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Showing posts from May, 2012

another question about rationing, without an answer

Today I met a man whose liver is failing. He drank way too much alcohol for many years and quit in February when he finally realized his liver was toasted, pickled, scarred, hardened, cirrhotic. He had begun to build up fluid in his belly that had to be drained with a needle because the medicines designed to help reduce it didn't work and made him feel terrible. Because the liver clears toxins created by metabolism, and his didn't, he began to be loopy and tired all the time. Today the fluid had built up again and when over 8 quarts of it was drained from his belly he was too weak to walk and had to stay in the hospital.

The single solution to his problem, barring the invention of a time machine so he can go back and not drink so much, is liver transplantation. He is not insured for a liver transplant. We talked about this and about his prognosis with the technology available to him, which is terrible, while he struggled to keep his eyes open. I am pretty certain he will remem…

Why don't doctors want to do primary care anymore?

I really loved doing primary care, taking care of patients in my community in a medical office and in the hospital when they needed that. I practiced primary care internal medicine for over 20 years, first as part of a health care cooperative and then in private practice, and it was very gratifying, never boring and fed my soul. This last year, across the country, almost no internal medicine residents chose to go into primary care. Graduates of family medicine residents were more likely to go into primary care, but many of them, too, chose specialties or hospital medicine. Though family medicine residency positions mostly did fill, over half of them were taken by foreign medical graduates who traditionally are less competitive for residency slots. Why?

An article in the New England Journal of Medicine discussed some of the challenges of being a primary care doctor and some of the changes in reimbursement that are expected to ease the shortage of those absolutely essential regular doct…

Waste avoidance and "rationing" in health care: how much money can we actually save?

Two articles in today's New England Journal of Medicine address waste and rationing. Rationing in health care is an emotion fraught term meant to awaken visions of long lines of people waiting for loaves of bread in grainy black and white photographs, but bearing the faces of sick loved ones instead of long dead strangers. Arrrgh. The first article, entitled "From an Ethics of Rationing to an Ethics of Waste Avoidance" is written by Howard Brody MD, an infectious disease specialist who was in clinical practice for many years and now is known as an ethicist. He makes the point that we need to pull ourselves away from the issue of rationing truly valuable medical care to focus on realizing that the procedures and treatments that we do that are truly not helpful are not only expensive but harmful and therefore unethical. He further suggests that using population studies to decide what works or does not work for an individual is inherently in error, and that if we successful…

Re-certification in Advanced Cardiac Life Support--the ethics and practicality of wrenching people from the jaws of death

My Advanced Cardiac Life Support (ACLS) certification expires in June of this year. At least that's how it used to be. Now my card says that June 2012 is the "recommended renewal date." These re-certification dates always sneak up on me, and if I go over two years between certification I need to take a two day class rather than a one day class, which is more expensive and time consuming.

ACLS is a protocol based set of guidelines published by the American Heart Association to standardize the treatment of cardiac arrest, heart attacks, strokes and heart rhythm disturbances. The first guidelines were published in 1974 and have been updated 6 times since then, most recently in 2010. ACLS is meant to help physicians deal with situations that require very quick action in order to have good outcomes, sort of like soldiers used to need to be able to take apart and reassemble a rifle quickly. ACLS often follows bystander cardiopulmonary resuscitation (CPR), also known as Basic L…

Choosing Wisely--a campaign to save healthcare resources by not doing stupid things

The most recent edition of the Journal of the AMA features an opinion article about a campaign to highlight the top 5 probably useless, dangerous and overused medical interventions for various medical specialties. This is the link: http://jama.ama-assn.org/content/307/17/1801.short, The authors,  Dr. Christine Cassel, the CEO of the American Board of Internal Medicine and Dr. James Guest, the CEO of the Consumer's Union, discuss the process that has led up to this approach.

In 2002 US and European internists came together to create a document entitled "Medical Professionalism in the New Millennium: A Physician Charter." This put into print a set of goals that were intended to spark various projects to improve what physicians do.  The primary principles were that patient welfare goes first, that patients have the right to autonomy in defining their medical care and that physicians should be held to behave in a way that promotes social justice, including fair distribution …

A day in the life: mostly how doing bedside ultrasound as a hospitalist is cool, and how charity care fosters community stewardship

I've been doing 12 hour shifts at a regional medical center that serves a predominantly blue collar community in Washington. My job as hospitalist involves showing up at 7AM on a Monday and meeting and taking care of about 16 new patients on the medical and surgical services as well as admitting a few more, usually from the emergency department. My shift ends at 7 PM or whenever I'm actually done. Mondays are big, but I do get to meet lots of people. The first two transitional days involve reviewing lots of data and I become gradually less dependent on my predecessor's clinical judgement. It would be ideal for patient care if the physician who admitted the patient stuck around until discharge, but that would logistically mean that physicians worked every day, all day and all night. Nobody would sign up for that, and if they did, they would be toasted to a crisp very soon and patient care would suffer. Transitions are inevitable, but always involve increased patient risk. S…

Ultrasound education and why ER physicians are different (Castlefest) (CORRECTION)

(CORRECTION PART: WOOPS. WHEN I FIRST PUBLISHED THIS, NOT ONLY DID I LEAVE IN ALL SORTS OF WEIRD STUFF, BUT I ALSO SPELLED MIKE MALLIN'S NAME WRONG AND GOT THE WEB ADDRESS OF HIS AND MATT'S SITE WRONG. I THINK IT'S ALL FIXED NOW.) Northern Kentucky is lushly, jaw droppingly beautiful in the spring. Green fields of grass stretch out from smooth highways and thoroughbred horses graze languidly. (Also I got some mild version of influenza and am hideously allergic to whatever particular grass pollen collects here so I’m thinking and seeing everything through a small amount of edema fluid.) The town of Versailles (pronounced ver-sails) has a small castle on its outskirts that was originally partially built by someone whose love grew cold before he could finish it. It stood partially finished for years, changed hands, burned down and was rebuilt, so it now exists as a venue for weddings and things like that. It was the location of an emergency and critical care ultrasound course…