Tuesday, June 21, 2005

Grand Rounds XXXIX or 1:39......
Welcome to Grand Rounds, the weekly collection of the best of the medical blogosphere. Over the past few weeks medical bloggers have been getting a lot of exposure in the lay press. With the recentLA Times article and the guest editorial in USA Today penned by DB:
Drug advertising results in more costly prescriptions. Few inexpensive drugs are advertised on TV. The commercials don't educate patients. Rather, they create a demand for a product based on an effective commercial rather than the patient's medical need.

Another medical blogger is hitting the big time, being linked by The Corner and Captain's Quarters, to name a few. Their attention is focused on Orac's exceptional take-down of a Salon.com article on the thimerosal bogey-man and its' follow-up:
The bottom line is that this article is indeed a humongous runny, stinking turd. Salon.com and Rolling Stone have let their readers down, contributed to the hysteria over a probably nonexistent link between mercury and autism, and utterly trashed their own credibility in the process. They've handed the antivaccination activists a significant propaganda victory and an article that they will be citing for years to come, frightening parents who wonder if vaccines are safe and wrongly adding to the guilt that parents of autistic children already feel by making them wonder if they were responsible for their child's condition

Do you recall a commercial for an insurance company that has a homeowner and plumber standing in a flooded basement. The plumber wants to get right to work but the homeowner wants his price, and the prices of his competitors? Well Insureblog informs us of a law in Illinois that would result in the publication of the cost of procedures to allow for consumer choice.
Interestingly, I noticed that the bill doesn't require the publication of success rates. In other words, one could find out the cheapest place for a given procedure, but not necessarily the best place. Remember, though, you get what you pay for.

The Grunt Doc is happy in his work.
In the first two hours of my shift I've done more acute-care medicine than in a literal month of shifts, and it feels good. Occasionally I wonder about my career path, and today is one of the days I'm glad I'm an Emergency Physician.
Give in to your anger! Join us! Become a trauma surgeon!

Speaking of surgeons my colleague out west has a discussion about the lack of open operative experience among today's resdients:
In the best of all possible worlds, newly minted surgeons would take jobs with older, more established surgeons that provide expertise and help ("mentoring," to use the current buzz word) -- here, again, I was and continue to be extremely fortunate in this regard. That is probably not attainable for many graduating residents. It is hard to conceive a situation where the RRC would mandate a certain percentage of cases to be done "open," either: can you imagine the consent form for patients at teaching facilities then ---- "if we determine that the resident helping with this operation has insufficient experience with the open technique, you'll get a bigger incision." That would be about as popular as Howard Dean at a NASCAR event.
Again the law of unintended consequences strikes again.

Dr. Rangel discusses the failure of TennCare with a horrific glimpse of the future:
In 2009 President Hillary Clinton will resurrect her long dead dream of nationalized government health insurance. Medicare and Medicaid will be combined and expanded into a massive program that will cover every American. It will be administered by the states and further subdivided into "managed care regions" which will act similar to the old HMOs.
And it's all downhill from there.

Dr. Tony, however, visualizes a brighter future.
The information from the analyzer was a blueprint for the exact "mechanical antibody" required to defeat Jane's virus. The recipe created the exact molecular milleu required for the assemblers in the capsule to replicate the mechanical antibody and continue to do so in Jane's GI system. These antibodies were bound to dendrimers, tree-like nanomolecules. On another branch were nutrients required by the specific virus that was infecting Jane. As the virus concentrated the nutrients, they unknowingly incorporated instructions into their own RNA that changed them from pathologic to healthful.

Nanotechnology at work.

Dr. Charles breaks down and engages in catblogging:
"That little scamp!" the old woman exclaimed to me, gently rubbing the wound on her hand that I had just finished cleaning. "I'll take all these antibiotics if you say I should, but that vicious little kitty is going to get it!"

Maria comments on the male half of Hollywood's latest "Hot Couple" and his views on psychiatry:
If Tom Cruise has not ever personally suffered from mental illness, it is my sincere hope that he is grateful for that blessing. His faith in Scientology is steadfast, but his proselytization of the merits of his faith, particularly in the realm of (anti) psychiatry, only reveals his ignorance and lack of empathy for those who do not share in his good fortune and blessings.

The Health Business Blog explores the expansion of angioplasty in Massachusetts.:
But why not take things a step further? Include the existing academic centers and relevant community hospitals in the study. At the end of five years, certify or re-certify only the top half of hospitals to perform the procedure, regardless of whether they are academic or community based. That kind of competition could spur real improvements for Massachusetts patients.

In a series that potentially has an infinite life, Kevin MD provides us with several examples of how he "practiced defensive medicine today":
I may have lost a patient, and drove up costs by advising a probable conjunctivitis to go to the ER, but at least there is zero possibility of being sued over this. It's a trade I'll make every time.
Me too, brother.

Speaking of a trip to the ED. The Cheerful Oncologist tells of a reaction to some of his potions:
It didn't take a session with an IBM mainframe to place the puzzle pieces together and come up with a plan. Let's remember folks - we doctors are skilled in the art of leaving no stone unturned when it comes to finding a diagnosis. Why is that, one might ask? Well, given the menacing cloud of litigation that doctors practice under these days, one would understand with Zeus-like clarity why I rushed this patient to the emergency room. The decision was justified if one notices the overlap between my patient's symptoms and those of a major perturbation of the old ticker. Hypersensitivity reactions that are minor can be managed at the bedside by turning off the infusion and treating with Benadryl, corticosteroids, oxygen, IV fluids. Major hypersensitivity reactions (called anaphylaxis) are treated like a cardiac arrest - no head-scratching over that diagnosis, eh? My patient's symptoms were atypical for an allergic reaction, and rather than assume that the most likely diagnosis was the actual diagnosis, I checked for other serious problems that could have lethal consequences if undiscovered.

JenSN tells the tale of a sickle cell patient after hip surgery and the difficulties of postop care.

Self exams for men go to the next level, courtesy of Mr. Sun.
I feel it is very important for men to be examined regularly, so I'd like to take this opportunity to walk everyone through the process I just completed in the hopes it will lower the barriers of fear surrounding this very necessary medical procedure.

He He.

From Clinical Cases, a post for the up-and-coming intern: How to put in a central line. Just don't forget the post-procedure film.

Has The Lancet become the Weekly World News of the peer-reviewed medical literature? Dr. Sanity tells us some from the Royal Society have taken the editors to the woodshed:
It is truly medical scaremongering to report the results of badly designed studies; or to report the results in a manner designed to frighten people. The only possible purpose of such studies is the self-aggrandizement of the authors and publishers--who hold their press conferences and intone seriously about the "risks" posed by this or that. In the case of vaccines, more people will die and suffer because they didn't get the vaccine, than the opposite.

From last week's host: Red State Moron examines when physicians practice outside the "mainstream":
Fellow Wilmington obstetrician Dr. Joshua Vogel said though she was considered too set in her ways or a renegade by some doctors, he admired her talents to deliver naturally in situations when other doctors would have automatically pushed for a c-section. "She was a valuable asset for patients," he said.
And draws the scrutiny of "the committee":
The first letter, written by Dr. Cobern Peterson, chairman of the Professional Review Committee, stated "concerns" regarding her practice. They include higher than average infant birth weights, much lower than average c-section rates and later than average gestational age of neonates at delivery.

The letter states "the main concern reiterated several times was an overall practice attitude rather than any individual case."

As an added bonus, the physician at the center of all this posts in the comments. An example of how those that stick up tend to be hammered down. In another post RSM opines on the recently introduced "Prenatally Diagnosed Conditions Awareness Act":
I don't disagree. It is challenge. It's a challenge to tell a woman that her baby has Trisomy 18. Or Trisomy 13. Or a hypoplastic left heart. And the authors message is constructive. But does it require federal legislation? On the basis of 141 respondents to a survey, we need federal legislation because, in essence, we are not doing our jobs? Am I understanding this correctly?
But it's for the children!!!!

A new medblogger, Information is Free does a neurologic evaluation of cell-phone use while driving:
One of the bedside tests we do of memory is to give someone a series of digits, after which the person is supposed to repeat the sequence. Most people can repeat a maximum of 7-9 digits without making a mistake. What this should give you is a sense of how much information anyone can handle moment-to-moment; it's not much
How about those Bluetooth headsets that make you look like Mr. Spock?

Ad Libitum takes a look at the misuse of the evidence-based moniker:
It's as if just including the phrase "evidence-based" adds a patina of respectability (and superiority) to the title of a paper or a policy. There's also no denying that sometimes including this phrase conveys an attitude of being holier-than-thou. It's like saying "Hey, I'm evidence-based, so you can't say anything against me." Never mind that in many cases this phrase is used very loosely and quite differently from the original intent behind it.

Dr. Emer hears a giant sucking sound. The sound of nurses leaving the Philippines:
In the last 10 years, the Philippines exported close to 90,000 nurses overseas.

In the last four years, 3,500 doctors left the country to take on nursing posts abroad.

The number 1 course choice here is now Nursing. I have friend lawyers, engineers, and yes, doctors who are all shifting to nursing to work abroad.
The top scorer on the physician's exam has announced he too, will enter nursing.

Alois does an economic comparason between a medical degree and baseball cards.

The Medgadget guys ask us: one snake or two?
So what does the staff of Asclepius symbolize? Dr. Blayley speculates the image's origin might arise from the practice of removing subcutaneous parasites. The worms would be pulled from an incision and wound around a stick -- the practice was so common that doctors may have come to advertise their services by depicting this procedure.
Imagine that in a DTC ad!!

Enoch finds his choice of urgent care allows him to be the father he wants to be:
After a lot of deferred gratification (4 y med school, 3 y residency, 2 y internet startup, 2 years pre-partner busyness) i'm now able to split my 40 hours/week into 3 shifts, 2 X 18 hour ones and one shorter 5-10 hour one. The rest of my time i spend at home with the kids, swimming, or going out to our preschool co-op, or parks, or playgroups.
Sign me up!!!

The Canadian National Health System suffered a blow from its' Supreme Court last week in a ruling that could expand the role of private health plans. Interested-Participant points out with pregnant women being sent to the states for care, maybe change is overdue:
The phrase "no room for her last week in hospitals in Toronto, London, Hamilton and Kingston" is disturbing and probably an indication that the current system is already functioning at maximum capacity, i.e. no room for another baby. It's not exactly clear why there isn't public outrage. Sending patients to another facility is common and understandable. Sending patients to another country because there's "no room at the inn" means that the entire health care system is deficient

The newly minted Dr. McBride offers up a discussion of the cost of prolonging life and wonders if longevity isn't everything:
I'd like to pose a question for the two, in hopes that they keep this debate going. Don't you have to recognize the non-mortality benefits of medical care? Medicine doesn't always make us live longer, but it can make us live better. Preventing a lot of non-fatal heart attack may not change average mortality that much, but it sure makes life quality better. And then there is psychiatry, which can provide a lot of benefits at virtually no decreases in mortality. And what about plastic surgery, arthritis, orthopedics and physical therapy, dentistry; the list goes on. Same thing. When you actually sit down and separate all the fields of medicine and health care, very few sectors are actually even aiming for improved quantity of life. A good portion of surgery and pediatrics and a smaller part of internal medicine (mostly cardiology and nephrology) have shown good headway by this measure. But to ignore the marginal benefits of quality of life brought by some health care sectors underestimates the overall marginal benefits. In other words, life expectancy gains aren't everything.

Lastly, Dr. Rangel examines the re-emergence of the Terri Schiavo case and the political turmoil associated with it. Get your end-of-life wishes in writing. And make sure your whole family knows them!

This is the time of the year for transitions in medicine. Some such as
Doc Shazam and Dr. Lassiter are finishing their residencies and are moving on to "real jobs". Others are changing specialties. And a few more are beginning what may be the most challenging year of their lives. Best of luck to you all.

That's all folks. I had a tremendous amount of submissions this week, so if you didn't get included, my apologies. Next week Grand Rounds XXXX will be hosted by Mr. Williams at the Health Business Blog. Want to host? Drop a line to Dr. Genes. The archives may be found here.
Happy reading!!
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