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Showing posts from May, 2013

Dear FDA (Food and Drug Administration), Please stop regulating the wrong things (ultrasound machines and fecal transplantation).

The Food and Drug Administration was created in 1927 in order to carry out the mission of the Food and Drug Act put into effect by Theodore Roosevelt in 1906. In the early 1900's and before, patent medicines killed and maimed people in gruesome ways and adding chemical substances to foods to mask the fact that they were rotten or substandard was felt to need some sort of legal response. The FDA initially was predominantly an organization designed to regulate sales and interstate transport of foul and dangerous foods and medicines.

Over the years the job of the FDA has expanded as technology has advanced, to include evaluation of new drugs and devices, including those designed and produced outside the US. The FDA has undoubtedly protected countless people from poisonous and malfunctioning medical products. There have also been stories of egregious failures of the FDA (see this New York Times article of 2009 regarding their inability to police conflicts of interest in biomedical re…

Why are health insurance premiums still rising this fast? Blue Cross proposes hike of 24.7% for county employees.

This morning when I got the local paper, I was greeted with a lead article which reported that Blue Cross of Idaho was asking the county to pay 24.7% more for employee's premiums in 2014. Nobody can afford something like this. They will, of course, start looking for alternatives.

I remember similar situations in the clinic where I worked for 12 years, a group that had about 35 employees. We would be happy enough with our insurance plan, which cost too much but did give us reasonable medical coverage, and then the premium prices would rise, significantly faster than did our revenues. We would scramble around, getting quotes and weighing options, engaging in negotiations and eventually would have to switch everyone to a different company with slightly worse healthcare coverage and fill out many forms, with no guarantee of a stable premium or benefits for the following year. As a physician I had access to the health insurance for the group, but very soon opted out because it was so …

A better POLST (Physician's Orders for Life Sustaining Treatment) and informed consent for resuscitation: can we do this better without "playing God" ?

To resuscitate or not to resuscitate--that is the question. Whether 'tis nobler to beat the heck out of a person on his or her way out in the hope of saving his or her one precious life, or to allow death to proceed at its own pace with expectation of a peaceful passing.

The United States has come a long way in the last 2 decades since 1991 when the Patient Self-Determination Act was instituted. In most hospitals patients are asked what their wishes are regarding resuscitation and many states have instituted POLST (Physician's Orders for Life Sustaining Treatment) forms which spell out which interventions are acceptable to individual patients when they are very sick, things like blood transfusions, antibiotics, feeding by nasogastric or gastric tubes, intubation and ventilation and chest compressions and electrical cardioversion in the event of cardiac arrest. Theoretically we discuss these things with every patient when they come into the hospital, but we don't really do…

A rant on the hopelessly ill (of course it's not their fault) and how maybe mass media could help

I have been working in the intensive care unit and have been finding it ethically difficult to facilitate the care of the some of the hopelessly and incurably ill patients who rotate through. Many of these patients live in nursing homes that are qualified to manage patients on chronic life support, not just tube feedings or oxygen, but ventilators and tracheostomy tubes. They can live like this for years, with deepening bedsores and pasty disused limbs, foley catheters, rectal tubes or colostomies, with gradually increasing colonization by multidrug resistant organisms. They are brought to the hospital and then the intensive care unit when the bacteria colonizing their endotracheal tubes finally take hold and cause pneumonia or when a catheter in a blood vessel or bladder becomes infected or when one of their vital signs tells their caregivers that some unspecified thing is terribly wrong.

Once a person is on chronic life support, usually nobody talks to them anymore and it is assume…

Healthcare economics and history--how we got here and how we might get out. (Notes for my talk to the League of Women Voters)

Hello and thanks for coming.

I’m going to be talking about what has taken me away from my practice this last year and what I’ve learned about how healthcare is doing and why it’s so expensive. I’m going to talk about what’s going well and not so well and the ways we can have an impact for the better.
In 2011 my friend and nurse practitioner died unexpectedly and my longtime medical partner decided to move far away to take a different job. This left me and my remaining partner to take care of our large practice.  We were both also covering patients in the hospital so had no more room to accept new patients. It  turns out that almost no more outpatient internal medicine physicians are coming out of residencies, so recruiting a new physician was not going to happen. I had also been writing and speaking about healthcare reform for a few years and felt like getting more and new experience would help flesh out my understanding of what was going on. So I left my job and the patients I loved…