WhiteCoat

Healthcare Update — 11-19-2012

Can you imagine your kids on this stuff? Two ounces of Cracker Jack’d will have 70 mg of caffeine – as much caffeine as a cup of coffee. Frito-Lay reports that the snack won’t be marketed to children and will be labeled different from the traditional Cracker Jack boxes.
Not sure how I feel about this.
On one hand, I think that companies should be able to market any legal product that they want. How is taking Cracker Jack’d any different than using energy drinks or No-Doz caffeine pills?
On the other hand, I don’t think that changing the labeling and marketing the product only to adults is going to prevent children from eating the Jack’d version. Kids still smoke a lot of cigarettes. In addition, unless Frito-Lay colors the popcorn differently – such as red popcorn for Jack’d version and traditional caramel color for the regular version – I foresee a lot of unintentional ingestions/overdoses. If there’s no way to differentiate caramel corn outside of the box, how can someone tell if their snack has been Jack’d?

One way to bring down medical costs. GruntDoc mentioned this group of docs on his blog as well. Oklahoma surgery center publishes list of prices for pretty much all-inclusive surgical care, and the prices are one-fifth of what the nearby Integris Health hospital system charges. For example, a bilateral sinus procedure costs $33,000 at the hospital – not including surgeon or anesthesiologist fees. The same procedure at the surgery center – including all doctors’ fees – is $5,885.
A plane trip and hotel plus surgical fees would cost a lot less than what most local hospitals charge. Domestic medical tourism – what a concept.
Hoping this care model expands.

VA Medical Center sued for prescribing four month supply of Seqoquel to patient who abused prescription drugs and previously attempted suicide by overdose. The patient was successful in her fourth suicide attempt when she took most or all of the pills and was found dead in her apartment.
When the shoe is on the other foot, now government attorneys argue that Seroquel is not particularly lethal (good thing for that or else the patient may have died from her overdose) and was “effective in treating [the patient’s] psychosis when taken as directed” (it was also effective in killing the patient when she took too much of it). Despite the risk of overdose, the attorneys argue that the greater risk to the patient was that she would run out of Seroquel, which seemed to help her. But one of the documented side effects of Seroquel is “suicide attempts.”
Obviously, we need to charge all the government employees involved in the patient’s care with murder.
After all, how is this case that much different from all the cases where the government is charging doctors with murder when patients overdose from using narcotic prescriptions inappropriately?

Making pediatric patients happy to wait. All rooms in Stanford’s Packard Children’s Hospital emergency department have iPads included. “One iPad is worth 10 milligrams of morphine,” says the department director. Until the iPad is dropped on the floor, that is.
I also wonder whether the idea will have unintended consequences. What if more than one kid is in the room? How do the hospitals manage “inventory control”? Will kids who don’t have iPads at home feign illness to go back to the emergency room? Any issues with privacy if parents look things up on the internet or take pictures using the iPad? Will patients/families become upset if there are not enough iPads to go around? How will hospitals deal with those expectations? Will there now be Press Ganey complaints because patients don’t wait long enough?
I give these docs credit for their ingenuity and don’t think that the above issues should preclude this practice, but I hope that there will be further reports describing any downsides to providing $500+ iPads as entertainment for waiting patients before this becomes a standard.

Canadian study shows that patients with mental illness related complaints wait a little longer for physician evaluation (82 vs. 75 minutes median), but that when crowding in the department increases, the patients with mental illness related complaints wait an average of 48 minutes less than other patients.

A couple of rare medical conditions in the news recently:
Angelman Syndrome – where children are unable to stop smiling and have significant developmental delays
Sleeping Beauty Syndrome or Kleine-Levin Syndrome – where victims sleep for extended periods of time or are awake for short periods of time in a fugue state which they do not remember. The subject of this article allegedly once slept for 64 days.

Dr. Bob Solomon writes a thought-provoking article in ACEP News about whether nurse practitioners will be able to fill the primary care physician shortage — a shortage that will only worsen as the Affordable Care Act is implemented.

Speaking about a shortage of primary care physicians, Dr. Natasha Deonarain writes on KevinMD.com about why she decided to opt out of taking Medicare. She predicts that the system will collapse by 2014 – the same year that all those patients get their new insurance.

Some Canadian patients will soon be able to surf the internet to determine what hospital can treat their emergency the quickest. That begs the question whether someone with an emergency should be sitting at the computer looking up hospital wait times, but that’s beside the point.

Unfortunately, not every patient knows what constitutes an “emergency.” England’s Nottingham hospital creates ad campaign urging people only to come to the hospital for emergencies. One of the ads is life-size cutouts of people in a line who “shouldn’t” have come to an emergency department and then the picture of a burial wreath at the end of the line with a statement that the patient “should have been at the front of the queue.”

That health care program that was passed last year to make health care more “affordable” – the Affordable Care Act – appearing to be having increasing number of unintended expensive side effects.
Premiums for employed workers estimated to rise 9% nationally next year. Wal-Mart will require employees to pay up to 36% more for their coverage.
Some employers who don’t already offer full benefits or whose benefits do not meet the ACA requirements are cutting employee hours. Part-time employees don’t subject employers to the Affordable Care Act requirements.

11 Responses to “Healthcare Update — 11-19-2012”

  1. Gene says:

    “Frito-Lay reports that the snack won’t be marketed to children…”

    Yes. Because mature adults wants to eat caffeine laced caramel covered popcorn. Just like we like to eat candy cigarettes.

  2. Matt says:

    “After all, how is this case that much different from all the cases where the government is charging doctors with murder when patients overdose from using narcotic prescriptions inappropriately?”

    Well, I think the murder overdose charges are state charges, not the feds, aren’t they? Not that it justifies either the civil defense or the criminal charge, but VA lawyers in defense of a civil case won’t have much knowledge or cause to know what state district attorneys are doing.

  3. CJL says:

    “Will kids who don’t have iPads at home feign illness to go back to the emergency room?”

    Parents already do this at the children’s hospital where I work. The hospital will give kids presents on their birthdays or Christmas, etc. And it seems a little too coincidental the number of kids who happen to come in on those days. Or parents who insist their child stays another night when they don’t really need to medically because the hospital rooms have two flat screen TVs and nurses to feed the kids and change their diapers…

    I’m really not all that cynical, but it definitely happens more than it should.

  4. Ian Random says:

    My portion of the health premiums went up so much this year, several hundred percent. The increase is more than my average yearly medical expenses.

  5. ndenunz says:

    Watch what happens to those I Pads when they trace an outbreak of C. diff. to one of them.

  6. rungirlrun says:

    Dr Robert’s opinion is thought provoking. However, what his article shows more than anything else his his closed minded conceited attitude. Just like there are better and worse doctors there are better and worse nurse practitioners. His assertion that nurse practitioners can only follow guidelines and cannot diagnose new problems on their own is ridiculous. His example of the NP who sent the patient from an urgent care for a CT secondary to a minor head injury is a poor example of inadequate care by a NP. All of us work with with colleagues who are much quicker to pull the trigger on doing head CT’s than others. Presumably Dr. Robert is one of those providers who are more conservative about ordering imaging, which I applaud, but, without knowing the details of the case it is difficult to say for sure, there is a stong possibility that another MD would’ve ordered a CT on that pt.
    Last week, I, a poorly educated NP, saw a patient in the ED that was sent to me by a MD from an urgent care with a “cellulitis” of her hand and arm after a bee sting. She had been treated with IM antibiotics the day before, the redness worsened and she returned to the same MD the next day who sent her to the ED for her “worsening infection and possibility of joint damage.” When the patient was questioned appropriately, based on the science of antihistamine reactions vs infections, it was very clear that she was simply having an antihistamine response to the sting and was inappropriately treated with antibiotics and sent to the ED by the MD.
    There are excellent doctors but there are also excellent nurse practitioners as well. It’s too bad Dr Robert’s pride is so blinding that he can’t see it.

  7. Jason says:

    Just a “fun fact” (which isn’t so much, actually) to recapitulate basic sciences for y’all…if you recall, and are old enough, you may remember the Angelman syndrome by the term “happy puppet syndrome”, which is now greatly avoided as it is considered pejorative. The fact is Prader-Willi. Does this ring a bell? Angelman and Prader-Willi are both found at 15q11 on the chromosome #15. However, if the deletion comes from mom, the child gets Angelman. If it comes from dad, the kid gets Prader-Willi.

  8. GuitarGirlRN says:

    Rungirlrun, you beat me to it! Thanks for commenting on the article by Dr. Roberts. In addition to being excellent diagnosticians, studies (and real-world experience) has shown that NPs in the ED work faster, see more patients, and get higher patient-satisfaction scores than either Physician Assistants or even medical residents. One hospital I worked at has seen a transition from PAs as physician extenders to NPs (FNPs and ACNPs) as independent practitioners providing excellent care in the ED.

    Also, in my state (NY), NPs are required to document close to a thousand hours of clinical time in order to qualify for the licensing exam–so I don’t see how one could become an NP by just “completing a few classes online.” Some programs utilize distance learning or online classrooms as part of the classroom experience, but I know this is becoming more common in all disciplines, including pre med and med school.

    The only thing I can add about an NP’s education is this: there are many nurses who go straight through from their undergraduate work, become RNs, and then proceed directly into NP and/or DNP (Doctor of Nursing Practice) programs, all without ever having practiced as a nurse. Only a few NP specialties require a few years of clinical time (specifically, Nurse Anesthetists are required to have a MINIMUM of two years clinical work experience in the ICU or ED before they can be considered for a CRNA program). I think bedside nursing experience is invaluable and should be mandatory in all NP specialties.

    • WhiteCoat says:

      Hey GG! Good to hear from you. When you going to start blogging again? I miss your snark.

      • GuitargirlRN says:

        Well hellooo back! It’s nice to be missed! Actually, I changed jobs to a hospital that actually CARES about its nurses, where the ED is so well-organized that i have been kinda happy. Much less snark. Also slightly boring. But now in the aftermath of Sandy, we’re getting SLAMMED, and so it’s a LOT more interesting. But also a lot harder to blog because people know exactly where I am and can probably narrow it down to the hospital. So ya know, anonymity and all that jazz. But again, it’s nice to be missed!

  9. WhiteCoat says:

    I agree with both RGR and GG regarding the fact that there are good doctors and bad doctors and that some NPs are undoubtedly better clinicians than some doctors. However, I’m going to play Devil’s Advocate about Dr. Solomon’s article.

    I know Dr. Solomon personally and he is a good person, soft spoken, and quite intelligent. I don’t find him to be conceited in the least. That being said, I also agree that his article could have been less caustic.

    I think that Dr. Solomon was trying to make two points in his article:
    1. He believes a medical provider’s pedigree is important in determining patient outcomes.
    2. There is a “brain drain” in medical training programs

    There are obviously going to be outliers at any level of training, so I don’t think it is fair to compare high-range outlier NPs with low-range outlier physicians in determining whether those at one level of training perform better than those at another level of training.

    You guys don’t seem to think that pedigree is as important in patient outcomes or in providing proper medical care. So the question that I have is how much and what type of training should be sufficient in order to diagnose and treat patients without direct supervision?

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