Archive for the ‘News Commentary’ Category
Tuesday, February 7th, 2012
I admire this lady’s chutzpah.
If Virginia wants to make an unnecessary ultrasound necessary before a woman can have an abortion, Virginia Senator Janet Howell wants to make unnecessary rectal exams and stress tests a prerequisite before men can receive Viagra prescriptions.
I bookmarked this link from Instapundit which is one of my favorite news aggregator blogs. However, I disagree with Glenn Reynolds’ opinion that the Virginia senator’s rider to the initial bill is “kindergarten payback” and that it is “sad” that Senator Howell is being lauded for her cleverness. OK. Maybe it is kindergarten payback.
The bottom line is that the state wants to make an expensive and unnecessary medical procedure a prerequsite to a woman being able to obtain an abortion. The proposed bill stated that the ultrasound is required to determine the gestational age of the fetus.
Why? If a woman appears to be past her first trimester or near fetal viability, then I can possibly see the utility in obtaining an ultrasound. But requiring the test on every pregnant patient seeking an abortion?
I don’t agree with abortion, and I have harsh feelings toward women who use serial abortions as a form of birth control. However, I still believe that a woman has a right to choose what happens to her body.
To me, it seems like the intent of the law is to put an additional financial burden on women seeking an abortion. Can’t pay for the ultrasound? The doctor is prohibited from performing the abortion.
Glenn Reynolds stated that “presumably the reason for an ultrasound is to let women see what they’re aborting.” That reason doesn’t meet medical necessity. What other reason would a legislature require a useless medical test in order to have a procedure performed?
Eventually, the bill was passed in the Virginia House with a modification requiring that the physician offer to perform an ultrasound prior to performing an abortion. This version has no teeth, but I believe it tees up the matter for further debate in another “addendum” to the law somewhere down the road.
The initial bill was just another example of an unfunded mandate and I am one of those that applaud Senator Howell for standing up to it.
Now it appears that they could use Senator Howell’s help in Kansas. Lawmakers there are proposing a law that provides malpractice immunity to physicians if they hide information from patients in order to prevent an abortion. The law also forces doctors to tell women that abortions potentially increase the risk of breast cancer. Maybe they can also create an addendum to the law requiring that doctors tell the husbands of pregnant women seeking an abortion that touching their woo-hoo while thinking impure thoughts will grow hair on their palms. Have the legislators been drinking on the job?
Utah is probably beyond Senator Howell’s help now. Recently, the Utah Supreme Court ruled that “unborn children” and “minor children” are legally the same for the purposes of wrongful death lawsuits. Great concept. Extending the definition further, under that logic, pregnant women in Utah now need to purchase two plane tickets – one for them and one for their “minor child.” They also need two movie tickets. Ohmigod. What if there are triplets? What if Octomom wanted to board a plane in Utah while she was still pregnant?
If pregnant women drink alcohol, using the Utah Supreme Court’s logic, they must be endangering the welfare of a child by force feeding their “minor children” alcohol. If they smoke, they must be breaking federal law by providing cigarettes to minor children. Child protective services should require an immediate Caesarian section (after performing an ultrasound and maybe a stress test) and should immediately take custody of all such children.
At least the dissenting Justice Nehring understood the absurd results that would result from the majority’s decision.
What is going on in this country?
Posted in News Commentary | 4 Comments »
Monday, February 6th, 2012
I finally took the time to read some other blogs today. One of the issues that I found disturbing was the case of Amanda Trujillo.
There are a lot of bits and pieces out there about what actually happened in this case. This blog post was reportedly an e-mail from Amanda describing the events. A summary of the post follows.
Amanda was a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care.
In April 2011, she was caring for a dying patient at Banner Del E. Webb Medical Center who had agreed to a major invasive surgery recommended by a staff surgeon.
Amanda used materials from her hospital to educate the patient about the details of the surgery and the aftercare.
The patient became upset, stating that the surgeon never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care).
Amanda also discovered that the patient “had no idea” that surgery could be refused or that the patient could enroll in hospice care. She educated the patient on those options as well.
Afterwards, the patient requested a case management consult to visit with hospice.
Amanda documented her discussions with the patient and informed the nurse at shift change that the surgeon needed to clear up a “gross misunderstanding” the patient had about the surgery.
“The surgeon became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken.”
She was fired and she is not able to find employment due to the actions taken against her license.
As a result of this incident, Amanda’s career has been destroyed. She is a single mom with three nursing degrees and now, unemployed and unemployable, she has no other option than public aid to feed her family.
Back in 1913, Supreme Court Justice Louis Brandeis once wrote:
“Publicity is justly commended as a remedy for social and industrial diseases. Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.”
I’ve tweeted to Amanda to contact me so that I can get more information from her. If the above events can be substantiated, what happened to Amanda was deplorable. And if the events can be substantiated, I’m going to shine some sunlight on the actions of other parties involved.
I’ll request the patient’s permission for release of the patient’s medical records from the hospital. With the patient’s permission, I’ll publish them here, including the surgeon’s notes and Amanda’s notes.
I’ll get the names of the nursing supervisor and everyone involved in Amanda’s firing, including the hospital CEO. We’ll take a look at their careers on this blog.
I’ll get the names of the people from the Arizona State Board of Nursing who reviewed this case and who recommended that Amanda lose her license and undergo psychiatric testing. I’ll publish any correspondence that they sent Amanda. We’ll take a look at just how they arrived at their conclusions.
And I’ll get the name of the surgeon who allegedly does not take the legal doctrine of informed consent too seriously and who allegedly uses temper tantrums as a means to bully people into submission. Maybe we can look into his background a little. If he did have a “tantrum” in a patient care area, has the hospital investigated him for his conduct?
Everything will be published here.
And if ends up that Amanda was wrong for what she did I’ll publish that as well.
That reminds me …
When two nurses complained to the Texas Medical Board that a physician was trying to hock herbal medications to hospital clinic patients, they were fired and prosecuted for criminal acts. The Texas Nurse’s Association became outraged, established a legal defense fund for the nurses, and fought for them. In the end, the doctor was the subject of a complaint by the Texas Medical Board, and the hospital at which the nurses worked was fined for firing the nurses.
Why isn’t the Arizona Nurses Association taking any action on Amanda’s behalf? I might have an idea.
It so happens that the President of the Arizona Nurse’s Association, Teri Wicker, is also the Director of Professional Practice at Banner Del E Webb Medical Center – the same hospital where Amanda Trujillo used to work. Has anyone asked her for comment?
More to come …
Posted in News Commentary | 21 Comments »
Wednesday, January 25th, 2012
Want more evidence about how many people expect perfect outcomes in medical practice?
Look no further than the Wall Street Journal: “What if the Doctor is Wrong?” by Laura Landro.
As a substantive basis for the conclusion that initial treating physicians are “wrong” when they haven’t yet reached a diagnosis, Ms. Landro interviewed two patients who, in the midst of a workup, left the doctor who was trying to diagnose and treat their problems. Said patients then went to a “mecca” to have their workup completed where … amazingly … the problem is “discovered” and “properly” treated. Even though the initial provider in all likelihood would have done the same testing that the “mecca” performed after reviewing the results of the initial testing – had the patient stuck around long enough to have the testing performed. Even though the “standard of care” may have been to do things exactly the way that the initial provider was doing them. Nope, they’re wrong because they didn’t get to the answer sooner.
When reading about all these “errors” I couldn’t help wondering: Did Ms. Landro have a neutral physician review the patients’ medical records to see whether the care provided to the patients was appropriate? Did Ms. Landro interview the initial treating physicians to determine what the next step in their treatment plans would have been? If so, she kind of left those points out of her article.
I understand the idea that second opinions can be useful and I agree that misdiagnoses are sometimes made. Until we find a single test that is 100% sensitive and 100% specific for diseases such as cancer or complaints such as abdominal pain, there will always be misdiagnoses made. Even once a diagnosis has been made, there are disagreements about how to proceed with treatment. Some prefer one medication for treating certain types of cancer, some prefer another medication. Does that make one side “wrong” and the other side “right”? Hardly.
The title of this article and the slant of this reporting make it appear as if doctors are “wrong” just because they don’t make a diagnosis after the first round of testing. Did Ms. Landro even explore how often the “meccas” get their diagnosis “wrong” on the first visit? Are the “meccas” that much better?
If patients want to mortgage their house to get the tens or hundreds of thousands of dollars necessary for a “down payment” at MD Anderson (original link to WSJ article here) or some other “mecca” when they likely would have gotten similar testing done had they stuck with their initial providers, that’s free market medicine at work.
When journalists imply that excluding diseases on a list of differential diagnoses in the midst of a workup or coming up with “inconclusive” results during testing is “wrong”, shouldn’t we start looking into journalistic malpractice?
What if the Journalist is Wrong?
Posted in Medical-Legal, News Commentary | 9 Comments »
Sunday, January 8th, 2012
There was a good article posted on My Health News Daily about the five most dangerous things around the house. They interviewed several experts (I must have been out of reach during my vacation, so I wasn’t quoted – although one of my friends was quoted) and came up with a pretty useful list of dangerous things around the home and how to make them less dangerous.
What are my top 5?
1. Pain medications and other narcotics. They kill more people via overdoses than anything else. If we want to just use the general category “medications,” I’d throw in blood thinners and diabetes medications as well.
2. Alcohol. ‘Nuff said about that.
3. Weapons. I personally like the idea of being able to protect our home. We own several guns and will probably purchase a couple more in the near future. They are safely stored. However, mix guns with alcohol or guns with anger and there is a huge danger. Teach children about proper gun use. Knives are also a problem – most of the time people are using knives to cut food and instead cut fingers.
4. Floors. I see a lot of elderly patients who either slip on bathroom floors or who slip on the edges of carpets and severely hurt themselves. That goes for stairs, too. Having non-slip tiles in the bathroom and bath tub will help. Also, making sure that throw rugs are securely taped will prevent slips and falls. Stairs and alcohol don’t mix. If elderly relatives need a walker, they shouldn’t be walking up and down stairs, either.
5. Television. First, I see about one kid every month or two who has a TV on a shelf fall on him or her. But televisions encourage a sedentary lifestyle, encourage people to snack while watching, and even provoke some fights where I end up sewing up someone who was talking jack about a video game.
Any other dangers?
BTW, the first one of you to say “get-gos” gets your IP address blocked.
Posted in Medical Topics, News Commentary, Random Thoughts | 6 Comments »
Wednesday, December 14th, 2011
I read this story about how transgender patients are upset because they are addressed incorrectly when they seek medical care. Because of this, some people are demanding sensitivity training for medical personnel and are alleging that “transphobia” must be occurring.
“Transphobia”?
Sorry, but I think that the whole transgender rights thing is going a little far when transgender people are offended because medical staff need to appropriately identify them before they receive medical care.
The article states that
“We tell them, hey, if a trans person comes in with a stomach ailment or a broken ankle there’s no need to go on a tangent about what different types of surgeries they may have had.”
Yeah. Good advice. Knowing that a man has ovaries would have no impact on my differential diagnosis of abdominal pain. None at all.
If a woman was taken for prostate surgery because medical staff didn’t want “offend” her by asking her whether or not the “MALE” designation on her ID bracelet was incorrect, you know these same people alleging “transphobia” would be demanding that all the providers’ licenses get revoked.
Don’t want to be embarrassed? Go to the hospital desk ahead of time and explain the situation or call the hospital ahead of time and discuss it with the administrator. Don’t get upset because someone is trying to properly identify you, then scream discrimination when none exists. Make it easy on us and we’ll usually try to make it easy on you.
If you act unreasonably, you’re probably going to end up offended, but it won’t be because of your current or desired gender.
Posted in Medical Topics, News Commentary | 32 Comments »
Friday, October 28th, 2011
I just read an article in American Medical News about medical malpractice insurance costs. Included in the article was a small graphic about how much internists pay for medical malpractice insurance.
Internists in Dade County, Florida paid medical malpractice insurance premiums that were 1400% higher than internists in the state of Minnesota. Illinois internists in Chicago paid more than 12 times as much in malpractice insurance premiums as their Minnesota counterparts. In other words, internists in select Florida and Illinois counties pay more for malpractice insurance in one month than internists in the state of Minnesota pay for an entire year.
There are similar premium disparities for general surgeons and obstetricians, with Long Island, NY and Las Vegas NV also consistently being on the list for high malpractice premiums
Does that mean that the Florida and Illinois physicians were 1200% to 1400% more negligent than doctors in Minnesota? Doubtful. It just means that Miami, FL; Chicago, IL; Las Vegas, NV; and Long Island, NY are places where insurance companies have determined that it is much more risky to practice medicine.
When doctors search for the best states in which to practice medicine, they should consider the medical malpractice environment when making that decision. Given these statistics, doctors should not practice in Miami, Chicago, Las Vegas, or Long Island if they want to reduce their medical malpractice risk.
Yet Florida lawmakers reach out to news stations and claim that the state “desperately needs more doctors.”
Suing your way to better health care doesn’t work very well, does it, Senator Nelson?
Posted in Medical-Legal, News Commentary | 3 Comments »
Thursday, October 27th, 2011
I really don’t like it when people call me “doctor.”
The only time that I ever refer to myself as “Dr. WhiteCoat” is when I first enter a room and introduce myself to a patient. That way they know that I’m not some schmuck off of the street who wandered into the wrong room. Patients came to the emergency department to be evaluated by a doctor and, like it or not, I’m that guy.
However, almost all of the staff that I work with call me “Whitey” and many patients call me by that nickname. The rest call me “Dr. Whitey” apparently because they feel uncomfortable addressing me without the “Doctor” moniker.
Personally, it annoys me to no end when people correct others and demand to be called “Doctor”.
I met a child’s parent at a football game and introduced myself.
“Hi, Mr. Smith, I’m Thaddeus WhiteCoat. Nice to meet you.”
“It’s Doctor Smith. Dr. Mark Smith.”
“Oh. My apologies. What’s you’re specialty?”
“I have a PhD in psychology.”
“Oh. Nice.”
In the back of my mind I was thinking about saying something like “Unfortunately, we’re in football stands so I can’t genuflect in front of you. Please forgive me.”
Enough rambling.
In the NY Times a couple of weeks ago, there was an article about nurses who want to be called “doctor.” Actually, the nurses in the article earned the title. They have doctorates in nursing or other PhD degrees.
Is it good public policy to allow a non-physician to use the title “doctor” in a medical setting without having a medical degree?
Personally, I don’t care what people want to call themselves. If your ego is that fragile, call yourself Grand Exalted Supreme Poobah Doctor Nightingale for all I care. Introduce yourself that way at dinner parties. Command people to address you that way. Knock yourself out.
When someone introduces themselves as “doctor” in a medical setting, it evokes a specific and consistent response from just about any patient: The person in front of me is a physician.
Whether the patient thinks the “doctor” is intelligent or a quack depends upon multiple other issues, but the presumption is that “doctors” have gone through a lot of medical training and are capable of independently evaluating, diagnosing, and treating the medical condition for which the patient is seeking care.
In my view, calling oneself “doctor” when one is not a physician is misleading. Think about it. What if you bought a “hybrid” car, then opened up the hood to find a regular engine with a “hybrid” soybean growing in a crevice. Hey, it is a hybrid, isn’t it ? Or what if you bought a “Big Mac” and unwrapped a sandwich with two buns and a piece of cheese that was made by some guy named “Big Mac”?
States tend to frown upon nurses and physicians assistants referring to themselves as “doctor” as well. Many state Medical Practice Acts, Nursing Practice Acts, and Physician Assistant Practice Acts prohibit non-physicians from leading a patient to believe that they are capable of independently providing medical care. There have also been lawsuits against physician assistants who have not disclosed their credentials.
Maybe the increasing number of non-physicians who refer to themselves as “doctor” will create a “caveat emptor” environment where consumers will inquire about the credentials of a health care provider before seeking care. I see that as a good thing.
Maybe hospitals will use the idea to enhance their advertising: “This hospital emergency department is staffed exclusively by board certified emergency department physicians.”
We haven’t reached that tipping point, yet, though.
Given the current medical practice environment where providers are attempting to cut costs by employing non-physicians, I don’t think it is appropriate for non-physicians to refer to themselves in a medical setting as “doctor,” even if they have earned some other doctorate degree.
If non-physicians want to demand that others call them “Doctor” at dinner parties, go through the explanation about how they are not a physician but have completed a doctorate in some other course of study, garner the eye rolls that go along with the explanation, and then deal with the whispers about how he or she is not a “real” doctor, hey … be my guest.
What do you think?
Posted in News Commentary, Random Thoughts | 40 Comments »
Sunday, October 9th, 2011
 I’m getting to dread Friday evenings in the emergency department.
This past Friday, I saw six patients who had assorted injuries from football games. Six.
Two of them had concussions, which goes along with a recent study published by the CDC showing that concussions are on the rise. See articles here, here, and here. CDC report is here.
There is a lot of debate on how to manage sports-related concussions.
The American Academy of Neurology essentially recommends discontinuing participation in the sport until symptoms resolve and appropriate evaluation … by a neurologist (or other physician with “proper training”) … prior to being cleared for participation.
The Consensus statement on concussion in sport (2008) recommends physical and cognitive rest until symptoms resolve and then a graded return to activity prior to medical clearance.
There is also an excellent but dated (1999) article in American Family Physician containing a summary of the then-current treatment recommendations for concussion. Several recommendations included discontinuing participation in the sport if several concussions occurred.
Anyone symptomatic when I see them gets taken out of sports and gym until cleared by their physician.
I also had another “oops” from Dragon Naturally Speaking related to the football injuries which was almost finalized in the medical record …
I dictated “… followed by hitting head on another player’s football helmet.”
Dragon spat out ” … swallowed getting hand in another player’s foot vomit.”
Haven’t seen foot vomit in a while, but I know I wouldn’t want to be getting my hand in it.
Posted in News Commentary, Patient Encounters | 5 Comments »
Wednesday, September 21st, 2011
While scanning the news this morning, I laughed out loud at Pennsylvania’s newest proposal to cut Medicaid costs.
According to this Kaiser Health News report, Pennsylvania plans to pay Medicaid recipients up to $200 to visit “higher quality and lower cost hospitals and doctors.”
Gary D. Alexander, the Pennsylvania secretary of public welfare, compared the idea to a shared cost savings. “If the state saves $1,000 on a medical procedure we may give the beneficiary $100 or $200 as a reward.”
Does anyone see a problem with this approach?
Let me lay it out for Mr. Alexander, just in case someone who reads my column has his e-mail address.
In some of the inner-city emergency departments where I have worked, there used to be a policy that patients would be given subway tokens … or bus fare … or cab vouchers at the conclusion of their ED visit. The theory was that hospitals didn’t want patients loitering in the emergency department waiting rooms after their visits trying to find a ride home. The policy was also viewed as creating good public opinion since the hospitals were making sure that patients had a way home if they came by ambulance and had no other means of transport. Ambulance transport to the hospital is provided at no cost to the patients. Ambulance transport home must be paid with credit card.
Once the general public got wind of the cab voucher policy, guess what happened. Patient volumes increased. Ambulance transports increased. Wait times went up. People waited hours for free medical care so that they could then get their free subway token … or bus fare … or cab vouchers at the end of their visit. The policies were quickly discontinued.
If Pennsylvania begins paying people to go to “better” hospitals, the cab voucher fiasco will occur in Pennsylvania, only on a much grander scale. Once Pennsylvania Medicaid recipients learn that they will be paid to go to a certain hospital for medical care, those hospitals will be deluged with patients. To those receiving public medical assistance, the medical care is free, the medical testing is free, and the medical procedures are free. Now, with a monetary incentive to have a procedure done at a given facility, what do you expect will happen? Patients get $200 if they get a cardiac catheterization at one hospital versus another? Twelve year olds will go to those emergency departments complaining of crushing chest pain. Patients get $50 if they go to one emergency department that provides “higher quality”? There will be lines out the door.
Medicaid will end up footing the bill for an increase in medical care because it has incentivized the patient population to seek out that care.
Brilliant. Just brilliant.
Mr. Alexander even went to a meeting of “300 health insurance executives” in Washington and pitched his plan. I’m sure he got a little round of golf claps for his innovative approach to reducing health care costs.
This is what happens when people who make policies have no practical experience in the industry in which they are making the policies. Mr. Alexander was a political science major in college and has a law degree.
You want to decrease utilization? Pay Medicaid patients that same $200 at the end of a year only if their medical resource utilization (ED visits/prescriptions/whatever other variable you want to control) is below the average utilization for other Medicaid recipients for that year. Kids get $50 per year. Send out letters to those who didn’t get the money telling them why they didn’t get their “incentive payment”.
That policy will pay for itself within the first two years.
But what do I know? I’m just a dumb ER doc without a political science degree.
Posted in Insurance, News Commentary, Policy | 10 Comments »
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Gender Equality in Unnecessary Testing
Tuesday, February 7th, 2012I admire this lady’s chutzpah.
If Virginia wants to make an unnecessary ultrasound necessary before a woman can have an abortion, Virginia Senator Janet Howell wants to make unnecessary rectal exams and stress tests a prerequisite before men can receive Viagra prescriptions.
I bookmarked this link from Instapundit which is one of my favorite news aggregator blogs. However, I disagree with Glenn Reynolds’ opinion that the Virginia senator’s rider to the initial bill is “kindergarten payback” and that it is “sad” that Senator Howell is being lauded for her cleverness. OK. Maybe it is kindergarten payback.
The bottom line is that the state wants to make an expensive and unnecessary medical procedure a prerequsite to a woman being able to obtain an abortion. The proposed bill stated that the ultrasound is required to determine the gestational age of the fetus.
Why? If a woman appears to be past her first trimester or near fetal viability, then I can possibly see the utility in obtaining an ultrasound. But requiring the test on every pregnant patient seeking an abortion?
I don’t agree with abortion, and I have harsh feelings toward women who use serial abortions as a form of birth control. However, I still believe that a woman has a right to choose what happens to her body.
To me, it seems like the intent of the law is to put an additional financial burden on women seeking an abortion. Can’t pay for the ultrasound? The doctor is prohibited from performing the abortion.
Glenn Reynolds stated that “presumably the reason for an ultrasound is to let women see what they’re aborting.” That reason doesn’t meet medical necessity. What other reason would a legislature require a useless medical test in order to have a procedure performed?
Eventually, the bill was passed in the Virginia House with a modification requiring that the physician offer to perform an ultrasound prior to performing an abortion. This version has no teeth, but I believe it tees up the matter for further debate in another “addendum” to the law somewhere down the road.
The initial bill was just another example of an unfunded mandate and I am one of those that applaud Senator Howell for standing up to it.
Now it appears that they could use Senator Howell’s help in Kansas. Lawmakers there are proposing a law that provides malpractice immunity to physicians if they hide information from patients in order to prevent an abortion. The law also forces doctors to tell women that abortions potentially increase the risk of breast cancer. Maybe they can also create an addendum to the law requiring that doctors tell the husbands of pregnant women seeking an abortion that touching their woo-hoo while thinking impure thoughts will grow hair on their palms. Have the legislators been drinking on the job?
Utah is probably beyond Senator Howell’s help now. Recently, the Utah Supreme Court ruled that “unborn children” and “minor children” are legally the same for the purposes of wrongful death lawsuits. Great concept. Extending the definition further, under that logic, pregnant women in Utah now need to purchase two plane tickets – one for them and one for their “minor child.” They also need two movie tickets. Ohmigod. What if there are triplets? What if Octomom wanted to board a plane in Utah while she was still pregnant?
If pregnant women drink alcohol, using the Utah Supreme Court’s logic, they must be endangering the welfare of a child by force feeding their “minor children” alcohol. If they smoke, they must be breaking federal law by providing cigarettes to minor children. Child protective services should require an immediate Caesarian section (after performing an ultrasound and maybe a stress test) and should immediately take custody of all such children.
At least the dissenting Justice Nehring understood the absurd results that would result from the majority’s decision.
What is going on in this country?
Posted in News Commentary | 4 Comments »