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Saturday, March 19, 2011
Monday, October 18, 2010
Who Are the Torture Doctors?
JAMA this month has commentary piece on the ethical failure of physicians in the CIA Office of Medical Services (OMS) who helped organize, calibrate, and supervise the torture of unarmed, often innocent prisoners at Guantanamo. The principle of "do no harm" was abrogated by these lackey yahoos as they provided a professional cover to acts universally condemned throughout modern history as torture by all civilized nations.
My question is: Who are these doctors? What are their names? Are any of them practicing medicine in our country? When is anyone going to be held accountable for the despicable, embarassing, morally devastating era of American torture?
The American Psychological Association has already mounted an attempt to strip the license of a Texas pyschologist who participated in the "enhanced interrogation" of Abu Zubaydah:
If any psychologist who was a member of the APA were found to have committed the acts alleged against Mitchell, "he or she would be expelled from the APA membership," according to the letter, a copy of which was obtained by The Associated Press. APA spokeswoman Rhea Farberman confirmed its contents.
We know that Captain John Edmondson, the former Commander of the Gitmo Naval Hospital, is on record as admitting that he countenanced the forced feeding of inmates on hunger strike (an ethical lapse condemned by 262 signatories to a letter to the editor in Lancet).
What else can Captain Edmondson admit to? Is he practicing emergency medicine now as a civilian? How many of the other doctors at Gitmo are now enjoying lucrative private practice careers? Have they all done as well as former Navy Surgeon General Donald Arthur (who now commands a salary north of $400,000 working as the chief medical officer for MainLine health)?
Horseshoe Abscess
These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.
What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.
Surgical Warranties
The mathematics and specific details of this article from Archives elude me to a certain (substantial) extent, but the main gist of it is this:
Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.
What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.
I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.
And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.
Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.
What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.
I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.
And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.
First, Do Nothing
(From the New York Times)
The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.
The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.
What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?
Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.
I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.
The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.
The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.
What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?
Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.
I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.
Making it Easier to Sue!
Rumors abound of a plan to revise the federal tax code in such a way that will benefit those poor, struggling plaintiff's attorneys. A bill introduced by Arlen Specter, currently being bandied about Congress, would allow personal injury lawyers to deduct costs accrued during the pre-trial and trial phases of a claim.
Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.
From the Washington Legal Foundation's Walter Schwartz:
If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.
That's just fantastic.
Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.
From the Washington Legal Foundation's Walter Schwartz:
If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.
That's just fantastic.
Get Rid of the 4th Year of Med School
A poorly kept secret amongst recent med school grads is the fact that the last year of medical school is a complete joke and waste of time. Most 4th years will do rotations in July and August in the specialty they hope to match in, for the purpose of cozying up to attendings for recommendation letters. But after that, it's a 6 month vacation until match day. I did a surgical ICU rotation in July and then followed that up with a stint on cardiothoracic surgery. I spent the rest of the year half assing my way through rotations like radiology, anesthesiology, and pathology case studies. Most days I got to the gym around noon for a 4 hour session of pick up hoops. And oh yeah, I borrowed about $35,000 to finance that lifestyle.
There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.
Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?
There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.
Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?
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