  I query the nurse.  Nurse says she's off to MRI.  I sit down in patient's room, watch TV for a bit, perhaps eat one or two of the sausage links off the plate of her sleeping roommate.  No, I don't do that.  I just go drink some more sour free coffee and see other people, silly.

I tell the nurse to text page me when she gets back.  She does so.  I race back between cases.  The patient "feels much better".  Her abdominal exam is rather unremarkable.  We shoot the shit for a while re: biliary pathophysiology (involving crudely drawn anatomic diagrams on the back of patient satisfaction survey forms; I like the way I draw the stomach but my gallbladder/biliary ductal rendition looks rather like the way a kindergartner would draw equine procreation).  There's an opening in the afternoon.  She doesn't want to ever experience the sort of pain she had last night.  I commiserate.  I can imagine, I say,  although I can't, having never experienced a gallbladder attack myself so to reproduce empathy I imagine that one time I spilled lye on my leg working at a metal treatment plant in the summer and the lye ate through my jeans, my epidermis, the dermis and bits of the subcutaneous fat.   

Wednesday, March 20, 2013

Ten Years


The picture above is from the height of the Iraqi insurgency in 2006.  Click on the picture and magnify it.  What it shows is a dead boy, 3 years old perhaps, with half his head blown off after an American raid in Baghdad.  The flap of translucent scalp catches the sun's rays.  His grandfather carries him from the morgue.  All of us have an obligation to spend a few minutes staring at that picture.  It is one of thousands.   

This is what we did.  That was a child we exterminated.  WMD.  Liberate Iraq.  The one true incontrovertible crime of the 21st century so far.  Aggressive war.  Pre-emptive war.   False pretences.  It has been ten years since we charged into disgrace.  Perhaps this ought to be a time for national reflection and collective shame.....   

Robot Rebuked

Once again, a paper has come out evaluating the efficacy and cost effectiveness of daVinci Robotic surgery.  From Diseases of the Colon & Rectum comes a retrospective review assessing elective robotic vs laparoscopic colectomy from 2008-2009 (over 12,000 procedures):
Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35–2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54–1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care ($19,231 vs $15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different.

Monday, March 18, 2013

Alone

We have this book of children's poems I've been reading at night to my daughter.  Most of them are stupid, nonsense-type verse about magpies and talking cows and little boys who wish for things that always come true but then there are a few from people like Shel Silverstein that are actually pretty decent.  The other night we came across an e.e. cummings selection I remember reading in high school called "Maggie and Milly and Molly and May":
maggie and milly and molly and may
went down to the beach(to play one day)

and maggie discovered a shell that sang
so sweetly she couldn't remember her troubles,and

milly befriended a stranded star
whose rays five languid fingers were;

and molly was chased by a horrible thing
which raced sideways while blowing bubbles:and

may came home with a smooth round stone
as small as a world and as large as alone.

For whatever we lose(like a you or a me)
it's always ourselves we find in the sea

After I read it she said to me, "daddy when we're alone, where does everyone go?" and I said "that's a very good question, sweetheart" and I got very sad but also proud; happy because she was able to identify the essence of a complex poem from a master of the form, and sad because maybe she is starting to realize that life is sometimes hard and lonesome and not everything stays the same and that there isn't always going to be someone around to tell you where to go or what to do.  I didn't have an answer right away.  She turns four this week.  I hope to be able to speak with greater wisdom when she is older....