Saturday, March 23, 2013

MRCP: Stop Already.

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

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

Wednesday, March 20, 2013

Ten Years

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

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

Robot Rebuked

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

Monday, March 18, 2013


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

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

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

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

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

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

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


Ezra Klein writes:
There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.  That may sound obvious. But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish........We spend less time in the hospital than Germans and see the doctor less often than the Canadians.  “The United States spends more on health care than any of the other OECD countries spend, without providing more services than the other countries do,” they concluded. “This suggests that the difference in spending is mostly attributable to higher prices of goods and services.”
But.... but.....I thought the problem in this country was that the ranks of doctors were filled with profit motivated dickheads like those in McAllen, Texas?  I thought the sole problem was our fee-for-service reimbursement system that rewarded more and more interventions and allowed doctors to game the system in order to enrich their coffers?  I thought the solution was to convert all doctors into salaried employees, to completely disincentivize them from any profit-maximizing motivations and allow the Good, Noble giant healthcare conglomerates like Mayo or the Cleveland Clinic be in charge of carefully doling out just the appropriate amount of healthcare services this country needs? 

Klein goes on:

Too Many Scopes

Colonoscopy is overdone in this country.  This is an observable fact.  I see patients every single day who get scoped every 2-3 years for no discernible reason.  I see inpatient 90 year olds who present with "GI bleed" (really just a little coffee ground emesis from dehydration/mild peptic ulcer disease) who end up getting black tubes snaked through their mouth and anus before they are returned to the nursing home from whence they came.  This happens constantly.  A study from Archives of Internal Medicine elucidates this phenomenon:
The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean.
A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older.
I post about this because, although the main problem with rampant, out of control healthcare expenditure in this country occurs at the macro-level via the health-industrial complex of hospitals, Big Pharma, the insurance carriers and the medical device industry, it doesn't excuse unscrupulous physicians acting like greedy assholes and the role individual doctors play in driving up costs.  Whether it's cardiologists performing unwarranted cardiac stent procedures or general surgeons taking out robin's egg blue gallbladders, we have to be able to shine the light on such behavior and shame those who betray basic medical ethics. 

Sunday, March 17, 2013

HRT for Menopause?

This article I saw on Yahoo News is an example of why patients ought not to go scouring the Internet for all their medical information.  The title of the article "Doctors Clear Up Confusion Over Hormone Therapy" is rather misleading.  Hormone replacement therapy (i.e. supplement estrogen and progesterone pills) has long been known to be the best intervention for refractory menopausal symptoms.  Unfortunately, a Women's Health Initiative study from a decade ago demonstrated that subsets of post-menopausal of women who took hormonal replacement therapy (HRT) medication increased their risk of developing breast cancer by 25%.  Afterwards, enthusiasm for HRT sort of tapered off.  As you could imagine.  This new statement avers that:
...while the therapy comes with risks, its benefits generally outweigh the harm for women under age 60, or those who've been in menopause for fewer than 10 years. The increased risk of breast cancer also appears to disappear a few years after treatment is stopped......doctors recommend low doses of HRT for women whose menopausal symptoms are limited to vaginal dryness and pain during intercourse. HRT is not recommended for women who've had breast cancer
So if you're under 60, have had symptoms less than 10 years, never had breast cancer,  and your symptoms are limited to vaginal dryness and dyspareunia, then HRT is for you.  I'm a little wary myself.  Curiously absent from the "consensus statement" are doctor's groups such as the American Medical Association, the National Cancer Institute, the American Cancer Society, the American Society of Breast Surgeons, and the American Breast Cancer Foundation.  The Asia Pacific Menopause Society, which I'm sure is a fine organization, just doesn't have the carry the same cache for me.... 

Wednesday, March 13, 2013

Cardiac Outcomes

Alice Park reviews David Jones' counter intuitive new book on the history of cardiac surgery and coronary angioplasty in most recent issue of Harvard magazine.  Jones, also a physician, is a professor of medical history at Harvard.  His latest book explores the rise of interventional cardiology and cardiac surgery since the 60's and how much of the rationale for such a procedure-dominated treatment strategy is undergirded by some surprisingly shoddy data. 
The first randomized clinical trial of bypass surgery’s efficacy, using data from a collaboration of Veterans Administration hospitals, was not published until 1977. Such trials were then becoming the gold standard of medical research (and still are). “Surgeons said trials were totally unnecessary, as the logic of the procedure was self-evident,” says Jones. “You have a plugged vessel, you bypass the plug, you fix the problem, end of story.” But the 1977 paper showed no survival benefit in most patients who had undergone bypass surgery, as compared with others who’d received conservative treatment with medication.
It's funny, coming from the perspective of surgical training, I don't recall ever hearing from disgruntled cardiac surgeons the actual reasons why bypass surgery had started to fall out of favor during the nineties and oughts.  All I heard was that fellows were having a hard time scoring jobs because bastard cardiologists were snaking all the cases.  Never did we discuss studies outlining the lack of survival benefit from CABG.  It seems obvious now that such an inquiry was a trip down the existential rabbit hole--- no one wanted to find out that the profession one had spent a third of one's lifetime preparing and training for was, in the end, no better in terms of providing survival benefit than simply telling someone to stop smoking, to eat better, and to get off the couch. 

Tylenol: That will be $16.95 please

I just have to highlight this.  In the AHA release in response to the Brill article, they address the issue of why it costs $17 for a single tylenol when you're an inpatient:
A dose of Tylenol provides a good example. In order to take medications in a hospital, even over-the-counter medicines, they must be prescribed by a doctor (a little bit of cost for the doctor), that order gets transmitted to the pharmacy (a little more cost), the order gets filled by a pharmacist or pharmacy tech who retrieves just one Tylenol pill and individually packages that one pill (still more cost), the pill gets transported from the pharmacy to the nursing unit where the patient resides (a little more cost), then the pill is retrieved by a registered nurse who personally gives the pill to the patient and then must document the administration of that pill in the patient medication administration record (a little more cost). All of this process to give a patient a single dose of Tylenol in a hospital bed is regulated by agencies that accredit hospitals – a condition of participation in the Medicare program. In other words, this is what hospitals must do to administer a pill in compliance with all pertaining regulations (a little more cost).
Apparently this was not written as an intentional parody.  At least I don't think so.  It's always possible that they're putting us on.  But maybe not.  Maybe they really have conducted thorough internal audits on the costs of "transporting the pill from the pharmacy to nursing unit" and "individually packaging a single pill".  Bureaucracies have been known to do worse. 

Friday, March 8, 2013

Profits and Hospital Systems.

The American Hospital Association has come out with a rebuttal to Steven Brill's Time Magazine article.  Brill had claimed that non-profit hospitals operate at a 11.7% profit margin.  According to some internal AHA survey, the actual number may be closer to 5.5%.  In the context of typical corporate profit margins, this adjusted number does not exactly make one weep for the hospital industry.  To wit, according to recent industry trends, even a 5.5% profit margin out-performs private stalwarts like the auto manufacturing industry, major airline carriers, textiles, heavy construction, and even the tobacco industry.     

I mean, the hospitals aren't raking in 25% profits like real estate investment trusts, but 5.5% isn't too shabby.  They do just fine.  CEO's of places like the Cleveland Clinic and Mayo and Johns Hopkins earn well over seven figures.  Even mid-level hospital executives usually take home twice or three times as much as the salaried docs who actually take care of patients and make sure all the billing information is filled out appropriately.

Are we OK with hospital systems who don't pay a cent in federal or local taxes generating bottom lines that American Airlines would take in a heartbeat?  This is not merely a question of pragmatics--- i.e. whether or not, given the exploding cost curve in the health care sector, it is feasible to expect hospitals to remain so profitable with their million dollar robots and Renaissance Hotel-esque entrance lobbies and 42 inch flat screen TV's in every room and outrageous facility fees and $18 charges for two Tylenol pills. 

The question, like it or not, transcends pragmatics.  It is the defining moral question of our time...

Understanding Sub-concussive Head Trauma

The link between Chronic Traumatic Encephalopathy (CTE) and repeated subconcussive head trauma (as in football) has been well documented.  What is less well understood is the pathophysiologic mechanism by which this process occurs over time.  This paper suggests that a disruption in the blood brain barrier (BBB) occuring after sub-concussive head trauma can elicit an auto-immune response, whereby auto-antibody production and infiltration of the brain could potentially lead to the long term cognitive damage as seen in CTE.

This is only the beginning.  Science lurches toward the truth.  And Pop Warner leagues can flip that hourglass over any minute now.  The end of football as we know it is coming, and quickly. 

Saturday, March 2, 2013

Matthew Yglesias Thinks Doctors are the Problem

The liberal blogger Matthew Yglesias' take on the Steven Brill's health care crisis tome is a strange one.  Rather than focus on Brill's substantive points about the medical-industrial complex, he elects to point out the one facet of health care spending that Brill downplays; i.e. doctor compensation.  Yglesias, from the Gawandean school of Avaricious Physicians, apparently, feels that we need to crack down even harder on physician reimbursements.  After all, doctors in the United States earn more than doctors anywhere else in the world.  To back such a claim he cites this chart from the OECD:

The Chargemaster and Non-Profit Charity Care

In Steven Brill's article, the main take home message is that pricing for hospital based services is arbitrarily far too high.  The starting point for negotiations between hospitals and the various third party payors (Medicare, private insurance plans) begins from a price listed in the hospital "Chargemaster", an all-encompassing compendium of charges for everything a hospital can bill for (example here).  No one knows where prices listed in the chargemaster originate from.  And so you end up with absurd situations where itemized bills will show that the tylenol the ER gave you for a headache got charged at $18.50 per pill.  Paper surgeon's gown for $32.  IV tubing priced at $125.00.  Troponin lab tests for $199.50.  The CT of your head, several thousand dollars.  Now hospitals themselves don't pay any attention to the chargemaster.  Those patients with Medicare or private insurance don't pay anywhere near the listed chargemaster price.  But if you have no insurance or some sort of shoddy, limited-reimbursement plan, then the bill you receive, when itemized, will include charges on ridiculous items that insurance plans routinely disregard as part of the facility fee, and all the prices will come directly from the chargemaster. 

So yes, those who are least able to pay get charged the most.  And many hospital systems adopt strict non-negotiation stances toward patients who are in financial difficulty.  Unpaid bills are quickly turned over to collections agencies, written off as "free care", or sometimes the hospital will actually litigate to squeeze everything they can from patients already teetering on the edge of financial catastrophe.