Grand Rounds Volume 6, Number 16

Posted on January 12, 2010
Filed Under Uncategorized |

The Holidays may be over, but there’s no rest for Santa or his cute little Congressional elves. So, after a respite that must have seemed all too brief, Santa has herded his diminutive (but ever-cheerful!) drudges right back into their Secret Workshop, to finish building for us kids the Healthcare We Can All Believe In.

DrRich, for one, can hardly wait to unwrap it.

Like the elves, those of us who participate in the Medical Blogosphere are right back on the job, with our observations, opinions and insights that (we trust) are helping to advance humanity to the next level. Indeed, DrRich thinks Santa and his elves would profit greatly if a Reader were hired to enlighten and entertain them with dramatic renditions from our blogs, while they diligently cobble together their Great Work.

But, alas! The federal budget cannot support such a Reader.

What we can offer them instead, we bloggers, is Grand Rounds (if only our leaders were sufficiently capable of connecting-the-dots to find it!), Grand Rounds being our compendium of the shiniest pearls of wisdom we have collectively (what else?) produced over the past week.

And so, to Santa, to the elves, and to anyone else enlightened enough to seek it out, DrRich is honored to present: Grand Rounds.

We begin with an act of incredible courage. David E. Williams of the Health Business Blog is brave enough to point out to all you older folks out there that, despite the fact that you are paying something each month toward your Medicare insurance, what you are paying does not begin to cover what you are costing Medicare (and the non-Medicare federal budget).  Like it or not, folks, you’re on the public dole.

Indeed, if a Martian were to come to America and, without preconceived notions, examine our federal budget, he/she/it could only conclude (after viewing the proportion of the budget dedicated to Medicare, Medicaid, Social Security, federal pensions, &c.) that the primary purpose of the American federal government must necessarily be: to take money from the young and give it to the old. Our alien friend, being Martian and therefore objective to a fault, would clearly see that any other ancillary functions the government might conduct in its spare time (like national security, law enforcement, commerce, the judicial system, maintaining armed forces, defending the borders, &c.) are mere trivialities in comparison, and barely worth mentioning.

Still, while thus having to concede that Mr. Williams makes a good point, DrRich, president and sole member of FOFA (Future Old Farts of America), wants him to know that he has been paying into Social Security and Medicare since the mid-1960s, with the clear understanding that (after reaching a certain age) DrRich would be able to withdraw from those programs amounts of cash and services worth several orders of magnitude more than what he has contributed to them, and that the young whippersnappers of the day would just have to suck it up and provide it (just as DrRich has had to provide for the greedy old farts who have taken his money for all these decades). And so, Mr. Williams, suck it up and provide it. And a word of advice: you should try to do a better job of fully populating the generation which follows yours (to support you in your dotage) than we baby boomers appear to have done. (Oops!)  Procreate, Mr. Williams, procreate!

As it happens, Toni Brayer has offered two posts this week that are directly related to what Mr. Williams has posted, and to DrRich’s response, respectively.  First, at the ACP Internist Dr. Brayer points out that not even the Mayo Clinic (one of the Obama-certified most efficient and effective healthcare organizations on our overheated planet) can afford to provide primary care to Medicare patients without losing their shirts. At the new Mayo facility in Glendale, AZ (a place to which many of us in FOFA would aspire to go to enjoy our final illnesses), Mayo will not accept Medicare payments for primary care visits. Rather, Dr. Brayer tells us, they will require patients on Medicare to pay for their primary care visits out of pocket. (Obviously, the folks at Mayo must read DrRich’s blog.)  And second, Dr. Brayer tells us at her Everything Health blog that, regarding procreation, the clock is ticking.  Hop to  it, whippersnappers!

James Gaulte of Retired Doc’s Thoughts also takes note of the Mayo Clinic’s conclusion that accepting Medicare patients is not compatible with a viable primary care practice, and (given that even the Great Masters cannot cope) wonders what mere “average” primary care docs will do regarding Medicare patients.  Even the Boston Globe, Dr. Gaulte points out, understands that Congressionally-imposed price controls may be able to limit the price doctors can charge for  healthcare, but not the cost doctors incur for delivering healthcare.  Once “a” becomes substantially less than “b,” even doctors (generally not known for their economic acumen) will figure out what they must do.

The Happy Hospitalist contemplates the reason for patient “bouncebacks” (i.e., being readmitted to the hospital shortly after being discharged). Performing an objective analysis of the cause of such bouncebacks soon will become critically important for providers, since Medicare (and other insurers, assuming there are any left) have announced their intention to stop paying for these re-admissions. While the theory behind the refusal to pay for bouncebacks is that they must have occurred because the hospital or doctor screwed up, Happy concludes (with good reason) that in many if not most cases, bouncebacks have a lot to do with the habits and behaviors of the patients themselves.

If Happy is right (and DrRich believes that he is), then preventing bouncebacks sounds like it will be difficult. (Any goal or system that depends on a fundamental change in human nature will fail - just ask Gorbachev.) Since hospitals and doctors will probably not be able to greatly reduce bouncebacks that are caused by patients’ poor lifestyle choices, poverty, poor education, etc., providers (given their absolute need not to be stuck with the bills from bounceback admissions) must necessarily take the only tact that remains available to them - profiling the patients most likely to bounce back and doing everything in their power to avoid them. (If you look in many major cities you will already see this happening, as the big hospital systems close their inner-city facilities, and build Taj Mahals in the affluent suburbs.) Happy has taken an important first step in constructing those desperately needed profiles.

Jolie Bookspan, the Fitness Fixer, describes the results obtained by a follower of hers who began a “healthy movement program.” DrRich has been thinking about starting his own healthy movement program. Whenever he finds himself shaking his head (say, while reading the latest 2000-page version of healthcare reform legislation), he will try to remember to alternate the initial deflection between left and right.

Greg Friese at Everyday EMS Tips has written a great post on why rescuers should NEVER just “go through the motions” in performing CPR on a patient who is clearly already dead. (That is, clearly dead - not just merely dead, but really, most sincerely dead.) While “going through the motions” in such circumstances has been advanced as a way to give comfort to observing family members, Mr. Friese convincingly argues that rescuers should never, never just go through the motions. His warning not to “just go through the motions” is so well written that DrRich has e-mailed the link to the Pittsburgh Pirates.

In a similar vein, Steve from The EMT Spot considers yet another point of apparent EMT dogma - a “rule” that is often taught to EMTs who respond to a dire emergency involving infants or children, namely, “Just transport the baby.” Steve bravely deconstructs the six reasons instructors often give as a justification for this rule, and, concluding that these reasons are not always true, demonstrates that sometimes it may be better not to transport. This is a tough one, and DrRich does not envy the EMT professionals who must make calls like this.

How To Cope With Pain continues a medication series with a useful article on opiates for pain control. Anyone dealing with pain control issues might benefit from this article. (DrRich particularly recommends it to those elderly pacemaker candidates for whom Dr. Obama has prescribed this very remedy.)

Kent Bottles of the ISCI Health Care Blog has posted a very well written and thoughtful article on seeing the world as it is, and not as we want (of fear) it to be. His article borders on actual philosophy, going to a basic question that, DrRich believes, we’re wrestling with in a very fundamental way in America today, namely: what are we to make of the bad things in the world?  Are we supposed to ignore the bad things and convince ourselves that all is well, or are we supposed to go through life in despair, or is there some other way? Is mankind perfectible, such that we should make every effort to achieve that perfect state on earth at any cost (e.g., communism); or should we instead make the best of the fact that evil is inherent in mankind, and try to deal with that fact as productively and equitably as possible, through some imperfect but best-case societal arrangement (e.g., capitalism)? Dr. Bottles’ treatment of this Big Question is quite good, and DrRich recommends it.

Touching on a theme that is close to DrRich’s heart, Dr D at Ask An MD ponders: “Why would anyone ration healthcare?” In answering this question, Dr D offers a convincing vignette in which he alleges that he has dispensed the most expensive tube of Vaseline in history. (DrRich suspects that he himself holds that record, but as the story is too disturbing to tell, he will defer to Dr D’s claim.)

Henry Stern at Insureblog presents a remarkable video of real, practicing physicians having a civil debate with Congressperson Conyers on healthcare reform. You will be impressed, DrRich believes, by the articulate arguments advanced by these non-AMA-hacks on what’s really needed. You may also be impressed, as DrRich was, by the respect shown to these doctors by Conyers. And despite the fact that when Conyers finally despaired of convincing doctors of the merits of his single-payer vision he allegedly played the race card, witnessing actual, nearly-civil discourse these days is quite refreshing.

Dr Shock offers us a review of the scientific evidence that Post Traumatic Stress Disorder can be successfully treated with virtual reality therapy, and in fact, VRT is being used to treat PTSD in the combat theater in Iraq.  DrRich had never heard of this approach and is impressed, and is glad that work is being done to help our soldiers who are suffering from this extremely disabling condition.

Dr. Wes ponders: Why Aren’t Doctors Asking, “Why the Secrecy?” In this post, Dr. Wes wonders where the doctors have been during the debate on healthcare reform, and why they have remained strangely silent and passive, despite the profound changes that are about to affect them and their patients. Perhaps, Dr. Wes speculates, “It’s a stubborn adolescent holding on to a fair universe.”  Or perhaps it’s a resigned sense of martyrdom. Whatever it is, DrRich agrees with Dr. Wes that physicians have not particularly distinguished themselves during this process. It is DrRich’s opinion, however, that physicians who abandon the new-age medical ethics now espoused by their professional organizations (those same organizations which capitulated to healthcare reforms before the nature of the reforms had even been revealed), and instead rededicate themselves to the ethical proposition the medical profession had formerly embraced for the past two thousand years - to always place the interests of their individual patients first - will know what they must do, and will find the courage to do it.

DrRich loves nurses, and always has. He especially likes nurse bloggers, and especially ones with an attitude. Muse, RN is a relative newcomer to the blogosphere, and for anyone who has not discovered her yet, this week’s submission will give you the flavor. Muse is rightly fed up with the frequent disrespect shown to the nursing profession, and to the systematic lack of political clout these indispensible professionals have. DrRich agrees with Muse that we’d all be better off (even doctors), if actual clinical nurses (as opposed to nurse administrators) grabbed the influence they deserve. After all, to the best of DrRich’s knowledge, the nursing profession, unlike the medical profession, has not yet thrown its ethical committment to individual patients under the bus.

When Stacey Butterfield of the ACP Hospitalist submitted a post on the pros and cons of bundling, DrRich was excited. Bundling, of course, is the courting practice employed in colonial America, whereby the prospective couple would be individually wrapped in heavy bedclothes, then placed into a bed to spend the night together (ostensibly with a “bundling board” between them). Bundling appears to have been widespread even among Puritans, and was endorsed as a suitable “test drive” procedure by none other than the happily-married John Adams himself. This bundling has always intrigued DrRich, since it seems to him a bit counter-intuitive to imagine Puritans going in for such a thing, and he has therefore suspected that a study of the practice would open a unique window into the Calvinist mentality (a mentality so deeply foreign to us modern Americans, what with our living Constitutions and situational ethics and whatnot).

So initially DrRich was disappointed to learn that Ms. Butterfield was talking about the other kind of bundling, the kind endorsed by Medicare and which, therefore, relates more to policy than to spooning. But her treatment of the pros and cons of bundling (the kind where a fee-for-service payment scheme is  abandoned in favor of an arrangement where hospital services are bundled together for a fixed payment) is well written and thought-provoking, and will be quite interesting to anyone who doesn’t approach her article thinking it’s going to be about sex. And even DrRich was led to visualize how bundling will be useful for covert healthcare rationing, so most of his disappointment was well assuaged. But next time, Ms.Butterfield, let’s please stay away from the old bait-and-switch.

Robert Centor of DB’s Medical Rants (one of DrRich’s all-time favorite medical blogs), has been writing for a long time on Lemierre syndrome, a potentially fatal and poorly recognized form of sore throat.  While his efforts have been widely recognized, it must be gratifying to get this kind of direct evidence that his efforts are saving patients’ lives.  On a personal note, DrRich would also like to congratulate DB on having just completed 30 years of being a ward attending physician, which is quite an accomplishment.  DB has posted 10 lessons he has learned on becoming an effective ward attending. Anyone who does this (or anyone who teaches any complex process to trainees) should take a look.

Amy Tenderich, who writes the excellent Diabetes Mine blog, speculates on the recent sudden death of Casey Johnson, the 30-year-old J&J heiress with type I diabetes. Ms. Johnson is said to have spent the last several months of her life in “suicidal drug haze,” and it would be easy to write the sad event off as being completely unrelated to diabetes. But Ms. Tenderich points out that people with type I diabetes are under great stress from a young age, and far more than most people, need to pay close attention to their health habits, and they need to do it each and every day. Furthermore, they are expected to live these medically perfect lives even through the turbulent years of young adulthood, a time when when most of us can fall off the wagon for a while and still recover and lead productive lives. The diabetics who get through this difficult period are among the strongest people DrRich knows. But Ms. Tenderich reminds us that not all get through it, and that Ms. Johnson’s diabetes may well have played a part in the sad trajectory of her short life.

Will Meek posts advice on Resolving Cognitive Dissonance. DrRich is no shrink, but as he understands it cognitive dissonance is the emotional discomfort you feel when you hold on for dear life to two entirely contradictory ideas at the same time. DrRich is confident that Dr. Meek’s advice for resolving cognitive dissonance is very good. Members of Congress appear to subscribe to Meek’s method 1A, which is, “never explore the inconsistency, or simply avoid looking at it and divert our attention to something else.”

Nicholas Fogelson of the Academic OB/GYN blog offers us a thorough treatment of the scientific evidence surrounding the risk of thromboembolic disease in women using the Ortho Evra contraceptive patch. This post is well worth the reading. Nicholas dissects the three major publications looking at the relative incidence of blood clots with the patch, whose answers do not agree, and makes a convincing argument that biased research designs were responsible for the two articles saying the patch does not increase the risk. The specifics of his analysis are interesting enough, but the article is worth reading if only for his conclusions, which address the design and interpretation of medical literature in general. DrRich has been fond of pointing out that the people who design medical research have a wonderful opportunity to bias the results to come out as they would like them to come out. This is true whether the studies are designed by companies (who want society to spend lots of money on their products), or by the insurers or the government (who want to find reasons not to spend any money on certain healthcare services). Dr. Fogelson shows another example of how this results-altering bias can be applied by researchers.

Thyroid disease is important, common, controversial, and almost certainly under-diagnosed. Dr Val of Better Health, in honor of Thyroid Awareness Month, interviews thyroid expert Dr. Victor Bernet on the importance of recognizing thyroid disease, and of treating it appropriately. DrRich believes it is especially important for non-physicians to read (or listen to) this interview. All too often, important thyroid disorders are overlooked, and are diagnosed only when the patient sufficiently “badgers” the doctor to look for it.

Life in the Fast Lane is a medical blog that comes to us from the land Down Under. It is written by a team of Australian physicians with a pleasantly Australian sense of humor and lots of practical medical knowledge. This week Chris Nickson submits a post on not putting your patient “in a box.” Yes, he’s talking about that kind of box too, but primarily he’s referring to the little boxes that show up on laboratory reports - “normal” lab values appear within the box, and abnormal ones are printed outside of the box. Unfortunately, all too many doctors practice medicine the same way the remote drone operators target Al-Qaeda leaders in the mountains of Pakistan - that is, by doing whatever maneuverings turn out to be necessary to line up the target inside the box. Dr. Nickson shows, in an entertaining and convincing fashion, why what’s good practice in the field of battle might not be good practice in the intensive care unit.

Douglas Perednia of The Road to Hellth deconstructs for us the real reason many of our political leaders, and all the best health policy experts, think it’s a good idea to tax Cadillac health plans. Dr. Perednia is one of the more incisive thinkers in the medical blogosphere today, and his conclusion (that the Cadillac tax is just another method to accelerate the denouement) seem pretty solid to DrRich.

Laurie Edwards of A Chronic Dose is “riled up” over the sensitive topic of whether people with chronic medical problems should have kids.  She makes a compelling argument that parents with chronic illnesses tend to be as good at parenting as those without chronic illnesses (who often bring to the table their own forms of distraction), and that the prejudices directed against them and the barriers placed in their path are unnecessary and unjustifiable. From his own observations, DrRich agrees completely.

On her Medscape Blog (On Your Meds: Straight Talk about Medication Safety) Barbara Olson has posted A Story of Grace, her reaction to the speech given by Dennis Quaid at the American Society of Health-System Pharmacists in December. In early 2007, Quaid’s infant children received an overdose of heparin through a medication error, and very nearly died. Quaid’s talk to the pharmacists, Ms. Olson points out, was full of encouragement and grace. It is well worth reading Quaid’s words (link provided), and Ms. Olson’s commentary.

Elyse of AntiClue - a blog about healthcare IT - offers the Top 6 Workflow Design Pitfalls to Avoid for healthcare system implementation. DrRich wishes our hard-working Congresspersons would pay particular attention to Number Three: Avoiding Grandiose Workflows.

And here’s a post from Nancy Brown of Teen Health 411 on what you need to know about Bat Mitzvah, a coming-of-age tradition that significantly contributes to the emotional development - and therefore the health - of its participants.

The Robert Woods Johnson Foundation Blog Team posts on Addressing the Primary Care Workforce Shortage to Come. They quote Deanna Okrent, senior health policy associate with the Alliance for Health Reform, as being concerned about the primary care shortage which will become even more acute once healthcare reform passes. Primary physicians please take heart! Ms. Okrent confirms DrRich’s prediction that policy experts will cure your malaise by improving your reimbursements somewhat, helping you to pay off your extravagant educational debts, and by recruiting armies of allied health professionals to work along side you as your peers. Do these experts understand you, or what?

Paul Auerbach of Medicine for the Outdoors tells us about proper hydration at high altitude. While everyone knows that people traveling to areas of high altitude are supposed to avoid dehyration, Dr. Auerbach describes new evidence that over-hydration can also be detrimental. This all sounds too complicated to DrRich. Perhaps rising sea levels will eventually eliminate enough high altitude locations that few will need to worry about it any more.

Rachel from Tales of My Thirties in a post entitled “Worst Case Scenario” tells an extremely affecting story about what goes through a young woman’s mind when she is confronted with a serious, potentially life-altering illness. Highly recommended.

Dot from Fibro World talks about the association between fibromyalgia and irritable bowel syndrome, and how to remain diplomatic and circumspect when well-meaning friends urge potentially disastrous dietary remedies upon you.

The anonymous author of the Safety Sciences blog asks the question, “Are Physicians Like Cobblers With Bad Shoes?” The answer, apparently (according to the latest research) is “yes.” Doctors, purveyors of good health, often fail to take reasonable care of themselves. There are many reasons for this, and some are suggested here. Chief among these, DrRich believes, are the personality traits traditionally displayed by doctors - driven, Type A, workaholic perfectionists, who are prone to burnout, premature cardiovascular disease, alcoholism and suicide. Thank goodness healthcare reform promises to cure this problem, by converting medicine into the kind of field that attracts the more laid-back, what-will-be-will-be Type B folks. Docs should be much, much healthier within a decade or two.

Eve Harris of A Healthy Piece of My Mind writes about the systematic difficulties in becoming a empowered healthcare consumer. As a reasonably intelligent person who has been immersed in medical issues for 40 years, but who still has difficulty navigating the system when he or a loved one is ill, DrRich can vouch for that.

Dr. Hebert of Dr. Hebert’s Medical Gumbo provides a reasoned argument in favor of healthcare reform.  While DrRich (as should be clear to any of his regular readers) is skeptical of current reform plans, he in fact agrees with almost all of Dr. Hebert’s problem statements and much of his reasoning.

Ves Dimov of Clinical Cases and Images: CasesBlog posts on the mysterious dancing epidemic that occurred in July, 1518 in Srasbourg, France, in which hundreds of people began dancing fervently (and apparently involuntarily) for weeks, until they died of exhaustion. Historians have attributed the phenomenon to ergotism, mass psychosis, religious fervor, or chorea.  Dr. Dimov does not provide us with a definitive answer, but does provide cool video of a woman with chorea, who displays involuntary dancing-type movements. She does not appear to display any type of fervor, hysteria or ecstasy, however, and the smart money appears to be on mass psychosis as the cause of the dancing epidemic.

The dancing epidemic, of course, puts DrRich in mind of the famous Laughing Epidemic that took place in Tanganyika in 1962. This event, well-documented in medical journals, swept first through a female boarding school and then spread to neighboring schools and villages. Victims were utterly incapacitated by uncontrollable, hysterical laughter, which lasted for days, and led to fainting, respiratory problems, and other illnesses. The whole event, attributed to a mass psychogenic illness, apparently was triggered by a joke. (Monty Python subsequently got a lot of mileage out of the concept.) So, while there’s probably not much we can do at this point with the dancing epidemic, if anyone knows the culprit joke that triggered the Tanganyikan Laughing Epidemic, can you please e-mail it at once to your Congressperson?

And finally, Bongi of Other Things Amanzi (and DrRich’s favorite South African medical blogger) tells an incredible healthcare-related story of gangs, robbery, execution-style killings, car chases, shoot-outs in public places, substandard police marksmanship, lifesaving emergency surgery, and death threats by a surgeon against the patient whose life he had just saved. Dermatologists (whose most exciting professional experience is the uptick in emergency calls they always get during the two weeks before Prom) can just eat their hearts out.

Thus ends Grand Rounds for this very frigid January week, a week that finds DrRich giving thanks for runaway Global Warming, without which he cannot imagine how cold we would all be.

Next week, Grand Rounds will be hosted by Dr. John La Puma.

Comments

16 Responses to “Grand Rounds Volume 6, Number 16”

  1. precordialthump on January 12th, 2010 7:01 am

    G’day Dr Rich,
    Congratulations having written perhaps the most impressive Medical Blog Grand Rounds I have seen. I suspect you have a new regular reader!
    Also, thanks for your generous commentary on Life in the Fast Lane’s ‘Don’t put your patient in a box’.
    Regards,
    Chris

  2. rlbates on January 12th, 2010 7:44 am

    Wow! Will have to read this edition at least twice. Thanks.

  3. the Muse, RN on January 12th, 2010 7:47 am

    DrRich, I am honored. Thank you for including me and for hosting Grand Rounds! It was an amazing grouping and I’ll be all day reading…omg! good stuff.

  4. hgstern on January 12th, 2010 9:00 am

    Lh my gosh - what an OUTSTANDING job! You’ve really tied a lot of disparate posts together - very readable and excellent commentary.

    Thank you for hosting - and for including our post.
     

  5. Dr. Wes on January 12th, 2010 9:38 am

    Dr. Rich-

    As usual, an instant classic. Thanks for the inclusion. (Link back coming when I get a moment between cases…)

  6. Laurie Edwards on January 12th, 2010 10:21 am

    Wow, what an amazing edition! Your in-depth commentary is great, and I am honored to be included. Thank you for your hard work!

  7. Kim on January 12th, 2010 10:39 am

    Dr. Rich,

    I do believe that there was a dancing epidemic here in the United States, somewhere around 1978. I believe it was called “Disco” and contrary to medical reports of the time, it was not caused by the Bee Gees. : )

    Fantastic edition! : )

  8. AmyT of www.diabetesmine.com on January 12th, 2010 11:22 am

    Thank you for such a thoughtful edition, DrRich!

  9. Toni Brayer, MD on January 12th, 2010 11:38 am

    What an inspired Grand Rounds. Excellent and your commentary makes me want to read each and every article. Brilliant…Congrats, Dr.Rich. Will link back.

  10. bongi on January 12th, 2010 11:40 am

    great edition. thank you very much for your too kind words.

  11. Dot on January 12th, 2010 2:15 pm

    Dr. Rich,

    You expertly struck the perfect balance between entertainment and important information. I just started my blog a week ago, so I feel very privileged to be included. Thank very much. I am still learning the basics and will do a linkback as soon as I figure out how to do it! Meanwhile, your website serves as an inspiration.

  12. The Happy Hospitalist on January 12th, 2010 8:28 pm

    Excellent job, for an old fart.

  13. Eve Harris on January 12th, 2010 9:16 pm

    Nicely done; disparate articles woven artfully together. Thanks for included A Healthy Piece of My Mind.

  14. Ray on January 12th, 2010 10:51 pm

    Great reading. Just started exploring medical Blogs.. wealth of information with a bonus humor… looks like there will be more readers as time goes..

  15. John on January 13th, 2010 5:34 pm

    funny!

  16. Jupe on January 14th, 2010 5:29 am

    Heh.
    At least the hat is groovy.

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