The New York Times published a story today involving the growing MinuteClinics at various Duane Reade pharmacies throughout the Northeast. They differ from the typical MinuteClincs which staff NP’s and PA’s and instead have actual doctors. This is an improvement, though it encourages the one-time visit, and leaves little chance for follow up, as the patient likely couldn’t make an appointment with anyone.
I love this quote:
“And doctors’ groups, whose members stand to lose business from the clinics, are citing concerns about standards of care, safety and hygiene, and they have urged the federal and state governments to step in to more rigorously regulate the new businesses”
Now why did they have to go and add that little gem? Couldn’t the statement stand on its own without it. It just undercuts the VALID concerns placed after it.
But anyway, this is not what made me angry about the article. That part is buried near the end. Apparently, Continuum Health, my former employer, is joining into an unholy alliance with Duane Reade to supply the very doctors I mentioned above. Here’s the quote:
“Under the partnership agreement, the doctors at Duane Reade will have admitting privileges at the Continuum hospitals and the drugstore clinics can streamline a patient’s journey to a specialist or through the emergency room, when that is necessary, because of the relationship, company officials said.”
So did everybody catch that? These doctors from Duane Reade will have ADMITTING PRIVELEGES!
Now, these Continuum hospitals hire numerous faculty attendings, and presumably by having these OTHER doctors staff these new clinics, they are undercutting their own faculty by siphoning away the business to these Duane Reade clinics. So at first this didn’t make sense to me.
But then a colleague explained it to me. They will be able to increase admissions to the hospitals, since these pharmacy docs have admitting privileges. So if they lose it on one end, they’ll get it back on the other. Good for them. It’s this kind of entrepreneurial thinking that makes me proud to be an American.
Of course, it will simply increase the amount of TOTAL CRAP that gets admitted to the unsuspecting medical teams. But hey, doctors can even learn from crap, can’t they?
Thursday, August 23, 2007
Tuesday, July 10, 2007
"LAW & ORDER: SPECIAL ETHICS UNIT"
An editorial in the NEJM this week concerns medical futility in Texas. Dr. Robert Truog MD writes about the case of Emilio Gonzalez.
Emilio had been diagnosed with Leigh’s disease, a pediatric illness which is fatal. Sometime before he was 2, he ended up on life support at Children’s Hospital of Austin for five months! Dr. Truog describes some of the painful events, especially how the mother refused to let the hospital move the child. She took the hospital to court, but before the judge could issue a ruling, the child died.
(Does this outcome vindicate the judgment of the doctors? Hmmmm….)
Anyway, it’s a sad ending to a sad case. But this is not what made me angry.
It’s Dr. Truog’s take on ethics committees themselves. Here’s what he says:
“ ...most members are physicians, nurses, and other clinicians from the hospital staff... they are unavoidably “insiders,” completely acculturated to the clinical world and its attendant values. This is hardly a “jury of peers” for a low-income woman of color and her infant son.”
He feels that the ethics committees agree too often with providers. (He states later that ethics committee at Baylor agreed with the clinicians 43 out of 47 times. Gee, I wonder why.)
I will tell you why: Because they know what they are doing.
First, I hate the seamy implication that because the woman is of “color” and is “low income”, that the doctors involved (pediatricians, I suppose) were more willing to treat them unfairly. They kept him on life support for FIVE MONTHS!!! And he died of his TERMINAL ILLNESS!!! (It’s like Terri Schiavo all over again).
Additionally, I do not understand AT ALL his beef that the committee is made up of mostly doctors, nurses and people who are “insiders”. WHO SHOULD IT BE??? Lawyers and people who have never cared for a sick person a day in their life!!???
I’m sure we’d all like someone with no clinical judgment or experience except what they’ve seen on TV to offer an ethical opinion. That makes as much sense as letting a postal worker manage your finances!
Ethics committees are correctly loaded with people who understand a life is at stake, and that family members are the best advocates of the patient. The fact that they agree with practitioners is a testament to the practitioners’ clinical judgment, NOT evidence of a “conspiracy”. I mean, did anyone ever meet someone on an ethics committee who wasn't a "touchy feely" do-gooder? I sure haven't.
Also, what is with his obsession with the whole “jury of peers” and “due process” systema? This isn’t a court of law. It’s an ethics committee. There is no need for a “jury of peers”. No one is on trial. Doctors, nurses, social workers and clinical minds are trying to come to a solution, much the same way a “tumor board” works. I don’t think anyone would call for a “jury of peers” at Tumor Board, if a patient’s cancer treatment was to be decided. That’s because it isn’t appropriate.
Dr. Truog has got it wrong.
Emilio had been diagnosed with Leigh’s disease, a pediatric illness which is fatal. Sometime before he was 2, he ended up on life support at Children’s Hospital of Austin for five months! Dr. Truog describes some of the painful events, especially how the mother refused to let the hospital move the child. She took the hospital to court, but before the judge could issue a ruling, the child died.
(Does this outcome vindicate the judgment of the doctors? Hmmmm….)
Anyway, it’s a sad ending to a sad case. But this is not what made me angry.
It’s Dr. Truog’s take on ethics committees themselves. Here’s what he says:
“ ...most members are physicians, nurses, and other clinicians from the hospital staff... they are unavoidably “insiders,” completely acculturated to the clinical world and its attendant values. This is hardly a “jury of peers” for a low-income woman of color and her infant son.”
He feels that the ethics committees agree too often with providers. (He states later that ethics committee at Baylor agreed with the clinicians 43 out of 47 times. Gee, I wonder why.)
I will tell you why: Because they know what they are doing.
First, I hate the seamy implication that because the woman is of “color” and is “low income”, that the doctors involved (pediatricians, I suppose) were more willing to treat them unfairly. They kept him on life support for FIVE MONTHS!!! And he died of his TERMINAL ILLNESS!!! (It’s like Terri Schiavo all over again).
Additionally, I do not understand AT ALL his beef that the committee is made up of mostly doctors, nurses and people who are “insiders”. WHO SHOULD IT BE??? Lawyers and people who have never cared for a sick person a day in their life!!???
I’m sure we’d all like someone with no clinical judgment or experience except what they’ve seen on TV to offer an ethical opinion. That makes as much sense as letting a postal worker manage your finances!
Ethics committees are correctly loaded with people who understand a life is at stake, and that family members are the best advocates of the patient. The fact that they agree with practitioners is a testament to the practitioners’ clinical judgment, NOT evidence of a “conspiracy”. I mean, did anyone ever meet someone on an ethics committee who wasn't a "touchy feely" do-gooder? I sure haven't.
Also, what is with his obsession with the whole “jury of peers” and “due process” systema? This isn’t a court of law. It’s an ethics committee. There is no need for a “jury of peers”. No one is on trial. Doctors, nurses, social workers and clinical minds are trying to come to a solution, much the same way a “tumor board” works. I don’t think anyone would call for a “jury of peers” at Tumor Board, if a patient’s cancer treatment was to be decided. That’s because it isn’t appropriate.
Dr. Truog has got it wrong.
Monday, July 9, 2007
SPECIALISTS: THE DELICATE GENIUS
A recent thread of posts about the relationship between PCP’s and specialists, spawned by Dr. Rob’s sardonic “open letter” has inspired me to comment on one particular beef I have with consults.
Specifically, in-hospital consults.
I won’t comment on the anger that bubbles inside me when a consult fellow will just outright “refuse” to see someone because they don’t think it’s an “appropriate” consult. That’s a whole different blog entry.
No, I want to comment on the annoying tendency of specialists to say absolutely NOTHING!
Here’s an example. An older patient comes with some bright red blood per rectum. They may have a history in the family of colon cancer, or maybe they were anemic. Whatever. The consult note usually reads thusly. First they mention the chief complaint, then they have a brief history, then there is the ubiquitous rectal exam.
And then at the end it says “Assesment/Plan: Colonscopy Monday.”
Ummmm, excuse me? That’s an assessment?
No, that’s a test.
So rarely is any thought offered in the note. Now, I’m sure the differential diagnosis is well scripted in their minds. But unfortunately, it doesn’t get put to page, and there is no communication until after the test, when you may get a courtesy call from the gastroenterologist who says “Yeah, colon looked clean. A few hemorrhoids.”
Well that’s just super. But of course, you never get an inkling of what they thought was MOST LIKELY! And it’s not just GI consults. Heme consults have irritated me with the annoying “So what do you want me to do? It’s medical management.” In other words, if they can’t do a bone marrow biopsy, and it’s a boring anemia case, then good luck to you.
(Oops, there I go, talking about fellows. Must … re…sist)
But I digress. Whether it’s a fellow or an attending consult, the note should be helpful and the PCP should not be left in the dark. Please just remember we didn’t call you only to do a test. Thought MUST occur!
Specifically, in-hospital consults.
I won’t comment on the anger that bubbles inside me when a consult fellow will just outright “refuse” to see someone because they don’t think it’s an “appropriate” consult. That’s a whole different blog entry.
No, I want to comment on the annoying tendency of specialists to say absolutely NOTHING!
Here’s an example. An older patient comes with some bright red blood per rectum. They may have a history in the family of colon cancer, or maybe they were anemic. Whatever. The consult note usually reads thusly. First they mention the chief complaint, then they have a brief history, then there is the ubiquitous rectal exam.
And then at the end it says “Assesment/Plan: Colonscopy Monday.”
Ummmm, excuse me? That’s an assessment?
No, that’s a test.
So rarely is any thought offered in the note. Now, I’m sure the differential diagnosis is well scripted in their minds. But unfortunately, it doesn’t get put to page, and there is no communication until after the test, when you may get a courtesy call from the gastroenterologist who says “Yeah, colon looked clean. A few hemorrhoids.”
Well that’s just super. But of course, you never get an inkling of what they thought was MOST LIKELY! And it’s not just GI consults. Heme consults have irritated me with the annoying “So what do you want me to do? It’s medical management.” In other words, if they can’t do a bone marrow biopsy, and it’s a boring anemia case, then good luck to you.
(Oops, there I go, talking about fellows. Must … re…sist)
But I digress. Whether it’s a fellow or an attending consult, the note should be helpful and the PCP should not be left in the dark. Please just remember we didn’t call you only to do a test. Thought MUST occur!
Sunday, July 8, 2007
LACK OF POSTS
Sorry for the lack of posts. I've just started my private practice and have been a bit busy.
I have some posts brewing, including my continuing series on "Blank MD".
Stay tuned.
I have some posts brewing, including my continuing series on "Blank MD".
Stay tuned.
Wednesday, July 4, 2007
A LITTLE HYPOCRITICAL?
I'm probably beating a dead hrose with the whole ER thread I wrote last week, but I just want to quote PandaBear. He writes a post about drug addicts, and says that one tried to fake his way through a chief complaint of rectal bleeding. He syas:
"It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit."
So even before he checks the guy's labs, he is saying he doesn't believe he's having a significant bleed. Probably what any sane internist/primary care doc would surmise.
But Panda also says this:
"And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry"
So he drew a stat hemoglobin and hematocrit, EVEN THOUGH he figured the guy was full of garbage. Why didn't he just kick the guy out of the ER if he was so sure? Why did he send the stat labs???
Because, my friends, even the Panda knows that liability is key, and just in case the guy is NOT full of it, he has protected himself. And he's in the ER, so he has access to those stat labs when he needs them.
So for those ER-heads out there who would laugh if an internist sent such a patient to the ER (or any other patient who could use a stat lab to rule out a life threatening condition), please reflect if you would have acted any differently had you recieved the call or lab result or whatever at your office or home. Clearly, the PandaBear is making the same mistakes the primary care guys are making.
I promise this is my last post on the topic. Until I get angry again, that is.
"It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit."
So even before he checks the guy's labs, he is saying he doesn't believe he's having a significant bleed. Probably what any sane internist/primary care doc would surmise.
But Panda also says this:
"And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry"
So he drew a stat hemoglobin and hematocrit, EVEN THOUGH he figured the guy was full of garbage. Why didn't he just kick the guy out of the ER if he was so sure? Why did he send the stat labs???
Because, my friends, even the Panda knows that liability is key, and just in case the guy is NOT full of it, he has protected himself. And he's in the ER, so he has access to those stat labs when he needs them.
So for those ER-heads out there who would laugh if an internist sent such a patient to the ER (or any other patient who could use a stat lab to rule out a life threatening condition), please reflect if you would have acted any differently had you recieved the call or lab result or whatever at your office or home. Clearly, the PandaBear is making the same mistakes the primary care guys are making.
I promise this is my last post on the topic. Until I get angry again, that is.
Sunday, July 1, 2007
SHOULD THESE PEOPLE GO TO THE ER?
Here are four scenarios:
1)A patient has their PCP paged at 6:30 PM, after hours, when the PCP is on the way home. They complain of diarrhea and abdominal pain that seems mild, but has not stopped.
2)An older patient comes in without an appointment and complains she saw blood in her toilet. She has felt dizzy and wanted to run in to see her PCP. But the office is swamped and she’d have to wait. There is no nurse to draw blood.
3)The lab calls with an emergency value. The potassium is 3.3.
4)It’s the weekend. The lab calls: INR is 5.
So what should a PCP do? Should he:
a)Tell these patients to wait until they can be seen
or
b)Tell them to go to the Emergency Room?
I don’t feel there is any other answer to the question than ‘B’. And I’ll tell you why. Because momma raised me to NEVER DIAGNOSE OVER THE PHONE! That is just something a doctor should not do under any circumstances. And unless the office has a nurse and a lab, as well as NG tubes, central line kits, and blood, you’d have to accept the fact that most PCP’s offices are not equipped to deal with these situations anyway.
Case one is based on an actual gastroenterologist in Florida who was told by a man’s wife he was having these symptoms. He advised Maalox and see him the following day. He ended up having IBD and dying that night. Oops. Malpractice ensued of course.
Case two is common enough. And I don’t want to personally wait on a CBC for a whole day, even with negative orthostatics, as that physical exam finding is notoriously unreliable (I can cite an ER doc who made this statement at a conference if anyone takes umbrage with that.)
Cases three and four speak for themselves. Even if I called the patient with low potassium at home and asked him to check his pulse, I’d STILL not take a chance. Same goes for the INR patient.
911doc made the following statement:
Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me. What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.
I say “Yeah, so what?" Is there something different an internist or FP could do in the office for these patients? I fail to understand the point and what should be different. What is an emergency room for? If the chest pain is even remotely possibly cardiac, that’s an emergency. At least for me it would be.
Whether the PCP shows up at the ER, whether the PCP sends a note, whether the PCP’s midlevel made the call are all complaints that have NOTHING TO DO with the point 911doc is making, which I find is false and hollow.
The fact is, is that hospital care doesn’t pay enough for the time spent. So if a PCP hasn’t placed a central line since residency, so what? An ER doctor probably doesn’t remember a lot of other things they once learned in medical school. Because they don’t need to know them anymore. And even if I placed a central line in my office, then what? I don’t have a 24 hour center in my office. Even if I ran a code, they still have to go to the hospital.
I had an ER attending tell me he wouldn’t do a paracentesis because he wasn’t covered for that under his liability insurance. The resident under him couldn’t believe it any more than I could. He probably just hadn’t done one in years. And you know what? Big deal. So I did it. And now it’s been years, and I probably would have to remember how.
Big deal.
Hey 911doc, here is your generalist. And nothing has happened to me! Your head just got a little too big.
1)A patient has their PCP paged at 6:30 PM, after hours, when the PCP is on the way home. They complain of diarrhea and abdominal pain that seems mild, but has not stopped.
2)An older patient comes in without an appointment and complains she saw blood in her toilet. She has felt dizzy and wanted to run in to see her PCP. But the office is swamped and she’d have to wait. There is no nurse to draw blood.
3)The lab calls with an emergency value. The potassium is 3.3.
4)It’s the weekend. The lab calls: INR is 5.
So what should a PCP do? Should he:
a)Tell these patients to wait until they can be seen
or
b)Tell them to go to the Emergency Room?
I don’t feel there is any other answer to the question than ‘B’. And I’ll tell you why. Because momma raised me to NEVER DIAGNOSE OVER THE PHONE! That is just something a doctor should not do under any circumstances. And unless the office has a nurse and a lab, as well as NG tubes, central line kits, and blood, you’d have to accept the fact that most PCP’s offices are not equipped to deal with these situations anyway.
Case one is based on an actual gastroenterologist in Florida who was told by a man’s wife he was having these symptoms. He advised Maalox and see him the following day. He ended up having IBD and dying that night. Oops. Malpractice ensued of course.
Case two is common enough. And I don’t want to personally wait on a CBC for a whole day, even with negative orthostatics, as that physical exam finding is notoriously unreliable (I can cite an ER doc who made this statement at a conference if anyone takes umbrage with that.)
Cases three and four speak for themselves. Even if I called the patient with low potassium at home and asked him to check his pulse, I’d STILL not take a chance. Same goes for the INR patient.
911doc made the following statement:
Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me. What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.
I say “Yeah, so what?" Is there something different an internist or FP could do in the office for these patients? I fail to understand the point and what should be different. What is an emergency room for? If the chest pain is even remotely possibly cardiac, that’s an emergency. At least for me it would be.
Whether the PCP shows up at the ER, whether the PCP sends a note, whether the PCP’s midlevel made the call are all complaints that have NOTHING TO DO with the point 911doc is making, which I find is false and hollow.
The fact is, is that hospital care doesn’t pay enough for the time spent. So if a PCP hasn’t placed a central line since residency, so what? An ER doctor probably doesn’t remember a lot of other things they once learned in medical school. Because they don’t need to know them anymore. And even if I placed a central line in my office, then what? I don’t have a 24 hour center in my office. Even if I ran a code, they still have to go to the hospital.
I had an ER attending tell me he wouldn’t do a paracentesis because he wasn’t covered for that under his liability insurance. The resident under him couldn’t believe it any more than I could. He probably just hadn’t done one in years. And you know what? Big deal. So I did it. And now it’s been years, and I probably would have to remember how.
Big deal.
Hey 911doc, here is your generalist. And nothing has happened to me! Your head just got a little too big.
Saturday, June 30, 2007
IM VERSUS ER PART II
In my last post I responded to 911doc's post about the decline of primary care by posting a vignette I experienced which crystallized one hallmark of ER medicine nowadays: DISPO!
Clearly the ER mentality is that the workup and stabilization are NICE, but the mindset has become that of an over-educated administrator: ADMIT EM OR STREET EM! Once the decision is made, the job is done, more or less. ER residents are inundated with this advice from the moment they start residency.
I want to address specifically the complaint about these lazy internists/hospitalists upstairs and their desire for "completeness".
What does "completeness" mean? Does it mean we want EVERYTHING done? Does it mean we expect a diagnosis if admitted?
No, of course not. What it means is basically not STICKING YOUR COLLEAGUES WITH SCUT!!
I will illustrate with one of my favorite personal examples.
When I was a third year resident, a famous incident occured between the ER and our department. It was a particularly busy winter evening, and during the night, there were so mnay patients in the emergency room, you could hardly walk without stepping over someone. There was a tremendous pressure to get people upstairs (naturally) and of course there were NO ICU beds.
One younger, sick patient had symptoms typical of meningitis. However, the ER was so desparate to get people out, they had assigned a bed on the regular medical floor, DESPITE that no LP had been done.
The famous part of this story, is that the third year IM resident, who was the liason between the ER and the IM department, LEAPED ON THE GURNEY and refused to let them move the patient. The ER was aghast, and they would NOT do the LP or anything else for the patient. So this IM guy gowns up (even though he's busy as hell), does the LP, and guess what... PUS comes out of her spine. So of course she has to go to the ICU, and he REFUSES to let them send the patient anywhere else.
Can you imagine?
So that's a good example of where "completeness" might mean one thing to the ER doctor, and something else to an internist/generalist.
The point is NOT to criticize ER docs. Its to point out that the system isn't perfect. So STOP lamenting how primary care docs are responsible for all your ills. It's not so.
Part III in my next post, where I'll address the idea about what kind of patient gets referred to the ER from the office.
Clearly the ER mentality is that the workup and stabilization are NICE, but the mindset has become that of an over-educated administrator: ADMIT EM OR STREET EM! Once the decision is made, the job is done, more or less. ER residents are inundated with this advice from the moment they start residency.
I want to address specifically the complaint about these lazy internists/hospitalists upstairs and their desire for "completeness".
What does "completeness" mean? Does it mean we want EVERYTHING done? Does it mean we expect a diagnosis if admitted?
No, of course not. What it means is basically not STICKING YOUR COLLEAGUES WITH SCUT!!
I will illustrate with one of my favorite personal examples.
When I was a third year resident, a famous incident occured between the ER and our department. It was a particularly busy winter evening, and during the night, there were so mnay patients in the emergency room, you could hardly walk without stepping over someone. There was a tremendous pressure to get people upstairs (naturally) and of course there were NO ICU beds.
One younger, sick patient had symptoms typical of meningitis. However, the ER was so desparate to get people out, they had assigned a bed on the regular medical floor, DESPITE that no LP had been done.
The famous part of this story, is that the third year IM resident, who was the liason between the ER and the IM department, LEAPED ON THE GURNEY and refused to let them move the patient. The ER was aghast, and they would NOT do the LP or anything else for the patient. So this IM guy gowns up (even though he's busy as hell), does the LP, and guess what... PUS comes out of her spine. So of course she has to go to the ICU, and he REFUSES to let them send the patient anywhere else.
Can you imagine?
So that's a good example of where "completeness" might mean one thing to the ER doctor, and something else to an internist/generalist.
The point is NOT to criticize ER docs. Its to point out that the system isn't perfect. So STOP lamenting how primary care docs are responsible for all your ills. It's not so.
Part III in my next post, where I'll address the idea about what kind of patient gets referred to the ER from the office.
Thursday, June 28, 2007
IM VERSUS ER
Happyman referred me to 911doc's column about the downfall of Internal Medicine and Generalists... but then proceeds to rip Primary Care doctors a new one, including hospitalists (which I was for the last 5 years) because they demand "completeness". He faults IM and FP's for punting to the ER for many different complaints, unwilling to take on the "liability". He laments how we don't want to run codes anymore.
So much is wrong and/or asinine about the column, I hardly know what to say. Being the Angry Doctor, I've decided to say the following: you are full of garbage, 911doc!
Let me tell you my personal favorite story concerning the ER:
One evening, I was admitting an 80 year old female who had multiple medical problems including heart failure, asthma, cancer, etc... yet despite this, she was a sweet old lady and still functioning well. I'm called to see her up on the floor at around 6 PM. I walk in and the woman is gasping practically. I check the ER "workup" sheet. This woman had gotten an X ray, the ubiquitus troponin, and Tylenol. Yes folks, they gave her only Tylenol for her shortness of breath.
OK, so I slap oxygen on her, I go review the X ray, and then I whip down to the ER to confront the physician who sent her upstairs. The attending physician listened to my diatribe, and then called over his resident and said "Dr. Angry wants to talk with you."
Fine, I said, if you want to sacrifice your resident to me, be that way.
I begin my tirade: "Ms. so-and-so is gasping upstairs. You didn't do anything down here for her, so obviously you couldn't have been that concerned. Why did you admit her?"
"Shortness of breath.", the resident replied.
"Well, she had a history of asthma. Did you give her any nebulizers?"
"No." he repsonds.
"Why not?"
"Because she wasn't wheezing."
"So then why did you admit her?"
"Shortness of breath" he replies.
"Her X ray was reported to have an infiltrate on it. Did you think about giving antibiotics?" I mused.
"Yeah, my attending and I looked at it, and we just didn't think she had pneumonia. She had no fever or cough."
"So why did you admit her?"
"Shortness of breath" he replies.
"She has a history of cancer. Did you consider a pulmonary embolus?" I ask.
"Yeah, she just didn't seem like she had a P.E."
"So why did you admit her?"
"Shortness of breath" he replied.
"She has a history of heart failure. Did you give any lasix?"
"No. There was no congestion on the X ray."
"So what did you admit her for?"
Do I even need to type his reply?
I was shocked. Usually my complaint about the ER is that they perform and administer many unnecessary things, making it harder for those lazy internists upstairs to make a diagnosis. Here was the exact opposite: they had done NOTHING! (Oh, except they gave Tylenol. I forgot.)
So I turn up her oxygen, I give her nebulizers, I give her antibiotics. I gave her lasix.
It doesn't occur to them that maybe she doesn't have a fever because she's immunocompromised from cancer. It doesn't occur to them to check for a blood clot, even with her unexplained dyspnea and history of cancer. That maybe she's not wheezing because she's having what they used to call stage IV asthma.
I get called two hours later and the nurses are like "she's still very short of breath." I say "OK, give her lovenox and get a stat CT angiogram" And guess what... she had THREE PULMONARY EMBOLI in her lungs. (Gee, good thing its not an emergency, right ER docs?)
So it's just as easy for me to make disparaging remarks about the ER's complete lack of motivation to diagnose (DISPO DISPO DISPO... the mantra goes, right?) as it is for these ER heads to lament how lazy primary care docs have become. Why all the intellectual dishonesty? We all know the truth: the REAL reason ER docs didn't do primary care is because they don't want to deal with chronically ill patients and their paperwork! If they had to look at a patient for more than twelve hours, they would start yelling "Why isn't this patient upstairs???" The worst time to BE a patient is that lull between ER admission and going upstairs because everybody knows the ER doc has lost interest in you.
My best friend is an ER doctor. And I did rotations through ER as a medical student and a resident. (I actually did more shifts than the ER residents themselves.. their way of dumping on the IM residents I imagine). It's a tough job and it requires real skill. But don't pretend that primary care doctors aren't doing exactly what they're supposed to be doing.
Part II of this rant tomorrow.
So much is wrong and/or asinine about the column, I hardly know what to say. Being the Angry Doctor, I've decided to say the following: you are full of garbage, 911doc!
Let me tell you my personal favorite story concerning the ER:
One evening, I was admitting an 80 year old female who had multiple medical problems including heart failure, asthma, cancer, etc... yet despite this, she was a sweet old lady and still functioning well. I'm called to see her up on the floor at around 6 PM. I walk in and the woman is gasping practically. I check the ER "workup" sheet. This woman had gotten an X ray, the ubiquitus troponin, and Tylenol. Yes folks, they gave her only Tylenol for her shortness of breath.
OK, so I slap oxygen on her, I go review the X ray, and then I whip down to the ER to confront the physician who sent her upstairs. The attending physician listened to my diatribe, and then called over his resident and said "Dr. Angry wants to talk with you."
Fine, I said, if you want to sacrifice your resident to me, be that way.
I begin my tirade: "Ms. so-and-so is gasping upstairs. You didn't do anything down here for her, so obviously you couldn't have been that concerned. Why did you admit her?"
"Shortness of breath.", the resident replied.
"Well, she had a history of asthma. Did you give her any nebulizers?"
"No." he repsonds.
"Why not?"
"Because she wasn't wheezing."
"So then why did you admit her?"
"Shortness of breath" he replies.
"Her X ray was reported to have an infiltrate on it. Did you think about giving antibiotics?" I mused.
"Yeah, my attending and I looked at it, and we just didn't think she had pneumonia. She had no fever or cough."
"So why did you admit her?"
"Shortness of breath" he replies.
"She has a history of cancer. Did you consider a pulmonary embolus?" I ask.
"Yeah, she just didn't seem like she had a P.E."
"So why did you admit her?"
"Shortness of breath" he replied.
"She has a history of heart failure. Did you give any lasix?"
"No. There was no congestion on the X ray."
"So what did you admit her for?"
Do I even need to type his reply?
I was shocked. Usually my complaint about the ER is that they perform and administer many unnecessary things, making it harder for those lazy internists upstairs to make a diagnosis. Here was the exact opposite: they had done NOTHING! (Oh, except they gave Tylenol. I forgot.)
So I turn up her oxygen, I give her nebulizers, I give her antibiotics. I gave her lasix.
It doesn't occur to them that maybe she doesn't have a fever because she's immunocompromised from cancer. It doesn't occur to them to check for a blood clot, even with her unexplained dyspnea and history of cancer. That maybe she's not wheezing because she's having what they used to call stage IV asthma.
I get called two hours later and the nurses are like "she's still very short of breath." I say "OK, give her lovenox and get a stat CT angiogram" And guess what... she had THREE PULMONARY EMBOLI in her lungs. (Gee, good thing its not an emergency, right ER docs?)
So it's just as easy for me to make disparaging remarks about the ER's complete lack of motivation to diagnose (DISPO DISPO DISPO... the mantra goes, right?) as it is for these ER heads to lament how lazy primary care docs have become. Why all the intellectual dishonesty? We all know the truth: the REAL reason ER docs didn't do primary care is because they don't want to deal with chronically ill patients and their paperwork! If they had to look at a patient for more than twelve hours, they would start yelling "Why isn't this patient upstairs???" The worst time to BE a patient is that lull between ER admission and going upstairs because everybody knows the ER doc has lost interest in you.
My best friend is an ER doctor. And I did rotations through ER as a medical student and a resident. (I actually did more shifts than the ER residents themselves.. their way of dumping on the IM residents I imagine). It's a tough job and it requires real skill. But don't pretend that primary care doctors aren't doing exactly what they're supposed to be doing.
Part II of this rant tomorrow.
Thursday, June 21, 2007
THE TRUTH ABOUT ESA'S
The New England Journal of Medicine published an interesting series of editorials this week about ESA’s. (erythropoesis stimulating agents, click here and here). For the non medically inclined, these are injectable agents which stimulate the bone marrow to produce red blood cells. I want to point out some fascinating things I learned from these articles.
One is that it is NOT indicated for anemia from cancer. It is only recommended for anemia secondary to chemotherapy, or at least it was only evaluated on that basis, an attempt to reduce the number of transfusions required.
Secondly, it is NOT approved by the FDA for alleviating fatigue or weakness or to improve a patient’s quality of life. In fact, the FDA has stated that there is “no evidence that [the agents] improve quality of life or cancer outcomes”.
I didn’t realize that, and from the commercials released by Amgen, you’d suspect otherwise. You remember those, right? An older woman is power walking and she describes how her fatigue was due to anemia and the Procrit had given her back her energy. Well, since there was no evidence to back up that little bit if play acting, why was it allowed to air?
Well, the FDA’s own Oncologic Drigs Advisory Committee recently criticized these very ads and director Richard Padzur made this helpful quote, saying the FDA should give “the American public…the reason why these ads were allowed to go on”.
I don’t think we need to look too far for the reason. My guess is, it’s green, made of paper, and can buy a lot of nice things.
Finally, I did not know that it INCREASED your risk of dying of your cancer. And I’m not just talking about hematologic cancers. Apparently HEAD AND NECK cancers! And METASTATIC BREAST CANCER! How in the world does this happen? No one has a clue right now, because there just isn’t any good test to detect if there are receptors on these tumors for the drug, or if its due to more angiogenesis and, thus, more tumor proliferation.
Talk about your poorly publicized facts.
I have given ESA’s to many anemic patients suffering from end stage renal disease and if they have chronic disease anemia without underlying bleeding, or if they required a lot of transfusions, but were refusing surgery or colonoscopy. I never tried to get the hematocrit about 30% and I don’t think these papers apply as much to my practice as an oncologist’s. But I still think its more evidence of chicanery between the FDA and Big Pharma, and 180 degrees removed from the best interests of patients.
Ok, off for a few days with the family. See you next week.
And STAY ANGRY!!!!!!!
One is that it is NOT indicated for anemia from cancer. It is only recommended for anemia secondary to chemotherapy, or at least it was only evaluated on that basis, an attempt to reduce the number of transfusions required.
Secondly, it is NOT approved by the FDA for alleviating fatigue or weakness or to improve a patient’s quality of life. In fact, the FDA has stated that there is “no evidence that [the agents] improve quality of life or cancer outcomes”.
I didn’t realize that, and from the commercials released by Amgen, you’d suspect otherwise. You remember those, right? An older woman is power walking and she describes how her fatigue was due to anemia and the Procrit had given her back her energy. Well, since there was no evidence to back up that little bit if play acting, why was it allowed to air?
Well, the FDA’s own Oncologic Drigs Advisory Committee recently criticized these very ads and director Richard Padzur made this helpful quote, saying the FDA should give “the American public…the reason why these ads were allowed to go on”.
I don’t think we need to look too far for the reason. My guess is, it’s green, made of paper, and can buy a lot of nice things.
Finally, I did not know that it INCREASED your risk of dying of your cancer. And I’m not just talking about hematologic cancers. Apparently HEAD AND NECK cancers! And METASTATIC BREAST CANCER! How in the world does this happen? No one has a clue right now, because there just isn’t any good test to detect if there are receptors on these tumors for the drug, or if its due to more angiogenesis and, thus, more tumor proliferation.
Talk about your poorly publicized facts.
I have given ESA’s to many anemic patients suffering from end stage renal disease and if they have chronic disease anemia without underlying bleeding, or if they required a lot of transfusions, but were refusing surgery or colonoscopy. I never tried to get the hematocrit about 30% and I don’t think these papers apply as much to my practice as an oncologist’s. But I still think its more evidence of chicanery between the FDA and Big Pharma, and 180 degrees removed from the best interests of patients.
Ok, off for a few days with the family. See you next week.
And STAY ANGRY!!!!!!!
Wednesday, June 20, 2007
A SUPPLEMENT THAT WORKS??? (MELATONIN)
I am fascinated by my recent revelation that melatonin somehow has effects on cancer. It originally came to my attention during my research on “Sleep MD”; specifically during a passage in a review article on melatonin in the NEJM in 1997. The mechanisms by which melatonin exerts this effect are not known. The following mechanisms are proposed:
1) inducing apoptosis in tumors with the melatonin receptor
2) stimulating production of IL2 (antitumor response)
3) modulation of oncogene regulation (???you got me)
Melatonin is an antioxidant, apparently it is a more potent free radical scavenger than vitamin E or the other antioxidants usually bandied about on TV.
Most of the studies have been done by a group of Radiation Oncologists in Milan, Italy. In 1995, one small study was carried out with patients who had metastatic breast cancer and it appeared to slow their disease. In 1996, they published a study in the journal Oncology which showed increased survival in a small number of patients with glioblastoma who got melatonin.
In 1991, a study by a different group of malignant melanoma patients showed a transient reduction in tumor size. Considering the miserable prognosis for such patients, it’s worth noting.
The most recent study from this group in Milan fascinates me. I went to my local medical library and had them print me out a copy. It was published just a few months ago and involved 370 patients, all of whom had either advanced non-small cell lung cancer, or advanced gastrointestinal tumors (colon and stomach). They received standard chemotherapy with or without melatonin (doses of 20 mg per day, which is higher than the typical sleep doses).
Turns out, there was statistically significant differences in overall tumor regression AND 2 year survival. (At the end of two years, there was 25% survival in the melatonin group, vs. 13% for the non melatonin group, p<0.05).
I am not a fan of nutritional and holistic supplements. But these studies illustrate the exact reason why: we need well performed, repeated studies with real results. THAT could make many physicians and science-minded people converts! So based on this data, I believe I would recommend melatonin to some cancer patients. It’s not a cure, but there is no cure for metastatic disease, is there?
And let the message go out to other supplements: if you want to be taken seriously, get your pathetic butts in the lab! Maybe someday, we can drive these herbalists/naturopaths out of business! (I can dream, can’t I?)
1) inducing apoptosis in tumors with the melatonin receptor
2) stimulating production of IL2 (antitumor response)
3) modulation of oncogene regulation (???you got me)
Melatonin is an antioxidant, apparently it is a more potent free radical scavenger than vitamin E or the other antioxidants usually bandied about on TV.
Most of the studies have been done by a group of Radiation Oncologists in Milan, Italy. In 1995, one small study was carried out with patients who had metastatic breast cancer and it appeared to slow their disease. In 1996, they published a study in the journal Oncology which showed increased survival in a small number of patients with glioblastoma who got melatonin.
In 1991, a study by a different group of malignant melanoma patients showed a transient reduction in tumor size. Considering the miserable prognosis for such patients, it’s worth noting.
The most recent study from this group in Milan fascinates me. I went to my local medical library and had them print me out a copy. It was published just a few months ago and involved 370 patients, all of whom had either advanced non-small cell lung cancer, or advanced gastrointestinal tumors (colon and stomach). They received standard chemotherapy with or without melatonin (doses of 20 mg per day, which is higher than the typical sleep doses).
Turns out, there was statistically significant differences in overall tumor regression AND 2 year survival. (At the end of two years, there was 25% survival in the melatonin group, vs. 13% for the non melatonin group, p<0.05).
I am not a fan of nutritional and holistic supplements. But these studies illustrate the exact reason why: we need well performed, repeated studies with real results. THAT could make many physicians and science-minded people converts! So based on this data, I believe I would recommend melatonin to some cancer patients. It’s not a cure, but there is no cure for metastatic disease, is there?
And let the message go out to other supplements: if you want to be taken seriously, get your pathetic butts in the lab! Maybe someday, we can drive these herbalists/naturopaths out of business! (I can dream, can’t I?)
Monday, June 18, 2007
THE "REAL" MEDICARE FRAUD
The New York Times offered an editorial by David Leonhardt, one of their economic writers, concerning the reason healthcare in this country is so expensive. Here’s his take:
The main reason so many people lack health insurance is because of its cost. And a big reason for that cost is the explosion of expensive, medically questionable care, be it knee replacement, preventive angioplasty or lumbar fusion
The example he cites is of lumbar fusion. Apparently, a tiny town in Idaho accounts for a disproportionate number of spinal fusion surgeries, and that the data on its efficacy is mixed. He also says that it cost Medicare 600 million dollars to provide these surgeries in 2003.
A large number, to be sure. I would note that after this introduction, Mr. Leonhardt abandons the topic of disparate medical procedures and manages to focus on Democratic presidential candidates’ plans for universal health care. I’m not sure why Republican candidates’ policies aren’t mentioned. Must be that ol’ “liberal bias” that seems to land George Bush in the White House every four years like clockwork.
But I digress. I have no idea if lumbar spinal fusion is medically questionable. I have not looked at the data. My personal feeling is that back surgery, in general, has disappointing outcomes. The newest one is “kyphoplasty”, but the data I was shown looked promising, as long as an orthopedist didn’t get greedy and try to do multiple vertebrae.
The point I want to make is that, while there may be too many lumbar fusions, that isn’t the biggest expenditure we should be focusing on. It’s EXPENSIVE ELECTRIC WHEELCAHIRS and other frauds! Consider this quote from a CNN article:
Medicare's 80 percent share for power wheelchairs grew from $22.3 million in 1995 to $663.1 million in 2002. That total already has been surpassed in the first nine months of 2003.
Some of these wheelchairs cost as much as used cars! Should a wheelchair cost so much? Of course not. I mean, a baby stroller is maybe a few hundred dollars. How does a wheelchair cost 5000 dollars? Isn't that what a Segway costs?
And I can’t count how many patients in my resident clinic asked me for a letter so they could get disability. One said to me that she couldn’t do her job because her “feet hurt”. I said “Why don’t you get a job on the phone.” She looked at me like I was crazy and said “Oh, I got schizophrenia, I don’t think so good.”
With so many “hard working” Americans sucking at the teat of Medicare and collecting disability and SSI, no wonder the system is going broke. If some of these deadbeats went to work and stopped defrauding their own government, maybe Mr. Leonhardt wouldn’t have to write this article. Why is so little attention devoted to this topic? I guess because it’s more fashionable to solely blame doctors and hospitals for exploding costs.
The main reason so many people lack health insurance is because of its cost. And a big reason for that cost is the explosion of expensive, medically questionable care, be it knee replacement, preventive angioplasty or lumbar fusion
The example he cites is of lumbar fusion. Apparently, a tiny town in Idaho accounts for a disproportionate number of spinal fusion surgeries, and that the data on its efficacy is mixed. He also says that it cost Medicare 600 million dollars to provide these surgeries in 2003.
A large number, to be sure. I would note that after this introduction, Mr. Leonhardt abandons the topic of disparate medical procedures and manages to focus on Democratic presidential candidates’ plans for universal health care. I’m not sure why Republican candidates’ policies aren’t mentioned. Must be that ol’ “liberal bias” that seems to land George Bush in the White House every four years like clockwork.
But I digress. I have no idea if lumbar spinal fusion is medically questionable. I have not looked at the data. My personal feeling is that back surgery, in general, has disappointing outcomes. The newest one is “kyphoplasty”, but the data I was shown looked promising, as long as an orthopedist didn’t get greedy and try to do multiple vertebrae.
The point I want to make is that, while there may be too many lumbar fusions, that isn’t the biggest expenditure we should be focusing on. It’s EXPENSIVE ELECTRIC WHEELCAHIRS and other frauds! Consider this quote from a CNN article:
Medicare's 80 percent share for power wheelchairs grew from $22.3 million in 1995 to $663.1 million in 2002. That total already has been surpassed in the first nine months of 2003.
Some of these wheelchairs cost as much as used cars! Should a wheelchair cost so much? Of course not. I mean, a baby stroller is maybe a few hundred dollars. How does a wheelchair cost 5000 dollars? Isn't that what a Segway costs?
And I can’t count how many patients in my resident clinic asked me for a letter so they could get disability. One said to me that she couldn’t do her job because her “feet hurt”. I said “Why don’t you get a job on the phone.” She looked at me like I was crazy and said “Oh, I got schizophrenia, I don’t think so good.”
With so many “hard working” Americans sucking at the teat of Medicare and collecting disability and SSI, no wonder the system is going broke. If some of these deadbeats went to work and stopped defrauding their own government, maybe Mr. Leonhardt wouldn’t have to write this article. Why is so little attention devoted to this topic? I guess because it’s more fashionable to solely blame doctors and hospitals for exploding costs.
Friday, June 15, 2007
SLEEP MD
I will continue my investigation of the “BLANK MD” product line. Check here for the beginning of my series. The ingredients in SLEEP MD can be found here.
The first ingredient listed, white willow bark, is also known as Salix alba. “Salix” is Latin for “willow” so that’s logical. They isolated salicin in 1828 from the bark. It is a derivative of salicylic acid, hence it does have ability to treat fever. Sometimes I hear NSAIDS make patients sleepy, so I suppose this may have utility, or if your insomnia is due to pain, in which case I might see a doctor (shudder).
There is a delicious helping of “Valerian extract”. (it says “deodorized grade”, so the stinky version must not be so helpful). A journal called “Sleep Medicine” (gee, I wonder what that’s about) published a systematic review of the literature on this tasty herb and guess what? I’ll quote them:
“The evidence for valerian as a treatment for insomnia is inconclusive.”
So far, we have a weak pain reliever and an inconclusive stinky herb. What else is in this crud?
There’s some lemon balm and hops extract. Maybe a Mike’s Hard Lemonade is in order.
OK, what about our old friend melatonin? In the 1950’s, the hormone melatonin was isolated, and over the years it was discovered that the pineal gland releases more melatonin when it’s dark, and inhibits its production when it’s light out. A study in the Lancet from 1995 seemed to find melatonin helped in elderly patients, but there were only TWELVE people in the study!
Studies done in the journal Sleep indicated young adults had faster time to sleep and a deeper hypnotic state (wheeeee…) There’s also inconsistent results in allieviating jet lag. Most of the studies are summarized in a nice review in the NEJM here. The most fascinating (to me) is that melatonin may slow METASTATIC BREAST CANCER! That’s right! You heard it here first folks (well, not first, but anyway.) Check out the citation here.
A review of chronic insomnia in the NEJM in 2005 notes the following:
Studies of melatonin, which have involved small numbers of subjects treated for short periods with various doses and formulations, have demonstrated conflicting results.
So melatonin may (or may not) help sleep onset, jet lag, and sleep potency.
Passionflower extract is also an old time medicine used for insomnia and anxiety. The problem is that no good scientific data exists to intelligently evaluate this compound. If you don’t believe me, just read these learned people here. Ditto for the Scutellaria lateriflora.
Coenzyme Q10 rounds out the slop, but I couldn’t find treatment of insomnia as even one of the common uses of this supplement. You can find a nice list here
So this is how Marvin Heuer, MD and this band of quacks make the big bucks. They package melatonin and valerian root together with some other garbage that has no science to back it up, and call it “SLEEP MD”!
All in a days’ work for these chowderheads.
By the way, melatonin from drugstore.com – 5.99 for 120 tablets
SLEEP MD from drugstore.com - 15.99 for 30 tablets..
The first ingredient listed, white willow bark, is also known as Salix alba. “Salix” is Latin for “willow” so that’s logical. They isolated salicin in 1828 from the bark. It is a derivative of salicylic acid, hence it does have ability to treat fever. Sometimes I hear NSAIDS make patients sleepy, so I suppose this may have utility, or if your insomnia is due to pain, in which case I might see a doctor (shudder).
There is a delicious helping of “Valerian extract”. (it says “deodorized grade”, so the stinky version must not be so helpful). A journal called “Sleep Medicine” (gee, I wonder what that’s about) published a systematic review of the literature on this tasty herb and guess what? I’ll quote them:
“The evidence for valerian as a treatment for insomnia is inconclusive.”
So far, we have a weak pain reliever and an inconclusive stinky herb. What else is in this crud?
There’s some lemon balm and hops extract. Maybe a Mike’s Hard Lemonade is in order.
OK, what about our old friend melatonin? In the 1950’s, the hormone melatonin was isolated, and over the years it was discovered that the pineal gland releases more melatonin when it’s dark, and inhibits its production when it’s light out. A study in the Lancet from 1995 seemed to find melatonin helped in elderly patients, but there were only TWELVE people in the study!
Studies done in the journal Sleep indicated young adults had faster time to sleep and a deeper hypnotic state (wheeeee…) There’s also inconsistent results in allieviating jet lag. Most of the studies are summarized in a nice review in the NEJM here. The most fascinating (to me) is that melatonin may slow METASTATIC BREAST CANCER! That’s right! You heard it here first folks (well, not first, but anyway.) Check out the citation here.
A review of chronic insomnia in the NEJM in 2005 notes the following:
Studies of melatonin, which have involved small numbers of subjects treated for short periods with various doses and formulations, have demonstrated conflicting results.
So melatonin may (or may not) help sleep onset, jet lag, and sleep potency.
Passionflower extract is also an old time medicine used for insomnia and anxiety. The problem is that no good scientific data exists to intelligently evaluate this compound. If you don’t believe me, just read these learned people here. Ditto for the Scutellaria lateriflora.
Coenzyme Q10 rounds out the slop, but I couldn’t find treatment of insomnia as even one of the common uses of this supplement. You can find a nice list here
So this is how Marvin Heuer, MD and this band of quacks make the big bucks. They package melatonin and valerian root together with some other garbage that has no science to back it up, and call it “SLEEP MD”!
All in a days’ work for these chowderheads.
By the way, melatonin from drugstore.com – 5.99 for 120 tablets
SLEEP MD from drugstore.com - 15.99 for 30 tablets..
Wednesday, June 13, 2007
WHY IS IT ALWAYS THE GOOD ONES
Two colleagues who are Cardiologists have decided within a few months of each other to abandon private practice. They both cited the same reason: dwindling reimbursement. One had just moved his office to a new site and after a month had had enough! He said that insurers just wouldn’t pay and office costs had gotten out of control. He said the whole thing was a mess.
The other was the first attending I ever had as an intern in residency (about eight years ago). As far as I am concerned, he is synonymous with my hospital. He’s an older doc who is very honest and smart. As such, he refuses to perform what Happyman calls the “trifecta” of ECHO, stress test and holter on every person that walks through the door. This left him the option of seeing, as he puts it “100 patients a day”. He is now joining a practice at a hospital across town.
So the message appears to be that if you are a smart clinical cardiologist, and you decide that a patient doesn’t need a bunch of expensive tests, you will actually LOSE money. If you are not clinically skilled, or if you just need to make more money, then doing a bunch of unnecessary tests becomes NECESSARY to stay afloat.
Obviously, if you put in an extra three years of fellowship in Cardiology, I think you are entitled to more money. I think you deserve it, primarily because of the liability factor. As an internist, if I’m not sure about something, I can just defer to you and then in court I can plead “Hey, I accepted that I wasn’t sure what was going on, so I appropriately called a Cardiologist.” So the buck stops with the specialist.
But I don’t think the extra money should ONLY come from unnecessary tests. That just encourages fraud and waste. And drives intelligent specialists to merge with hospitals to reduce costs and overhead. So then the HOSPITAL can foist unnecessary tests on the public.
I am doing the “reverse commute” soon, leaving the hospital for private practice. I’ll let all of you know whether I fall on my face or not.
Soon, I will return to the “BLANK MD” product line which so angers me.
The other was the first attending I ever had as an intern in residency (about eight years ago). As far as I am concerned, he is synonymous with my hospital. He’s an older doc who is very honest and smart. As such, he refuses to perform what Happyman calls the “trifecta” of ECHO, stress test and holter on every person that walks through the door. This left him the option of seeing, as he puts it “100 patients a day”. He is now joining a practice at a hospital across town.
So the message appears to be that if you are a smart clinical cardiologist, and you decide that a patient doesn’t need a bunch of expensive tests, you will actually LOSE money. If you are not clinically skilled, or if you just need to make more money, then doing a bunch of unnecessary tests becomes NECESSARY to stay afloat.
Obviously, if you put in an extra three years of fellowship in Cardiology, I think you are entitled to more money. I think you deserve it, primarily because of the liability factor. As an internist, if I’m not sure about something, I can just defer to you and then in court I can plead “Hey, I accepted that I wasn’t sure what was going on, so I appropriately called a Cardiologist.” So the buck stops with the specialist.
But I don’t think the extra money should ONLY come from unnecessary tests. That just encourages fraud and waste. And drives intelligent specialists to merge with hospitals to reduce costs and overhead. So then the HOSPITAL can foist unnecessary tests on the public.
I am doing the “reverse commute” soon, leaving the hospital for private practice. I’ll let all of you know whether I fall on my face or not.
Soon, I will return to the “BLANK MD” product line which so angers me.
Monday, June 11, 2007
THE MILKEN CODE
“The business of America is business!” Calvin Coolidge once said. (Well, he actually said “the chief business of the American people is business”, but hey, close enough). Nothing wrong with that, right? Profiting from any new technology is as American as apple pies and facelifts.
So when I read in the New York Times’ Week in Review section that a startup company called 23andme is going to be selling transcripts of what it deems to be the important parts of your DNA genome, I thought to myself “Gee, what a great idea.”
And if you believe that was my first thought, then you haven’t been reading my blog. Companies such as Illumina, Applied Biosystems and 454 Life Sciences can supply your entire genome for the low, low price of $100,000! The Times tells us that some of the people who have already signed up include Paul Allen, co-founder of Microsoft, Stephen Hawking, and Larry “Loan me 50 dollars” King. Oh, and Michael Milken. Gee, what a treasure trove of information his genome will be.
So many problems exist with the idea of having your genome on a disk that I hardly know where to begin. One is the theft issue. If you think thieves can benefit from your social security number, just think what they can do with your genetic blueprint. I think your insurance company would looooove to get their hands on it, which brings up another thorny ethical problem. There are some laws that protect us against genetic discrimination, but that field is still being sorted out.
I also do not look forward to having a patient show up and say “It looks like I’m positive for a DR2 mutation. I want to get tested for vasculitis.” What do I say to such a patient? Do I have to spend a half hour explaining to them that they have no signs or symptoms of vasculitis? That the blood tests are not definitive? That insurance would likely not cover the tests? That there’s no preventive measure to take anyway? Will there be any time left to actually check their blood pressure?
On top of all of this, an interesting article appeared in the April 11, 2007 issue of JAMA. Researchers tested 85 variants of 70 genes previously reported to be associated with coronary artery disease. And guess what… they found that NONE… that’s right, NONE of the variants were more common in the patients with CAD.
What does that mean? That means WE DON’T KNOW S%&$ about genomics! So for those of you who are plopping down 100 GRAND to get your genetic code, GOOD LUCK doing anything with the information!
Jackassess! (That means YOU Larry King!)
So when I read in the New York Times’ Week in Review section that a startup company called 23andme is going to be selling transcripts of what it deems to be the important parts of your DNA genome, I thought to myself “Gee, what a great idea.”
And if you believe that was my first thought, then you haven’t been reading my blog. Companies such as Illumina, Applied Biosystems and 454 Life Sciences can supply your entire genome for the low, low price of $100,000! The Times tells us that some of the people who have already signed up include Paul Allen, co-founder of Microsoft, Stephen Hawking, and Larry “Loan me 50 dollars” King. Oh, and Michael Milken. Gee, what a treasure trove of information his genome will be.
So many problems exist with the idea of having your genome on a disk that I hardly know where to begin. One is the theft issue. If you think thieves can benefit from your social security number, just think what they can do with your genetic blueprint. I think your insurance company would looooove to get their hands on it, which brings up another thorny ethical problem. There are some laws that protect us against genetic discrimination, but that field is still being sorted out.
I also do not look forward to having a patient show up and say “It looks like I’m positive for a DR2 mutation. I want to get tested for vasculitis.” What do I say to such a patient? Do I have to spend a half hour explaining to them that they have no signs or symptoms of vasculitis? That the blood tests are not definitive? That insurance would likely not cover the tests? That there’s no preventive measure to take anyway? Will there be any time left to actually check their blood pressure?
On top of all of this, an interesting article appeared in the April 11, 2007 issue of JAMA. Researchers tested 85 variants of 70 genes previously reported to be associated with coronary artery disease. And guess what… they found that NONE… that’s right, NONE of the variants were more common in the patients with CAD.
What does that mean? That means WE DON’T KNOW S%&$ about genomics! So for those of you who are plopping down 100 GRAND to get your genetic code, GOOD LUCK doing anything with the information!
Jackassess! (That means YOU Larry King!)
Thursday, June 7, 2007
MARVIN HEUER, MD: REDUX
Just to recap my series on Dr. Marvin Heuer, MD. Be sure to read each thrilling installment.
MARVIN HEUER, MD PART I
MARVIN HEUER, MD PART II
THE PHYSICIANS RECOGNITION AWARD
SUPPLEMENTS INVADE IRAQ
Dr. Heuer received a medical degree in the 70’s and actually saw real patients (I believe) for six years. Then he joined Smithkline in the 1980’s and started a journey where he sold his soul, and broke it into so many pieces, that all that is left is a powdery substance that, when added to water, produces a power drink that builds muscle mass.
Seriously, look back at Part II to get a sense of how many "medical" businesses he was a part of. From hawking pharmaceuticals, to infertility clinics, to “novel vaccines”, to bogus nutritional supplements, to an ANIMAL HYDRATING BEVERAGE (gee, I thought it was called “water”). How low can a doctor sink when he is spending time creating drinks for non humans???
Here’s a list of diseases his CV suggests he did research on:
Rheumatoid arthritis
Osteoarthritis
Osteoporosis
Hypertension
Antidepressants
Seizures
Hormone replacement therapy
Overactive bladder
Candidiasis
Acute exacerbation of chronic bronchitis
Community acquired pneumonia
Endometriosis
Diabetes
Lipid lowering
Sinusitis
Migraine
Most researchers spend their whole life on one topic. Not Dr. Heuer. If a drug company comes calling, he ANSWERS the call with aplomb!
Here is a picture I find particularly amusing and apropos. Here’s Dr. Marvin posing with a fellow "researcher" marveling at a fabulous new product meant to better mankind:
Makes him proud, I bet. Shown with Jay Cutler (who the heck is Jay Cutler), Dr. Heuer has finally become a punch line. A very sad one.
This is the man behind the “science” of the “BLANK MD” product line.
Weep for him.
MARVIN HEUER, MD PART I
MARVIN HEUER, MD PART II
THE PHYSICIANS RECOGNITION AWARD
SUPPLEMENTS INVADE IRAQ
Dr. Heuer received a medical degree in the 70’s and actually saw real patients (I believe) for six years. Then he joined Smithkline in the 1980’s and started a journey where he sold his soul, and broke it into so many pieces, that all that is left is a powdery substance that, when added to water, produces a power drink that builds muscle mass.
Seriously, look back at Part II to get a sense of how many "medical" businesses he was a part of. From hawking pharmaceuticals, to infertility clinics, to “novel vaccines”, to bogus nutritional supplements, to an ANIMAL HYDRATING BEVERAGE (gee, I thought it was called “water”). How low can a doctor sink when he is spending time creating drinks for non humans???
Here’s a list of diseases his CV suggests he did research on:
Rheumatoid arthritis
Osteoarthritis
Osteoporosis
Hypertension
Antidepressants
Seizures
Hormone replacement therapy
Overactive bladder
Candidiasis
Acute exacerbation of chronic bronchitis
Community acquired pneumonia
Endometriosis
Diabetes
Lipid lowering
Sinusitis
Migraine
Most researchers spend their whole life on one topic. Not Dr. Heuer. If a drug company comes calling, he ANSWERS the call with aplomb!
Here is a picture I find particularly amusing and apropos. Here’s Dr. Marvin posing with a fellow "researcher" marveling at a fabulous new product meant to better mankind:
Makes him proud, I bet. Shown with Jay Cutler (who the heck is Jay Cutler), Dr. Heuer has finally become a punch line. A very sad one.
This is the man behind the “science” of the “BLANK MD” product line.
Weep for him.
Wednesday, June 6, 2007
SUPPLEMENTS INVADE IRAQ
An overseas military newspaper called “Stars and Stripes” published an interesting article recently. Apparently, two soldiers currently serving in Iraq felt compelled to try the weight loss supplement Hydroxycut (I can’t imagine losing weight would be my first priority if I were in Iraq, but anyway…)
Both men ended up in the emergency room. One of them, 20 years old, had a change of mental status and collapsed. The other, a 19 year old, had a potentially fatal arrhythmia. Colonel Frederick C. Good, the treating ER physician wrote a letter stating:
“Hydroxycut … should not be used in a combat zone with the inherent problems encountered in regard to hydrating adequately and eating regularly,” according to the letter. “… The use of this product or any similar products is strongly discouraged, and any remaining product should be discarded. This product and any similar products are not a shortcut to fitness, and no substitute for a regular Physical Training program.””.
Seems like straightforward advice that’s pretty sound.
Starightforward that is, unless you’re Dr. Marvin Heuer, MD!!!
You see, Dr. Marvin is the head of Iovate, and they make Hydroxycut. Here’s his take:
“My gut feeling as a physician who has worked in the emergency room is that there were tons of other factors there that may have had an influence,” said Heuer in a telephone interview…
So he’s telling our soldiers “It’s perfectly safe!” and it sounds like he’s encouraging its use, EVEN THOUGH a military doctor is advising our soldiers to avoid it. Now, I’m not sure what effect these supplements played in these soldiers’ medical problems. However, since they are fighting for our country, and since there’s potential for harm, and very little benefit, maybe Dr. Heuer could do the responsible thing and just shut the f%$# up.
Both men ended up in the emergency room. One of them, 20 years old, had a change of mental status and collapsed. The other, a 19 year old, had a potentially fatal arrhythmia. Colonel Frederick C. Good, the treating ER physician wrote a letter stating:
“Hydroxycut … should not be used in a combat zone with the inherent problems encountered in regard to hydrating adequately and eating regularly,” according to the letter. “… The use of this product or any similar products is strongly discouraged, and any remaining product should be discarded. This product and any similar products are not a shortcut to fitness, and no substitute for a regular Physical Training program.””.
Seems like straightforward advice that’s pretty sound.
Starightforward that is, unless you’re Dr. Marvin Heuer, MD!!!
You see, Dr. Marvin is the head of Iovate, and they make Hydroxycut. Here’s his take:
“My gut feeling as a physician who has worked in the emergency room is that there were tons of other factors there that may have had an influence,” said Heuer in a telephone interview…
So he’s telling our soldiers “It’s perfectly safe!” and it sounds like he’s encouraging its use, EVEN THOUGH a military doctor is advising our soldiers to avoid it. Now, I’m not sure what effect these supplements played in these soldiers’ medical problems. However, since they are fighting for our country, and since there’s potential for harm, and very little benefit, maybe Dr. Heuer could do the responsible thing and just shut the f%$# up.
Tuesday, June 5, 2007
THE PHYSICIANS RECOGNITION AWARD
On Dr. Marvin Heuer’s CV, there is a list of awards he has received. According to the GAKIC website:
“He has been honored with the American Medical Association's Physicians Recognition Award 13 times”
An impressive accomplishment! Thirteen times! How could he have been so recognized 13 times?? Did he discover plutonium? Save a busload of nuns?
Well, I checked the AMA’s website to see how one qualifies for this prestigious achievement. This is what they say:
The American Medical Association (AMA) Physician’s Recognition
Award (PRA) has recognized physician participation in continuing
medical education (CME) for more than 35 years. Established in 1968, the AMA PRA certificate and the related AMA PRA credit system recognize physicians who, by participating in CME activities, have demonstrated their commitment to staying current with advances in medicine.
So kudos to Dr. Heuer for keeping up with his CME THIRTEEN TIMES!!! Just imagine what would happen if you actually DID save a busload of nuns.
Seriously, they give an AWARD for keeping up with continuing medical education? Isn’t that like giving your kid a candy bar for cleaning his room? I've gone to a lot of the Grand Rounds given at my hospital this year. So I guess I'm entitled to one of those babies. Oh, or at least I would, IF I were a member of the AMA.
I guess even a pharmaceutical com0pany whore can pad his resume.
“He has been honored with the American Medical Association's Physicians Recognition Award 13 times”
An impressive accomplishment! Thirteen times! How could he have been so recognized 13 times?? Did he discover plutonium? Save a busload of nuns?
Well, I checked the AMA’s website to see how one qualifies for this prestigious achievement. This is what they say:
The American Medical Association (AMA) Physician’s Recognition
Award (PRA) has recognized physician participation in continuing
medical education (CME) for more than 35 years. Established in 1968, the AMA PRA certificate and the related AMA PRA credit system recognize physicians who, by participating in CME activities, have demonstrated their commitment to staying current with advances in medicine.
So kudos to Dr. Heuer for keeping up with his CME THIRTEEN TIMES!!! Just imagine what would happen if you actually DID save a busload of nuns.
Seriously, they give an AWARD for keeping up with continuing medical education? Isn’t that like giving your kid a candy bar for cleaning his room? I've gone to a lot of the Grand Rounds given at my hospital this year. So I guess I'm entitled to one of those babies. Oh, or at least I would, IF I were a member of the AMA.
I guess even a pharmaceutical com0pany whore can pad his resume.
Monday, June 4, 2007
MARVIN HEUER, MD PART II
In a previous post, I introduced the chief science officer of the bogus “BLANK MD” product line, Dr. Marvin Heuer. I just want to hit some of the highlights of his career, or at least the stuff I was able to learn through the internet.
Most of this information is obtained from his CV, which you can look at here.
Dr. Heuer spent the years 1974 to 1980 actually being a doctor. I’m guessing at some point he realized that there was more money to be made in pharmaceutical research… a LOT more.
So he spent much of the eightes and nineties working for SmithKline, Ayerst Labs, Wallace Labs, Smithkline AGAIN (this time with Beecham) then worked for a biotech trade company called Medical Alley for six years, and ended up at the Womens Health Clinic at the University of Florida in 1997. In 1998 he joined Integramed, a small cap company with a national network of fertility clinics. He left a year later.
In 2002, it looks like he took a job as Vice President of Scientific Affairs at a company called Novavax. You can see the contract he was offered here. Looks like they offered 50,000 bucks just to sign the contract. Niiiiiiice. He also got some stock options. The company creates “novel vaccines” according to their website. I’m not sure if his hire was the reason the stock plunged that month about 12 bucks per share (from 14 to 2). The only product I see available is Estrasorb, an estrogen cream treatment for hot flashes and such. He no longer appears connected to the company.
Currently, he is the head of a startup from UF called BIOGALAXY. They specialize in “hydration” products. Ugh. They also make oral hydration and multivitamin formulas… FOR YOUR DOG!!! (I AM NOT MAKING THIS UP... click here).
His CV indicates he authored or coauthored 22 abstracts, Eight of them concerned a gold salt used for rheumatoid arthritis called auranofin, whose brand name is Ridaura. And guess which company makes Ridaura??? You guessed it… Smithkline, Dr. Heuer’s bread and butter for 20 years. IS this true scholarship? Methinks not.
Here is a list of many of the companies Dr. Heuer has done research for:
Smithkline Beecham
Ayerst labs
Wallace labs
Scherring labs
Upjohn labs
Nautilis Inc.
Ciba – Geigy
Wyeth labs
Lederle labs
Abbott labs
3M
Zeneca Pharmaceuticals
Novo Nordisk Pharmaceuticals
Eli Lilly
Proctor and Gamble
Ortho McNeil
Pfizer
The list goes on and on. If there’s a company not on there, please contact Dr. Marvin Heuer. I’m sure he’ll be in touch with them soon.
I’ll close tomorrow on Dr. Heuer with a few last comments. But much more to come on the “BLANK MD” product line.
Most of this information is obtained from his CV, which you can look at here.
Dr. Heuer spent the years 1974 to 1980 actually being a doctor. I’m guessing at some point he realized that there was more money to be made in pharmaceutical research… a LOT more.
So he spent much of the eightes and nineties working for SmithKline, Ayerst Labs, Wallace Labs, Smithkline AGAIN (this time with Beecham) then worked for a biotech trade company called Medical Alley for six years, and ended up at the Womens Health Clinic at the University of Florida in 1997. In 1998 he joined Integramed, a small cap company with a national network of fertility clinics. He left a year later.
In 2002, it looks like he took a job as Vice President of Scientific Affairs at a company called Novavax. You can see the contract he was offered here. Looks like they offered 50,000 bucks just to sign the contract. Niiiiiiice. He also got some stock options. The company creates “novel vaccines” according to their website. I’m not sure if his hire was the reason the stock plunged that month about 12 bucks per share (from 14 to 2). The only product I see available is Estrasorb, an estrogen cream treatment for hot flashes and such. He no longer appears connected to the company.
Currently, he is the head of a startup from UF called BIOGALAXY. They specialize in “hydration” products. Ugh. They also make oral hydration and multivitamin formulas… FOR YOUR DOG!!! (I AM NOT MAKING THIS UP... click here).
His CV indicates he authored or coauthored 22 abstracts, Eight of them concerned a gold salt used for rheumatoid arthritis called auranofin, whose brand name is Ridaura. And guess which company makes Ridaura??? You guessed it… Smithkline, Dr. Heuer’s bread and butter for 20 years. IS this true scholarship? Methinks not.
Here is a list of many of the companies Dr. Heuer has done research for:
Smithkline Beecham
Ayerst labs
Wallace labs
Scherring labs
Upjohn labs
Nautilis Inc.
Ciba – Geigy
Wyeth labs
Lederle labs
Abbott labs
3M
Zeneca Pharmaceuticals
Novo Nordisk Pharmaceuticals
Eli Lilly
Proctor and Gamble
Ortho McNeil
Pfizer
The list goes on and on. If there’s a company not on there, please contact Dr. Marvin Heuer. I’m sure he’ll be in touch with them soon.
I’ll close tomorrow on Dr. Heuer with a few last comments. But much more to come on the “BLANK MD” product line.
Friday, June 1, 2007
MARVIN HEUER, MD PART I
I have been blogging about the “BLANK MD” product line. Somewhat randomly, I’m trying to examine them piece by piece to better understand just why this product exists and which people are behind it.
A look at their website indicates that the head of the product line’s “MD Advisory Board” is a kindly-looking older physician named Marvin Heuer, MD.
Who is Marvin Heuer, MD?
Well, according to this website, he is the Chief Science Officer for “Team Muscletech”, which makes “Anator p70” (a “muscle gene activator”, whatever unnatural compound that might be). He is also the Chief Science Officer for GAKIC (catchy name. It stands for ‘glycine-l-arginine-alpha-ketoisocaproic acid’), AND the chief science officer for Iomedix (which makes the MD product line). Busy guy.
But it isn’t a coincidence. He’s chief science officer for Iovate, and they make all this stuff. He seems to be an expert on all sorts of supplements. How did he develop this talent? Does he have a background in the fields necessary to tackle building muscle mass AND to help heartburn, sleep disorders, cholesterol problems, AND arthritis and rheumatologic disease???
I don’t know about all that. But upon researching about this gentleman, I discovered two things:
1)He has taken part in a LOT of research, and
2) You can find a LOT of stuff on the internet.
He is a medical doctor. It appears he graduated from Minnesota Medical School and then did an internship and became a Family Practitioner in the 70’s. At some point, he decided that seeing patients probably wasn’t where it’s at, and became a researcher, where he took part in studies conercerning FOURTEEN DIFFERENT DISEASES!!!
Impressive. Some doctors struggle to just master research in one or two areas. This man has dipped his beak in topics as widely different as migraine, Urinary tract infection, and osteoporosis.
Oh, did I mention that the research was funded by almost ANY DRUG COMPANY YOU CAN NAME???
I do not know Dr. Marvin Heuer personally. He may be a great guy, the salt of the earth. He certainly doesn’t seem like a monster. But based on my cursory look at him, he appears to be a bit of a mercenary. And I think his “MD” product line is garbage.
Much more to follow (with documentation of course).
A look at their website indicates that the head of the product line’s “MD Advisory Board” is a kindly-looking older physician named Marvin Heuer, MD.
Who is Marvin Heuer, MD?
Well, according to this website, he is the Chief Science Officer for “Team Muscletech”, which makes “Anator p70” (a “muscle gene activator”, whatever unnatural compound that might be). He is also the Chief Science Officer for GAKIC (catchy name. It stands for ‘glycine-l-arginine-alpha-ketoisocaproic acid’), AND the chief science officer for Iomedix (which makes the MD product line). Busy guy.
But it isn’t a coincidence. He’s chief science officer for Iovate, and they make all this stuff. He seems to be an expert on all sorts of supplements. How did he develop this talent? Does he have a background in the fields necessary to tackle building muscle mass AND to help heartburn, sleep disorders, cholesterol problems, AND arthritis and rheumatologic disease???
I don’t know about all that. But upon researching about this gentleman, I discovered two things:
1)He has taken part in a LOT of research, and
2) You can find a LOT of stuff on the internet.
He is a medical doctor. It appears he graduated from Minnesota Medical School and then did an internship and became a Family Practitioner in the 70’s. At some point, he decided that seeing patients probably wasn’t where it’s at, and became a researcher, where he took part in studies conercerning FOURTEEN DIFFERENT DISEASES!!!
Impressive. Some doctors struggle to just master research in one or two areas. This man has dipped his beak in topics as widely different as migraine, Urinary tract infection, and osteoporosis.
Oh, did I mention that the research was funded by almost ANY DRUG COMPANY YOU CAN NAME???
I do not know Dr. Marvin Heuer personally. He may be a great guy, the salt of the earth. He certainly doesn’t seem like a monster. But based on my cursory look at him, he appears to be a bit of a mercenary. And I think his “MD” product line is garbage.
Much more to follow (with documentation of course).
Thursday, May 31, 2007
GNC
I am researching my next post, so I’ll just write a blurb about a visit to GNC. It seems like this blog has become all about supplements lately, and Happyman said he thinks supplements often do make wild claims, which seems to go against the DSHEA rule I cited in my post “BLANK MD II”, which basically forbid saying they can treat or mitigate a disease, unless the FDA has stated they can.
So I went to GNC to take a look for myself at some of the labels.
Turns out this was a waste of time.
For anyone who hasn’t been to a GNC lately, here’s what I learned:
1) They have a smoothie/energy drink bar, similar to what you find in the lobby of gyms and health clubs, or a typical jamba juice. You can get all kinds of additives, and the calories are listed.
2) The owners were all Indian or Pakistani. I’m not sure if this is just in New York or everywhere, but I got the feeling they were laughing at the customers.
3) Their supplements are all GNC labeled, so there isn’t a good representative sample for supplement labels. As far as their own products go, however, their labels were very vague, and always carried the disclaimer at the bottom about how the stuff isn’t regulated, etc etc.
4) Abut 90% or more of what they sell is geared toward gigantic muscle bound gym rats. The back of the store (and front) is FILLED with huge canisters of powdered muscle “milk” with labels that have lightning bolts and lettering that looks EXTREME!!! There is also a large shelf of power bars and the like.
I think I’ll have to visit the Vitamin Store or InVite to get a better sampling. The GNC labels were very fair.
So I went to GNC to take a look for myself at some of the labels.
Turns out this was a waste of time.
For anyone who hasn’t been to a GNC lately, here’s what I learned:
1) They have a smoothie/energy drink bar, similar to what you find in the lobby of gyms and health clubs, or a typical jamba juice. You can get all kinds of additives, and the calories are listed.
2) The owners were all Indian or Pakistani. I’m not sure if this is just in New York or everywhere, but I got the feeling they were laughing at the customers.
3) Their supplements are all GNC labeled, so there isn’t a good representative sample for supplement labels. As far as their own products go, however, their labels were very vague, and always carried the disclaimer at the bottom about how the stuff isn’t regulated, etc etc.
4) Abut 90% or more of what they sell is geared toward gigantic muscle bound gym rats. The back of the store (and front) is FILLED with huge canisters of powdered muscle “milk” with labels that have lightning bolts and lettering that looks EXTREME!!! There is also a large shelf of power bars and the like.
I think I’ll have to visit the Vitamin Store or InVite to get a better sampling. The GNC labels were very fair.
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