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Showing posts from December, 2012

Transitioning from fee for service medicine and spending money where it does the most good

I just read in a recent issue of "Aequanimitas," the newsletter of Johns Hopkins Osler medical service, a brief interview with J. Mario Molina, the CEO of Molina Healthcare, an organization which coordinates managed care for recipients of Medicare and Medicaid for several states. It looks like he must have been one of my senior residents when I was an intern. It sounds like he practiced for a few years before taking on the leadership of his family business. He expressed his firm belief that medical care would soon be moving away from paying physicians for the individual services they perform and, instead, paying them for keeping patients healthy. Since it will be organizations, not doctors, who are paid for care, it will quickly become clear that paying for anything that prevents dire illness with its astronomical associated costs will benefit the whole. Medical institutions may find themselves in the business of making their communities healthy. This is not foreign to larg…

In the wake of marijuana legalization, what exactly are the health risks?

Colorado and Washington state have legalized the recreational use of marijuana. I thought this would take longer to legislate, especially with the recent backlash from the federal government about medical marijuana. Eighteen states (including California, Alaska, Vermont and Oregon) allow marijuana to be used for medical reasons, but have restrictions on which conditions can be treated with it, which don't necessarily correlate perfectly with the diseases for which it is effective. I have worked in a state which doesn't allow legal marijuana use for anything, but have seen patients from neighboring states who did use medical marijuana and have tried to stay abreast of the laws and issues surrounding use.

Marijuana is relatively nontoxic. Nobody has ever died of overdosing on marijuana, though it is theoretically possible. Combining marijuana with other drugs can lead to overdose death, and combining marijuana with driving or other activities which require fast reaction time has…

Evidence based medicine--but which evidence?

In the last year I've become more and more comfortable using online resources to determine the best treatments for the diseases I see. My favorite site is Up To Date, which has experts write articles which review the literature and share their experience to produce very readable background information and succinct recommendations. Up To Date is expensive, but most hospitals that have computer systems also have subscriptions to it, so it's easy to access when I am reviewing labs, tests or other data.  I've also been impressed with the American College of Physicians PIER (physicans information and education resource) which is available to me as a member of the ACP and has links to new articles and practical recommendations. It is less exhaustive than Up To Date, for instance there is no specific article dealing with Brucellosis (a cattle related infectious disease), but very easy to use and right up to the minute. For absolutely free I can use Medscape, as can anyone readin…

Multitasking and information toxicity--is that why I feel stupid?

Today I've been feeling stupid. My job absolutely requires critical, creative thinking and the ability to focus well, which was really hard today. But I don't think I'm actually stupid. I think it has something to do with the task at hand.

So this is how today went. I think it kind of explains the stupid feeling.

My morning shift started at 7:30 in a small but busy 45 bed hospital that serves a chunk of rural Alaska.  The night shift doc told me about the 13 patients who I needed to take care of that day. Seven of the patients were new to me, admitted the night before. For those patients, I needed to review their medical histories in the computerized medical record and get to know them, with a focused physical exam and an interview to determine what needed to be accomplished in the hospitalization. For all of the 13 patients, I needed to review all of the lab tests completed in the last day  and all of the radiological studies and check their vital signs and review the nu…