The blog of Freedom and Individual Rights in Medicine (FIRM)
Like workers in any public service, doctors always say that morale has never been lower. But this time many are threatening to vote with their feet and practise overseas. Normally the General Medical Council, which regulates the profession, gets 20-25 requests a day for certificates of professional status, which make it easier to work abroad. From September 16th-18th it received a staggering 1,644 requests.
1) Many publicly reported science results are still provisionalThis latest piece is relatively non-political. But it is uncompromisingly pro-bacon.
2) Beware of sloppy statistics
3) Beware of the bias towards positive dramatic results
The authors of the IOM report identify several possible methods for encouraging patients to get more involved in their diagnoses. First, they suggest that the act of diagnosis should no longer be treated as a solitary task that takes place mostly inside a single clinician’s brain—but rather as a team effort that includes patients and their families. To achieve that, the authors admit, the entire culture of the healthcare system needs to change to one that welcomes patient feedback...I personally think that patient should obtain their own personal copies any important medical records (including radiology studies on CT, pathology reports, etc.) in case they wish to review them at home or in consultation with an independent physician.
While I have no understanding of how the new price was determined, it will eventually have to withstand the scrutiny of the market. If the price is set higher than the market will bear, because it is no longer under patent, other manufacturers will enter the market lowering prices. Ideally this would happen near instantaneously but, because of legislative barriers to entry, which include a multi-step approval process, it will take some time. Better alternatives to the current regimen may also appear in time as well.
Overall, however, infectious disease products have become less attractive to pharmaceutical companies and this, at root, is why we are left with just one manufacturer for many important non-patented products. The disincentives to enter this market are myriad and the ultimate answer to this scenario is not more intervention but to remove artificial barriers to entry, inviting the appearance of competitors in the market...
Our results confirm that an increase in pain while travelling over speed bumps is associated with an increased likelihood of acute appendicitis. Absence of pain over speed bumps is associated with a significantly decreased likelihood of appendicitis. Although the specificity was relatively low, as a diagnostic variable pain over speed bumps compared favourably with other features commonly used in diagnostic assessment, with a better sensitivity and negative likelihood ratio than all other features assessed.And some comparison data with other clinical signs (Table 2 in the article, click on image to see full-sized version):
Moreover, some patients who were “speed bump positive” but did not have appendicitis had other important abdominal diagnoses, such as a ruptured ovarian cyst, diverticulitis, or pelvic inflammatory disease...
Dr. Jones can’t manage his practice, care for his family and study for the certification exams administered by the American Board of Internal Medicine. The tests purportedly insure doctors’ competence, but, like many physicians, Dr. Jones says the questions often have nothing to with what he sees in his practice and are little more than a game of medical Trivial Pursuit. Dr. Jones can’t afford the thousands of dollars for study guides and classes to learn obscure, often irrelevant information, and has no time to review the material every night for months. He failed the test, so his hospital will no longer allow him to admit patients because he couldn’t answer questions about diseases he will never encounter....The article also describes how other specialties (such as the anesthesiologists certification board) are adopting other methods to ensure physician quality through tests and quizzes that are more relevant to clinical practice.
This medical protection racket has made millionaires of ABIM top officers, financed a ritzy condominium, limousines and first-class travel, all while sucking huge sums of cash out of the health care system. But now, after decades of unchecked rule by ABIM, cracks are appearing in the organization’s facade of power. Thousands of doctors began a widespread revolt months ago and, in the last few weeks, evidence that their efforts are succeeding has started rolling in...
[A recent study in the Annals of Internal Medicine] concluded that internists incur an average of $23,607 in MOC costs over 10 years—with doctors who specialize in cancers and blood diseases out $40,495. All told, the study concluded, MOC will suck $5.7 billion out of the health care system over 10 years, including $5.1 billion in time costs (resulting from 32.7 million physician-hours spent on MOC) and $561 million in testing costs. And remember—all that time and expense is for a program that has not been proven to accomplish anything.
The professional group that represents anesthesiologists will become the first medical board to scrap a widely criticized test that most physicians take every 10 years to demonstrate that they are up to date in their specialties, officials said Wednesday.(For more background on the MOC controversy, see these earlier Newsweek pieces "The Ugly Civil War in American Medicine" and "A Certified Medical Controversy".)
Prospective donors are told, "It's easier to get into MIT and Harvard than it is to get enrolled as one of our donors."To donate, Eric had to pass a 109-point clinical assessment. There is a laundry list of factors that would disqualify a donor: obesity, illicit drug use, antibiotic use, travel to regions with high risk of contracting diseases, even recent tattoos. His stools and blood also had to clear a battery of laboratory screenings to make sure he didn't have any infections.After all that screening, only 3% of prospective donors are healthy enough to give. "I had no idea," he says about his poop. "It turns out that it's fairly close to perfect."And that, unlike most people's poop, makes Eric's worth money. OpenBiome pays its 22 active donors $40 per sample. They're encouraged to donate often, every day if they can. Eric has earned about $1,000.
1) Most drug trial results are still not being reported to a central registry.Fortunately, free market incentives are driving more drug companies towards full disclosure of both positive and negative study results -- which will benefit patients.
2) Negative results funded by private industry (e.g., pharmaceutical companies) are more likely to be reported than from government-funded research.
The new regulations, being written by and for the nation’s capital city, will create a registry of all personal trainers in the District only. But they are expected to become a model that winners and losers in the fight believe will be replicated elsewhere.Personally, I find the idea of an agency deciding "who has the right to tell someone how to exercise" to be deeply disturbing.
The credit — or blame — for the newfound urgency can be traced in part to President Obama’s Affordable Care Act. A variety of workplace wellness programs and preventive health-care initiatives called for in the law could soon translate into rivers of billable hours for those with credentials to keep American waistlines in check.
And that means the race is on to be eligible for those credentials, which could eventually lead to the ability to bill insurance companies for services, much like such professionals as dieticians and physical therapists. With billions of dollars potentially at stake, lawyers and lobbyists are engaged in a no-holds-barred fight to shape the nation’s first-ever rules over who has the right to tell someone else how to exercise.
Heal is one of several startups putting a high-tech spin on old-fashioned house calls—or “in-person visits,” since they can take place anywhere. The services provide a range of nonemergency medical care—from giving flu shots to treating strep throats and stitching lacerations—much like a mobile urgent-care clinic.The article also notes that for some customers, it's cheaper to pay for this at-home service than to take time off from work to go to the doctor's office.
The companies use slightly different models. Pager, in New York City, dispatches doctors or nurse practitioners via Uber, for $200. Heal, in Los Angeles, San Francisco and Orange County, Calif., promises to “get a doctor to your sofa in under an hour” for $99. (A medical assistant goes along to do the driving and parking.)
RetraceHealth, in Minneapolis, has a nurse practitioner consult with patients via video (for $50), and only comes to their homes if hands-on care like a throat swab or blood draw is necessary (for $150)...
Most of the services don’t accept insurance, but they say patients can pay with health savings accounts or submit out-of-network claims.
Such ventures are fueled by a confluence of trends, including growing interest in the so-called sharing economy, where technology connects providers with excess capacity and consumers who want on-demand services. Many doctors and nurses who work for hospitals are eager for extra work in their off-hours, the companies say. The services carry malpractice insurance, but say overall low overhead keeps prices down.I just hope the government doesn't impose onerous regulatory burdens on this growing sector.
And thanks to the boom in mobile-medical technology, providers can carry key equipment with them, from portable blood analyzers to hand-held ultrasounds.
Most of Donald Trump’s public statements include the rote declaration that Obamacare is a disaster. This is true, of course, but it doesn’t tell us anything new. It’s only when he starts elaborating on his objections that one gets a sense of what he believes, and he doesn’t talk like a friend of the free market. During last week’s Republican debate, for example, he was asked about his past praise of single-payer health care and replied, “As far as single-payer, it works in Canada, works incredibly well in Scotland.” This answer was both antithetical to free-market thinking and profoundly ignorant...
They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates. When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements.And:
This was an insult that the senior surgeon at my hospital could no longer countenance. “The so-called best surgeons are only doing the most straightforward cases,” he said disdainfully. Research since then has largely supported his claim...
It's not that quality metrics are completely useless. But they can be dangerously misleading. And they can create perverse incentives that harm both patients and physicians. (Via H.R.)Surgical report cards are a classic example of how a well-meaning program in medicine can have unintended consequences. Of course, formulas have been developed to try to adjust for the difficulty of surgical cases and level the playing field. For example, a patient undergoing coronary bypass surgery who has no other significant diseases has an average mortality risk of about 1 percent. If the patient also has severe kidney dysfunction and emphysema, the risk of death increases to 10 percent or more. However, many surgeons believe that such formulas still underestimate surgical risk and do not properly account for intangible factors, such as patient frailty.The best surgeons tend to operate at teaching hospitals, where the patients are the most challenging, but you wouldn’t know it from mortality statistics. It’s like high school students’ being penalized for taking Advanced Placement courses. College admissions officers are supposed to adjust grade point averages for difficulty of coursework, but as with surgical report cards, the formulas are far from perfect.The problem is compounded by the small number of operations — no more than 100 per year — that a typical cardiac surgeon performs. Basic statistics tell us that the “true” mortality rate of a surgeon is not what you measure after a small number of operations. The smaller the sample, the greater the deviation from the true average.
Tech culture is very appealing when juxtaposed against the hierarchy and myriad hoops to be jumped through in clinical medicine.Another quote:
Many of the dropout docs expressed a desire to improve the doctor-patient experience. In interviews with KQED, several said they spent very little time administering care during medical school, and they felt that patients were too often kept out of the loop.If young physicians find entrepreneurship more rewarding than clinical medicine, perhaps those who are setting the rules governing clinical medicine need to re-examine their policies. Until then, med school graduates should pursue whatever careers that they find the most professionally and personally satisfying.
A recent study found that doctors-in-training spend an average of just eight minutes with each patient. This is a drastic decrease from previous generations and is linked to more record-keeping requirements and restricted on-duty hours.
