Medical Grand Rounds, Vol 4, No. 41

July 1st, 2008 by DrRich

Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:

Lists of Grievances

Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)

Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.

Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.

The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!

And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.

Inalienable Rights

DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!

The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?

Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.

Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.

The Spirit of the Individual, That Which Made America Great

Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.

Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.

David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.

Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.

Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.

Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.

Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.

Standing Up To Powerful Authorities

Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.

JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.

DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.

The Freedom From Misinformation Act

Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?

Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.

When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.

David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.

And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.

The Obligations of the Individual in a Free Society

Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.

Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.

Tories

Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.

Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.

Picnic Advice, or Don’t Be Stupid

RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.

The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.

What Doesn’t Kill You Will Make You Stronger

Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.

Service and Sacrifice

Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.

The Most Important Aspect of Any Holiday

Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.

Next Week’s Grand Rounds

Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.

Posted in Uncategorized | 15 Comments »

Why the Colette Mills Dilemma Won’t Happen Here

February 20th, 2008 by DrRich

The January 27 issue of the Sunday Times of London tells the tragic story of Colette Mills, a 58 year-old British woman who lost her battle with the National Health Service (NHS), and as a consequence appears doomed to lose her battle with breast cancer.

After her initial treatment for breast cancer, Ms. Mills was placed on the drug Taxol to reduce the odds of cancer recurrence. The NHS paid for both the surgery and the Taxol. However, Ms. Mills also wanted to take the drug Avastin, which, clinical trials have shown, can reduce the chance of recurrent cancer by about 50% when it is taken in addition to Taxol. Ms. Mills, aware that the NHS will not pay for Avastin, wanted to pay for the drug herself, and asked the NHS for permission to do so. The NHS said no. Ms. Mills appealed. Unfortunately, four months into the appeal process her cancer returned and has spread to other parts of her body, making her appeal for permission to pay for Avastin moot. Her prognosis now appears grim.

According to Sarah-Kate Templeton, Health Editor of the Times, Ms. Mills is “the victim of a ruling which states that any patient who wants to pay for additional drugs not prescribed by the NHS should lose their entitlement to their basic NHS cancer care and pay for all their treatment.”

The British Department of Health holds firm to the idea that individuals paying for supplemental treatment “would ‘undermine’ the ‘fundamental principle of the NHS, now supported by all the main political parties, that treatment should be free at the point of need.” That is, you get the healthcare the government says you get, and no more, even if you’re willing to pay for it yourself.

Since the British system is often held up as an example of one we in the U.S. should emulate, we ought to ask, “Will a universal American healthcare system also prohibit individuals from purchasing their own supplemental healthcare?”

This is a question that proponents of universal healthcare, at least those proponents running for political office, assiduously avoid. But the answer to this question is almost certainly, yes. Judging from the original Clinton healthcare plan in the early 1990s, from the actions of the federal government since that time to restrict the ability of individual Medicare patients to pay for “extra” care themselves, and from more recent actions aimed at outlawing retainer practices, it is pretty clearly the (unstated) aim of the Wonkonians to ultimately prevent individuals from supplementing their government-provided universal healthcare with their own resources. One size will have to fit all.

Indeed, this very issue (whether people are to be permitted to spend their own money protecting their own health) is likely to shape up as the central battle in American healthcare reform. By DrRich’s estimate, the very reason none of today’s prominent Wonkonians are talking about a straightforward government takeover of healthcare (favoring instead a more meandering course to that end), is that they don’t think they can win the “individual autonomy” battle right now. Americans, they judge, still need 5 or 10 years of softening up. But we’re getting there. After a few more enervating years dealing with our current healthcare mess, both the Gekkonian health insurance industry and the average American will be ready to throw in the towel, and accept whatever terms the Wonkonians care to offer.

Even then, lingering notions of individual autonomy might still threaten to make things occasionally uncomfortable for government officials. But not to worry. DrRich is here to reassure nervous Wonkonian bureaucrats. After their constituents have finally drunk the government-healthcare KoolAid, American Wonkonians won’t face kind of nasty dilemma now confronting honest British bureaucrats because of disruptive patients like Ms. Mills.

The reason is straightforward.

Fundamentally, the problem imposed on the NHS by Ms. Mills was one of medical progress. As reported in the London Daily Mail, medical “specialists fear that the NHS will be ‘crippled’ by the increasing range of breakthrough treatments.” (When the chief concern of the healthcare system is controlling costs rather than optimizing healthcare, breakthrough treatments are revealed as the true threats they are.)

The good news is that once American healthcare goes to a British (or Canadian) model, the world’s great engine of medical progress (i.e., the profit-driven American healthcare system) will grind to a screeching halt. With the American profit motive out of the way there won’t be any more new therapies which the Ms. Mills of the world can selfishly demand the right to purchase. Happily, American officials will be spared the kind of regrettable discomfitures now plaguing their British counterparts. The entire problem (whose extent is sadly illustrated by some of the headlines - e.g., “Sentenced to Death By Idiocy” - to which well-meaning British bureaucrats are now being subjected), will simply disappear.

So, not to worry. It won’t happen here.

Posted in Wonkonian Rationing | No Comments »

How to Think About the Obesity Dividend

February 10th, 2008 by DrRich

An article published last week in the Public Library of Science Medicine Journal has created tremendous buzz in the media and the blogosphere. This article compared the lifetime cost of healthcare (beginning at age 20) for obese individuals and for smokers to the lifetime cost for non-smokers who maintained a healthy weight. Naturally, the study concludes that the healthy individuals can expect to live longer than the obese and the smokers (84 years vs. 80 and 77 years, respectively). However, the healthy young people will consume $400,000 in lifetime healthcare costs, vs. only $365,000 for fat people and $321,000 for smokers. Therefore, healthy people, over their lifetime, are a bigger drain on the healthcare system than the obese and the smokers.

The reason this study has attracted so much attention is that it appears to fly in the face of conventional wisdom, which considers it axiomatic that our obesity epidemic is one of the major threats to the stability of our healthcare system. (Interestingly, relatively little of the commentary has had to do with the cost savings the study attributes to smokers. Not only are smokers less expensive to the healthcare system than even the obese, they also die substantially younger - and thus burn through fewer Social Security dollars. When you add to that the stiff tobacco tax smokers pay throughout their entire lives, one might argue that not only are smokers cheaper than healthy people, they may actually constitute a societal profit center. Apparently we have already internalized the inherent benefits to society provided by smokers, however, judging from the relative silence toward this aspect of the study.)

The evil of obesity has become a touchstone. Consider the evidence: All three remaining viable presidential candidates have asserted that it’s the obesity epidemic which is largely responsible for draining our healthcare coffers. (One assumes that the formerly-obese Gov. Huckabee, though less viable as a candidate, agrees with this assertion. DrRich cannot begin to speculate on what Dr. Paul’s obesity platform might look like.) Ms. Clinton, as usual, is perhaps the most straightforward in setting out her feelings on this point of healthcare: According to her website, “About 30% of the rise in health care spending is linked to the doubling of obesity among adults over the past 20 years. Had the prevalence of obesity remained the same today as it was in 1987, we would spend 10 percent less per person - approximately $200 billion - on health care today.”

Even more tellingly, it has become acceptable even in polite circles to openly discriminate against, if not overtly disdain and humiliate, the obese. Fat people are now expected to pay for two seats on airplanes. Mississippi is considering legislation to prevent the obese from eating in restaurants. And in Britain, whose healthcare system has been held up as a model for Americans, doctors themselves are saying that obese patients should be barred from receiving medical services. (Though, in defense of his colleagues, DrRich wishes to point out that these same physician-humanitarians are also calling for the withholding of medical care from the elderly and smokers - so in truth they are not being unusually unfair to the fat.)

So in light of this carefully cultivated scorn for the obese - who are clearly being groomed as a prototype, as a group whose characteristics (ostensibly, their lack of self-discipline, or their sloth, or their selfishness, or whatever other characteristics we can attribute to them that makes them seem different from “us”), justify special treatment in order to serve the overriding good of the whole - in light of this, what are we to do with this new study which says that obesity saves money for the healthcare system? Do we reverse course, and embrace the obesity dividend? Do we encourage supersizing, and, far from refusing to serve them, offer the overweight free second portions? Do we give them deeply discounted heavy-duty suspensions? Better yet, do we give away free Marlboro starter packs to the fat? (Just think how much money we’d save with obese smokers.)

Thankfully, no.

DrRich has pointed out innumerable times the absurdities we find ourselves promoting when the chief purpose of the healthcare system becomes avoiding costs rather than maximizing health, that is, when its chief job is covert rationing. (The Happy Hospitalist has provided us with an enlightening riff on this topic as well.) It is therefore gratifying to say that this is one of those cases where we don’t have to engage in such absurdities. Let’s be plain about it: We don’t need to reevaluate our current vilification of obesity (and smoking) just because people who have these conditions may save us money in the long term.

The reason? We don’t care about the long term.

Who cares that in 60 years, today’s healthy 20-year-olds are going to cost us a lot of money? They’re largely free to the healthcare system for at least several decades. In contrast, the obese and the smokers, what with their chronic diabetes, heart disease, kidney disease, joint replacements, strokes, lung disease, etc., etc., are going to cost us money each year, starting today.

If we actually cared about the long term, we’d be doing something about the Social Security and Medicare entitlements we’ve already signed up for, which in a little more than 20 years will require confiscating more than 50% of each American paycheck, just in payroll deductions. (Never mind income tax.) Heck, just looking at their pay stubs will probably cause most of today’s healthy 20-year-olds to die of apoplexy by the time they’re 40. In any case, the entitlements we’re obligated to provide will threaten societal disintegration long before today’s healthy young adults ever need elder care. Consoling ourselves with the idea of projected long-term savings is like consoling ourselves with the idea of beautiful spring alpine flowers when we’re directly in the path of an onrushing avalanche. Projected long-term savings are completely irrelevant.

The obesity dividend is just smoke, and can be safely ignored. For the greater good of our social welfare, we’re far better off doing what we’re doing today - castigating and humiliating the obese into right actions, and if that fails, then simply following the example provided by one of the civilized healthcare systems we’re encouraged to use as a model, and discriminating against them when they need healthcare. Once we’ve established this useful prototype, we can apply it to whatever additional groups we can identify as targets of our collective indignation.

Whatever it takes to avoid confronting the rationing issue head on.

Posted in General Rationing Issues | 8 Comments »