The ethics of eight (babies that is)

All over the blogosphere people are discussing the California woman who gave birth to 8 babies.  The media was quick to call it a miracle, but it seems it only took a few hours before bloggers, journalists, and doctors began to seriously question the mother’s intentions.  It seems crazy enough to want 8 kids at once, but now rumor has it that the mom is single, living with her parents in a 2 bedroom house, and already has six kids (all under the age of 7 nonetheless).

If you want to be entertained (or appalled), I recommend reading the comments section on articles discussing this woman.  You’ll see a variety of viewpoints expressed, from those who think we should just leave this woman alone, to those who think the government should mandate how many kids a person can have and restrict who can receive fertility treatments.

I guess I fall somewhere in the middle.  Read the rest of this entry »

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Money (that’s what they want)

I’ve rounded the corner of my third year of medical school, where students have to start thinking about their future since we will begin applying for residency this summer/fall.  3rd year is a chance to try out a lot of the specialties, and hopefully find your niche.  You decide what you like or dislike about each area (internal medicine, surgery, pediatrics, neurology, etc) and decide how that fits into your needs or desires.

Some students are lucky – they knew, for example, that they wanted to be a neurologist right from the beginning of med school, they were fortunate to love it during their 3rd year rotation, and can now focus on arranging their 4th year electives to reflect this choice.  Maybe they weren’t sure what they wanted to do, but they loved pediatrics and can’t imagine doing anything else.

Other students thought they knew what they wanted to do, rotated in the specialty and hated it, and are now completely clueless and a bit panicked as to how they will approach their last year of medical school. (a lot of my future-surgeon friends seem to fall into this category)

Then there are students such as the one currently rotating with me on pediatrics.  Read the rest of this entry »

When you wish patients would die

I haven’t blogged in quite a while, and my husband was harassing me to post something new.  I’m currently in my third year of medical school rotating through various specialties in the hospital.  It’s not that I’m too busy to blog (though I’m quite busy between hospital scut work and studying), it’s just that this year feels like such a whirlwind of emotions sometimes that it’s hard to put them out into the blogosphere without feeling a little exposed.  But maybe those are the types of topics that make for the most interesting read.  So I give you a topic that reflects what was going through my mind a few days ago: when you wish patients would die.

Try not to read too much into that – I don’t want to harm or kill my patients.  But sometimes you see people who have been suffering for so long, that you wish for an end to their suffering.  Unfortunately for some people, the only end that would provide this is death.

Read the rest of this entry »

It’s the lifestyle, stupid!

I was reading a NY Times article discussing the top residency choices for this year’s match (which I think is today – the day when graduating medical students find out where they will be going for the next 3-5 years of their training). The article follows a married couple from Harvard hoping to get into a dermatology residency, which, along with plastic surgery and ENT are easily the most competitive spots to snag.

Call me cynical, but the quotes from the med students about why they chose derm sound more like BS spouted within their personal statements and along the interview trail rather than what’s really motivating them. Consider this gem:

Ms. Singh said she initially planned to emulate her mother, a physician who focuses on treating major adult diseases.

A lecture on skin-pigment conditions like vitiligo changed her mind.

“Nobody can see if you have hypertension or asthma, but everybody knows if you have a pigmentary disorder and these changes are a lot more obvious and devastating to patients with skin of color,” Ms. Singh said.

I’ll tell you what changed her mind – she survived medical school and is probably graduating at the top of her class with multiple research publications. This means she can have her choice of specialty…add onto that the fact that she already has 2 young children – why in the world would she go into general surgery or family practice, when she can work 35-40 hours a week (or less!) and make good money? (let’s not forget she has six-figures worth of student loans to pay off) Unless she absolutely loved some other specialty, she would have to be a little crazy not to consider dermatology. I’m not trying to downplay the importance of dermatologists – appearance is obviously very important in our society even if it isn’t life-threatening, and they definitely treat people with more “serious” conditions like skin cancer. But there is no reason for dermatology to need all of our best and brightest, other than the fact that it is the epitome of a lifestyle specialty.

What I also find amusing, which is not discussed within this article, concerns forthcoming physician shortages. You would think that a specialty as lucrative and competitive as dermatology would see no shortage amongst its ranks – after all, they more or less have their choice of any medical student available and should have no problem keeping up with demand. Yet even dermatologists are facing similar shortages as other areas of medicine. It can take weeks or months to get a referral to a dermatologist. This is not the NHS, where such waits would be expected because of the role of the British government to cap spending – this is the US, with a supposed “free-market” healthcare system. And then you begin to realize (if you haven’t already) that we’re not a free-market health care system. The reason for physician shortages are due in large part to licensing restrictions (the MD monopoly, or “medical cartel” as it’s sometimes affectionately called)…medical schools keep their class-sizes low (though many are finally starting to expand), and lucrative residencies keep their available spaces artificially low. Doctors of those “chosen” specialties like derm get to work as much or as little as they want, and make some serious money. Specialists get their big houses, fancy cars, and afternoons free to play golf, while the regular folks get longer waits and higher prices (which means higher insurance premiums, which inevitably results in more uninsured folks because they can no longer afford to pay the high premiums). See how this all starts to fit together? You should start to ask yourself why physician groups oppose or place restrictions on other non-physician health care providers (“Minute Clinics” with nurse practitioners, chiropractors, optometrists, etc)…are they really only looking out for your best interests, or could it be possible that they are also concerned with their own pocketbooks and lifestyle? Just sayin…

~ Lily

Those drug reps are good! (or…er…bad?)

I shadowed an internal medicine specialist last week, and as I was trailing behind him like a lost puppy (ah…the joys of being a clueless medical student) someone who appeared to be his buddy joined us as we reviewed charts and examined some imaging studies that had been ordered. The doctor and his buddy (who I presumed to be another doctor given that he was wearing a pair of blue scrubs) talked about their plans for the weekend, what topics should be presented at an upcoming conference, and then started discussing the pros/cons of various procedures and new techniques that might be helpful.

It was at this point that I got a closer look at the “buddy”, and noticed something inscribed on his scrubs that was neither his name nor the name of the hospital…it was the name of a drug company! Eek! I had been fooled! He was handsome, charming, and seemed to know the medical lingo (perhaps his good looks and perfect hair should have been the first clue?). He followed this doc around for a good 3 hours (maybe even more since I had to leave), including being present for a procedure on a patient, which seemed entirely unnecessary given that there was no “product” being used on this particular person. Drug reps definitely know which doctors respond to their attention, so the doc I was shadowing must have been a huge fan of their products.

It was weird to see the close relationship the two had, but did the patients know the physician was getting followed around all day like that? That he was getting paid to speak at conferences on behalf of this company? I don’t have a problem with drug reps per se…I understand products need to be marketed and sold, and I’m all in favor of competition…but if you publish a paper in a journal, you have to disclose all of your financial ties to show any potential bias you might have. Shouldn’t you do the same for your patients?

I’ve set a goal for myself for next year (my 3rd year of medical school, when I start rotations in the different specialties) – I’m going to see how long I can last without taking a single thing from a drug rep. No pens, no free lunches, no little gadgets…nothing. It’s mostly because I want to force myself to be aware of all the different ways the drug companies woo doctors/nurses/students…and because I like a good challenge. If I last a week, I’ll be proud…if I last a month, I’ll be amazed (free food is really hard to pass up when you’re poor and in a hurry). I’ll try and update the blog with all of the cool stuff I’m passing up, as well as how long it takes before I succumb to peer pressure. It’ll be fun! 😉

~ Lily

Thoughts on the John Ritter case

I was perusing my blog feed this morning and came across a CNN article discussing the wrongful-death lawsuit against doctors who treated the actor John Ritter. Ritter was treated for a heart attack, when in fact he was actually suffering from a “torn aorta” as the article puts it, which in more technical terms is an “aortic dissection.”

It’s tragic that he (or anyone for that matter) has to die at such a relatively young age – 54 is much to early to go. But for me the significance of the case is to serve as a great reminder of how non-scientific medicine can be. Don’t get me wrong – there’s a lot of science to medicine, and a lot of treatments are prescribed because of solid evidence and many years of research comparing different treatments with outcomes. You’d think by now we’d be experts at treating someone who comes to the emergency room complaining of “chest pain”, until you realize how many different problems can present themselves under that single descriptive term. We’re taught in medicine to come up with a list of possible diseases each time a patient complains of a certain ailment – we call this the “differential diagnosis” and it includes both what we think is likely to have occurred as well as a list of long-shots. For instance, if someone came to the hospital with “chest pain” a doctor would consider serious problems such as heart attack, pulmonary embolism (blood clot to the lung), aortic dissection (torn aorta), pneumothorax (collapsed lung), and cardiac tamponade (blood around the heart that limits its pumping ability)…but would also consider benign problems such as indigestion, esophageal spasm, etc. They then go through their list and try to target their questions to rule in/out the various conditions, focusing on the more serious ones first since those pose the most immediate threat. In the case of John Ritter, his family history of heart problems may have come into play. Medications, alcohol/tobacco use, or previous medical ailments might also influence which diagnosis you lean towards.

I should add at this point that I’m not a doctor, let alone a cardiologist – I’m a medical student with a very introductory understanding of how this process works. Most emergency room doctors would have probably considered the various problems listed above, taken a detailed history of the patient, and then decide which course to pursue. If they suspected a heart problem, they would probably obtain a chest x-ray as well as an EKG to look for electrical abnormalities that might indicate a heart attack (and call the cardiologist to come down and examine the patient). But this is where it starts to get tricky – an EKG is a great tool, but will not always show electrical changes even if someone has had a heart attack or is on the verge of a heart attack. Thus if the patient’s history strongly suggests heart attack but is not confirmed by an EKG, the doctor might still treat as if it were so. I have no idea what happened in the case of John Ritter, but perhaps that is one possibility of what took place. The classic presentation of aortic dissection is sudden onset chest pain that migrates…if Ritter’s pain wasn’t radiating (or if the doctor didn’t ask whether it was radiating) that diagnosis might be missed – that doctor would not have ordered a CT scan to look for tearing of the aortic wall, and might go on to treat as if the patient had something else.

Even if it is caught, aortic dissection is a terrible diagnosis with a very high death rate – surgery is required to immediately fix the tear before it occludes blood flow to vital organs and causes permanent damage/death.

In summary, I’m not writing this post to make excuses for the doctors involved in the case – I have no idea as to the specifics involved and what was or wasn’t considered. I’m merely trying to provide insight into how this whole medical process works, since most people outside the system are entirely clueless. Medicine is a wonderful tool with the potential to have huge impacts on our health and quality of life…but it is a mix of science and art, with the two frequently so intertwined that it may be difficult to distinguish where one stops and the next begins. Fancy tests only tell you so much, and are generally meaningless without a thorough history of the patient (I wonder how much money we could save by simply providing more time for talking with the patient, which may then allow us to avoid having to use the fancy high-tech toys at our disposal). Regardless of whether John Ritter’s death was the result of a medical mistake or an inevitable outcome, it’s tragic that he had to die at a young age. Hopefully medicine will evolve to provide more accurate distinctions between the various types of “chest pain” so that such tragedies may be avoided in the future.

~Lily

CNN article

Med students bringing sexy back?

Or more appropriately, rapping their own version of the song renamed “Diagnosis Wenckebach”, a reference to a specific heart arrhythmia named after some dead physician that every medical student (and probably nursing student for that matter) is forced to learn about and memorize (side rant – why are so many medical conditions named after someone, which tells me absolutely nothing about what might actually be going wrong in the patient?). Having recently finished a cardiology section, I found the video especially amusing:

~Lily

Obese? Sorry, we can’t serve you (Daily dose of crazy – Southern edition)

No, it’s not April 1…and yes, the title of this post spells out what will be the case for Mississippi restaurant-goers if a house bill (no. 282) introduced by state Representatives W. T. Mayhall, Jr. (R), John Read (R), and Bobby Shows (D) passes. According to the first page of the bill:

“Any food establishment to which this section applies shall not be allowed to serve food to any person who is obese, based on criteria prescribed by the State Department of Health after consultation with the Mississippi Council on Prevention and Management…”

This applies to any state-licensed food establishment, which is probably nearly every restaurant in the state. And since Mississippi has an obesity rate of around 30%, that means that about a third of the population would not be able to dine out. A restaurant that fails to comply may have it’s permit revoked.

Nanny state, anyone? Who has the right to tell you what you can or cannot eat? The government apparently thinks it has that responsibility…at least in Mississippi. I really hope this bill doesn’t pass, and I doubt it will because it’s such an outrageous affront to the rights of people in that state. But it does serve as a reminder of the responsibilities the government will assume if we let them into our lives. For instance, if we put the government in charge of health care, such as through a single-payer system, then perhaps it would be up to our legislators to keep us in line by punishing or prohibiting unhealthy behavior. Consider the UK, where about 1 in 10 people are denied surgeries because they smoke or are obese. I don’t want to pay for someone else’s poor choices, but I also don’t want the government punishing me for mine. To me, this is what insurance is for – protecting yourself against future risks, not (contrary to what many people seem to think) subsidizing someone else’s risks. Greater risks equal greater premiums, pure and simple.

To me, the obesity thing is discrimination…but in a state-run society such discrimination might be ethically justified if it kept costs down and allows more people access to services. Is this really the path we want for our country? First we go against the obese, but who would be next? We’ve already attacked smokers, maybe we should go after people who drink too much, or who aren’t necessarily obese but still live incredibly sedentary lives. If you don’t eat 3-6 servings of fruits and veggies a day then you’ll be denied health care. I know these seem like extreme examples, but are they really that far-fetched? According to the UK article I linked above, physicians across the pond think lifestyle should play a greater role in determining who receives health services. If they continue down that path, they’ll end up with either a country of boring clones who conform to their ideals, or a country where only a minority of it’s citizens have full access to the services their tax-dollars support.

Fortunately I don’t condone discrimination, so I don’t condone a society run entirely by government bureaucrats.

~Lily

Source – The Smoking Gun

Who gets to make end of life decisions?

This is currently being debated by our neighbors to the north, where a situation is unfolding involving the family of an 84 year old man on a ventilator and the hospital/medical staff currently treating him.

Background:

Samuel Golubchuk is an 84 year old Orthodox Jew who suffered brain injury and multi-organ failure, and was at some point admitted to the hospital and hooked up to a ventilator. Many times when we imagine a brain-injured person hooked up to such a machine, we (as a lay person) assume that they can’t breathe on their own – note that this is certainly not always the case, and that mechanical ventilation is often provided to people who are merely having difficulty breathing and need some assistance until they get better. Sometimes people can be removed from ventilators, and sometimes they are so sick that it is one of the only things keeping them alive. Before the advent of mechanical ventilators, death was usually based upon the heart – when your heart stopped beating, you were dead. But now we have so many ways of keeping the body alive, that death (from a medical point of view) is based upon brain function – you are dead when you no longer have meaningful brain activity. It all gets confusing when you add the various terminology including vegetative state, persistent vegetative state, etc where a person’s body appears alive, but clinically/medically they are defined as “dead.” For simplification, it is enough to know that Mr. Golubchuk is not (based on what I’ve read) clinically brain dead – he is merely very sick, and at the age of 84 this is never a good sign. He may not die immediately, but certainly the odds are not in favor of his living for much longer.

Now, enter into this picture the Canadian health system, and the doctors it employs. The hospital treating Mr. Golubchuk, having decided the prognosis is not favorable, wants to remove his ventilator and “hasten his death.” Though not stated directly, we must look at this as a case of resource rationing – the system only has so many ventilators available, and it would be a more efficient use of resources to give the ventilator to someone who has better odds of surviving (e.g. a younger patient).

Enter Mr. Golubchuk’s family – they argue that his condition has been improving, and that he has even regained consciousness. As Orthodox Jews, it is against their religious beliefs to remove the ventilator – plus the patient had signed an advance directive specifically saying that he wants to be kept alive. Says Prof. Shimon Glick, a leading Israeli medical ethics expert:

“From a halachic point of view, removing a feeding tube from a patient who has any brain function is active euthanasia, equivalent to murder… But here, in addition, unless the patient has specifically indicated by advance directive that such is his desire, one has a violation of the patient’s autonomy, as well.”

Alright, so enough background – what do you think should be done in this situation? If you were paying taxes to support such a system, is it fair for your money to be spent on someone who has a small chance of recovery at the expense of other people who might benefit more? If you were in that situation, would it be fair to have your beliefs and specific wishes (as indicated on a legal document) trumped by a physician who has decided the plug should be pulled?

There is no easy answer in this case, given the public funding of the health care system. Many people (in the US at least) seem to think that a national health care system would solve all of our problems, but it really should be seen as a trade-off. Some people gain access into a system that was previously unaffordable, but in the process you lose a (significant) degree of liberty. For me, a libertarian, this is unacceptable. I do not want a doctor, hospital, or government official dictating my health care choices. I don’t want to be “rationed” according to someone else’s belief system. In fact, this quote from Dr. Jeff Blackmer (executive director, office of ethics, for the Canadian Medical Association) scares the bejeezus out of me:

“Our viewpoint is that we want to make sure that clinical decisions are left to physicians and not judges…These decisions are not made lightly and they’re not made in haste, and they’re not made with anything except the best interest of that individual patient at heart.”

The only person who has the patient’s best interests at heart is the patient! And if the patient is incapacitated, as in the case of Mr. Golubchuk, it should defer to his legal wishes or immediate family.  From the standpoint of an American hospital, this situation is baffling. Certainly we have end-of-life issues as well, but rarely of this sort. From the perspective of the Canadian health system, however, the case may be rare but is unlikely to be unique (particularly when you consider our rapidly aging population). How many times each day must difficult decisions be made within such a system as to who gets what test/procedure/equipment, and who doesn’t? I’m not saying the US system is perfect (far from it!), but our way of”rationing” is very different. Americans who favor a single-payer national health system need to think carefully about situations such as these. How much of your individual decision-making abilities are you willing to hand over to a stranger? It will be interesting to see what the Canadian judge decides in this case (I believe it is scheduled for sometime this week).

~Lily

Sources:

Insure Blog – “A troubling conundrum

Jewish Post (1/7/07) – “Canadian judge to rule on Jew facing euthanasia

Retuers (UK – 12/14/07) – “Canadian life-support case pits religion vs. science

Medical marijuana and the Presidential hopefuls

Not exactly as important to many of us as the US economy, but “Granite Staters” has gone through and assigned grades to each of the Presidential hopefuls (Democrat and Republican) based on their stance toward medicinal marijuana. Of the 17 candidates profiled, 5 received a grade of “A+”, meaning they are very receptive to allowing sick individuals to use marijuana for pain relief or other medical purposes:

Republicans – Ron Paul and Tom Tancredo

Democrats – Mike Gravel, Dennis Kucinich, and Bill Richardson

All of the Democrats are in the B-A range, while the Republicans (with the exception of the 2 above) all receive an “F”. While I certainly agree that those 5 candidates deserve an A+, I don’t think many of the other Democrats are worthy of their A or B rating. The candidates who support medical marijuana should do so under the premise that it is a state, rather than federal issue – that is, the federal government should get their noses out of other people’s business, and let the states decide how they plan to regulate who should qualify for medical marijuana, how much people should be allowed to purchase, etc. This is essentially what the “A+” candidates state – says Rep. Ron Paul:

“I would like people who are dying with cancer and AIDS to have access to whatever they want and make their own choices, especially under a state law.”

The problem in my opinion is that several of the Democrats who receive high ratings would not legalize marijuana use for terminally ill, rather they state that the federal prosecution of medical marijuana users is not a priority. Says Sen. Hillary Clinton (who received an “A”):

“With respect to medical marijuana, you know I think that we have a lot of rhetoric and the federal government has been very intent upon trying to prevent states from being able to offer that as an option for people who are in pain. I think we should be doing medical research on this. We’ve ought to find what are the elements that claim to be existing in marijuana that might help people who are suffering from cancer, nausea-related treatments. We ought to find that out. I don’t think we should decriminalize it, but we ought to do research into what, if any, medical benefits it has.”

At least Sens. Barack Obama and John Edwards say they will end the federal raids – Clinton specifically says it shouldn’t be decriminalized. How the heck does that view warrant an “A”? She would let people suffer pain and nausea until proper research is conducted. I’m all for exploratory research on why marijuana seems to help some people, but the problem with any study is that it will be difficult to get conclusions that apply to every patient. Most terminally ill people might not respond to marijuana, so a broad study might show that it is not effective. But a small percentage of people may greatly benefit from its use – why should they be denied the opportunity to see if it works for them? By far the best (and by best, I mean worst) comment comes courtesy of Sen. John McCain:

“I believe that marijuana is a gateway drug. That is my view and that’s the view of the federal drug czar and other experts . . . I do not support the use of marijuana for medical purposes. “

Seriously McCain…”gateway drug”? He sounds like a bad 1980’s anti-drug commercial. A quick poll of our population shows that nearly 1/3 have tried marijuana at least once in their lives. Do you think 1/3 of our population has gone on to use and abuse other drugs like heroin and cocaine? Me neither. I suggest that the Senator peruse the website drugwarfacts.org before making any more false assumptions regarding drug use.

And just for fun…

~ Lily

Prohibition doesn’t work (health care edition)

Normally when I say prohibition doesn’t work, I’m referring to current drug and alcohol laws which punish people who use responsibly and do nothing to stop the people who abuse or put others at risk. This time, however, I refer to a Missouri law (courtesy of the Baltimore Sun) that makes it illegal for a certified midwife to deliver babies. According to the article:

“A state lawmaker whose wife was aided by a midwife pushed through legislation this year that would allow midwives to practice freely in the state”

In round 1 of midwives vs. the medical establishment, the midwives won – the new law was passed and subsequently signed by current MO Governor Matt Blunt. But the medical establishment, who “argue that home births without physicians are perilous ventures”, couldn’t let it rest and fought to overturn the law. In round 2, the medical establishment won, and the law is currently awaiting its turn in front of the Missouri Supreme Court.

Do you really think the medical establishment (of which I will soon be a member) are arguing against this law because they believe home birth is “perilous”? No – they argue against it (or rather, a lobbying group that claims to represent their views argues against it) because it hurts their pocket books. Every woman who gives birth at home is a woman not paying for a hospital bed, nurse, obstetrician, anesthesiologist, laboratory technician, etc. And, surprise – most of them do just fine giving birth at home. It’s not like women have been giving birth without doctors for 200,000 years…oh wait…they have. I’m not saying there aren’t risks involved when giving birth at home – things can and will go wrong from time to time during labor and delivery. Mom can be hypertensive, baby can be breech or have the umbilical cord wrapped around, blood is lost – these may range from minor to very serious. They occur in the hospital setting as well, though in that setting there is a team in place to respond immediately (something which cannot be said about a home birth). Of course I would also argue that a lot of the procedures done in a hospital setting may put the mother at more risk than a natural birth (anesthesia always carries a risk, and cesarean sections are invasive and thus probably increase the risk of infection or serious bleeding).

Still, pregnant women are adults who can decide risks for themselves. It’s obviously very important to many of these women to give birth at home – not only are they choosing a midwife over a hospital physician, but they are willing to break the law and risk arrest in order to get what they want, and in the process are effectively creating a home-delivery black market. If these “medical establishment” groups really cared about the safety of the women, they would listen to their reasons for choosing a midwife or home-delivery, and they would try and compete:

“Kerr of suburban St. Louis said she had an easy time finding a midwife through friends. She said many women choose home births with midwives to limit hospital pressure to use drugs for pain or to have a Caesarean; to have a more intimate, controlled and personal birth; or because of religious beliefs that keep them away from hospitals. “

Hospitals are noisy and offer little privacy, and there probably is pressure from certain doctors to use drugs for pain even after the woman has made it clear she intends to go without. Bottom line – let the woman decide who she wants to deliver her baby, and in what manner she wants it done. The only time the law should intervene is if someone is masquerading as a health care provider – i.e. a person pretending to be a certified midwife or physician. These women are adults capable of making adult decisions, including evaluating the risks and benefits of each alternative. We should not force our values onto them, even if we strongly believe we are correct; we should not use the force of law to get these women back into hospitals (it hasn’t worked yet, and in fact only succeeded in creating an illegal market for midwives) – instead we should try and create alternatives within the hospital or physician setting in order win back their trust and create an environment where they would enjoy giving birth.

~ Lily

Just what we need, more FDA regulations

Via the NY Times comes word that Senator Edward M. Kennedy (Mass.) and Representatives Henry A. Waxman (California) and Tom Allen (Maine) have introduced a proposal that “would give the Food and Drug Administration power to quickly ban marketing of over-the-counter products linked to potential safety risks.” I tried to do a bill search to find more details (the article is very brief) but had no luck.

Sometimes I feel that if the FDA (or perhaps the lawmakers that keep pushing to expand its power) had their way, you would have to get their permission before putting anything into your body (although that’s basically the point we’re at today). The lawmakers don’t want to quickly ban marketing for OTC products that are dangerous, but rather those that are potentially dangerous. Everything is potentially dangerous (seriously…everything) – you can drink too much water and die. Consider the woman who died earlier this year while participating in the radio contest “Hold your wee for a Wii.” Why should some panel of officials get to decide what is potentially dangerous or not? Sure, many of them are doctors, but that doesn’t make them experts in everything – the risk vs. benefit of any drug or product is going to vary by individual. This is not a “one size fits all” situation, and it shouldn’t be legislated that way. Perhaps one day we will have FDA officials on every corner to hold our hand as we cross the street…it is potentially dangerous, after all.

On a complete tangent, while searching through bills relating to the FDA I came across this gem – “The Domestic Pet Turtle Market Access Act of 2007” (S.540.IS). The bill is attempting to give a little power back to citizens who wish to purchase pet turtles less than 10.2cm in diameter. Glad to see our Congressman are working hard for the things that really matter in life.

Source – NY Times “Proposal Gives More Power to FDA

~Lily

Impending doctor shortage?

Courtesy of Reuters comes an article that discusses the coming retirement and career changes of physicians between the ages of 50 and 65. That group represents about 1/3 of all doctors in this country, and according to a survey conducted a fourth are planning on leaving the profession in the next few years:

Specifically, 14 percent said they were planning on retiring, 7 percent said they were looking for a medical job in a non-patient care setting, and 3 percent said they were seeking a job in a non-medical field.

It’s not really news to see that 14% of older physicians are planning to retire – a lot of people in that age range are nearing their retirement. The survey finding I did find interesting was this:

When asked about the work ethic of physicians entering practice today, 68 percent of the respondents said that these younger doctors are not as dedicated or as hard working as physicians who entered practice 20 to 30 years ago.

Ha! Granted I’m only a medical student and not a physician, but it’s quite funny to me that they don’t think I’m as hard-working as they are. Many people don’t know what it’s like to be in medical school, but it pretty much takes up you’re entire life. We study all the time, and when I say all the time I don’t mean a 40-50 hour week. I mean you wake up, go to class, maybe take a break for lunch, study, take a break for dinner, and study more. Weekends are usually filled with some degree of more studying. We don’t study this much because we want to, but because that’s what it takes to pass exams, and more importantly, prepare to pass the licensing exams (USMLE). I’m not as bad as some of my classmates, but I definitely have a few friends who literally study from 8 am to 10 or 11 pm, and then spend almost their entire weekend in the library. Medical students don’t really go out and party (at least at my school), unless it’s the day after an exam when we get a brief break. It’s just funny to me that older docs don’t think we work as hard, especially given that a lot of the material we have to learn now was not taught when they were in medical school because the medications didn’t exist or the disease mechanism wasn’t well understood. Our professors have to update their lectures every year to reflect all of the advances made in medicine. I will say that I doubt this generational view is specific to physicians – I’d bet that if you surveyed any older professionals about their younger peers, they would say the youngsters don’t work as hard. Another finding of the survey, which was a bit sad to me, is this:

Fifty-seven percent of older physicians said they would not recommend medicine as a career to their own children. Similarly, 44 percent said they would not select medicine as career if they were starting out today.

I understand that sentiment – it’s not that they don’t like treating patients, but is likely due to the fact that the medical field has significantly changed from when they started out. Paperwork is a nightmare, and you really don’t get to spend a lot of time with each patient. Patient’s definitely don’t like this, but neither do a lot of doctors! They want to spend more time with each patient, but if you saw all of the paperwork that must be filled out and all of the phone calls that must be made (regardless of whether it is private insurance or through a government system like the VA), you’d see that a huge chunk of their day is taken up in those less-than-desirable activities. Plus reimbursement is always an issue. Obviously they make a good living, but payment incentives tend to lie more with performing procedures rather than talking with the patient to understand all of the factors that are contributing to their illness.

The major concern, with older physicians leaving the profession, is whether the country will face a doctor shortage. The truth is, who knows? A lot of studies now point to both a doctor and nursing shortage in the near future. But, not too long ago a lot of studies predicted a surplus, to which the industry responded by restricting entry into the profession. The problem with the surplus studies is that they were made based on the assumption that our entire country would be under managed-care by now…a prediction that has since proved false. I think there is a good chance that there will be a doctor/nurse shortage – fortunately some actions are being taken to alleviate this, but unfortunately some are contributing further to the problem. First, the good – many medical and nursing schools are adding positions to their classes, and new schools are opening up. This is great, and in the next 5-10 years we should (hopefully) see a noticeable increase in health care providers. The bad news, is that lobbying groups and regulatory agencies continue to put restrictions in place to limit supply. Mostly this is done to ensure that these groups’ constituents continue to earn high wages (supply vs. demand), though they lobby under the pretense that they’re “ensuring quality” or something to that effect. Consider, for instance, that the medical licensing board has continually raised the minimum passing score. An intelligent person would say it’s great if 97-99% of medical students pass their licensing exam – it means that the schools are preparing them and covering all of the important material, and that the students are really working hard. But this group wants to maintain the pass rate at around 94% – so every time it starts to creep up, they raise the minimum pass score or make the exam harder (I don’t pay $40,000 a year and work my ass off to fail an exam). It’s great to increase the overall quality of the profession, but do those measures actually increase quality in the areas patients most desire? Doubtful – the best way to increase quality in areas that are important is to let the patient decide, not a licensing board or lobbying group. All they manage to accomplish is a further increase in their wages, which makes the medical care they provide expensive and unattainable for a significant portion of our population.

If we’re really serious about health-care – and given all of the attention it gets during election time I’m assuming we are – then we should deregulate some of this stuff. Lessen the licensing requirements and let the market pick quality physicians (they’d probably be less socially-inept bookworm and more warm-caring physician). Remove restrictions that physician-lobbying groups place on other health care providers – let nurses, physician-assistants, optometrists, physical therapists, etc occupy their rightful place in our health-care system. They’re capable of a lot more than we’re allowing, and it’s insulting and stupid to waste all of that talent and manpower (seriously…be skeptical every time you hear these lobbying groups tout “quality” as their motivation to place further restrictions on another group). Not only would this lower prices of care, it would open up the system to people who are currently shut-out. These regulations don’t ensure quality as much as they ensure that an increasingly larger share of people cannot afford the most basic care. That’s tragic, and completely unnecessary…it really doesn’t have to be this way, and there are better solutions to increase access that don’t involve a Hillary Clinton-styled single-payer system.

~ Lily

For those who thought SCHIP was actually about children…

…I would call your attention to the New York Times article discussing the recent vote upholding the President’s veto of the bill. In the article, Rep. Thomas M. Davis III (R-VA), one of the members of Congress who opposed the President’s veto had this to say about his decision:

“He’s not going to get his way on this,” said Mr. Davis, who voted to override the veto and predicted that Mr. Bush would ultimately be forced to sign a measure similar to the one he rejected.

“And he’s jeopardizing people’s careers,” added Mr. Davis, who is contemplating a race for the Senate.

People always complain about not being able to get straight answers from politicians, and there is no doubt that most are highly skilled in the art of circumlocution, but that doesn’t mean they are never honest. In Mr. Davis’s case, his words are plain and his meaning unmistakable, supporting legislation is not about serving the public or upholding the constitution, it is about doing whatever it takes to advance one’s own career.

To me, this is a great argument for why we need term limits…and also why we are likely never to get them.

~ Fox

Beware of MRSA!

That’s the word out of the CDC and a recent report in JAMA. Not really news, since MRSA (methicillin-resistant staphylococcus aureus) is known to be problematic in hospitals. What is news, however, is that the resistant strain is also becoming more prevalent in communities, and by recent estimates has outpaced AIDS in terms of annual US death rates. Formidable, though the other side of this is that HIV is practically a chronic condition for many in this country thanks in large part to multi-drug antiviral regimens that keep the disease in check and prolong the lifespan of those diagnosed. Still, MRSA should not be taken lightly.

Is there anything you can do to protect yourself against MRSA? Don’t get admitted to the hospital, for one (by staying healthy – obviously you shouldn’t avoid going to the hospital if you are very sick). Every time nurses/doctors poke and prod you, you’re at risk (catheters, surgeries, etc). If you don’t see your nurse/doctor wash their hands in front of you before performing an exam, ask them if they washed their hands. Most will wash their hands before and after each patient, sometimes out in a hallway or other room where you might not see them, but it doesn’t hurt to ask and make sure – your health is at risk if they don’t, so you have every right to know. Most hospitals and doctor’s offices also have hand-sanitizer pumps all over the place that should be frequently used. Hospitals in Great Britain recently banned the use of neckties in an attempt to control hospital-acquired infections, since ties are rarely washed and thus are known to harbor germs for a long time. If you’re not in the hospital but get a scratch or other wound, you should always wash it carefully to avoid any infection, staph or other.

Hopefully health care works will be more careful in their use of antibiotics – indeed, several drugs are “use-restricted” at hospitals so they may still be used as a last-ditch effort, reserved for only the most drug-resistant bacteria.  But if a bacteria is resistant to those drugs, quite frankly there’s not much that can be done, and people die as a result of overwhelming infection.  Last but not least, if you are taking a prescription antibiotic you should always finish the entire dose as directed, to avoid breeding your own drug-resistant bugs. Only time will tell whether these measures are enough to limit the dangers of MRSA and other resistant bacteria.

Source

~ Lily

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