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October 03, 2008

Interesting lawsuit

Read all about this 7-1/2 year pregnancy.

January 30, 2008

Emergency medicine's body of knowledge

As you already know from my previous posts, I don't often blog about my job. If you want good blogging about emergency medicine, I suggest you read the EM folks on my blogroll. Panda Bear has been especially hilarious lately. Obviously, I disagree with Dr. Bear about politics (I hope it's not obvious exactly how) but I think he's spot on about what it's like working in emergency medicine. His posts almost always leave me nodding my head and thinking, "yeah, yeah, damn straight." Except when he writes about politics, when I usually think to myself "puh-leese." Oh, well, to each his own.

But don't confuse my silence about my job for apathy. Even though residency is kind of grueling and sometimes frankly sucks a$$, it's also pretty damned fun. The variety and (sometimes) acuity of the stuff you see is cool.

To give you a sense of how fun emergency medicine can be, check out some of the practice questions I've been using to study for an inservice exam coming up in February:

  • Infection with which of the following helminths is known to cause a fatal hyperinfection...
  • Which of the following statements regarding lightning strikes is correct?
  • A 26-year-old man with known hemophilia A presents after being hit in the head with a baseball...
  • A 23-year-old man is brought in by ambulance after falling off a roof...
  • A 68-year-old man with a history of Type 2 diabetes and hypertension presents with cellulitis of his arm following a scratch from his cat...
  • Which of the following is most likely to be a complication of placing an internal jugular central venous catheter...
  • A 24-year-old woman presents after an altercation at a night club...
  • Which of the following statements regarding lung abscess is correct?

In real life, of course, we see a lot of "patient presents at 3 a.m. complaining of a left ring finger itch for the past three months." Still, though, I say bring them on. Anyone, anywhere, anytime. Even if they're absolute nut jobs.

January 10, 2008

Law vs. Medicine, and law school vs. medical school

I've gotten several email requests over the past few weeks from people who are trying to decide whether to pursue a career in law and/or medicine, asking what the professions are like and what the training for each of them entails. Since more people with the same question may find my blog but won't want to email me directly, I thought I'd post a generic version of what I've said about the subject here.

Keep in mind, of course, that my insight is limited. Yes, I've finished both law school and medical school, and I'm now a medical resident. This gives me an interesting perspective on the training programs for both professions. But remember that I've been practicing medicine for eighteen months as a resident. I've never practiced law. My knowledge of law practice comes from my time as a summer associate with a very large firm called Sidley Austin in Chicago, and from talking with law school friends that have been practicing in various capacities and places for eighteen months.

Nevertheless, that's still some pretty unique (*smirk* to you-know-who) experience, and I'm happy to share it.

Both professions are hugely diverse, and this makes it hard to generalize about them. In my opinion this also makes both fields very interesting -- there's a million little niches in each that
suit very different kinds of people.

With the disclaimer out of the way, let's move on to the generalizations:

Medicine is literally a hands-on profession. Most docs end up pushing on stomachs and listening to various organs with a stethoscope. True whether you're an emergency doc or an internist or a surgeon. Even the pathologists and the radiologists are probing individual patients in some way (dead patients and pictures of patients respectively).

The mental work that docs do is usually diagnostic -- pattern recognition -- which sometimes doesn't feel like "thinking." They gather all the data together, recognize from past experience what kinds of data are missing and what questions haven't been asked, and then fit all those data into the patterns they've got floating around in their head. This process of diagnosis is usually instantaneous. "Ok ma'am, you've been vomiting for two days, you've had an appendectomy several years ago, you're not a diabetic, and your abdomen is diffusely tender. Badda-bing, I think you've got a bowel obstruction." Why? Because it fits the pattern.

When you're doing this, it doesn't really seem to be a mental process in the same way that writing out an argument in the social sciences or humanities does. In fact, it can seem mindless. So much so that many docs feel they need to do something else to get their intellectual kicks -- research, philosophy as a hobby, health policy, whatever.

The plus side is that you are actually helping a real person who's standing in front of you (or curled up in the fetal position in front of you). You're doing something in the real world and you see the effects of what you do.

Contrast this with law: this is a writing profession. Lawyers deal with written documents and produce written documents, almost without exception. This can mean that the effects of what you do aren't so immediate as they are in medicine. As a lawyer, you certainly have no special manual skills like most
doctors do -- you can't put a central line into some guy'sneck, you can't do any kind of surgery. The skills you have are all about documents.

Even if you're a trial lawyer that argues to a jury, you're still dealing with words, arranged in a particular way, only this time delivered orally instead of on paper. Even trial lawyers spend the majority of their time going over written depositions, writing motions to the judge, etc. And most lawyers who don't do trials work almost exclusively in writing -- corporate lawyers drafting documents for deals, appellate lawyers writing briefs, government lawyers reviewing policies.

There's a lot of room to think, in the traditional academic sense, if you're a lawyer. (Not so much as a junior associate, but as you get more experienced.) You can strategize, persuade, marshal evidence, and all the other stuff that lawyers are famous for doing. It's not as free-wheeling as arguing with your friends about Barack Obama's health plan, but hey -- it's still an intellectual and creative kind of brain work.

The downside, in my opinion, is that the effects of what you do are often much more difficult to discern in law than they are in medicine. You slave away on a motion for weeks, and then the judge denies it. Or, worse, the motion is granted, but then your client settles. You have to use your imagination sometimes to believe that what you did had some direct effect on the world. True, in medicine the patient may still end up dead, but in general you'll see the effects of what you do in medicine more than you will in law.

If you hate being in a cubicle, realize that most of the really well-paid lawyers do
just that -- sit in a cubicle. Lawyers who like to be on their feet are usually prosecuting or defending small-time crime, or (occasionally) they make a name for themselves and work on the big stuff. But this is only one small niche within the legal profession. Most lawyers are desk-driving wordsmiths.

Then there are other factors. In my own biased opinion based on limited experience:

Lawyers are much better conversationalists than doctors.
Doctors can't write worth a damn, and they're less curious.
Most people in both professions are risk averse.
Lawyers are much more money and status conscious than doctors.
But the doctors who are money-conscious are insufferable.


One other thing I should mention: the road to getting a medical license is a long one. That shouldn't stop you if you want to do it, but you've got to be prepared for the long haul, and you have to enjoy the journey.

Speaking of school: in medicine, the trick is to get into *any* American medical school. There are relatively few of them, and they all have high admission standards. Law school is different. The trick for law school is to get into a *good* law school. There are a million law schools, and for most of them, all you need to do to get in is have a pulse and be able to sign for student loans.

What this means is that in medicine, so long as you get in, it doesn't matter where you go to med school. Sure, Hopkins would be nice, but if you don't like Baltimore you can go to your state med school and do just as well. In law, if you don't go to a good law school, you'll find your employment prospects limited when you graduate. Don't let the schools tell you any different: shoot for the best law school you can get into.

For a list of good law schools, see Brian Leiter's rankings. There are other rank lists out there and these rankings are absurd, but I've said a lot about that already and won't repeat myself here. These list just give you an idea of which schools will give you the most options as a graduate.

Remember, too, that you might want to consider why you want to enter either profession. The word on the street is that both lawyers and doctors don't have as much prestige as they used to. Practitioners of both professions are, more and more, becoming highly-paid employees, and there's nothing very highbrow about that. So if prestige is what you're after, think twice. Think about starting your own business, or becoming an artist. There's many more than two ways to skin a cat.

November 29, 2007

ER overcrowding

The public doesn't really care about the problem of ER overcrowding, right?

Well, maybe as a matter of public policy, Iraq and immigration have a firmer grip on the public's collective attention. But for people who have had to be a patient in an ER, and have had to wait for hours and hours to get a simple medical problem addressed, ER overcrowding is a big deal.

It's certainly a big deal for people who work in ERs. As a resident, I work in three very different ones, and I know that people often have to wait a long time before being seen -- unless they come in complaining of stabbing chest pain and have a blood pressure of 80/40. If you're not one of these lucky few, the typical ER experience is, "have a seat, I hope you brought some knitting with you to keep you entertained." My first job when they finally come back is to apologize for the long wait.

The reasons for overcrowding depend on whom you talk to. Some people say that it's because of the large and growing number of uninsured patients who can get care nowhere else. Some say, bullshit. Here's Michael Saloman, president of the California chapter of ACEP:

Crowding in the ER is actually a symptom of hospital crowding. There is a shortage of nurses and hospital beds in Modesto. Admitted patients are forced to wait on ER gurneys for hours because there is no place to put them upstairs. If all ER beds are occupied, then patients in the waiting room can't be seen. That is the reason ERs are crowded.

People, people! Let's not get hot under the collar. Just ask me, and I'll tell you that you're both right. Think about it: many of the ERs beds are occupied by admitted patients that can't go upstairs because there's no room to put them. This can effectively turn a 30-bed ER into one with ten or fewer beds. The rest of them are occupied by admitted patients, getting their q8 hour antibiotics and being forbidden to eat after midnight.

But let's be realistic: if all the people in the waiting room who need a med refill or have the flu, and who can't go see a doctor at a clinic because they don't have any insurance would get up and leave, the waiting room would be a lot emptier. Sure, these people are easily treated and released, but that doesn't mean that treating them takes no time, or that they don't need a private area where they can be seen and examined.

So what's the solution? Simple. First, build more hospital beds. Second, make sure everyone has health insurance and a nice, warm, conveniently-located clinic where they can see a doctor. Third, stop eating junk food (and don't wait for the FDA to regulate added salt in food). Fourth, get more exercise.

Like I said: simple.

April 10, 2007

What medical problems do you have?

When I ask this question of patients in the ER, it's amazing how often they forget to tell me about serious diseases that completely change the way I want to treat them. It happens so often, in fact, that I'm tempted to say this to all my patients when I first walk in the room:

"Tell me what medical problems you have. And tell me everything. I'd better not go out there and look you up on the computer and find all sorts of shit that you haven't told me about. I want you to come clean with me now. If you have diabetes, you'd better just tell me now and get it over with. Because I'm going to find out, one way or the other. And if I find out that you're a diabetic or that you have lupus or some shit like that and you haven't told me, I'm also going to assume that you also have dementia, or that you've been sniffing glue."

Of course, all of this is (somewhat) in jest. I'm lucky enough to be a healthy person; I can tell you all the medical problems I've ever had since I was born, mostly because there's been so few of them. I had ear infections. I had an effusion in my knee once. I've had intractable vomiting from eating bad refried beans at a disreputable mexican restaurant in Sedona. I remember all of these things because they're so unusual.

But I suppose that if I had diabetes, or lupus, and I'd been living with it for years and years, I might forget to mention it when I went to the ER. Maybe. Assuming, of course, that I was also hypoxic or hypoglycemic or high from breathing the fumes from a tube of Krylon spray paint.

Sheesh.

March 30, 2007

More on resident work hours

Assuming for the moment that excessive resident work hours is a problem, it would seem to be one of those problems that isn't likely to be solved by either professional self-regulation or by the market.

Daniel Goldberg's nice post about resident work hours reminds me that even if residents weren't as accepting of their brutal schedules as they seem to be, they probably wouldn't be able to do very much about it. As Goldberg points out, medical students and residents don't have a lot of bargaining power compared with their hospital employers, who benefit economically from low-cost resident labor. Moreover, there aren't a lot of other players in the current health care market who should be expected to argue forcefully for reduced work hours. Insurers and employers in our fragmented system would find it hard to capture the economic benefits of fewer medical errors made by overworked residents.

Professional self-regulation shouldn't be expected to solve the problem either. The medical professional societies and hospital groups that comprise the ACGME (the organization that regulates work hours) are all served nicely by the current system. The professional societies benefit because the total number of residents is kept small. Residents in training may suffer, but after graduation they benefit from larger salaries. Hospitals of course like cheap resident labor paid for mostly by the government. Although each additional resident usually means more money for the hospital, in the face of restrictions on the number of residents Medicare will pay for and the relatively higher costs of PAs, NPs, and attending MDs, the hospitals are not going to support limiting resident work hours. Residents are the cheapest hospital laborers available.

So if the market won't fix things, and professional self-regulation won't fix things either, who's left? Yep, the government. What's the likelihood that the government will step in to limit resident work hours? Almost nil, because "patients" as a group aren't as focused a lobbying group as are the hospitals and the professional societies. So absent another high-profile case like Libby Zion's, nothing is going to happen.

Of course, I've ignored the serious argument that shorter work hours do not directly correlate with increased patient safety. There is evidence that medical errors are more likely with an increasing number of handoffs and signouts -- the happy medium between overworked residents and too many handoffs hasn't been identified yet. Add to the fact that this happy medium is likely to be different depending on the specialty, the severity of illness, the number of patients, and the stability of the resident's schedule, even if the government did want to do something, it wouldn't be clear what exactly it should do.

This uncertainty about how to solve the work-hour problem doesn't mean that I dislike excessive hours any less. It doesn't make me any more sympathetic to the simplistic non-arguments advanced by traditionalists that amount to "more time in the hospital = better training." It just means that I'm glad to be going into a specialty where I can limit my own hours if I want. And I think we ought to spend more time and money gathering information about what kind of training systems work best.

March 21, 2007

On-call hours

Via Gruntdoc, this post from former infantryman in the United States Marines (a group who aren't generally known to be weak whiners) and now emergency medicine resident Panda Bear M.D. about on-call hours in medicine:

....The fact that your program has bitten off more than it can chew and cannot maintain it's commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program's problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates.

Read the post, and read the comments. Everyone who knows me knows that I hate call -- give me the power to change one thing in medical training and it would be this. Residents are on-duty without sleep for far many hours in a row. The threat of federal legislation a few years back led the ACGME to implement an 80-hour work week rule, but this rule is often violated, and the rule itself isn't strong enough. Believe me, you can be worked beyond physiological reason under the current 80-hour rule.

The most fascinating thing to me about the whole thing is the seeming complicity of the residents. Panda Bear describes it thusly: "their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy." Even if you don't agree that the residents are brainwashed, it's clear that they aren't the ones pushing for a more rational and physiologically sound schedule.

Consider this study performed at the University of Chicago by Dr. Vineet Arora and her colleagues. Despite finding that a nap period significantly reduced overall fatigue for on-call medicine interns, "use of coverage by interns on the nap schedule was impaired by their desire to care for their patients and concerns about discontinuity of care." In other words, when given the opportunity to sign over their pagers in the small hours of the night and sleep, medicine interns chose not to do it (although they did sign over their cross-cover patients).

These residents gave different reasons for not signing out their pagers, including a concern for patient care and a desire to stay informed about what was happening with "their" patients. Is this reluctance to just go to bed the result of brainwashing? The study can't tell us. There's really no way to know. The question is whether the reluctance of interns to sleep is something we ought to encourage, defer to, or override. I tend to think the latter, because I don't think sleep-deprived interns deliver good patient care. But, as Panda Bear's post points out, there's no definitive study out there that tells us how many hours are too much.

Given the economic incentives of hospitals, the absence of such a study means that the problem will probably get worse before it gets better. And we should be asking: what kind of evidence must we have before we take action to solve the problem?

March 15, 2007

Today is Match Day

Today is the day when we find out which lucky souls will get to spend the next three years doing emergency medicine at the University of Chicago. If things work out right, they'll all be as happy as I was last year. (Kayvon... we still need to talk!)

One year later, I'm still just as happy. I'm chronically sleep-deprived, occasionally cranky, and sometimes downright bitchy, but I'm still happy.

March 13, 2007

One of the best private med schools: the University of Colorado

In the mail today was an envelope from Richard Krugman, chair of the AAMC and dean of my medical alma mater, the University of Colorado School of Medicine.

It contained good news and bad news. The good news: CU placed 15th among medical schools in the AAMCs ranking of NIH research expenditures, the school placed 4th among public medical schools in its research earnings, and the school just received a $6 million private research grant for a stem cell biology program. It sounds as if the medical school's budget is healthy, at least from a research perspective, and the state of Colorado ought to be proud of its accomplishments.

But, um... the bad news is that the state legislature continues to withhold its support from the school's educational mission. Less than 2% of its operating budget comes from the state, and because research dollars can't be used to support educational activities, tuition has increased to cover the shortfall. The average debt of CUs graduating students is now over $100,000 (although this is probably in line with the median debt of all public medical schools).*

I've posted about medical school tuition and debt before (1, 2). It is reasonable to assume that high med school debt makes primary care careers less attractive to new graduates relative to specialties like interventional cardiology (some studies cited here). Given that we all keep complaining about the rising costs of medical care, and that these costs are in part driven by an oversupply of high-cost specialist physicians relative to an undersupply of primary care doctors, high medical student debt should bother us.

The question we have to answer has never been whether or not to spend tax dollars on the public good called "physician training." Rather, the question is when should we pay, and how much. Right now, we've decided to pay later -- cutting funding for medical education up front and paying for the consequences of increased student debt at the end. We subsidize the medical care provided by high-cost specialists -- through medicaid, SCHIP programs, and tax breaks, among other things. We continue to contemplate some kind of national health care system. We fund loan-forgiveness programs for new graduates who elect primary care despite the relatively paltry incomes that these fields offer.

But we ought to wonder whether we might get a bigger bang for our buck if we paid more up-front to ensure that medical school tuition at public medical schools was reasonable. We might save a lot of money by eliminating the administrative waste that accompanies loan-forgiveness programs if new M.D.s didn't start out with staggering debt to begin with.

The letter I got from Dean Krugman says that a current student will call me soon to ask for my contribution to the school. I'm looking forward to talking with that student about some of these things, and about the new curriculum that (finally!) is in place at Colorado.

Here's some more materials about the debt issue from the AAMC.

* Jolly, P. Medical school tuition and young physician indebtedness. Health Aff. 2005; 24:527-35.

March 08, 2007

How to be a considerate ER physician

Spending time on off-service rotations gives you a good view of the ER from the outside. Here's something that I used to know in my head, and that I now know in every organ of my body:

If an ER doc calls a trauma consult for a patient with abdominal pain from trauma eight hours after the patient first came to the ER, that doc should have done a rectal exam already. It's just considerate, not to mention good patient care.

I'll try to remember this when I'm back in the ER.

October 29, 2006

In the ICU, and thinking about Huckleberry

I'm in the ICU this month. It's a great place (the only place?) to learn what I need to be a competent ER physician -- but it's no less draining for knowing that.

The medical ICU is a joyless place. It's a place where very sick people stay, usually at the end of their lives, to absorb all the high-tech medicine that we can possibly throw at them, in order to live a few more weeks than they would have otherwise. Yes, there are important exceptions, where we save a patient's life in the ICU and he or she leaves to spend time with their families and go for walks on sunny days in their favorite park -- but this is still an exception.

Add to this the horrendous hours, which makes it impossible or at least very difficult for residents to get to know each other as anything other than tired, overworked, cogs in a machine. Throw in the intern's inevitable lack of knowledge and gross inefficiency, and it shouldn't be surprising that there's not much joy for them in the ICU. Speaking for myself at least, there isn't.

My brother just lost his cat, Huckleberry. He was the greatest cat. Friendly, intelligent, and always hungry! He had some klnd of cancer that deformed his jaw, and he had to have it taken off. For a cat who loved to eat, that must have been a particularly large loss. My brother, because he loved this cat, did the best thing for him in the end, and had him "put down" by the vet. Huck, RIP.

If Huckleberry had been a person, he would almost surely have been laid up in the ICU for the last few weeks of his life. He'd have been unconscious, with a feeding tube down his throat to substitute for the eating he'd loved before the cancer. The people "caring" for him would have been overworked and unfamiliar with him as anything other than a reason for more chores. They'd have been more concerned with writing down all the numbers that the machines hooked to his body were spewing out 24 hours a day than with "caring" for him in any sense that could have mattered.

I'm not saying that we should euthanize people. I'm saying that the end of Huckleberry's long life was probably better, being my brother's cat, than it would have been as a human being.

***

Here's a poem I've posted before that means more to me now that I'm spending so many hours in the ICU.

Three Elegaic Poems
Wendell Berry

I
Let him escape hospital and doctor
the manners and odors of strange places
the dispassionate skill of experts

Let him go free of tubes and needles
public corridors, the surgical white
of life dwindled to poor pain

Foreseeing the possibility of life without
possibility of joy, let him give it up.

Let him die in one of the old rooms
of his living, no stranger near him.

Let him go in peace out of the bodies
of his life --
flesh and marriage and household.

From the wide vision of his own windows
Let him go out of sight; and the final

time and light of his life's place be
last seen before his eyes' slow
opening in the earth.

Let him go like one familiar with the way
into the wooded and tracked and
furrowed hill, his body.

II
I stand at the cistern in front of the old barn
in the darkness, in the dead of winter,
the night strangely warm, the wind blowing,
rattling an unlatched door.
I draw the cold water up out of the ground, and drink.

At the house the light is still waiting.
An old man I've loved all my life is dying
In his bed there. He is going
slowly down from himself.
In final obedience to his life, he follows
his body out of our knowing.
Only his hands, quiet on the sheet, keep
a painful resemblance to what they no longer are.

III
He goes free of the earth.
The sun of his last day sets
clear in the sweetness of his liberty.

The earth recovers from his dying,
the hallow of his life remaining
in all his death leaves.

Radiances know him. Grown lighter
than breath, he is set free
in our remembering. Grown brighter

than vision, he grows dark
into the life of the hill
that holds his peace.

He's hidden among all that is,
and cannot be lost.

September 26, 2006

Emergency medicine...

... can sometimes make a difference. This story demands a link.

Notice, though, that the key fact here is that an otolaryngologist "was miraculously in the building." Miraculous might be the right word, because for financial reasons many emergency departments don't have access to on-call specialists when they need it.

June 12, 2006

More AMA junk mail

I received another piece of junk mail from the AMA today. Ever since I graduated from medical school in 2002, they've tried to drown me in solicitations for everything under the sun. Especially offers for insurance policies.

But today's envelope was worse. It was a real, honest-to-goodness USPS priority mail envelope containing an invitation to join for half price. Oh, goody: only $210.00 for a six-month membership.

Sorry, but I'll pass. I don't like the thought that if I join, some of my dues money will be used to buy priority-mail envelopes for the next round of solicitations. That seems like a waste of money to me.

There are, I'm sure, many good reasons to belong to the AMA. Physicians can do a lot of good when they act together, and sometimes the AMA itself will entertain some creative proposals (like a tax on soda). But in my limited experience, the AMA just isn't providing the kind of leadership that a physician organization is capable of.

Maybe when I see a few more good policy suggestions, and a bit less junk mail in my mailbox, I'll think again about joining the AMA.

June 08, 2006

A bad idea: implied preemption of state law requirements for drug labels

Should drug manufacturers, assuming they meet all the labeling requirements imposed by the FDA, be subject to liability for failing to meet more extensive or different labeling requirments imposed by the states?

This article in the NEJM ($), criticizing the FDA's new labeling regulations, buries its most important paragraph deep in the middle of the piece:

The most troubling aspect of the FDA's new plan, however, has nothing to do with providing information to prescribers. In an unusual move after the end of a five-year period of comments on the initial rule, the agency used the passage of the new labeling regulations to quietly add a new section to its preamble that will make it extremely difficult for anyone to bring legal action against a drug manufacturer for harm caused by one of its products.

Whether you find this troubling or not will depend on what you think about the trustworthiness of the FDA and drug manufacturers, the appropriateness of private lawsuits in areas subject to extensive government regulation, and the relative role of state and federal law.

For years, the pharmaceutical industry had sought to pass legislation that would prohibit litigation over adverse effects as long as the medication was approved by the FDA; Congress has consistently rejected this idea. But after the comment period for the new labeling regulation had closed, language was added to the final rule stating that any FDA-approved label, "whether it be in the old or new format, preempts . . . decisions of a court of law for purposes of product liability litigation."

Drug manufacturers would love for Congress to explicitly preempt state laws governing drug labeling, but so far, Congress has chosen not to do so. There's nothing that explicitly prevents states from passing drug labeling laws that impose more extensive requirements on drug manufacturers than imposed by the FDA under the federal Food, Drug, and Cosmetic Act.

Usually when an industry wants federal preemption of state laws, but can't convince the Congress to go along, the industry relies on the doctrine of implied preemption to argue that courts should refuse to enforce state laws anyway. Their argument is that when Congress legislates extensively about a given subject, it has implicitly exercised its power to preempt state law. State legislation on the same subject, even if it doesn't actually conflict with federal requirements, would alter the federal regulatory regime in ways that Congress would never have intended.

This doctrine leaves the preemption decision to the courts. But federal agencies do influence the final decisions about implied preemption, and that's why this new language from the FDA is important. When courts are presented with the argument that federal law implicitly preempts state law, they will often grant some deference to the interpretation of that federal law by the agencies charged with implementing it. For example, if the FDA interprets the Food, Drug, and Cosmetic Act to preempt state labeling requirements, it's more likely that a court will find that state law is preempted. That's why this part of the article is misleading:

Beginning at the end of this month, the new regulations would preempt nearly all action by patients in state courts against drug manufacturers for unanticipated injuries resulting from the use of their products. This immunity would apply even if a company failed to warn prescribers or patients adequately about a known risk, unless a patient could prove that the company intentionally committed fraud — a very hard test to meet.

The FDA's opinion about preemption isn't itself legally binding, but it does make it more likely that the courts will go along with drug manufacturers' preemption arguments.

Is any of this a good thing? There's a strong case to be made that in the absence of any state law to the contrary, a state jury shouldn't be able to hold a drug manufacturer liable for a "failure to warn" in a case where the manufacturer complied with FDA labeling requirements. The FDA does rely on clinical trial data to determine what warnings are appropriate. Its judgments shouldn't be routinely discarded by lay juries.

However, things are different when a state passes a specific law requiring warnings in addition to those imposed by the FDA. Contrary to what the FDA suggests, a drug's "safety" isn't something objectively inherent in the drug, and that can be objectively determined in scientific studies. Does a 1 in 5 chance of constipation make a drug unsafe? A 1 in 300 chance of a heart attack? Although the statistical likelihood of adverse side effects can be objectively measured, the safety of a drug is in the eye of the beholder. There's no reason why the FDA's decision that some risks are insignificant enough to be left off a warning label should prevent states from requiring that these risks be disclosed anyway. At least, not until the Congress decides to explicitly preempt state laws that require this additional disclosure.

The FDA argues that "State-law attempts to impose additional warnings can lead to labeling that does not accurately portray a product’s risks, thereby potentially discouraging safe and effective use of approved products or encouraging inappropriate use and undermining the objectives of the act." But this just amounts to an assertion that what's "appropriate," "safe," and "effective" is exclusively a matter for the FDA to decide -- and Congress hasn't explicitly given it this authority.

Implied preemption arguments should be approached skeptically, especially in cases where Congress has considered and declined to exercise its power to expressly preempt state law. The FDA's arguments for preemption should be treated even more skeptically, since they essentially restate the position of the drug manufacturers that has not succeeded in Congress.

The new regulations are here: www.fda.gov/OHRMS/DOCKETS/98fr/06-545.pdf.

May 29, 2006

I hope I'm not fated for this...

I'm looking forward to starting my emergency medicine residency. I know it's going to be an exciting time, and that I'll have some amazing experiences.

Nevertheless, I can't help but worry a little bit about the risks that a career as a doctor entails. What risks are these? Well, Hospital Impact points out one of them:

Some of the physicians are socially challenged. They are locked up for 12 or more years in college, medical school, residencies or fellowships where they are completely removed from the real world. Unbelievable pressure is placed on them, and then they are set free and told to "Be normal." Hah.
In addition to social awkwardness, being a doc can make it tougher to handle rejection:
Accustomed to sequential success, physicians are not optimally equipped for the rejections, false starts or dead ends that are part and parcel of life for most of humanity. Practicing medicine today has its woes but we are to an overwhelming degree in demand, valued, respected and well compensated especially in comparison with individuals in most other occupational fields. (HT: GruntDoc.)
Even worse, a medical career can sometimes even dumb you down if it becomes the only thing that's important in your life:
Medicine is a demanding mistress, always with its siren call in your ear, signaling you your ever dumber fate. The success of the few does not alter the dynamic for the many. Interests and enthusiasms fade and ultimately wither. Like expectant lovers, promised “tomorrow” too many times, they leave or die.
I don't think that any of these evil things will be my fate as a doctor, but it's still good to worry about them. After all, some doctors always end up as social cripples or one-dimensional human beings. Most lawyers just starting out never think they're going to turn into unethical sleazeballs, either, but some of them always do.

Some of the best advice I've gotten on these matters came from my Legal Ethics professor in law school. He compared a legal career to a mountain climbing expedition. Your ethical commitments, just like your tolerance for mountaineering risk, are decisions that are often made best in advance -- in base camp. Before peer pressure and high-altitude hypoxia lead you to make stupid climbing decisions high up on the mountain, you should decide how much bad weather you're willing to risk in order to summit. Likewise, new lawyers as much as possible ought to make their ethical commitments before the pressures of a case and the lure of easy money lead them to compromise their values at the expense of their clients and themselves.

The same thing applies to new doctors facing known career risks, ethical and otherwise. Am I going to abandon my interests? My decision now is no. After I develop some expertise, will I be afraid to try anything new? I'll commit myself now to fighting that temptation. Am I going to ignore my friends and family? I'm deciding now that I won't.

Residency is going to be a lot of hard work, and it's going to be exciting. But I'll still pay attention to the unlikely risks, and avoid them if I can.

May 18, 2006

Doctor pulls kitchen shift

"It's impossible to say which is harder -- cooking or doctoring,'' she says. "But they do both share the same goal -- to make people happy and feel good.''

(Via Kevin, M.D.)

April 19, 2006

PowerPoint: Less is More

On the interview trail for an emergency medicine residency spot, I was hit with a cold realization. My three blissful years of law school are coming to an end. It's time to go back to the world of medicine, and this means returning to an arena in which virtually every formal presentation is likely to be accompanied by PowerPoint slides.

I'm yawning with anticipation.

At the University of Michigan Law School, professors lecture with all the lights on, and they almost never use PowerPoint. This might surprise all those academic physicians out there who don't think it's possible to convey information without dimming the lights and firing up the projector. Dispite what many doctors seem to think, PowerPoint is not a required teaching tool. My roughly 400 or so classmates who've learned a lot of law over the past three years can all testify to that.

Lawyers do, occasionally, use PowerPoint in the courtroom. But the good ones don't let PowerPoint use them. TaxProfBlog has a post about how trial lawyer W. Mark Lanier -- the guy who persuaded a Texas jury to award his client $252 million in Vioxx suit against Merck -- hired a guy named Cliff Atkinson to help him with his PowerPoint slides. Atkinson is trying to do something about what he calls "PowerPoint fatigue" and TaxProf calls "the deadening sameness of Microsoft Corp.'s commonly used presentation software." This kind of language should rings a bell for a lot of emergency physicians and residents out there (for my sake).

My only worry is that Atkinson might not be quite radical enough. Sure, he talks a tough game. On page 14 of his 5 ways to reduce powerpoint overload (pdf), Atkinson says:

When you think you’re impressing people by putting everything you know on your PowerPoint slide, you’re actually doing the opposite by shutting down their cognitive processing. And when people are sitting there bored, they’re likely not thinking positive thoughts. When it comes to PowerPoint, less is more. . . ." (Emphasis mine.)
Atkinson is absolutely right, which is why I wish he'd gone on to say, "hey, do you ever think of just getting up and talking? Without any PowerPoint at all?" But I suppose that wouldn't be great for his consulting business' bottom line. Even though he says that less PowerPoint is more, Atkinson doesn't actually advise us to use less PowerPoint. And that's kind of sad and wimpy.

April 04, 2006

The best argument against prosecuting midwives is...

I'm not one of those people who thinks that watching a baby get born is such a miraculous and transformative experience -- I'm just not that transfixed. So I suppose it isn't surprising that the debate over home births and midwives doesn't matter much to me one way or the other. Feminism, the medical establishment, the miracle of birth. . . yawn. If the state made home births illegal, or if they went to the other extreme and stopped regulating midwives altogether, I'd get along either way.

What really gets my goat, though, is that a mom or a newborn baby would encounter an unexpected problem and because of some yawner of a law, not get the emergency care that they need. This is why the prize for the best argument against prosecuting unlicensed midwives goes to:

"The current law, Ms. Welch said, drives midwives underground. "I don't want to have a midwife hesitate to take a woman to the hospital because she is afraid she will be arrested," she said.

March 16, 2006

University of Chicago!!!

The exclamation points say it all!

More later after I get back from class. Oh, and Kayvon, you're getting a call from me soon.

UPDATE (1.5 days later): Ok, so now everyone knows what match I was hoping for. Chicago is such a great city, and I can't wait to get back to good old Hyde Park. I've been trying to get back, in one way or another, for about twelve years now. . . . My peeps from Sidley and many of my friends from Michigan Law will be there too -- starting their legal careers while I'm starting my career in emergency medicine. We'll definitely have to have some beers.

Apart from the city of Chicago, I'm thrilled to be a resident at the University of Chicago. My rotation there as a fourth-year medical student (November of 2001!) was probably the best single month of medical school for me. It felt like I learned more substantive medicine in that month than in any other. The attendings, the residents, the staff, the patients -- all great. When "they" say that some programs just click for you, that's U of C for me. I felt the same way when I went back for my residency interview last December. Four years had passed, but if anything I came away even more impressed with the faculty. The residents I met all seemed curious and sharp. Most importantly, they seemed like people I'd enjoy working with.

Plus, Chicago has the coolest helicopter in the business. As an undergrad I always loved to watch it flying low over the campus, and now I'm going to be flying on it! *big shit-eating grin*

Ok, off to celebrate some more. . . .

March 13, 2006

I'm going to be an emergency medicine resident!

Today, I learned that I've matched. Somewhere. I don't really know where yet, other than it's at one of the nine programs I listed on my rank order list.

I've avoided the scramble, and that makes me extremely happy. It would have been tough to try to get one of the very few unfilled positions in emergency medicine. Fortunately, I've already got one.

I'm enormously grateful to everyone who's helped me get to this point. Ever since I went to the ED of the old St. Francis Hospital in Colorado Springs as an EMT student and watched the victims of a mass shooting in a biker bar brought in and cared for, I've wanted to be an emergency physician. I've always thought I could be a pretty good one, if only because I think it's so fun, and challenging, and worthwhile. Now it'll be up to me to make the most of my three (or four) years of residency. I'm extremely fortunate to be here, and I'm going to make the most of it.

Wherever I end up.

Trip to Emergency Department: $1870.56

The best way to learn about health care costs is to incur some yourself.

Two weeks ago I got sick from eating bad refried beans, so I went to the ER because I was dehydrated and couldn't stop vomiting. Today I got the bill. It's really amazing.

The folks there took good care of me. They gave me IV rehydration, three liters. They gave me some IV antiemetic meds so I would stop vomiting. They ran a few basic labs. They didn't overtreat me, by any stretch. No abdominal X-rays, no CT scans. No ultrasounds. No crazy labs looking for zebras like porphyria.

Today I got the bill: $1870.56. Ridiculous. Outrageous! But that isn't really the amazing thing.

Why is it ridiculous, apart from its sheer size? First of all, the itemization is insufficient. Take drugs, for example. There's a line for "pharmacy" (298.95), "drugs/detail code" ($91.98), and finally, "other rx services" ($117.00). I was looking forward to finding out how much the ondansetron would cost, but how can I tell from this? I remember how many doses of each drug I got, but how can I tell whether they made a mistake? Are they charging me for five doses instead of three?

I'd like to pay this bill, but not until I'm confident that it's correct. This skimpy information gives me no way to know if it's right or not.

The biggest single charge on the bill is "emergency room." $697.00. Did I incur that cost by just showing up and getting in line? Perhaps there's something to this argument about reducing costs by making them more transparent to patients. If patients know they'll be hit up for seven hundred dollars just by showing up at an ED, a lot of them might choose not to go at all. If people are deciding between going to a movie or going into the ED for some unnecessary medical care, this might be a good thing. But, contrary to the evident beliefs of some of the most reactionary opponents of universal coverage, I don't think many people are like this. I was reluctant to go to the ED, and I want to spend my career in one. Most people, I think, try to avoid the ED until they see no other alternative (which sometimes happens at 3 a.m., I admit). This bill is really huge (but that's still not the most amazing thing).

For the curious among you, here's the entire bill for a simple ED visit for nausea and vomiting:

Pharmacy $298.95
IV Solutions $215.31
Med-Sur Supplies $20.37
Sterile Supply $67.95
Laboratory $23.10
Lab/Chemistry $449.20
Lab/Hematology $140.30
Lab/Urology $49.40
Emerg Room $697.00
Drugs/Detail Code $91.98
Other Rx Svs $117.00

When I was treated, I put a deposit on my credit card. Thus, the last line:

Patient Payment - Thank You! $300.00

Thus, the total bill is $2170.56. Outrageous (but not the most amazing thing). The next step, of course, is to call the hospital to see if I can get a more itemized bill. I'll keep you posted.

But hey -- what's the most amazing thing about this bill? It's not that it's so big, although that's part of it.

The most amazing thing about this bill is that, even if I find no errors in my favor, and I can't get the hospital to come down at all, I'm still coming out at least even with where I would have been had I signed up for the school's insurance plan! Yep, that plan had an annual premium of about 2000 bucks. When you throw in the copay of about 50 bucks, I'd have still been up shit creek -- even with this trip to the ED -- had I signed up for the insurance. I made the judgment that I probably wouldn't incur medical bills this year beyond that, and even with this huge bill, I was right!

Lesson? For someone like me (who's lucky enough to be reasonably healthy) the only thing more outrageously expensive than medical care is medical insurance.

March 12, 2006

Bad refried beans

That's about the only reason I can think of for why I got sick for two days in Sedona over spring break. Heidi and I ate the same food everywhere but at evil Casa Rincon. That's where Heidi laid off the frijoles refritos and I made sure they disappeared down my gullet -- for about 8 hours, at least. Then it was my time to pray to the porcelain God.

(Or should I say, "order Buicks over the big white phone?)

That first day I had to go to the ED for some IV rehydration and antiemetic therapy. Phenergan and ondansetron, baby. I'm curious to see how much it's all going to cost.

Interestingly, the malpractice negotiation exercise that we're doing in my Law, Medicine, and Society class involves a case of missed appendicitis that led to a $25,000 hospital bill after the patient required multiple abdominal surgeries and time on a vent. Even more interestingly, his initial presentation to the ED was exactly the same as mine in Sedona: abdominal pain and vomiting with no abdominal tenderness. The big difference, of course, is that 48 hours later I was better. The patient in our exercise returned with the same symptoms. Still no abdominal tenderness. Of course, he didn't have the benefit of a prescription for antiemetic suppositories, either....

February 22, 2006

Economic incentives made me do it!

Back in the middle ages, we were fond of explaining every problem by attributing it to God's will. That era is over, but we haven't abandoned our love of universal knee-jerk explanations for everything.

The New York Times has an article about the medical "misdiagnosis crisis" that resorts to our era's equivalent of God made me do it. Of course, I'm talking about "economic incentives."

Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.

There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.

While there may be some truth here, let's not forget that doctors are motivated by things other than money (although they sometimes make it difficult to convince others of this).

A Very Big Day

Apart from Match Day itself, today is the biggest day in the whole residency match process.

Today is the deadline for submitting my rank order list for this year's residency match. After I submit my list, I'll be contractually committed to accepting a position at whatever program pops out of the Match Computer in March. And the identity of that program depends heavily on how I order my list. So, today is a Very Big Day.

It feels like a big day even though my list has been set for a long time already, and even though I'm pretty excited about most of the programs on my list. Because I'm not in medical school or surrounded with medical students, though, I feel like today is my own private holiday -- with a visit from the mailman to boot!

I think I'll celebrate by doing the reading for my Federal Courts class tomorrow: state procedural foreclosure of federal habeus corpus review. Ok, and a cold beer to go with that.

[For people who aren't familiar with the medical residency match, here's what happens. Residency applications aren't handled like applications for law firm jobs or clerkships. Instead of each firm or judge making you an offer which you are free to accept or decline, each residency applicant submits a list of all the programs they'd like to be considered for to a central organization, the National Resident Matching Program (NRMP). Meanwhile, each residency program submits a list of all the candidates they would like to train. These lists are ordered from the most desired program/applicant at #1, to the least desired program/applicant that's still acceptable. A big Central Computer uses a mysterious algorithm to match applicants with residency programs given how highly each ranks the other. For example, if I rank a program #1, and that program ranks me #1, then the computer will match us up (and we'll both be happy). It's a little more complicated when I've ranked a program #4 and they've ranked me #33.]

January 24, 2006

Doctors need a political clue

Ask any physician if there's something about the health care system that's broken, and you're likely to get an earful. Malpractice law usually heads the list, followed closely by declining reimbursement and intrusion by insurers and regulators into the doctor/patient relationship. All of these issues are so irritating for doctors in part because they can't be solved by physicians alone. Solving any one of them will involve going up against non-physician interest groups -- insurers, regulators, and trial lawyers -- that have their own ideas of what's best for the public and for themselves. In other words, doctors are going to have to fight and win some political battles.

This, by itself, is why doctors should unilaterally stop accepting all gifts from drug companies and medical device manufacturers.

Forget about whether it's legal. Forget about whether there are some vaguely plausible arguments that consulting fees and free lunches are harmless. Doctors need to convince the public that they, and not the insurers, bureaucrats, and trial lawyers, are the "real" patient advocates. They can't go on assuming that the public will trust physicians more than they will anyone else. Those days, if they ever existed, are long gone.

Because doctors won't stop playing footsie with gift-giving corporations, the public can read about how Medtronic "paid" $400,000 to one surgeon for eight days of "consulting work." They can read about how medical students are "acculturated" to accept gifts from drug companies, and about how "80% [of medical students] said they were entitled to these gifts because of financial hardship." (Here's the JAMA link, for those with a subscription.) Regardless of the propriety of these gifts, doctors can't just assume that patients and the public are going to buy their long-winded defenses of these kinds of lucrative relationships. When physicians are quoted in the newspaper defending questionable practices along with the deeply-distrusted pharmaceutical industry, they're digging themselves a deep political hole. People start to think their doctors are greedily chasing the money like everyone else.

Once we realize that we've got some important political battles to fight, physicians might be more inclined to come down hard on any behaviors that even smell funny. What would help doctors politically more than anything else is if the public could read about how the AMA and their state medical society were enthusiastically supporting a ban on accepting gifts from industry. Sadly, one of the authors of this article is quoted as saying he thinks "it's not very likely" that doctors will endorse the proposal.

I'm sure most doctors agree the consulting fees and the trips to the strip club aren't worth the hassles of a malpractice system that doesn't compensate injured patients or punish negligent doctors. The problem is that physicians don't seem to realize that these two issues are connected. But we're in the realm of politics, baby, and that means that trust is everything. Perhaps more than anything else, doctors must fight to earn the public's trust. Doctors, here's some political advice: get a clue. Stop accepting drug company gifts; make even the suggestion of improper influence manifestly absurd. You might have a chance to recover your leadership role in healtcare debates.

January 21, 2006

Pennsylvania EMS recruiting video

Via Random Acts of Reality, watch this video.

"You've got to have badass in your blood."

January 08, 2006

Yay, Bayh-Dole!

Ever since the Bayh-Dole Act was passed, universities have scrambled to patent everything they could in the hopes of reaping rich rewards from the licensing revenues that are occasionally possible when you hold a lot of patents.

This article from JAMA ($) suggests that that revenue is not in fact very significant for the vast majority of universities, and that in many cases the costs of maintaining a technology transfer office to handle the patent applications and the licensing eats up any revenues that flow from technology licenses.

Only a few universities reap large net revenues from licensing. Surprisingly, these aren't always the universities that spend the most on research. Harvard? Stanford? Neither make a ton of money from licensing, at least relative to their research expenses. The universities that score big usually score big because they get lucky. For example, Florida State pulls in big cash because they have the patent on the anti-cancer drug Taxol. The University of Florida cashes in on the Gatorade trademark (wtf??).

The authors argue persuasively that, as a tool for motivating productive research, technology licensing hasn't had a huge effect in the U.S. They point out that other countries considering this model ought to worry that if they don't have a robust system of publicly-funded research, relying on technology licensing is more likely to slant research toward the benefit of the rich, who can pay large licensing fees. That this hasn't happened in the U.S. is probably because we still have a healthy amount of public research funding available.

October 22, 2005

Residency applications

By now most of you know that I'm applying for a residency position in emergency medicine. To all of my law school classmates who were jealous of my free time when they were preparing their applications for judicial clerkships: you can gloat now.

Writing the personal statement for my residency application is not an easy thing to do.

After all, it's not really a personal statement, it's an argument. In one page or less, you've got to make the argument that you're a great candidate who is eager to learn, loves patients, is a joy to work with, and is someone who will eventually be a leader in the specialty (among other things). Of course I think I'm all that, but making the arguments on my own behalf isn't easy.

You want to make a powerful argument for yourself without sounding arrogant. You need to reassure the program faculty that although you're confident you'll realize your lofty ambitions, you haven't forgotten that the road to success is paved with patience (patients?) and hard work.

It'd be a lot easier if I could just say that I wanted to practice emergency medicine because it's fun. Even the drunks. At 3 a.m. on Saturday. After the internal medicine attending has chewed you out for what she thought was an inappropriate admission. Even after all that, it's still fun. Maybe I'll say that, too.

"But wait!" the program faculty will say to themselves. "He's too naive. He hasn't considered the fear of random malpractice suits. Silly lawyer!"

Ahem. I just hope that my recommenders don't remember any good military quotes.

October 20, 2005

Mathematical medicine?

Can medical research benefit from the insights of applied mathematicians?

The problem with medical research to date is that it isn't a mature science, the way physics is. It can draw connections, such as between obesity and lifespan, but it yields little understanding of why or how things are connected. And it can't predict outcomes.

"What we claim to have known is correlative rather than mechanistic," says Dr. Jim Keener, an expert in mathematical biology at the University of Utah who spoke at the centre's opening. "It's historical rather than predictive. It's qualitative rather than quantitative."

Mathematical medicine, which has been growing steadily in the past 10 years, promises to fill those gaps.


Prognosis has always been the achilles heel of medical science. No doubt the mathematicians will be useful, but we'll never be able to predict every outcome with certainty.

Even the physicists can't do that.

October 18, 2005

Emergency medicine and critical care

Despite the fact that emergency physicians specialize in identifying and caring for critically ill patients in the emergency department, they do not have access to certification in critical care medicine (CCM). For the benefit of patients, this should change. A few recent articles give me hope that it will.

Huang et. al., in an article published in both Annals of Emergency Medicine (46(3): 217-23) and Critical Care Medicine (33(9): 2104-9) lays out the argument. Recent studies have found that ICU patients do better (for less money) when they're cared for by a trained intensivist. The problem is that there are too few trained intensivists available. Internists, surgeons, anesthesiologists, and pediatricians, if they complete a CCM fellowship, are eligible to obtain certification in critical care, and have been for some time. But there is evidence that interest in CCM fellowships among residents in these specialties is low. At the same time, there are many emergency medicine residents who are chomping at the bit to specialize in critical care and would pursue fellowship training if they had a reasonable expectation that they'd be able to practice in the ICU. Without the ability to obtain certification in CCM, their prospects for finding such opportunities are highly uncertain.

In an editorial published in the same issue of Annals, Dr. David T. Overton writes:

There seems to be little logical rationale to limit critical care fellowship training and board certification only to graduates of internal medicine, anesthesia, general surgery, and pediatric residencies. Unlike some other subspecialties, critical care medicine has always been a multidisciplinary field. Indeed, critical care medicine has as much or more in common with emergency medicine as with these other specialties. As Huang et al point out, emergency medicine residency curricula are Residency Review Committee program requirements–mandated to include at least 2 months of critical care. In fact, they often contain considerably more (mine contains 6 months).

Drs. Somand and Zink point out in their article in Academic Emergency Medicine (12(9): 879-883) that turf wars over CCM between the new specialty of EM and other established specialties played a large part in the struggle to achieve primary board status for emergency medicine. Basically, the American Board of Internal Medicine agreed to support the American Board of Emergency Medicine's petition for primary board status only after ABEM had agreed not to pursue authorization to issue certification in critical care. The history of these turf wars are fascinating, but it reveals that there isn't much patient-care justification for excluding EM physicians from CCM certification.

As I read Somand and Zink's history, these turf wars arose because of the fear that emergency medicine physicians would start to horn in on in-hospital continuous care at the expense of internists. Well, now that we have several decades of experience with emergency medicine as a recognized specialty, I think we can put that fear to bed. EM residents go into EM because, among other things, they want to care for critically-ill patients in the ED. (If they wanted to do what most internists do, they'd have become internists.) The ICU is a quintessentially interdisciplinary place, so it's no surprise that some significant subset of EM residents would want to extend their practice to that arena. At a time when too few internists, surgeons, and anesthesiologists are specializing in ICU care, it's absurd not to welcome the emergency physicians aboard.

October 02, 2005

Health care priorities

Health care resources, as we all know, are scarce. How has our country chosen to distribute these resources?

In Michigan, family medicine is "dying" as medical students are lured away from primary care.

More than a quarter of Michigan's 12,700 primary care physicians are at retirement age, according to a recent report from the Michigan State Medical Society. At the same time, today's medical students are being lured to specialty fields that promise better pay, more manageable hours and the chance to work with flashy new technologies and treatments. (Via Kevin, M.D.)

At the same time in California, EM physicians are finding it harder and harder to find specialists who will care for their patients:

Hospitals are paying $600 million a year to ensure that on-call physicians are available - and still some communities are having problems finding specialists," Emerson said.

Kivela said that if a patient shows up at the emergency room with a broken jaw and has no insurance, the emergency room physician has a dreadful task of finding an oral surgeon willing to come in and take the case.

"I'll have to call eight or 10 different doctors," he said. "I'll spend two hours making these calls while a bed is taken up in the emergency room while sick patients wait." (Via Symtym.)

This may be absurd, but it's not chaotic. We have a system that draws money and talent away from the most cost-effective fields of primary care and into the less cost-effective specialties, while this same system also makes it more and more difficult for a patient to gain access to those specialists. It's no wonder that our country performs so poorly on virtually all measures of public health like life expectancy and infant mortality.

Of course, we haven't gotten here by accident. We've chosen to endure these piss-poor public health results because we don't want to disturb our unquestioned ability to provide the world's best high-tech medical care to those patients who can afford to pay for it themselves.

We've chosen to lower medicaid and medicare payments to primary care physicians because we're both unwilling to bear the tax burdens of these redistributive public health programs, and we prefer to spend what tax revenue we do collect on the development of high-tech medical treatments. These high-tech solutions are favored by the private sector because they're a lot more lucrative than low-tech primary care. We've chosen to funnel our finite amount of health care resources into the pockets of pharmaceutical companies, medical device manufacturers, hospitals, and specialist physicians who primarily treat the wealthy self-insured. This has been at the expense of cost-effective primary care and low-income chronically ill patients.

Is this a good thing? Some of us think not. More of us -- at least to the extent that our policies reflect our democratic preferences -- think it is.

October 01, 2005

Tort reform and HMOs

Most physicians who talk about "tort reform" today are talking about changing the mechanics of malpractice suits against doctors. I wonder, though, whether we're not overlooking some important issues that have nothing to do with malpractice liability caps.

Dr. Wax says the following:

Managed care plans require that a physician accept all patients who choose him, dictate how often he may see the patient, the amount he'll be paid and when, and, in many instances, what he can prescribe. They can rescind previously paid compensation at will, and do. In reality, HMOs are practicing medicine since they must approve every test, course of treatment, and referral to a specialist, yet they are rarely, if ever, legally responsible. Meanwhile, the physician is left to suffer the consequences of any malpractice suit.

Back in the late 90s this kind of complaint seemed to be a lot more common. Now, though, you almost never hear it anymore. The only issue that seems to matter these days is malpractice reform, specifically liability caps and the rising cost of malpractice insurance. What ever happened to the HMOs?

Continue reading "Tort reform and HMOs" »

September 20, 2005

For shame! (updated)

NEW YORK -- A doctor's group critical of drug companies is protesting its exclusion from the American Academy of Family Physicians' (AAFP) annual Scientific Assembly—a major event for pharma marketers.
Come on, is exclusion really necessary? Well, maybe it is if the event is less a "scientific assembly" than it is an opportunity for pharmaceutical firms to ply doctors with gifts rather than persuade them with scientific evidence. (Via Matthew Holt.)

EDIT: GruntDoc links to Dr. RW, who links to the No Free Lunch website. Apparently the AAFP has changed its mind. Good for them.

The best part of this story?

No Free Lunch has accepted the AAFP’s invitation and plans to be present at the session which opens September 28 at the Moscone Center. Attendees are encouraged to visit The No Free Lunch booth, #1613, immediately adjacent to that of the California Table Grape Commission.

Open dialogue about the pharmaceutical industry's influence on physicians may not be, but it's reassuring to know that table grapes are definitely "within the character and purpose of the Scientific Assembly."

Here's the AAFP's press release.

September 16, 2005

Medical student depression: what to do about it

This week I posted links to two interesting pieces about medical school:

1. Medical students tired, underworked? (a NYT article about sleep deprivation among medical students)

2. Medical students: tired, bored, and depressed? (a New England Journal piece about the high rate of depression among medical students)

Let's take the depression piece first. There have been some good comments on physicians' blogs about the reasons why medical students get depressed. Sydney at Medpundit acknowledges that medical school is a "completely transformative process" and a time of profound change, and then she blasts the brutality of the clinical teaching:

The third year of medical school, when students enter the hospitals and see patients, also marks the moment that their teaching is handed over entirely to practicing physicians - and they are brutal. The brightest and best students are treated as know-nothing scum and burdens to be born by the rest of the medical team. There is never, never, any praise - only denigration. At least, that's the way I remember it, with few exceptions.

I don't know how many years it's been since Sydney graduated from medical school, but her venom here reminds me of several conversations I had with alumni of my medical school. They were still viscerally angry at the way they were treated as medical students, even though they'd graduated ten years earlier.

This anger certainly isn't universal. Several commenters on Dr. Kevin Pho's blog seem to have had a much more pleasant experience:


Med school was the best four years of my life. The comraderie was great. I became more efficient and it seemed easier (perhaps because it was always interesting) than actually getting into medical school. I also met my wife, ran a marathon, and had a lot of good times while going 120K in the hole.

My own experience in medical school was a little bit of both. I ran three marathons, but my times got worse with each race. (I attribute that to the chronic sleep deprivation of med school...) Medical school was a happy time because I was learning so much and doing so many interesting things. You can't help but be thrilled when you've learned enough to take a thorough and efficient history from a patient in the ED, or when you can start to decipher an EKG, or (even better) when you've learned to juggle both tasks in a busy ED at three in the morning (my attraction to emergency medicine may be obvious here). On the other hand, I can remember being treated like a "know-nothing scum" on some of my rotations. That's not fun. I remember feeling isolated because I almost never got to rotate through a service with my friends, and just when I felt I was starting to get to know people on one rotation, it was time to move to a different one, sometimes at a different hospital, and once again I wouldn't know anyone at all. I hated the feeling that I was constantly being evaluated, and not just on my patient care and my knowledge, but on my "enthusiasm." Sometimes it all felt like I was never allowed to just be myself.

I don't know if any of these anecdotes are helpful for identifying systemic reforms. Much of how you experience medical school depends on your individual situation. If you're lucky enough to meet some good mentors, or an inspirational former cardiologist from El Salvador, or your future spouse, then you'll like it a lot more. Perhaps any systemic reforms ought to be aimed at ensuring that these things happen more often.

Here's some off-the-cuff suggestions:


  1. Give medical students more control over their schedules. There's plenty of studies out there showing that hopelessness is correlated with feeling unable to control what happens to you. Medical school curricula that don't allow any electives until the fourth year, rotations that give students no control over their call schedules, and attendings that don't give students any responsibility for deciding when to go home each day all contribute to the sense that you're not driving your own bus. Also, if you have more control over your schedule, the chances that you'll rotate with your friends will increase, so your sense of isolation will decrease. It's probably much more effective to give students more control than it is to limit their work hours or give them more time off.

  2. Adopt a zero-tolerance policy for unprofessional behavior by attendings and residents. It's unprofessional to belittle a medical student (or anyone else) at any time, but especially in front of the patient or the medical team. Attendings who routinely do this often claim that they're just providing constructive criticism, but it's funny how their constructive criticism of people with authority over them is never the same as their criticism of underlings. These attendings know what's right, but they just choose not to do what's right. Everyone's going to be grumpy or angry from time to time, but there are professional and unprofessional ways of expressing anger. Apologies are always free. If medical school deans and department chairs are proactive and lead by example, the instances of unprofessional conduct towards underlings will decrease dramatically. It's got to start from the top.

  3. Each service should explicitly define the role of the medical student as much as possible. Many of the problems described in the NYT article above come from not being clear about what the medical student's role is. Vague slogans like "the medical student's role is to learn as much as possible and to assist the team" aren't inaccurate; they're just insufficient. Is the student's primary job to learn as much as possible? Then he or she shouldn't be expected to get burritos for the team at 11 pm. Let them do it if they want, or if it's fair, but don't forget to ask why they aren't reading about the patient they just admitted instead. Or maybe the student's role is to assist the team -- like it often is on a busy ob/gyn service. Be explicit about that. "Hey, we're so busy that the best way to teach you and still care for our patients is to designate you as the all-around gofer. Expect it, keep your antennae out, and you'll learn a lot." Maybe the only role for the student is to observe, like perhaps on a third-year neurosurgery rotation. In that case, explicitly allow the student to go home when there aren't any more cases scheduled.

Medicine can be an infinitely rewarding profession. The intrinsic desirability of the career shouldn't be an excuse for medical schools to get lazy and to neglect the basic principles of effective education. Medical school deans ought to worry when they see such high rates of medical student depression, and they ought to think seriously whether there's anything they can do about it. Even if most depression turns out to be caused by the student's first exposure to sickness and death, for example, the medical schools could ameliorate this problem by admitting more students with clinical backgrounds like EMTs and nurses who've seen sick patients before.

Ultimately, we owe it to our patients to make sure that we're the best physicians we can be. Depressed physicians can't function as well over the long term as non-depressed physicians. If the medical schools did their part, and if the medical students did theirs (by taking care of themselves and seeking help when they need it), our patients would reap the benefits.

EDIT: You can read more anecdotes at over my med body.

September 15, 2005

Vioxx and the jury system

Evan Schaeffer has posted his defense of the jury's decision in the first Vioxx trial:

That was the promise of Vioxx, but it wasn’t to be. And now, as a result, a very small minority of commentators are calling for tort immunity for drug companies and discussing reforms to the jury system that would benefit drug companies. I think these ideas are radical and unnecessary. The tort system and the jury system may not be perfect, but they are certainly better than any of the alternatives, especially those involving granting favors to drug companies that might lead to even greater health risks.

Medical students: tired, bored, and depressed?

On the heels of the NYT article I linked to yesterday comes this article in the New England Journal of Medicine:

White Coat, Mood Indigo — Depression in Medical School
...
Medical students are more prone to depression than their nonmedical peers. Researchers recently surveyed first- and second-year medical students at the University of California, San Francisco (UCSF), and found that about one fourth were depressed. Others have suggested that although the rate of depression among students entering medical school is similar to that among other people of similar ages, the prevalence increases disproportionately over the course of medical school.
...
Students may become depressed at any point in medical school, but Gartrell has found that the period of greatest distress occurs during the third and fourth years, when students rotate through the hospitals and clinics. "In the clinical years, there's just far greater commitment of time, plus as match pressure begins to emerge, it's an extremely stressful time for a lot of people," she said. Students are often separated from friends and classmates and must work with a constantly changing set of residents and attending physicians, which contributes to their sense of isolation. Gartrell said that many of the female students she sees are worried that the mounting demands of training and clinical practice will not allow them time to find a partner, marry, and have children. Haynes noted that the increase in sleep deprivation during rotations may also expose mood disorders.

Again, I'll have to defer comments 'til later. Gotta run to Crim Pro now.

September 14, 2005

Medical students tired, underworked?

The New York Times has this article about medical students:

While sleep deprivation and long workdays are deemed rites of passage for medical students, there is growing concern among medical educators that students may be spending excessive hours in hospitals doing work of little educational value, to the detriment of their education and health.

I'll have to hold my comments for later -- must read for class now.

September 03, 2005

FDA rejects over-the-counter Plan B

By now everyone's heard that Susan Wood has resigned from the FDA in protest over the agency's decision to indefinitely delay the approval of the OTC emergency contraceptive known as Plan B (levonorgestrel, the "morning-after pill").

Ordinarily I wouldn't have given this much thought, since I try to avoid the abortion issue whenever I can. It was only because the forceful denunciation of the FDA's decision (pdf) in the New England Journal of Medicine was so fun to read that I'm posting about this now. Not since Terri Schiavo have we had such a good demonstration of the political power wielded by social conservatives, even when they're totally out to lunch on the substantive arguments of the issue.

The arguments supporting FDA approval of this emergency contraceptive drug for over the counter availability are solid. The scientists on the agency's advisory committee voted overwhelmingly in favor of it. There's been a lot of hand-waving by the FDA about safety in younger women, and about the agency's authority to approve a drug for both prescription and OTC use by people in different age groups. The major arguments against Plan B, however, come down to two. First, that Plan B causes abortion, and second, that unrestricted access to Plan B by people younger than 17 would harm them in some way.

The first argument is weak on several levels. Most studies that I can find suggest that levonorgestrel prevents pregnancy by interfering with ovulation, not by preventing the implantation of a fertilized ovum (see, e.g. Croxatto et. al., Contraception 70 (2004), pp. 442-50; general discussion here). But even if, as groups like Concerned Women for America point out, we don't know the exact mechanism of action, it's hard to sympathize with their stance on this issue. To block access to a safe method of preventing unwanted pregancies because the drug might occasionally prevent implantation of a fertilized egg demonstrates the absurdity of the extreme anti-abortion position. An unwanted pregnancy can be profoundly harmful to an adolescent girl, to say nothing of the potential harm to the child. That the strict anti-abortionists would prefer these harms over the harm to an occasional fertilized egg that's prevented from implanting in the uterus is patently absurd. This kind of policymaking deserves the label "extremist."

The second argument, that access to Plan B without a prescription would harm women under 17, is equally weak. Wendy Wright of Concerned Women for America argues that OTC availability would increase rates of sexually transmitted disease, but I don't know how much credibility she should be given after she says things like this:

What's more, experts have found that men will frequently buy it, and some slip it to unsuspecting women. An age restriction would not hinder men who would buy the drug and give it to underage girls.

It is naive to assume any over-the-counter scheme for the morning-after pill would be effective. A 17-year-old could buy it for a 13-year-old girl. Or worse yet, a pedophile could purchase this drug for his victims.

This wingnuttery sounds like what we'd expect from someone who was profoundly afraid of people under seventeen having sex, and/or who deeply misunderstands the connection between the availability of a drug and the likelihood of criminal behavior.

We should be concerned about underage people getting sexually transmitted diseases, and we should be concerned about pedophilia, but the connection between these things and Plan B is just too speculative. What's not speculative is that Plan B prevents unwanted pregnancy, and that unwanted pregnancy harms people, often in a very profound way.

The FDA can't do its job properly if it's being pushed and pulled by politicians who ought to be debating social policy in other arenas. If Congress doesn't want Plan B approved, they ought to legislate to that effect. Leaning on an agency that's charged with ensuring drug safety will only diminish the agency's credibility, and in the post-Vioxx era, it doesn't have a lot of excess credibility to play around with.

June 05, 2005

Hospital construction

If someone suddenly asked me why I thought health care costs in this country keep escalating despite all the Medicaid cuts and reductions in employer-provided health benefits, the first thing that would come to my mind is all the new hospital construction.

Who knows if that's even part of the right answer or not. All I know is, I see a ton of money being spent on shiny new hospitals everywhere I look. In Denver, the University of Colorado Health Sciences Center is putting up some very impressive new facilities at the old Fitzsimons army medical base. In Ann Arbor, the University of Michigan is building new hospitals and biomedical research centers like it was their job. In Chicago, the University of Chicago has just finished the new Comer Children's Hospital, and Northwestern is building the new Prentice Women's Hospital.

I wonder how much of the philanthropy that's funding this hospital boom is actually helping people with little to no access to timely medical care...

April 29, 2005

Lizard drugs

A diabetes drug derived from a poisonous lizard has been approved by the Food and Drug Administration, its developers, Amylin Pharmaceuticals and Eli Lilly, said yesterday.


The drug, called Byetta, will be the first in a new class of drugs to reach the market for Type 2 diabetes, the form that usually occurs in adults. . . .

Byetta is a synthetic version of a peptide, or small protein, found in what has been variously described as the saliva or the venom of the Gila monster, a poisonous lizard that lives in the Southwest and Mexico.

April 20, 2005

Health care flab in the land of hypomania

Although we have many reasons to be proud of our doctors and hospitals, Symtym reminds those of us in the U.S. that we're still living in the world's medical money pit.

America does some things right, but it could stand to learn a little bit about the things other nations do better. How, then, can I not link to Ezra Klein's effective and short summaries of the health care systems in France, England, and Canada? While none of these nations is quite as pleasant as the USA for rich people who get sick, each of them manages to squeeze a whole lot more efficiency (and efficacy) out of their health care spending than we Americans do.

Perhaps some Johns Hopkins psychologist will explain to us someday why our healthcare system is so bloated and flabby despite our overabundance of hypomanics. Or maybe Ezra Klein, that nauseatingly over-achieving student at UCLA (sounds like hypomania to me!) will tell us all about the rest of the world, and we won't listen. Stay tuned, folks -- there's never a dull moment when the subject is health care in the United States.

March 09, 2005

Just thinkin'

So, if the Supreme Court overturns the 9th circuit in Gonzales v. Oregon, what happens next? Would that ruling effectively kill (pardon the pun) Oregon's Death With Dignity Act?

Could Oregon physicians help people commit suicide without using controlled substances? Could they just inject people with potassium chloride without premedicating them with sedatives? Would that be humane?

Are there any sedative drugs not under the control of John Ashcroft and his successor, Alberto Gonzales? Just wondering...

March 07, 2005

Antitrust violation?

Pfizer Stirs Concern with Plans to Sell Heart Drugs Only as Pair (NYT)

* * *

Pfizer's plan might seem to violate antitrust law, which can prohibit companies from "tying" products together or refusing to sell one unless customers buy another. But antitrust lawyers said the company's plans were legal, as long as the F.D.A. approved the drugs in combination.

"It's the F.D.A. that's doing the tying," said Herb Hovenkamp, a law professor at the University of Iowa. "Assuming the F.D.A. accepts Pfizer's test results and certifies this drug only when it's taken in conjunction with Lipitor, then that would then become the government's restraint, not Pfizer's restraint."


We should find out what percentage of the development costs of torcetrapib were paid for with taxpayer money and NIH grants before we let either Pfizer or the FDA off the hook on this one.

March 04, 2005

Health Literacy

[H]ealth literacy can save lives, save money, and improve the health and well-being of millions of Americans health literacy is the currency of success for everything I am doing as Surgeon General

--Surgeon General Richard Carmona (2003)

The one panacea that nearly all Americans believe in is individual choice. There's no social or political or economic ailment that we think can't be cured with a devolution of more decision-making authority to the individual. Hence our love of free-market economics, and our obsession in bioethics with "autonomy."

Both of these obsessions are animating our most recent attempts to restrain our skyrocketing health care costs. If we can only give individuals more "say-so" over their health care, costs will plummet and quality will go up. Despite the rich supply of international examples demonstrating that a modern society can get better health outcomes for less money when the government takes a more active role in insuring all its citizens' health care, and in monitoring its quality, we Americans find it easy to dismiss such examples in favor of our home-grown cure-all: more individual choice. MSAs, defined-contribution plans, more effective advertising of doctors' and hospitals' performance histories, private Social Security accounts, direct-to-consumer drug advertising -- all these policies and more are designed to provide information to the health-care consumer so that they can make the decision for themselves, and by doing so, improve health-care quality and lower its cost to boot.

Ah, panaceas. Hope does spring eternal.

No doubt that individual choice, in some if not most contexts, is the best possible aspiration we can have. The problem with aspirations is that sometimes they don't match up with reality. The fact is, many people (including myself) just aren't well-enough informed (for many different reasons) to exercise the kind of individual choice that we believe will cure all our health care ills. Some observers have noted this problem, and have curiously referred to it as a lack of health care "literacy."

A 29-year-old African-American woman with three days of abdominal pain and fever was brought to a Baltimore emergency department by her family. After a brief evaluation she was told that she would need an exploratory laparotomy. She subsequently became agitated and demanded to have her family take her home. When approached by staff, she yelled I came here in pain and all you want is to do is an exploratory on me! You will not make me a guinea pig! She refused to consent to any procedures and later died of appendicitis.

This vignette comes from a report issued by the National Academies Press called "Health Literacy: A Prescription to End Confusion." The authors are rightly concerned that although "health consumers" are being asked to make ever-more complicated choices, "over 300 studies have shown that health information cannot be understood by most of the people for whom it was intended...." The vignette is misleading because it suggests that health literacy comes down to teaching everyone the meaning of the word "exploratory." But this general illiteracy isn't the real problem. The real problem is that each of us is being asked to make more and more complicated decisions that are difficult for even the most highly educated among us to make. A few weeks ago I asked for some information from an insurance company about an HSA. Heath Savings Accounts are all the rage these days as a way to "empower consumers" to "take control" of their own health-care spending decisions. When I got the information in an email, I couldn't understand it. Sorry. I know, I have an MD; I'm about to get a JD; I've been around and seen some things. But this HSA stuff was just plain confusing.

It's a testament to the power of our belief in individual choice that the report's authors blithely assume that our health illiteracy can be corrected (usually by another beloved American panacea, education). Another possibility -- that these 300 studies reveal the inherent limits of our individualist approach to solving all our health-care problems -- isn't considered.

Perhaps you'll get a sense of how futile correcting our collective "health illiteracy" might be when you read some of the report's specific "visions" for a health-literate America:

  • everyone has the opportunity to improve their health literacy.

  • people are able to accurately assess the credibility of health information presented by health advocate, commercial, and new media sources.

  • health practitioners communicate clearly during all interactions with their patients, using everyday vocabulary.

  • rights and responsibilities in relation to health and health care are presented or written in clear, everyday terms so that people can take needed action.

Ok, and no one should ever sleep late, the Cubs should win all their games, and the stock market should go up continuously forever. Anyone who pays any attention at all to the real world will realize that these visions are either utopian, or they're trite and silly.

Robert M. Fineman's overly-indulgent review of this report in this week's New England Journal of Medicine says more than its author seems to know. "Although it is a minor point in a review of this outstanding contribution to the public health literature, I believe that an almost Talmudic-length commentary is needed to describe the assessment, policy development, assurance (implementation and evaluation), infrastructure, and capacity-building activities and resources needed to end the confusion regarding health literacy in the United States today." Since "ending the confusion" would amount to describing how normal human beings might be remade into superhuman health care consumers, I suspect the commentary would have to be a lot longer than even the Talmud.

You won't find me holding my breath waiting for the "health literacy" crowd to produce any such thing.

February 20, 2005

'Futile' treatment for incompetent patients

Dr. Bard-Parker has a thoughtful post about a 79-year-old patient with a terminal illness whom doctors at the Massachusetts General Hospital want to remove from life support against the wishes of her family.

Dr. Rangel has an equally thoughtful post about an infant in Texas born with a birth defect that requires prolonged ventilator support, leads to severe mental retardation, and is uniformly fatal before adulthood. Doctors at Texas Children's Hospital in Houston want to disconnect the infant from the ventilator against the wishes of his mother.

When it comes to the question of making treatment decisions for incompetent and terminally ill patients, Bard-Parker draws the reasonable distinction between initiating new treatment and withdrawing treatment in progress: "I have no problem with the withholding of aggressive or invasive therapies to patients that would not benefit from them or change the eventual outcome, despite family wishes[.] I also believe that families can and should make decisions about the withdrawal of care." This position corresponds with our intuition that families ought not to be able to compel physicians to provide futile treatment. It also acknowledges that the family is probably the best proxy for the patient when the decision concerns something that looks like "refusal" of treatment that doctors are already providing.

But does this make too much of the distinction? The patient at Mass. General has been in a hospital bed and on a ventilator since 1997. Her condition is incurable. Assuming that the patient is in fact not conscious and has no hope of ever regaining consciousness, the family's insistence that the patient be kept on the ventilator looks more like they are compelling the hospital to provide futile treatment. The physicians in the ICU must perform affirmative acts that they regard as futile -- something that the family could not require of surgeons if they insisted that a futile procedure be performed on the same patient.

Dr. Rangel points out that the physicians in both Massachusetts and in Texas have good reason to believe that continued treatment will only cause the patients to suffer. Should a doctor be compelled by the family to prolong suffering, if they cannot be compelled to 'initiate' suffering?

Dr. Rangel asks:

Is the system broken? Too often I hear about court decisions that dismiss the opinions of medical professionals and allow terminal patients to continue to suffer. Probate courts appear to be far less responsive to the continued suffering of terminal patients with incurable conditions than they are to the demands of patient families no matter how irrational or disconnected they are from considering what is best for the patient. Why is this the case?
Dr. Rangel identifies one reason: fear of euthanasia. Judges might feel (reasonably) that they are not in the best position to have an intimate knowledge of the situation, and might decide (again, reasonably) to "play it safe" by requiring that treatments continue.

But Rangel is surely right that this approach can lead to patient suffering. That's why legislatures have good reason to provide protocols that relieve the judge of the need to make case-by-case decisions about withdrawing medical treatment. The Texas Advance Directives Act (link to pdf file here) seems like the right approach. The law requires hospitals who want to withdraw treatment against the wishes of the family to obtain an ethics committee consult, undergo a waiting period, and attempt to transfer the patient to another facility who will abide by the wishes of the family. In this case, a judge will most often only have to decide whether there is a reasonable expectation that an extension of the waiting period will make it possible to identify a facility that will accept the transfer of the patient.

I don't think Dr. Bard-Parker needs to fear an American version of the Groningen Protocol, but I also think Dr. Rangel exaggerates the "faux standard of care" imposed by the courts. Fortunately, I think most families and physicians will be able to come to some kind of consensus regarding futile treatment. When they cannot, legislatures and courts together can fashion sensible rules to deal with the dispute. This doesn't mean they always will, only that they are capable of it if the rest of us hold them to high enough standards.

February 16, 2005

Educating doctors

Dr. Centor responds, more graciously than I would have, to an email defending drug reps.

The substance of the emailer's argument is that without drug salesmen to help doctors stay up-to-date, physicians would be incapable of keeping abreast of the latest drug information.

Technically, the drug reps are right when they claim to be educating physicians. This is exactly why they ought to get the heave-ho. If they were merely selling, and not educating, they'd be much less dangerous. Education is powerful stuff, but it's not always a good thing.

We like to think of education as an unvarnished good, because we confuse education with the mere acquisition of knowledge. Education certainly includes the acquisition of new facts, but it also involves ranking these facts, using these facts, and identifying which of these facts are more important than others. All of this involves judgment, which is in turn dependent upon values.

This is why education is valuable, and why it's dangerous. We trust people who have been educated in medical school and residency to practice medicine not merely because they've learned some facts and skills about anatomy and physiology, but also because they've learned to make judgments about these facts and skills that are consistent with the values we believe a physician should have. We would not say that an equally knowledgeable person who was taught his medicine in a school of Exquisitely Slow and Creative Torture had been educated to be a doctor.

If this is true, and if it's true that drug reps really are educating physicians, is this a good thing? Do we want our physicians taught by representatives of Big Pharma? Do we think this kind of education is best for our patients? Big Pharma teaches facts about drugs, but as Dr. Centor suggests, they also teach other things: the newer drug is better; any drug is usually better than no drug; most patient complaints should result in a drug prescription. These aren't necessarily the values of a good physician.

If it's true, as Dr. Centor claims, that our current system of CME isn't working, he's also correct that the solutions should come from the state medical societies and the medical schools. Not the drug reps.

February 11, 2005

The COX-2 wars

Via Kevin, M.D., this juicy account of the Vioxx vs. Celebrex war reveals a profound difference of opinion on the question of how malleable doctors' prescribing habits really are.

Merck believed that doctors could be influenced, and they were willing to pay to do it. The doctors, on the other hand, all seem to be singing a different tune.

-- Dr. Roy Altman (selected by Merck to run a clinical trial involving Vioxx, to which the drug company contributed $25,000):

He also said his involvement in the trial did not affect his prescribing.
-- Dr. Robert Ettlinger (subject of a Merck memo urging that he be "kept busy" with clinical trials and describing him as "neutralized"):
The physician said in an interview that he was "absolutely shocked" that he had been singled out for attention, saying he regularly gave speeches for many drug companies. Such work never affected the drugs he prescribed, including Vioxx or Celebrex, he said.
-- Dr. Keith Feder (founder of a nonprofit foundation that accepted a $25,000 grant from Merck, which according to a Merck representative would give a "return on investment" of "51 percent share of [the] COX-2 market in 2000"):
In an interview, Dr. Feder confirmed that the foundation had received money from both Searle and Merck, but said that the grants helped support a continuing medical education program and were not intended to influence his prescribing habits and did not do so.
-- Dr. Max Hamburger (asked drug companies to subsidize retreats for a physician group during which the physicians would put together guidelines on what drugs to prescribe):
In an interview, Dr. Hamburger said that his group solicited funds from a large number of pharmaceutical companies to support its educational meetings and that payments from those drug makers did not influence the medications prescribed.
If there are physicians out there who actually admit that their prescribing habits were influenced by drug company largesse, no New York Times reporters have found any yet.

February 09, 2005

3 out of 1,000,000,000

Following up on this post, a reader sends a link to this story about a Swedish investigation into the safety of Red Bull energy drink.

Apparently, three otherwise healthy people in Sweden have keeled over dead shortly after drinking Red Bull. Two of the victims had mixed Red Bull with vodka; the other had just completed a "heavy workout at the gym."

This "outbreak" of Red Bull-related deaths doesn't seem to have stimulated much interest outside of Sweden (insert obligatory bad pun apology here). The UK isn't planning any investigations, and the U.S. FDA has been a bit preoccupied with statins and COX-2 inhibitors. There may be other nations as concerned as Sweden, but I haven't heard of any.

In the overall scheme of health risks, I don't think we have much to worry about from Red Bull. Over 1 billion cans were purchased worldwide last year, and I imagine quite a few of them were consumed just after exercise, or with alcohol. Meanwhile, most of us in the industrialized world keep dying of heart disease, cancer, and car crashes.

Besides, a trusted source informs me that Red Bull effectively kills the taste of vodka. Surely that's worth the risk.

February 05, 2005

Medical student debt

The Mad House Madman has a great post about the magnitude of medical student debt.

The bottom line: it's staggering. Even at the historically low interest rates we've experienced over the past few years, the payments required to service this kind of debt are huge. And as the Madman notes, these payments will get a whole lot bigger as interest rates begin to climb.

I posted a piece about a month ago about what I think is one of the major reasons for this ballooning debt: the failure of state governments to check the skyrocketing tuition rates of public medical schools.

I'm looking forward to the next post in the series, which promises to discuss the effects of debt on the decisions medical school graduates make. I suspect it will come down to this: new physicians must chase after money much harder than they would have had to absent the debt. In an age where health care costs are preventing many citizens from obtaining basic care, the last thing we need is a new generation of doctors who are desperate for more money. Sadly, that seems to be exactly what we'll get.

February 04, 2005

Requests

Thursday's announcement by the NIH that it will "request" that scientists who receive funding from the public agency to post their research on a freely-accessible website seems to have pleased no one. Is this an example of gutless policymaking, or a courageous refusal to give in to either side's extremists? Perhaps only NIH Director Elias Zerhouni knows for sure.

Regardless, it's more likely that NIH-funded scientists will respond to this request from Zerhouni than that big pharmaceutical corporations will comply with their trade association's request that they post the results of all clinical trials of their drugs on the internet. In the case of the individual scientists, any scepticism we may have about their likelihood of compliance is mere speculation. In the case of the big drugmakers, scepticism is demanded by their track record.

Last August, Glaxo SmithKline settled a lawsuit brought by Eliot Spitzer charging that it had suppressed unfavorable research data about the links between its antidepressant drug Paxil and suicidal thoughts in adolescents. The lawsuit drew attention to the distorting effects of the selective release of favorable data from drug company-funded clinical trials. The International Committee of Medical Journal Editors decided that they would not publish the results of trials that were not publicly registered at the time they were launched, and pressure mounted for Congress to mandate that all clinical trials be registered.

Big Pharma responded by announcing a new -- and entirely voluntary -- program for posting information about all "hypothesis-testing" clinical trials to an existing government site at www.clinicaltrials.gov. The information posted to the site would go well beyond the current requirements that companies post information about clinical trials involving treatments for diseases that are serious or life-threatening.

The problem is, the pharmaceutical industry isn't complying with the current mandatory reporting requirements for clinicaltrials.gov. On June 7, 2004 (before the Paxil scandal became news), Rep. Henry Waxman of the House Committee on Government Reform sent a letter (pdf) to the president of PhRMA describing the failure of the drug industry to post required information. The letter pointed out that FDA officials were concerned with the low rate of industry participation despite repeatedly sending notices describing the exact requirements of the law.

Even if PhRMA has a plausible argument for why drug firms were not required to post more often on the clinicaltrials.gov website, their reluctance to provide any more information than was absolutely required suggests that they might not choose to voluntarily comply with a request to post more data.

Requests can sometimes get the job done. This just might not be one of those times.

January 23, 2005

Client and patient responsibilities

A post by Carolyn Elefant got me thinking about what kinds of responsibilities clients have to their lawyers. Are these anything like what patients owe to their physicians?

Elefant writes about Rompilla v. Beard, an ineffective-assistance-of-counsel case that was recently argued before the Supreme Court. Apparently, the inmate-client in the case is arguing that his lawyers didn't review the court files diligently enough to find evidence in the record of the client's low IQ, alcoholism, and troubled childhood that might have saved the client from the death penalty. The lawyers apparently claim that they asked the client directly whether he had any problems with alcohol, and the client said no.

Elefant writes:

A court ruling finding the attorney rendered ineffective assistance won't just impact criminal practice - but will affect how all of us deal with our clients. Essentially, such a ruling would require the court to find that we cannot take our clients at their word. Now sure, attorneys have an obligation to diligently investigate a client's case - but that's more to determine whether the case is feasible rather than to continuously question what our clients have told us. And when clients begin to realize that it doesn't matter what they say because attorneys can't take them at their word, the trust so integral to the attorney client relationship will diminish.

Do clients have any obligation to tell their lawyers the truth? A quick search of the ABA model rules of professional conduct turned up very little on the subject of client responsibilities in general, and nothing on any obligation of truthfulness.

In comparison, the AMA expects patients to tell their physicians the truth. Policy E-10.02 states that:

(1) Good communication is essential to a successful patient-physician relationship. To the extent possible, patients have a responsibility to be truthful and to express their concerns clearly to their physicians. (2) Patients have a responsibility to provide a complete medical history, to the extent possible, including information about past illnesses, medications, hospitalizations, family history of illness, and other matters relating to present health.
These patient responsibilities don't excuse the physician from her duty to seek out the information, but the idea is that the relationship between a professional and an autonomous client can only work if both parties act responsibly.

Surely this must be the same for the lawyer/client relationship, unless it's a whole lot more paternalistic than the ideal physician/patient relationship. To the extent that lawyers are expected to treat their clients as autonomous persons, the clients ought to shoulder their share of the burdens. Otherwise, attorneys might turn into babysitters, and clients into children. Elefant writes:

Moreover, I want to empower my clients, not coddle them. Clients deserve as much. So, I take my time to explain the applicable law, why my clients must provide me with certain pieces of information and why that information must be accurate. But if we send a signal to clients that their input doesn't matter, and if they don't provide it, then the attorney and not the client will pay the price, we encourage them to remain passive bystanders rather than active participants in the judicial process. And that makes us attorneys caretakers rather than advocates.

January 05, 2005

Some new standard questions

Here's a good chance to practice our (hopefully) renewed skepticism in the face of the influence that big drug manufacturers have over clinical research.

The results of two new clinical studies on heart disease are grabbing headlines, and are likely to get a lot of public and professional attention. Both studies were sponsored by big pharmaceutical companies that make cholesterol-lowering statin drugs. According to the NYT, both studies suggest that C-reactive protein, or CRP, is an independent marker for important clinical endpoints--in the case of one study, heart attacks, and in the case of the other, heart disease progression. These studies might suggest that physicians should try to reduce their patients' CRP levels as well as their cholesterol levels. More aggressive use of statin drugs would be one way for physicians to do this.

The drug companies will almost certainly encourage patients, in the sonorous tones of the inevitable Pfizer ad, to "ask your doctor about CRP, and whether Lipitor is right for you." Bristol-Meyers-Squibb will trumpet the results of these studies in their Prevachol ads weighing down the next issue of American Family Physician. Both firms will certainly instruct their sales force to mention both studies in the detail lunches they provide in the back room of doctors' offices across the country.

Before the docs start reaching for their prescription pads, we can hope that they'll subject these studies to the usual close statistical and clinical scrutiny that responsible physicians should direct at any study. They'll note that neither study demonstrates that CRP is a cause of bad clinical outcomes. They'll realize that both studies looked at patients with known heart disease, and question the applicability of the results to healthy patients. Perhaps they'll also (God forbid) remember that exercise reduces CRP too.

Since we're wishing on stars, let's hope that they'll subject the studies to an economic and political scrutiny, too. How many studies may have been started or finished (but never published) which showed no independent correlation between CRP and any clinical endpoint? How much control did Pfizer and BMS have over the data in these two studies?

Seems to me, that's the physician's job. To exercise his or her best judgment on behalf of patients.

December 19, 2004

"Safe" drugs

In a NYT article discussing the controversy over the drug industry's heavy marketing of COX-2 inhibitors like Vioxx and Celebrex, we read the following:

But the rapid rise and now shaky future of [COX-2 inhibitors], some researchers say, is emblematic of the way drug companies' efforts to spur the use of costly new medicines can distort the medical realities of safety and effectiveness.
Is there such a thing as a "medical reality of safety"?

We often talk as if there is such a thing as a "safe" drug and an "unsafe" drug, and as if the FDA's job is to distinguish one from the other. But safety is like beauty--it's in the eye of the beholder. When I go on solo backpacking trips, it doesn't seem to me like I'm doing anything that's particularly dangerous. I suspect that my mom often disagrees with me. Who's right? Answering this question is like trying to figure out once and for all if Georgia O'Keefe's paintings are pretty or not.

There is really no such thing as an objectively "safe" medical treatment. The question we should be asking of the FDA is whether it is protecting the public in the way that we think is most appropriate. This means that critics and supporters of the FDA will have to make messy political arguments, because we will often disagree about what "appropriate" means. The crucial questions are who gets to decide whether a drug is safe, and what limitations we ought to place on efforts to influence that decision.

It's tempting to think that there's some sort of objective standard of "safety" to which we can appeal to short-circuit the political disagreement, but alas, there is no such standard. Anyone who tells you different is trying to sell you something.

December 08, 2004

Real people and "medical error"

Maria at Intueri describes what it can be like to make one of those "medical errors" that the policy wonks keep talking about. At least we know that Maria's a real person and not a robot.

Speaking of robots, I wonder whether the Massachusetts Blue Cross/Blue Shield's decision to finance a new electronic medical record system portends a greater involvement by health insurers in the push for systemic reforms that might reduce medical mistakes. I suppose it will come down to whether the insurers believe that the reforms will lead to lower costs. Scratch that: if it will lead to lower costs for the insurers. We're talking about the health care industry, and that means cost-shifting first and foremost.

December 02, 2004

private-sector obeisance

I'm no economist. To my layperson's mind, an article in this week's New England Journal of Medicine ($$) demonstrates how our nation's irrational fondness for the private sector can cloud our thinking and lead to obfuscatory doublespeak.

But I'm not an economist. Perhaps someone more well-versed in the subtleties of the dismal science can help me out. Seriously!

The article addresses the shortage of vaccines, both the episodic shortages exemplified by this season's flu vaccine debacle, as well as the more chronic shortages of childhood vaccines. The authors acknowledge that there are many reasons for vaccine shortages, but they emphasize the limited number of suppliers as the major target for reform efforts.

Although it is not obvious why a greater number of suppliers would necessarily result in fewer vaccine shortages (there is nothing beyond the bald assertion that this is so), the authors focus on reducing barriers to entry and increasing the incentives for private vaccine producers. They dredge up a 2003 Institute of Medicine report on financing vaccines, and they write:

An alternative that was proposed in the 2003 Institute of Medicine (IOM) report Financing Vaccines in the 21st Century attempts to find a balance that limits governmental intervention while ensuring market stability. The IOM report identified the large and growing government share of the vaccine market (55 percent of childhood vaccines) as a key disincentive for investment and market entry. It consequently recommended elimination of the Vaccines for Children program in order to remove the government from the business of directly purchasing vaccines. Because research and development are driven by anticipated profits, the IOM report recommended that the government subsidize the costs of vaccines to further stimulate private investment in the field [internal cites omitted].
I'm no economist, but this seems kind of goofy. Why would it make any difference whether the government is purchasing vaccines, or subsidizing the costs of producing them? Why couldn't the government merely increase the price it pays for vaccines, if what it wants is to encourage more private firms to enter the market? Either way, the government is providing money to private firms to produce vaccines, and the real issue is whether the government is providing enough.

My suspicion is that the major difference between "purchasing" and "subsidizing" is psychological. "Purchasing" carries connotations of direct government control of markets, and in this country, the idea is a major risk factor for anxiety disorders and interrupted sleep. "Subsidies," on the other hand, have that "public-private partnership" ring to them, which usually implies some scheme or another to privatize what the government is perfectly capable of doing on its own, as well as or better than the private sector.

The authors of the article are not blind to the indispensibility of government for any reasonable vaccine program:

Vaccines have strong spillover effects for instance, since they prevent the spread of contagious diseases, they benefit those who are not vaccinated as well as those who are. Consequently, some people will avoid the cost and inconvenience of getting vaccinated and rely on others to maintain community protection. Such products tend to be underused unless the government promotes them. Thus, subsidization has a clear economic rationale.
Even so, this being America, any proposal for government subsidies has to tout its eminent reasonableness by simultaneously emphasizing its iron resolve to "remove government from the business of directly purchasing vaccines."

It all sounds pretty goofy to me. But hey, I'm no economist.

December 01, 2004

Health care costs

"Everyone knows" that health care costs in America are out of control. I don't use scare quotes to suggest that this is incorrect, only to emphasize that it's a matter of common knowledge. If there's one thing everyone agrees on, it's that we're spending "too much" on health care.

Our nearly universal agreement that costs are too high provides opportunities for meaningful reform. Unfortunately, it can also tempt us to tolerate conditions that are unjust and harmful, simply because they can can plausibly be spun as cost-control measures.

For example, we continue to tolerate the immunity from state liability suits that HMOs enjoy under ERISA. Our collective concern for overall health care costs has repeatedly scuttled efforts in Congress to ensure that HMOs are held accountable for the decisions they make.

Because of the federal ERISA statute, an HMO that negligently denies care recommended by a patient's physician is often immune from state suits alleging malpractice, breach of good faith, and other claims. Even in cases where patients are able to successfully sue HMOs under ERISA, the remedies available are often woefully inadequate to compensate injured patients. We've encouraged HMO's to "manage care" by involving themselves in treatment decisions, hoping that this will lower costs. This might be a wise thing to do. We've also refused to hold HMOs accountable for the decisions they make, mostly because we fear cost increases. This decision may not be as wise.

Apart from the obvious problem that privilege without responsibility is generally a recipe for abuse, our toleration of HMO immunity under ERISA may burden physicians with lawsuits they would not otherwise have had to face. An injured patient may feel that the HMO bears some or all of the responsibility for a negligent treatment decision, but because of ERISA, most lawsuits against HMOs will go nowhere--especially if the decision results in a lesser quantity of medical care. In these situations, the physician and the hospital are the only viable targets for lawsuits. The docs end up in court, and the HMO gets off the hook. I don't have any empirical data on how often this happens, but it is a plausible scenario.

Our obsession with costs may also lead us to overlook the equally serious problems of lack of access to care and the rising number of uninsured Americans. For example, as we hype HSAs and defined contribution plans primarily because they promise to relieve the burden on employers to pay for their employee's health care coverage, we may not pay enough attention to what effect these cost-control measures will have on access to care.

My point is not that high overall health care costs aren't a problem, only that we ought to make sure that other serious problems that plague our health care system aren't overlooked.

November 15, 2004

How fat is your state?

Colorado is the least obese state in the country, according to a public health survey by the United Health Foundation.

Even so, a whopping 16 percent of Colorado's population is obese, defined as a BMI greater than 30. Every other state has a higher obesity percentage than this. (We are a FAT country, boy howdy.)

Despite the strong obesity showing, Colorado is only the 13th healthiest state overall (the healthiest is Minnesota). One reason is that it ranks a lowly 48th for access to prenatal care.

How healthy is your state? Click here to find out.

November 14, 2004

Malpractice reform

William R. Brody, the president of Johns Hopkins University, provides a pithy account of what's wrong with our system of medical justice.

If this piece suffers from anything, it's that Brody is just complaining. Physicians need to start offering some real suggestions--beyond just caps on damage awards--for making the system work better.

"Myth No. 2: We need to preserve the current legal system to guarantee a fair hearing and provide compensation for patients harmed by the health care system."

If we feel that patients should be compensated for iatrogenic medical injuries, why should we make this compensation dependent upon proving fault? Since the costs of medical malpractice insurance are passed on to employers, insurers, and ultimately to patients, in some sense we are all purchasing insurance against injuries caused by medical treatment. But our fault-based system means that even though we're all buying this insurance, only some of us who are injured will be able to collect. If we can't get a good lawyer to take our case; if the evidence has been flushed down the toilet; if no physicians will testify on our behalf; we're out of luck. Sorry.

One solution would be to adopt a no-fault system, where all injuries are compensated regardless of whether anyone was negligent. Of course, we'd still be faced with the problem of differentiating between an injury caused by our treatment and a bad outcome caused by the illness. The increased frequency of compensation might drive costs up, but the lack of windfall jury awards and the removal of incentives for "defensive medicine" might drive costs down. If the current system is so bad, we might want to try something like a no-fault system, and see what happens...

"Myth No. 3: The malpractice system is necessary to punish and remove incompetent health care providers."

Some patients' groups oppose no-fault because they want to be able to punish negligent physicians. Some patients also oppose caps on damages because they (rightly) feel that negligent physicians should be held accountable.

If the physician lobby wants relief from the current malpractice system, they should stop carping about the trial lawyers and start offering some constructive alternatives for holding negligent physicians accountable. They might start with reversing their opposition to publicizing appropriate data from the national practitioner data bank (1, 2, 3). They might consider reversing their position on enterprise liability (1, 2) which would make institutions such as health plans or hospitals liable for the errors of the physicians they employ, supervise, and contract with. This exposure to liability would motivate these institutions to identify and remove incompetent doctors. They might support a more vigorous oversight by state licensing boards. The only unacceptable option is to continue to rely entirely on self-policing by the medical profession. This merely gives the trial lawyers more ammunition in their campaign for the status-quo.

"A few new caps on liability costs aren't going to solve the problem. It's time we begin a comprehensive reform of the medical justice system."

Perhaps caps on damages are a necessary first step, but they won't solve many of the problems that plague our current system. Caps won't necessarily change the frequency of claims, which is an independent reason for rising malpractice premiums. Even if they successfully reduce malpractice premiums, caps alone will do nothing to alter the random nature of malpractice lawsuits. Physicians will still have to contend with the unsettling reality that a lawsuit might strike like lightning at any time. Hence, caps will also do nothing to curb the habit of "defensive medicine," because the fear of random lawsuits will remain.

If physicians are serious about changing our irrational system of medical malpractice, they're going to have to think beyond just caps on damages. The chance for physicians to play a leadership role on this issue is still there, but an obsession with caps will ensure that this opportunity will pass them by.

----

For some interesting comments by physicians on malpractice reform, you might start here (suing HMOs) and here (medical expert witnesses.)

November 09, 2004

Grand Rounds

The medbloggers have got a great thing going: every week one blogger hosts grand rounds, a compilation of the best of the medical blogs. This week, GruntDoc is hosting, and the posts should be interesting to everyone!

When I first started blogging, it was a lot easier to find good law blogs than it was to find good medical blogs. But I think the medbloggers have caught up with the blawggers. This year's 1L class doesn't seem to have spawned a lot of blogs, while some fantastic new medbloggers have arrived to compliment the strong veterans.

The best new development in law blogging has come from professors, not students. I'm talking about the new network of Law Prof Blogs.

November 07, 2004

How now mad cow?

Let's talk about something other than the election, something more optimistic. Let's talk about mad cow disease.

I wouldn't have thought of mad cow disease, except that in my Legislation course, we were divided up into groups and asked to write a piece of legislation that would protect America from the scourge of bovine spongiform encephalopathy. The story behind this public health menace is fascinating.

Continue reading "How now mad cow?" »

October 29, 2004

Sleepy doctors

The rationale for keeping resident physicians in the hospital for thirty six hours straight and working them up to one hundred hours a week has been steadily weakening, as evidence accumulates linking sleepy residents with reduced performance and a higher rate of patient-care mistakes.

Dr. Bard-Parker summarizes two new studies in the New England Journal of Medicine that support the common-sense intuition that sleepy interns are more error-prone. He rightly points out that these studies haven't completely resolved the issue. As residents spend less time in the hospital, the frequency of patient hand-offs from one resident to another will likely increase. This lack of continuity may itself be a source of error, as Dr. Centor points out.

It seems that the best solution--the one which results in the highest quality patient care--would be to structure residency work hours to balance out these two effects. Most likely, the ideal balance would be different for different specialties and medical settings. Work hours might be much shorter (or longer) in the ICU than on the medicine floors, the psych unit, or the emergency department. If this is correct, then the current ACGME regulations might have to be amended to account for the different practice realities of different specialties.

Another option would be simply to rescind the regulations and trust the specialties to exercise self-regulation of resident work hours that favors patients. While most residency program directors might favor this option, I wonder if it would be wise. Apart from the irrational traditionalism that some program directors still cling to, there are very real financial and institutional pressures that might lead to residents working hours that were best for the bottom line instead of for the patients. This was the reason for the ACGME restrictions in the first place (or, if you're more cynical, it was the threat of work-hours legislation). Assuming the right mix of leadership and institutional support, however, this would allow for the flexibility that is certainly required to set the best policies.

Apart from this, though, is another concern, suggested by some of the comments on Dr. Bard-Parker's post, and by the article cited in his previous post. Shortened work hours might be negatively affecting the ability and willingness of residents to take responsibility for the patients they care for.

My own suspicion is that if you need to work a surgeon, or any physician, 100 hours a week to ensure that they are adequately committed to patient care, you've picked the wrong resident in the first place. No one is suggesting that surgery, or any other medical specialty, should be a "lifestyle" profession. This idea, it seems to me, is a relic of the traditionalist view that physicians must martyr themselves to demonstrate their commitment to patients. It's a different question, of course, whether a resident might not have to occasionally pull 100 hours a week in order to provide the highest level of patient care. But to claim that a resident who doesn't do this isn't sufficiently responsible or committed is irrational.

Anyway, for a good sense of what it might be like to work long hours as a resident, read this.

For your diarrhea quote of the day, go here.

October 26, 2004

I'm gonna get mine.*

I've decided that as a healthy young person, I resent the elderly and the sick. They're the reason health insurance costs so much! If those people with diabetes, cancer, and other chronic diseases would take responsibility for their own health, instead of relying on the same insurance that I have to pay their medical bills, I wouldn't have to pay so much for my health insurance! Their presence in the same insurance risk pool as me is unfair.

In fact, I'm fed up with the whole concept of health insurance. It's really just a cross-subsidization of the sick by the healthy, and in America we shouldn't have to tolerate these collectivist wealth-transfers. So I'm gonna get myself an HSA!

They're a great way for people like me to stop subsidizing the old and the sick with my hard-earned money. If I go out and buy some health insurance with a really high deductible--more than $1000--then I can go to the bank and open an HSA. I can contribute $2600 or the amount of my deductible, whichever is less, every year to my HSA tax-free! The money rolls over each year, and I can withdraw it to pay for medical bills without any tax liability. That way, if I ever sprain my ankle playing Ultimate Frisbee, I can use the money in my HSA to pay the bills. But the best part is, I won't be in the same insurance risk pool with all those costly old and sick people anymore! They're not going to go for a plan with such a high deductible--it would cost them way too much, seeing as how they're always going to see their doctors for med refills and chronic pain.

Now, I know that when I drop my regular insurance plan and get an HSA instead, I'll be driving up the price of the old plan. But I don't really care. This is America, and if the old and the sick can't afford their insurance premiums, that shouldn't have anything to do with me.

George W. Bush's whole health care plan is built on HSAs. He doesn't like the idea of subsidizing the sick any more than I do. It's my money!

*All kidding aside, I probably will get an HSA. Universal third-party payment is unnecessary and certainly drives costs up. Bush's problem is that he's obsessively focused on overall costs; he doesn't have any plan for covering the uninsured, and doesn't care if some sick people are priced out of health insurance altogether. (More on HSAs here, via Health Care Blog.)

October 15, 2004

Dangers of biotechnology?

Via A&L daily, I found this great review by Jonathan Rauch of the report put out by the President's Council on Bioethics, Beyond Therapy: Biotechnology and the Pursuit of Human Happiness.

Rauch makes an intriguing argument: even if biotechnology eventually allows us to "enhance" ourselves in a way that severs our connection with what it means to be human, the results might not be as bad as we might think. Use of these technologies might not spiral out of control as some pessimists fear, but instead might be self-limited:

At its core, the councils fear is that biotech is a slippery slope with no bottom. Yet there are already all kinds of enhancement tools that most people forgo. Cosmetic surgery is readily available and fairly inexpensive. But it remains very much a minority taste, showing no sign of becoming the norm. For that matter, Americans could live longer, look better and even feel happier by exercising vigorously for a few hours a week. Most dont. What is surprising is not how much people will do to make themselves better than normal, but how little.

. . .Instead of running out of control, biotechnology may be subject to a natural restraining principle, a natural equilibrium. That possible equilibrium is what we call wellness.

Rauch describes wellness as the condition of not having to think about your health at all. You're neither sick and obsessed with regaining your health, nor are you like a bodybuilder on anabolic steroids who's obsessed with maintaining his "enhanced" condition. Wellness is an equilibrium point that attracts those who lie on either side of it.

If it is true that most humans naturally seek wellness rather than perfection and know wellness when theyve got it, then we have much less to worry about than Beyond Therapy fears. Some people, like Michael Jackson, might stop at nothing to improve themselves; but those people would remain a minority, more pitied than envied, cautionary lessons rather than exemplars. The distinction between therapy and enhancement would hold for most people, most of the time. In fact, the weird effects of future biotechnological enhancementswhich could make Michael Jackson look normal in comparisonmight make wellness more appealing than ever. The idea of being better than normal may prove a bigger flop than the Edsel.

Rauch's argument is appealing-- his point about people's unwillingness to excercise is particularly on-target. He may well be correct that even if biotechnology is able to offer us enhancements that alter our understanding of what it means to be a human being, we human beings won't accept the offer.

Before we allow Rauch's insights to make us sanguine about the dangers of biotech, though, we ought to consider the following:

  • Biotech enhancements might not always be simply offered to us in the way that Rauch describes. Germline engineering, for example, might allow parents to make enhancement decisions for their children. These kids might never know what it was like to experience ordinary "wellness," since some significant part of who they are will have been "enhanced" from birth. These enhanced people won't have chosen their enhancements for themselves. Moreover, these germline genetic enhancements wouldn't imply any need to be "obsessed" over one's health in the way that Rauch's bodybuilder is obsessed. The wellness equilibrium might still apply to the child whose genes have been enhanced, but because the enhancements have been made before birth, it won't serve as a brake on the technology in the way Rauch describes.

  • There are other ways that biotech enhancements might be imposed upon us. The government might try to develop human/animal chimeras that might be useful as soldiers (bye bye Draft, hello Army of the Gorilla Men). What might begin as an optional means of implanting medical records under the skin might be developed into a permanently-implanted identity card (no need to show ID at the airport ticket counters). The great "efficiencies" that these technologies provide ought to make us skeptical that these uses will be easily abandoned.

  • Apart from the unwilling imposition of biotech enhancements that negate the "natural equilibrium" of "wellness," we might consider the possibility that competitive pressures might unduly influence our choices about biotechnology. While it's true that too few people reap the benefits of exercise, the societal obsession with thinness induces millions of people to spend outrageous sums on diet books, magazines, and pills. If exercise was as easy as buying a weight-loss pill, many more people might pursue "enhancement" beyond the state of wellness, because of the perceived social requirement to be thin at all costs. This pressure to become thin would only increase as it became easier to do so, and fewer and fewer people were left that did not meet the society's definition of "thin." This competitive pressure might also induce people to enhance their IQs beyond the state of "wellness." After the technology became available, employers might seek to hire only those people that had chosen the enhancement. Universities seeking to admit the "smartest" people might end up admitting only those who had chosen to "enhance" themselves, and thus the pressure to choose the enhancement might become irresistible as "falling behind" became the only alternative.

    The point of all this may be only that if you're inclined to worry about the dangers of biotechnology, it's not hard to do. I agree with Rauch that we ought to count our blessings for the Council's worrying, since someone, somewhere, ought to be doing it.

    Perhaps the only thing that George W. Bush has done right since taking office is to appoint Leon Kass to chair the Concil on Bioethics.

  • October 10, 2004

    Merck, the FDA, and Vioxx

    The October 7 online issue of the New England Journal of Medicine ($$) includes two accounts of Merck's September 30, 2004 decision to withdraw the anti-inflammatory drug Vioxx from the market.

    As the articles describe, Vioxx was the largest prescription-drug withdrawal in history. More than 80 million patients had taken the drug, many to treat symptoms of arthritis, and sales were in excess of $2.5 billion. Merck spent more than $100 million per year in direct-to-consumer advertising for Vioxx.

    Vioxx was so commercially successful because it had a lower incidence of gastrointestinal complications (such as stomach ulcers) when compared with other anti-inflammatory drugs. But almost immediately after the drug had been approved by the FDA, studies began to suggest that Vioxx might pose an increased risk of cardiovascular complications such as heart attacks and strokes.

    The data from these studies were inconclusive. It was only after the results of another study designed to assess the drug's effect on colonic polyps conclusively demonstrated that Vioxx increases the risk of potentially fatal cardiovascular events that Merck decided to stop selling the drug.

    The Vioxx story leaves both Merck and the FDA smelling bad:

  • The FDA knew for years that Vioxx might increase the risks of cardiovascular events, but it (a) never required any studies to investigate this specific possibility, and (b) never required Merck to stop advertising the drug directly to the public. Thus, the FDA largely failed in its duties to protect the public health.
  • Merck knew that Vioxx might increase the risk of stroke and heart attacks, but instead of conducting a study that might have decided the issue, it chose to aggressively market the most favorable explanation of several plausible ones for the increased cardiovascular risks that other studies were suggesting. More to the point, Merck chose willful blindness.

    There's been some discussion elsewhere about the possibility that by suing Merck over Vioxx, overzealous trial lawyers will lead the FDA and the drug companies to become too hesitant to put beneficial new drugs on the market (see Nick Genes, Chris Rangel, Trent McBride). This should be a real worry. When the FDA abdicates its responsibility to the public, and the drug companies bury their heads in the sand to protect their sales numbers, trial lawyers pursuing their own self-interests can sometimes lead to "reforms" that aren't in the public's best interest, either.

    Nevertheless, we shouldn't confine our criticisms to trial lawyers (this applies to the "malpractice crisis" as well). Instead, we ought to be asking whether specific regulatory reforms might prevent another Vioxx episode in the future:

  • Should drug companies continue to be allowed to advertise directly to the public? Would it be wise to prohibit drug companies from using superficial TV ads to induce demand for an arthritis treatment that might increase the risk for fatal complications? Might it be better to require that drug companies promote their drugs in ways that allow more communication of the possible tradeoffs that the use of the drug entails?
  • Should we demand that the FDA be more proactive when reasonable suspicions arise that a drug like Vioxx might cause excess deaths from severe complications? Merck withdrew Vioxx on the fortuitous results of a trial that was not designed to assess the cardiovascular risks of the drug. If that trial had never been done, the question about cardiovascular risk might not have been answered for years. Merck was certainly not asking the question; it was aggressively spinning suggestive data in its favor instead. No one else had any obvious incentives to ask the question. Except, of course, for the public, whose representatives in the FDA were asleep at the wheel (see Kevin, M.D. for more on the FDA).

    See Matthew Holt and Donald E. L. Johnson for discussions about the overall state of the pharmaceutical industry following the withdrawal of Vioxx.

  • October 04, 2004

    Vioxx, Celebrex... "Prexige"?

    Reading this NYTimes article about the possible fate of the COX-2 inhibitors after Merck pulled its version (Vioxx) from the shelves, I had the pleasure of learning that Novartis calls its version "Prexige," and that Pfizer has another drug in this class called "Bextra."

    All these Xs made me think it was time to dig up an article about how drugs are named.

    (Note: the comments for this post are closed. This many drug names in one post will attract too much spam. My blog would be drowned under 300 comments offering "Erecto" over the internet...)

    August 19, 2004

    Sick

    Last night, I suffered with the worst illness I've had in the last ten years. Ok, there was that diarrhea incident back in medical school, but that was probably food poisoning, so it doesn't count.

    Anyway, back to suffering. Last night: bilateral otitis media secondary to ass-kicking pharyngitis of unknown origin, resulting in two ruptured tympanic membranes and not very much sleep. *cue violins*

    This actually makes me feel very lucky that my health is good, and that a once-a-decade sore throat is just about the worst that it gets. Yep, I'm very lucky.

    July 16, 2004

    Fall from truck; ATV vs. tree

    The odds and ends of a surgeon on call.

    July 05, 2004

    Silly economist


    One of the things I did this weekend was read this book, What's Your Life Worth? Health Care Rationing... Who Lives? Who Dies? Who Decides? by David Dranove, a healthcare economist. There were good insights here, and some good comic relief, too.

    The central point of the book is that we're not spending our health care dollars as efficiently as we could be, because we haven't embraced the techniques of cost-benefit analysis/cost-effectiveness analysis ("CBA/CEA") with enough enthusiasm. Everyone is familiar with these techniques. They're just the old "biggest bang for the buck" approach dressed up with a lot of jargon, and applied to health care spending. Dranove argues that if healthcare payers (the government, employers, and insurers) would explicitly adopt what he constantly (and misleadingly) refers to as the "scientific" approach of CBA/CEA, we could "save many more lives" with the money we choose to spend on health care.

    So far, so sleepy. Everyone expects these kinds of arguments from an economist, but Dranove actually says some interesting things in this short book written for the layman. Before I get to the parts that had me laughing out loud in the Starbucks, I'll talk about what I think are the really worthwhile insights of Dranove's book. (You may want to skip ahead to "CEA and QALYs" if you're only reading this for the laughs.)

    Continue reading "Silly economist" »

    June 17, 2004

    drug trial registries: pro and proer

    I'm usually a "big picture" kind of guy, but when it comes to the recent controversy over whether drug companies should be required to post all of their clinical trials to a public registry, it's worth dwelling on the details.

    First, the major proposals to create registries would require varying amounts of information to be made public. The still-in-the-oven proposal from the International Committee of Medical Journal Editors (scheduled for release later in the year) would only require drug firms to publicize the existence of all clinical trials in a public registry. While this would be an improvement over current practices, doctors and patients would still not have access to the data. Instead, the registry would be useful only if it encouraged a healthy skepticism: "I see this study in JAMA reporting the favorable effects of a new drug, but I see from my own perusal of the public registry that only one study has been published out of the five that were started..."

    There are two reasons why this proposal is too limp: (1) not every doc is going to have the time or the inclination to check every positive, published study against the public registry--especially when she's running late because of that burrito lunch with the drug rep. (2) The skepticism might sometimes be unfair, because a study could have been stopped for reasons that do not reflect poorly on the drug--all clinical trials at an institution could have been suspended because their IRB was asleep at the wheel, for example.

    For these reasons, the public registry proposal from the AMA is better. It would require that the outcomes of every clinical trial be posted to the registry. For this sensible idea to work, though, the FDA would have to stop going along with the absurd notion that the study data was proprietary. The need for physicians and patients to evaluate the safety and effectiveness of drugs aggressively marketed to the public should not be held hostage to some misguided notion of intellectual property more suited to the manufacture of Pez dispensers (how do they do that, anyway??)

    Some critics make the argument that any registry would increase the costs of research, in part because drug firms would be "afraid to make a mistake." But this fear is much greater when a firm knows that its competitors can hide their mistakes. The public understands that some drugs won't work; that's why we do studies in the first place. Besides, arguments about cost lose their luster when you realize that drug firms spend about as much on marketing as on research.

    As an aside, even when and if a public registry is implemented, don't assume that the pharmaceutical companies will comply with any required reporting... (pdf file, small. Go ahead! Open it!)

    June 15, 2004

    All about influence

    It looks like Eliot Spitzer isn't the only one concerned about drug company non-disclosure of clinical trial data: now the International Committee of Medical Journal Editors is weighing a policy that would require pharmaceutical firms to publicly register the commencement of clinical trials in order to get the results published later. Apparently the editors of journals like the New England Journal of Medicine and JAMA don't appreciate being unpaid marketing agents for Big Pharma.

    Also, the American Medical Association adopted a resolution supporting the establishment of a public registry today. It seems the docs and the journals agree that the worth of a study can only be judged in context--a context that Big Pharma tries to avoid when it might mean reduced revenues for them.

    And just think about how much medical research we could fund with 286.9 million dollars.

    June 13, 2004

    800-pound gorilla opines on healthcare

    Hey, I don't know what gorilla you were thinking of, but I'm talking about Michael E. Porter, the Harvard Business School professor.

    Porter has written an article (via HealthLawBlog) claiming that the health care system in this country suffers from too much of the wrong kind of competition. His solution? More competition, but of the right kind. Porter firmly believes in the power of competition to compel improvements in health care delivery. This, and his track record in promoting effective management strategies in other industries, will almost guarantee Porter a careful hearing in the boardrooms of the largest corporations and among most influential policymakers.

    Perhaps most interesting, then, is that Porter, the competition maven, buries the following in the middle of his article: "the larger, more controversial step would be for the government to require health coverage for all, with subsidies for low-income people." That this sensible proposal should be advanced in the context of an argument for the competitive marketplace reveals, at the very least, that Porter's not another run-of-the-mill ideologue.

    According to Porter, competition in the health care industry is between the wrong players, over the wrong objectives. Currently, health plans, hospitals, and networks are competing to shift costs onto other parties, and this drives costs up without creating any value in terms of better medical care. Porter would like to see competition among providers and health plans not to shift costs but to prevent, diagnose, and treat specific diseases. After all, notes Porter, this is what happens in other well-functioning industries: the participants compete to create value, and this competition leads to innovations and lower costs.

    The health care industry is dysfunctional because there's little accountability, prices are opaque (see my earlier post on transparent drug pricing), and the "winner" is the plan or provider who most successfully shifts costs to someone else, instead of offering the best service at the best price.

    Although it's too early to be sure, Porter, unlike a disappointing majority of pro-market reform advocates, seems to have recognized that so long as there is no universal health insurance coverage, the strongest short-term incentive for providers and payers will always be to avoid the uninsured and to push the sick out of the insurance pool. The efforts to do this are the purest form of waste--they drive costs up and retard innovation. (Which leads me to wonder whether the implacable opponents of universal coverage are motivated more by a love of the market, or by an overweening and irrational fear of the state.)

    One question the article raised for me is this: Porter talks about health as a "value" much as the products of other industries is a value. To the extent that participants in the health care market can capture this value, it makes sense that they will compete fiercely to provide it. But can employers or health plans really capture the "value" provided by, for example, long-term nursing home care? If, as I suspect, they can't, Porter's prescriptions for change would seem to provide no ready solution to the quaint social problem of taking care of economically valueless people.

    But this problem aside, I think Porter is on the right track. At least he's willing to rethink the health care system from the bottom up.

    June 12, 2004

    Transparent drug pricing? Good luck. . .

    In a quixotic quest for transparency, several large employers are trying to negotiate drug prices directly with the manufacturers, instead of relying on pharmacy benefit managers ("PBMs") to negotiate for them.

    I don't know if this is going to work or not. What's interesting to me is what the article reveals about how opaque drug prices are now:

    Consider this example: A 30-day supply of 40-milligram tablets of Lipitor, a cholesterol treatment that is the world's best-selling drug, costs $112.48 at the "average wholesale price.'' For the average employer drug plan it is reduced to $97.51, not counting various rebates from the manufacturer. But at the Drugstore.com Web site, available to anyone, the price is $94.99.

    Buying drugs, it seems, is a byzantine labyrinth of buyer groups, rebates, pass-throughs, and (probably sometimes) kickbacks. The result is that it's hard to talk about "the price" for a brand-name drug, since everything depends on who you are and where you're buying.

    Continue reading "Transparent drug pricing? Good luck. . ." »

    June 05, 2004

    Governor Lamm on health care

    Former Colorado Governor Dick Lamm makes some interesting comments about our health care system in an interview with the Rocky Mountain News:

    Both you and I know our current systems of handling retirement are unsustainable. Social Security is unsustainable. Medicare is unsustainable. I can see a path to Social Security's solvency where we raise the retirement age and do some other things. But with Medicare I can see no path.

    I'm looking you in the eye and telling you I don't think you deserve a heart transplant if you're over 75. You just don't. We had 70,000 women give birth last year without adequate prenatal care.

    Continue reading "Governor Lamm on health care" »

    May 25, 2004

    Drug prices skyrocket. Duh...

    Now that we've chosen to bestow massive subsidies upon the pharmaceutical industry with that Rube Goldberg contraption and sorry excuse for statesmanship called the Medicare prescription-drug benefit, does this surprise anyone?

    Anyone who's surprised, raise your hand and say "duh, I never thought..."

    I'll post more later. Exasperation with right-wingers has just given me nausea and gas.

    May 15, 2004

    Influence

    Here's an all-too-rare case of a pharmaceutical company actually held accountable for its marketing practices:

    Pfizer, the world's largest pharmaceutical company, pleaded guilty yesterday and agreed to pay $430 million to resolve criminal and civil charges that it paid doctors to prescribe its epilepsy drug, Neurontin, to patients with ailments that the drug was not federally approved to treat.

    That a pharmaceutical company would overzealously market its drugs is a real shame, but it's not especially disappointing. What's most disappointing is that once again, the marketing campaign seems to have successfully influenced physicians' prescribing habits:

    These marketing practices, though, were extremely effective, according to internal company documents. Doctors who attended dinners given by the company to discuss unapproved uses of Neurontin wrote 70 percent more prescriptions for the drug than those who did not attend, one memorandum showed.

    There are still a handful of willfully-blind doctors who continue to insist that physicians are not influenced by the marketing efforts of the pharmaceutical industry: the armies of well-dressed young drug reps visiting the office, the pleas from patients for the purple pill they saw advertised on the TV last night, or the "educational" junkets to places like Las Vegas to hear from paid-for speakers before heading off to the casino or the golf course.

    Every story like this one, though, makes that argument just a little bit more difficult to make. At least with a straight face.

    April 15, 2004

    Love, friends, and pills

    Seems like love and friends are good for heart attack victims. They're kind of like a new, effective pill developed by, say, Pfizer.

    So who, I wonder, will pay for them? Love is cheap, but friends cost a lot.

    April 06, 2004

    Tinkering with CPR, blood substitutes

    The CPR basics of pump-and-breathe keep getting refined.

    While investigating the usefulness of a medical device, a team of researchers noticed that paramedics were giving too many breaths to patients when administering CPR, said the study published electronically on Monday by the journal Circulation.

    (The headline of this article is misleading. It isn't that "too much CPR" is a bad thing; it's that performing CPR less than optimally is, well, less than optimal.) We keep learning more about what "optimal" really is.

    ACLS keeps being tinkered with too. Vasopressin now seems all the rage:

    Vasopressin use among patients with post-event asystole, however, was associated with significantly higher rates of hospital admission and hospital discharge. For these patients, use of vasopressin rather than epinephrine conferred about a 40 percent greater likelihood of survival to admission.

    And paramedics in Denver are now carrying the blood substitute PolyHeme:

    We are pleased that patient enrollment in this ambulance trial with a blood substitute may now begin, said Ernest E. Gene Moore, M.D., Chief of Surgery and Trauma Services, Denver Healths principal investigator. This study could potentially lead to a change in the initial treatment of critically injured and bleeding patients that may result in improved survival.

    All in all, it seems like a great time to be in emergency medicine!

    March 30, 2004

    Paternalism in medicine

    Trent McBride, over at The Proximal Tubule, has started an interesting discussion among medical bloggers about medical paternalism. DB's Medical Rants has a good response, and so does Educated Guesswork.

    Since issues of regulation, public safety, and profit take center stage here, this one might be interesting for the law bloggers to follow as well.

    As a self-styled libertarian, McBride is understandably opposed to what he considers the paternalism of prescription-only restrictions on access to pharmaceuticals:

    In no area is this more apparent than in the prescription-only status of most medicines. It always amazes me that this fact is never called into question, especially among my medical school colleagues. There is no shortage of debate in and about medicine on just about any other topic, but we accept this culture of the gatekeeper almost without question. You would think just once you would here somebody say, "Doesn't anybody find it odd that it is illegal for this patient to buy this drug unless I write it down on a little piece of paper and then sign it." Maybe I lack imagination, but I can't think of another aspect of the human experience where one set of people, not members of the government, wield that amount of power over others.

    McBride provides an interesting history of the (surprisingly recent) legislative movement towards prescription-only drugs. He then offers up some solid critiques of this legal regime, citing to studies showing that regulation hasn't made us any safer. He concludes that, except in the case of antibiotics, the requirement for a physician's prescription should be scrapped.

    As is often the case when things taken for granted are squarely confronted, the case for prescription-only drugs does look weaker after reading McBride's critique. I'm not so sure I disagree with him. Some thoughts come to mind, however:

    1) The practical consequences of removing the physician as gatekeeper to medications might be, in the short term, disastrous. The reason is that the current regulatory regime has induced a widespread belief among the public that OTC medications are, by and large, safe. Libertarians might not like this, but it's a fact, and a fact that extends to virtually the entire consumer market. Caveat emptor died two or three generations ago. Any changes in the law ought to be (as usual) done with a lot of forewarning.

    2) Let's not play fast and loose with the word "paternalism." It muddies the discussion if we don't restrict it to a precise and limited meaning. I would suggest that we use "paternalism" to refer to cases in which one person's judgment is arbitrarily or unjustifiably substituted for another's. This would mean that when a patient, upon rational and deliberate reflection, decides to defer to a doctor's expertise, the doctor is not being paternalistic when he makes the decision. Restricting the use of "paternalism" would enable defenders of a physician's judgment to make a stronger argument than "I support paternalism sometimes." Paternalism is a pejorative term. McBride, as a libertarian, might have good reason for using it to describe virtually all physician decisions. But those who disagree with McBride are not obliged to use terms in the way that McBride does.

    3) I'm extremely sceptical of McBride's assertion that the price of Claritin and Prilosec dropped because of the move to OTC status, and not because they went off-patent. I'd like to see more evidence for this, so I'll keep an open mind. Also, a question: aren't the OTC dosages much less than prescription-strength? If so, this is another possible reason for the price-per-pill drop. Let's make sure we're comparing equivalent dosages.

    That's enough griping, though. I love Trent's post. Especially this:

    My purpose in writing this is to get health care personnel, especially medical students, to think about it. It is not something that is ever discussed, but it no doubt should be. We must come to terms that this is a violation of liberty, and then ask ourselves two questions. Is this violation justified? And can we look ourselves in the mirror if it is not?

    Anyone who can get medical students to question the status-quo deserves a big 'ol Texas-size thumbs-up!

    March 17, 2004

    Match Day

    March 18, 2004 is a seriously huge day for almost all 4th-year medical students. It's Match Day.

    At 1:00 pm (1300 hours) Eastern Standard time, most every senior medical student in the country will open an envelope, and in that envelope will be the name of a residency program. The students opening these envelopes won't know until then which program they've been matched with. A program on the East Coast? West Coast? Unknown.* The only thing the students do know is that they've already committed themselves, contractually, to whichever program in in their envelopes. When the students sent in their rank order lists, they agreed to begin their residencies at whichever program they were matched with.

    No wonder most of them are nervous, anxious, and excited.

    No wonder that this system is the target of a lawsuit.

    The suit alleges that the Match process is an illegal anticompetitive scheme that allows hospitals to keep wages for resident physicians well below market rates. Supporters of the Match claim that it benefits both hospitals and medical students by eliminating the chaos that occurred before the adoption of the Match.

    My opinion? It's probably both.

    Wages for residents across the country are essentially uniform across geographic regions and specialties. And they are much, much lower than the wages a resident can command while "moonlighting," or performing work outside of the residency. When you figure in the hours residents work, their wages can sometimes be as low as $10 an hour, making them the cheapest source of medical labor in the entire hospital.

    There are generally more residency positions than there are medical school graduates to fill them. If the hospitals weren't conspiring to keep wages low, this undersupply of graduates of American medical schools would cause hospitals to bid up wages and sweeten their working conditions to attract scarce applicants. But wages aren't in danger of going up anytime soon. Working conditions may or may not have improved with the passage of new work-hour restrictions, but the plain fact is that hospitals are not competing for residents on the basis of wages.

    On the other hand, there are undoubtedly some benefits which residents receive under the Match. Exploding offers? Nonexistent. Third-years inking employment contracts with the choice residencies? Doesn't happen. People familiar with the market for judicial clerks, which until recently was chaotic in just these kinds of ways, will certainly appreciate the benefits of the Match system.

    Like AMSA, I haven't taken a position on the lawsuit yet. I'm sympathetic to the argument that resident wages are too low, and I don't buy the hospitals' line that residencies are "training" and not employment (they are both training and employment, much like the early years at a big firm for a law school graduate). But I also remember how few of my classmates in medical school really resented the Match process, and how smooth and trouble-free that process seemed to be.

    So at this point, I'll just wish everyone a HAPPY MATCH DAY!!!

    (More from blogborygmi and A Chance to Cut.)
    ____________

    * Not completely unknown. If you didn't put a program on your rank order list, it won't be in your envelope on Match Day.

    February 12, 2004

    Patient privacy and abortion law

    John Ashcroft's Justice Department has issued subpoenas for medical records at several hospitals in an attempt to enforce the ban on "partial-birth" abortions.

    Some of the hospitals have challenged the subpoenas in court, with a federal judge in Manhattan demanding that the records be produced, and another federal judge in Chicago throwing out the subpoenas on grounds that they impermissibly intrude upon patients' privacy.

    Sheila M. Gowan, a Justice Department lawyer, told Judge Casey that the demand for the records was intended in part to find out whether the doctors now suing the government had actually performed procedures prohibited under the new law, and whether the procedures were medically necessary "or if it was just the doctor's preference to perform the procedure."

    The department said in its unsuccessful effort to enforce the Northwestern subpoena that the demand for records did not "intrude on any significant privacy interest of the hospital's patients" because the names and other identifiable information would be deleted.

    Citing federal case law, the department said in a brief that "there is no federal common law" protecting physician-patient privilege. In light of "modern medical practice" and the growth of third-party insurers, it said, "individuals no longer possess a reasonable expectation that their histories will remain completely confidential."

    Actually, there never has been an expectation that medical histories would remain completely confidential. The question was always, how confidential will they be? Perhaps what the Department meant to say was that in the past, disclosures have been allowed in limited cases for the sake of improving patient care, or for preventing imminent harm to third parties. Here, the disclosures seem not to be for this purpose. Here, the Justice Department is proposing to review the "medical necessity" of the treatments rendered. This does seem to deviate from past practices.

    Completely anonymous disclosures are also commonplace for statistical research and quality-control. But it doesn't seem that the subpoenas are requesting this kind of anonymous release of information. The justice department wants to know the names of the physicians who may have performed certain procedures. If there were reasonable grounds for believing that the physicians were harming their patients, perhaps the disclosures would be justified. But it doesn't seem like that's the case here; the Justice Department only asserts that the procedures might have been the "doctor's preference."

    My first impression is that the "Chicago rule" of throwing out these subpoenas is the only defensible one. . .

    February 10, 2004

    "Teamwork training"

    The advocates of a systemic approach to reducing medical errors would appear more credible if they didn't water down their suggestions for reform with limp distractions such as "teamwork training":

    Among the remedies they advocate are greater use of computers, which can detect dangerous drug interactions and incorrect dosages, enrollment of health professionals in "teamwork training" and more open disclosure of mistakes.

    These are some good suggestions. But that bit about "teamwork training" is nothing but throwaway verbiage.

    January 18, 2004

    Beyond Therapy

    Gregg Easterbrook reviews Beyond Therapy: Biotechnology and the Pursuit of Happiness by the President's Council on Bioethics.

    Easterbrook seems opposed to the idea of stopping any of this technology; he certainly believes that any attempts to do so would be futile. But he points out that the possible ethical consequences are real, and that we're unprepared to deal with them because we've refused to squarely confront the issue:

    The muddled regulatory structure results in such theater-of-the-absurd actions as an Environmental Protection Agency decision legally to classify some types of corn as a "pesticide," and a Food and Drug Administration ruling on whether genetically engineered salmon is a "drug."

    Continue reading "Beyond Therapy" »

    January 14, 2004

    Physicians not competent to make health policy

    Economists, however, are perfect for the job.

    This appears to be the belief of Donald Johnson over at The Business Word:

    The Institute of Medicine calls for universal health insurance by 2010.

    I'm sorry, but I think this committee is stepping outside its area of core competencies. Most of the committee members are academics and physicians, not economists or policy makers. They're well-meaning but keep putting out reports that lack credibility (emphasis mine).

    "Lack credibility?" Only for those who worship at the Church of Omniscient Economics, like Mr. Johnson apparently does. These true believers deny the existence of a) serious disagreements among economists over policy matters, and b) the importance of perspectives other than the economic in formulating policy.

    I could make a living out of posting to this blog and explaining how it reveals the ungrounded assumptions of the far right. Apparently, "academics and physicians" aren't "competent" to make health policy decisions, but of course, "economists" always are. As for "policy makers," the nation needs more academic and physician policy makers. They shouldn't all be economists, or America is doomed.

    Mr. Johnson, of course, may not actually be a dues-paying member of the Church of Omniscient Economists. He could merely disagree with the conclusions of the Institute of Medicine that our country would benefit from universal health insurance. Unfortunately, countering this argument would take work. Attacking the Institute of Medicine as "incompetent" is much less likely to be successful, but it's much easier.

    December 27, 2003

    "Many are sick, and have no insurance. Can the free market give it to them, Frodo?"

    Dr. Chris Rangel and I (among others) have been going back and forth about single-payer national health insurance.

    Dr. Rangel's latest post, while failing to quote any characters from The Lord of the Rings, nevertheless deserves a response. Especially because among its many accurate and perceptive observations are scattered misleading and conclusory statements purporting to locate the solution to our health-insurance woes in the free market.

    I believe the free market is inherently incapable of achieving a goal which virtually everyone agrees is a worthy one: covering every American citizen.

    Let's start with a treatment that ought to be near and dear to our fatty-plaque plagued hearts: automatic implantable defibrillators.

    "Despite what Carey claims, you don't have to be "rich" to get one of these devices."

    What counts as "rich" is in the eye of the beholder. From the perspective of the typical Wal Mart-esque service industry employee (an increasingly common perspective among American citizens), having adequate health insurance is, like owning a yacht, increasingly an exclusive privilege of those much wealthier than themselves.

    "You just have to have insurance. This is not the same as rationing. And his analogy comparing defibrillators to organ transplants typifies the scary mindset of most liberals when it comes to their approach to rationing in health care. Even if we take into account the extreme expense of transplantation the real reason that these are rationed is because there are simply not enough organs to go around! The last time I checked we didn't have any problems with manufacturing defibrillators nor any lack of physicians to implant them."

    To the contrary, this is rationing of the worst kind. Unlike the case of organ transplantation, however, where we ration organs because of their limited availability, in the case of implanted defibrillators we ration them because of the limited opportunities to profit from their implantation.

    Continue reading ""Many are sick, and have no insurance. Can the free market give it to them, Frodo?"" »

    December 19, 2003

    Single-payer opponent Rangel quotes Sam Gamgee

    Anyone who can manage to quote Sam Gamgee in a post about single-payer health insurance is certainly deserving of a response.

    But rather than "nit-pick every detail and nuance" of Chris Rangel's most recent attack on the idea of a single-payer system, I'll stick to rebutting the general themes.

    Continue reading "Single-payer opponent Rangel quotes Sam Gamgee" »

    December 15, 2003

    I promised: a response to RangelMD

    Dr. Chris Rangel's criticism of the single-payer proposal advanced by Dr. Steffie Woolhandler and the Physicians' Working Group for Single-Payer National Health Insurance is thoughtful and a pleasure to read.

    Unfortunately, it suffers from a misunderstanding of the reasons for our current health-care problems, and from a misunderstanding of Woolhandler's proposal.

    These twin misunderstandings are rooted in an inaccurate conception of the "free market."

    Although the health care industry does not entirely fit the economic model for a free market it does have enough elements of a free market system to make it vulnerable to unintended consequences of a single payer system.

    Rangel surely has it right here; in fact, there is always a risk of unintended consequences whenever a society embarks on any reform effort. For example, in the early '90s, our nation attempted to solve the problem of skyrocketing healthcare costs by introducing market reforms intended to improve efficiency. HMOs, utilization review, investor-owned hospital chains, and similar market-based mechanisms would, we hoped, introduce the "discipline of the market" into the old fee-for-service system and lead to lower prices.

    Unfortunately, there are often unintended consequences of increased privatization and reliance on market mechanisms. As Woolhandler et. al. point out, these efforts have largely failed. Quality of care in for-profit hospitals is often lower than in public or non-profit hospitals; patients are frustrated by the reluctance of HMO's to cover needed services; physicians resent being second-guessed by insurance bureaucrats, and the drug industry continues to market "me too" drugs while pricing many of their other products out of reach of many sick and elderly patients who need them. This behavior continues despite the fact that the drug industry continues to have the highest per-capita return on investment of any industry in America, all while paying the lowest taxes of any industry.

    Given these facts, Dr. Rangel's comparison of Woolhandler to Karl Marx, and his equation of basic healthcare to a government-secured right to own a car, is no more than hyperbolic rhetoric, and is not helpful.

    Continue reading "I promised: a response to RangelMD" »

    December 13, 2003

    The case against single-payer

    It's all laid out right here, folks, with the characteristic thoughtfulness and depth we seem to always get fromChris Rangel.

    I disagree, of course, but counterposting must wait. Sleep calls.

    December 12, 2003

    Great blog. . . just great.

    Just read this one entry (about drug-development costs) and I think you'll agree with me that this blog is fantastic.

    December 08, 2003

    Buying influence

    From DB's Medical Rants, information and commentary on Big Pharma's influence on medical research:

    Being a paid consultant has the veneer of appropriateness and respectability. The researchers easily delude themselves that as scientists they are immune from influence. Unfortunately, this naivety allows them to unknowingly make mistakes.

    They justify their actions as necessary to support their overall research. They truly mean well. However, much like Dr. Faustus they are selling their souls. This is the dirty secret of much medical research.

    We need a new ethical standard. We need to understand why we engage in this dance. We need to stop.

    Unfortunately, I think we'll have to make them stop. The siren song of $$ is, again, proving resistant to wholly voluntary "ethical standards."

    December 07, 2003

    Single-payer


    Thanks to Alas, a blog.

    December 03, 2003

    Great ER blog

    My dad has alerted me to a great blog by an ER nurse. I've linked to SpankysPlace under "Medical Blogs."

    Several hours go by. Were still waiting for the x-ray read. The blind radiologist was on that night and it always took him forever to read an x-ray. Blind you say? Yes, legally blind, white cane and all. His wife would drive him to work everyday and he would walk in with his white cane in one hand and his giant magnifying glass in the other. I once watched him read an x-ray. He would start in one corner and systematically cover the entire x-ray. And he had never been sued.

    (I would link to my dad's blog, but he doesn't have one. . .yet.)

    November 27, 2003

    U. of Colorado medical school in turmoil

    As an alumnus, I've been keeping my eye on the controversies that seem to plague the University of Colorado School of Medicine:

    [T]his school has been in a state of internal strife and turmoil for so long that the national medical community must wonder what's next - pistols at high noon?

    Continue reading "U. of Colorado medical school in turmoil" »

    November 24, 2003

    Browsing the medical blogs

    GruntDoc has changed the style of his blog. . .

    DB's Medical Rants discusses the expensive and unneccesary clinical skills exam for medical students:

    During a time when we urge students, residents and all physicians to base their practice on evidence, the NBME has added a new expensive examination without first collecting any evidence of its importance.

    Let's not forget that the American Medical Student Association has opposed this exam for the past five years. Bravo, AMSA!

    November 14, 2003

    medical malpractice panel, v.2

    I just got back from a panel discussion on medical malpractice reform. I'm glad to see that hospital life goes on as usual. This means residents and medical students rushing into grand rounds with their take-out lunches, gobbling down the food while they look at xeroxed New England Journal articles, and occasionally getting paged in the middle of the presentation.

    There were actually some residents who weren't reading or getting paged, and who actually seemed to be paying attention to the presentation, so don't let me give you the impression that no one was listening (in other words, this wasn't the typical internal medicine grand rounds...).

    Anyway, back to the discussion. The first speaker tried to convince us that the current system was broken, with some interesting statistics:

    >50% of physicians will be sued at some point in their careers
    <5% of other professionals get sued (lawyers, accountants, etc.)

    (Suggests that medical malpractice is somehow unique...)

    <10% of the patients who are injured actually sue
    >50% of patients who sue have not been injured
    >75% of suits result in no payment

    (Suggests that the current system is woefully inefficient...)

    The debate that followed was essentially concerned with this question: how bad does our current system have to be before we should take the inherent risk entailed by trying something different?

    Continue reading "medical malpractice panel, v.2" »

    November 08, 2003

    Terri Schiavo debate

    But not by me.

    Some great posts in the blogosphere are here and here.

    November 02, 2003

    Is employer-provided health insurance a good thing?

    There's some interesting points made here.

    October 30, 2003

    "The Socratic Method" vs. "Pimping"

    On Brian Leiter's blog, there are some links to some good discussions of the "Socratic method" of law school teaching.

    All of which made me think of the pimping that goes on in medical school.

    Both techniques are controversial in the same way: are they effective teaching tools, or merely an effective means of selective humiliation? Both have their critics and defenders, and neither seems likely to be resolved within my lifetime.

    That essentially the same debate about the same technique takes place in both law and medicine leads me to ask if there's anything common to the two professions that could explain why these debates matter. Remember that an outsider might well wonder what's the big deal; you're in school, a teacher asks you questions, so what? Why are law students and medical students so obsessed with this?

    Law students share with medical students one characteristic that is virtually guaranteed to make the public, interrogative teaching techniques of both professions controversial: they both are gripped with the desire to "know the right answer." Much of their self-esteem is built on their long track records of succeeding in school, of answering the teacher's questions correctly. Whatever their other insecurities or failings, most law or medical students can at least be proud of their high grades, their high test scores, and their hard-earned knowledge.

    When a medical student on rounds is barraged with obscure and seemingly random questions to which he doesn't know the answer, he often feels humiliated, regardless of the conscious intention of the attending or resident asking the questions. Why? "Because I didn't know the answers!" The mere proof of ignorance, displayed in front of others, is enough to make him feel humiliated. "What am I if I don't know? A loser!"

    Same thing with law students. If they can't give the "right" responses in class in front of everyone, they feel like failures at the one thing they've always been good at: pleasing the teacher and mastering the material. Even without any intention on the part of the professor to humiliate anyone, these law students will feel humiliated.

    So the "controversy" surrounding the Socratic method is a lot like that surrounding "pimping." And no matter how respectful the attending is, no matter how encouraging the professor is, there will be many medical students and law students who feel humiliated every time they're publicly asked a question to which they don't immediately know the answer.

    October 29, 2003

    law school vs. medical school

    People often ask "what's the difference?" between law school and medical school.

    Well, I can only answer based on my own experiences and interpretations, but here's one difference:

    A few months into my first year of medical school, I began to realize that I wasn't getting very much out of the classes. I felt in virtually every case that if I had skipped class and spent that hour reading my notes or reading a textbook, I could have learned more than I did by listening to the lecture in class. (Of course, this doesn't apply to anatomy lab, which doesn't count as a "class" or a "lecture" in my opinion. Anatomy lab is a whole different kind of fish.)

    In law school, I'm often tempted to skip class. But unlike in medical school, I'm finding it difficult to justify skipping class in favor of just doing more reading on my own.

    Law school classes, so far, seem more valuable than the preclinical medical school classes.

    Why? My law school classes seem to offer something "beyond the textbook" in a way that medical school lectures never did. Take today's torts lecture, for example. We were discussing the doctrine of respondeat superior and vicarious liability, under which an employer is liable for the negligent actions of an employee even if the employer itself did nothing wrong. We'd seen the doctrine applied in a few cases from the casebook, and the casebook editor had discussed a few wrinkles, such as what happens when the negligent party isn't an employee but instead is an independent contractor? All that was fine and good. But in class, we didn't just rehash the discussion in the textbook. Instead, we asked "Why?" Why does this doctrine make sense? Should we keep it, or get rid of it? Using the cases in the book as weapons for our arguments, we advanced our understanding of the legal doctrine in a way that would have been much more difficult, if not impossible, if we had just stayed home and reread the casebook.

    I don't want to glorify my law classes (God forbid). Very often the rhythm of the professor's voice starts to put me to sleep, and my eyes glaze over when we stop to discuss a point I don't find very interesting. I get tired of straining to hear a student who's been called on and is giving a cautious, timid answer that doesn't move the discussion forward but just bogs it down and slows it up.

    But it is true that if I try to stay alert, I'll almost always find a way to make the hour irreplaceable in a way my medical school lectures never were.

    There could be many reasons for this. Medical textbooks could just be superior to law casebooks. Medical lecturers could be inferior to law lecturers. The Socratic method may make the law classroom a much more active place than the medical classroom ever was. All these could explain the difference, but I don't think they do.

    Here's the difference, in my opinion: in medical school the most significant goal by far was memorization. The lectures didn't help me to memorize anything, so they were, to put it bluntly, superfluous.

    In law school, although we need to memorize things, the real goal is making cogent arguments. And I find that attending class, listening to the professor, responding to the questions, and listening to classmates helps me to form and use arguments to a greater extent than it would help me to skip class in favor of rereading the casebook.

    I'm sure I'll start to notice some other differences between law school and medical school, and when I do, you can rest assured that I'll point them out on this blog...

    October 09, 2003

    New heart failure drug. Whoopee.

    The FDA has just approved Pfizer's aldosterone antagonist Inspra (eplerenone) for the treatment of heart failure. It had already been approved for treating hypertension.

    Please forgive me if I don't get up and dance for joy.

    I'm not saying it isn't a good thing to have a new, more effective drug on the market if you're suffering from congestive heart failure. I'm also glad Pfizer is continuing to introduce new drugs for the treatment of life-threatening conditions, rather than limit itself to lucrative "lifestyle" drugs like Viagra.

    But I am reminded that our country's approach to medicine, drug development, and public health succeeds in some ways by failing in others.

    Inspra isn't going to be cheap. For the well-heeled and well-insured suffering from congestive heart failure, the drug will be a good thing because it will be available. But for the rest of us, Inspra may not only be unavailable, but may also contribute to rising health-insurance premiums and force more of us to drop our health insurance altogether.

    Insurance companies offering policies that include new drugs like Inspra in their formularies have to recoup the costs somehow. Since new brand-name drugs tend to cost more than the average drug in a formulary (which includes many inexpensive generics), offering the new drug increases the average cost of all medications. All else being equal, premiums have to go up. As premiums go up, more people find themselves unable to afford the coverage. The ranks of the uninsured grow.

    And as more people become uninsured, more people do not receive any treatment at all for their heart failure, let alone the newest and best wonder-drugs. The cost of treating some people with Inspra, in our current system, is undertreating others with the same condition, or not treating them at all.

    Here is where the public policy arguments begin. Some argue that this result isn't a bad thing. Over time, the overall sophistication of the treatment available to everyone increases because we encourage private pharmaceutical firms to innovate and to reap the financial rewards. In this sense, American medicine is the "best" in the world.

    I don't buy it.

    First, I don't agree that it's any better to sacrifice the basic health care available to some people for a marginal improvement in the advanced treatment available to others.

    Second, I don't accept that we face an all-or-nothing choice between developing new drugs under our current system, and halting the advancement of medicine by altering that system to make it more equitable. But that's exactly what the pharmaceutical companies argue when anyone suggests policies aimed at reducing drug costs.

    Given the pharmaceutical industry's profitability, it would seem that there is plenty of room to reign in drug prices while preserving the incentives the drug companies need to develop new drugs. That's just common sense.

    In the meantime, we can celebrate the introduction of Inspra and other marginal improvements in the treatment of heart failure and other ailments. We can also cross our fingers and hope that we'll continue to be able to afford our insurance premiums, and that we'll be able to see a doctor and buy some basic medicines if we get sick.