Time for some excellent questions and comments.

What study is your use of metoprolol in heart failure based upon and where did you get your information that Coreg 12.5 mg and metoprolol 25 mg are equivalent doses and where do you get a 25 mg tablet of metoprolol?

These are good questions, and I can only answer one for certain. The MERIT-HF study supported metoprolol for CHF – Fagerberg B, et al. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet June 12, 1999;353:2001-7.. I got the equivalent dose information from the COMET study – specifically this quote from theheart.org describing the COMET study –

They were randomized to carvedilol (target dose 25 mg twice daily) or metoprolol tartrate (target dose 50 mg twice daily). These doses were chosen because it was believed that they would give a comparable degree of beta blockade in both groups.

This comment comes from an earlier post, which is superceded by – COMET results previewed

The medical community has been working under market conditions that have applied to only a few other industries. There is of course the possibility of raising prices, but the buyers, in most cases insurers of patients and the government, have dictated reimbursement and effectively fixed prices, either by contract or by law. Only a few patients, very few, actually pay the charges at listed price. So there is not truly a free market in medical care. What there is is a sort of demand economy, where a few very large buyers, largely leveraged by the federal government and the reimbursement schedules paid by Medicare, fix the market prices, and where other payors usually follow suit. Of course, doctors are free to exclude insurers that pay poorly, the reason why so many refuse to accept Medicaid and Medicaid-like plans, lowball HMOs and plans that practice mendacious claims denials and downcoding.

It is a business of compromises. See enough patients that have plans that pay enough quickly enough so you can meet your bills and make a living for yourself that adequately compensates for your time, training and risks. Nothing is really different from other small businesses that way. As for patients, very few people have ever paid their full bill for their medical services as they might for other commerce where there is no third-party payor. This has been the case in the U.S. for more than a generation. Copayments, when they are due, are largely token payments and represent only a small proportion of the costs or the full payment expected. So patients usually are not rational participants in decisions about consuming medical care. There isn’t exactly market transparency and those receiving care aren’t the ones who pay the full bill and so don’t feel the need to contain costs.

This is wisdom from CHenry. This echoes much that I have written over the past few months. Medical practice functions under a perverse system of fixed charges and increasing overhead. As Robert Prather argues, we need a true free market for medicine.

well…don’t we all live in a society where we buy name brand items…from cars to clothes to the restaurants we eat….MD’s sure are picky and I am sure their loved ones get the best medicine…the ones that are promoted

I beg to differ with this comment. Many physicians prefer generic drugs for their families, especially those who eschew free samples. I personally see no reason to spend more for an advertised trade name drug – when a generic will work just as well.

As a resident who has felt the changes of adapting to an 80 hour work week first-hand, I also have dealt with the difficulty of balancing the responsibilty of getting my interns out of the hospital on time with teaching them the importance of their responsiblity in appropriate patient transfer and care. I feel that this bill threatens at some level our clinical judgement by pressuring an already stressed out team to neatly wrap things up, often dumping a tremendous work load on either a busy on-call team or a day-float.

Even if they are allowed to leave, I want my intern’s to at least intellectually.. want to stay. I want them to
learn to build relationships with their patients that makes the work not a burden or a time-clock slot but an opportunity to spend more time with someone who is suffering and in need of their help. Unfortunately relationships don’t always come in a pre-packaged 12 hour time slots, they take time. If I can teach them that, then it doesn’t matter how much time they spend at the hospital, they will have learned what it is to care for a patient, and that’s all I want in my doctor.

First, I want to thank my former student for this insightful comment. It is exciting to receive comments from people I know!

Read this comment carefully. The resident makes some very important points. Rules (like the ACGME guidelines) can be dangerous. We really do not want physicians in training to develop a “punch the clock” mentality. We want them to care for their patients. Some days, weeks and months may require longer hours; some days, weeks and months may allow shorter hours. Arbitrary rules can negatively impact patient care and professionalism.

The ACGME has a laudable goal. I fear the unintended consequences of using rigid rules to legislate common sense. This July looms as an uncontrolled experiment in housestaff education and patient care. I will be there on the front lines with the new interns. I will report on our new system.

I have been diagnosed with eosinophilic fasciitis. Symptoms began in JANUARY. Swollen hands; carpal tunnel followed. By MARCH, Pale pink rash on knees and back of thighs, which became very painful, burning. Finally diagnosed 5/6/03 from biopsy of rash back of knee, which by then ws leathery. Now lungs are involved. Am on 40 mg. of prednisone (since 5/6/03) and 200 mg.of doxyciline. Wondering when I will get well. Please rant!

I wish I could answer questions like this one. We (physicians) often do not know when patients will improve. Often we try therapies, and then observe the response. This happens more often with less common diseases (like the one mentioned in this comment).

I wish I could give perfect medical advice to everyone who writes. Unfortunately, medicine remains part science, and part art. Sometimes, we do have to try therapies without out knowing how the patient will respond. In doing so, we try to balance risks and benefits.

I apologize for the long winded response. I cannot answer your question – and my frustration is minimal compared to the frustration that you must have concerning this problem.

…

So this ends another Q&A. I hope everyone has had a great weekend. And remember that Father’s Day is only 2 weeks away!!!