DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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Q&A 9

Thanks for the many comments and questions. I pick for Sunday based on my assessment of reader interest, or my own interest.

I am troubled by your answer to one of yesterday’s Q&A questions and further troubled given your rant today regarding “When doctors sell out.”

Yesterday you indicated the current medical system is flawed in that doctors who make correct diagnoses are not rewarded, but rather are punished when something might go wrong (punished perhaps by being dragged into court). I assume you mean the satisfaction of a healthy patient is not a reward in and of itself, but rather there should be some financial incentive for physicians who make the right diagnosis. That is, because doctors might be “punished” by a malpractice claim, they should be equally rewarded for doing their job correctly. Should the same system be in place for a police officer who stops a crime, an air traffic controller who succesffuly allows planes to land without an accident, for the same pilot landing the plane, or countless other professionals whose only reward is a job well-done and the satisfaction of knowing they did their job well?

Compounding my frustration, is your comment in today’s rant about doctors selling supplements when you said “While money is not necessarily the root of all evil, it certainly can cloud one’s judgement.” Is this the same “cloud” that you propose as a financial incentive for doctor’s who perform their job correctly???

I have thought carefully about how to answer this question from a long time reader. He raises some very interesting points, which I will do my best to answer.

I probably did not make my first point clearly enough. In medicine, even when we do everything properly, patients can still have bad outcomes. Unfortunately, sometimes patients (or families if the patient has died) view the bad outcome as the physician’s fault. This tendency increases in our “blame someone” culture. Thus, we may have penalties for bad outcomes, regardless of our actions.

In most professions, and indeed in most jobs one receives rewards for a job well done. Promotions occur in law enforcement; higher fees result in law; more business results for a restaurant. Physicians have no such “upside”. All generalists that I know already have too many patients. Fees are fixed by the insurance companies. Overhead keeps increasing.

I hope that I have explained the frustration and imbalance here. A job well done does give great satifaction – but only when the outcome is a positive one. We do not need great rewards, but we do need a better system to avoid penalties – and being named in a malpractice suit, regardless of the outcome of the suit – is a huge penalty.

The second question really compares apples and oranges. Supplement selling probably clouds physician judgment. Once once has a financial interest in something one sells, one will tend to sell that thing. Rewards for good work represent a different financial incentive. Here the incentives are aligned with the patient and physician’s best interest – the health of the patient. Perhaps my wording was a bit imprecise. The problem I see is when physicians receive a financial reward not for providing medical care, but rather for something which the sell (using their MD as a sales advantage).

While I agree that advertising can have its pitfalls, as a psychiatrist I am pleased that patients come in for
treatment-with me or with anyone else. It has been my experience that very few patients request medications that they have heard about on TV. What they do request is treatment for the condition that they learned they were suffering from when educated by the advertisement.

Currently, only 50% if depressives in this country receive a diagnosis, half of those receive treatment and only 8 per 100 patients with depression are currently treated to remission (the currently accepted standard of treatment).

If residency programs do not train physicians adequately in the recognition of mental illness, and as long as some doctors still refuse to diagnose or treat it, then the most effective way to assure treatment will be consumer-driven. I applaud those companies that continue to advertise antidepressants on TV and would also like to note that these companies are amazingly philanthropic in their willingness to provide free medication for the indigent. We also rely heavily on them to continue to put money back into research to further decrease the mental illness burden for future generations.

I posted this comment just for the alternate viewpoint! Psychiatry may represent the main area of benefit for these ads! As a generalist, I do not want to argue about Nexium or Celexa. I do understand this psychiatrists point – and it is well stated – but I do not find it generalizable to most medical conditions.

“it is our right and who is to decide you have to live in pain ”

This comment refers to a post on euthanasia from last May! I personally cannot accept active euthanasia as an option. Passive euthanasia is perfectly acceptable. Let me try to clarify.

I care for terminally ill patients regularly in the VA hosptial. When we have such a patient, we make a complete assessment of their quality of life issues. We can do a good job of treating pain and other symptoms.

I would never give a patient a narcotic dose with the purpose of ending his/her life. However, I will give a patient enough narcotics so that they do not have pain, even if that dose could possible stop respirations. This line, in my mind, is very clear. It has to do with intent. I will allow a patient to die in peace; I will not purposely cause a patient to die.

I find the latter a slippery slope. Once we (physicians) cross the point so that we help patients die, we will always have difficulty defining acceptable criteria. How does one develop criteria to prevent physicians from using euthanasia too “loosely”?

Thus, I remain on the side of aggressive palliation – for those interested read this rant from last October – More on palliation .

Re: Statins and muscle pain

Should endurance athletes ( say a triathlete anticipating a 6-6.5 hour maximal effort in a half ironman race ) stop their statin prior to the race? If so, then for how long? Incidently, races of this length and longer can cause elevated CPKs and in some cases mild elevations in cardiac CPK levels. This data makes no mention about pre-race statin ingestion.

I wish I knew the answer to this question. Someone should perform a study, perhaps at first during a 10K. I suspect (having no data, just hypotheses) that most patients would have no problems. But I really do not know the answer.

Well, anecdotally (is there such a word?) speaking, I probably still won’t volunteer. I get one mild cold once a year, and “walking pneumonia” about every fourth, but the worst was the last time I took the vaccine. I prefer the pneumonia.

Probably idiosyncratic, I do not discourage others from taking it.

This comment represents the problem physicians have in promoting prevention. Patients (and sometimes physicians) rely on anecdotes rather than data. This process is known as the availability heuristic . You can read more about the heuristic – Availability heuristic

Definition: A heuristic or “rule of thumb” strategy biased for estimating probabilities (of past or future events), based on how easily the related instances of that event come to mind.

Example: Although diseases kill many more people than accidents, it has been shown that people will judge accidents and diseases to be equally fatal. This is because accidents are more dramatic and are often written up in the paper or seen on the news on t.v., and are more available in memory than diseases.

Background: People use heuristics to solve problems or reduce the range of possible answers to questions. Although at times it can result in the correct solution, the availability heuristic can also result in erroneous solutions to problems/questions. In using this rule of thumb, people judge frequency based on a quick count of examples. The use of this strategy is very widespread, and is used in making both trivial and important judgements. People tend to overestimate the frequency of certain rare events if they are dramatic and sensational and underestimate those that are more frequent but occur in private, ordinary situations. This appears to be because the rare, dramatic and sensational events are more easily available in memory.

 

The reader is wrong. We have many studies which show clearly that flu vaccines do not cause illness. But I doubt that I can convince him.

SARS is a respiratory ailment. If a person is very fit, doing a lot of cardio to strengthen the heart and lungs, are they less likely to succumb to such a virus?

First, we really do not know enough epidemiology to fully answer this question. In general, with any viral infection, host factors have great importance. I suspect that being fit improves ones odds, but this virus does act very aggressively in a small percentage of patients.

As an RN who just recently recieved her MSN in nursing education and would like to go into teaching other nurses the profession, it is really hard to leave the bedside knowing that I will make less money. THere needs to be more incentive to get that higher degree. As far as replacing the number of nurses we need through enrollment, that will be a long process, but the problem took a long time to evolve, it may take a long time to solve also. The problem is going to get worse, and the more qualified nurses we do produce, the better care for patients and the society we live in.

AMEN!!!

I am a Human Resources Staffing Specialist who also happens to be a college student. I’m doing a research project on the 80-hour workweek and I’m trying to get some additional information. Do you happen to know where I might find how hospitals are going to comply with this rule? At my hospital, a large academic medical center in Philadelphia, we are planning on utilizing nurse practitioners and physician’s assistants to make up the difference. My project is going to focus on how hospitals are planning to make up the hours lost by the residents as well as a cost analysis. Obviously, this rule will have a major financial impact on hospitals, large and small.

Tip O’Neill (from Speaker of the House) once said – “All politics is local”. I suspect that you will find a wide variety of solutions to the 80 hour workweek problem. You will find variations within the same hospital. Let me try to clarify a bit.

Most medicine and pediatric programs will make minor modifications, being fairly close to the 80 hour work week already. Radiology, anesthesiology and pathology should have no problems. Surgery programs will have the greatest problem, as they are currently the most frequent offender. I suspect that many programs have not really determined how they will address the new rules. And some will try to ignore these rules (see last week’s Q&A for example). Good luck in your project!

Final comments

Thanks again for the many comments and questions this week. You, the readers, make me think, keep me honest, and make this blog much better. As usual I apologize for not answering all questions or highlighting all comments. I have decided to avoid the omeprazole controversy as I have nothing else to add at this time.

Now it looks like a beautful morning in Alabama – off to the golf course (I know that is a cliche for a physician – but I really do love golf)!

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