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Heard Around The MedBlogosphere, 12.22.08

Here’s my weekly round up of quotable quotes from my peers:

NHS Blog Doctor: Antibiotics do not cure snot. [Please go to the site for a fabulous illustrative photo.]

KevinMD: Since work-hours were restricted in 2003, there are no studies that have shown any marked improvements in patient safety or outcomes. Worse, errors have arisen from the so-called “patient hand-off,” the period of communication where rested doctors replaces those who are fatigued. Does increasing the frequency of patient hand-offs outweigh the benefit of better rested doctors?

Richard Reece, MD: The moral for doctors: Don’t expect as much leverage as in the past when negotiating with hospitals, even though you represent their main revenue stream.

Paul Levy: The medical community in Boston likes to boast about the medical care here, but we don’t do a very good job holding ourselves accountable.

Dr. Wes: Thanks to exorbitant costs of implementing EMRs in physician practices, the Medicare requirements for billing and prescribing electronically, and the prohibitive documentation requirements mandated by CMS in the name of “quality,” independent physician practices of all types will have no choice but capitulate to larger entities that have a fully integrated electronic medical record paired with collection software.

Heart found in a car wash (h/t Dr. Wes)

Ramona Bates, MD: I don’t think I would ever want to be part of doing a posthumous face lift or blepharoplasty or other cosmetic procedure, but I would be willing to debulk tumors if it would help families or individuals say “goodbye” more easily.

WhiteCoat Rants: For $79 you can blow into your iPod and it will play you a song if your blood alcohol is more than 0.08. You know this device wasn’t made for parents.

Just what we need. A bunch of drunk teenagers farting around with their iPods and getting into a “who can get the highest blood alcohol” contest.

The Happy Hospitalist: It frightens me to hear people say they want to work in medicine and work in a similar capacity as physicians, evaluating, diagnosing and managing disease, but not want to put in the time and sacrifice to be residency trained in depth and scope…

Science-Based Medicine: Our soldiers, grievously wounded in combat, deserve only the best science-based therapy available… If I were to propose treating our injured soldiers with bloodletting and toxic metals (both common methods in the 1700s and early 1800s) based on the concept that it would put the “imbalance of the four humors” back into balance, the Pentagon and the military medical establishment would toss me out on my ear as a dangerous quack–and rightly so. But introduce a method that claims “ancient Chinese wisdom” based on somehow magically redirecting the flow of a mysterious “life energy” by sticking small needles into parts of the body that correspond to no known anatomic structures through which “qi” flows, and suddenly the Air Force is funding a program to train medics and physicians treating our wounded soldiers how to do this method based on the same amount of convincing scientific evidence that qi exists as for the four humors (none) and in the face of no strong clinical evidence that it’s any better than a placebo.

Rural Doctoring: Hospitalists, take note: this is an example of why people go ape-sh*t crazy in the hospital:
•    Her right arm is completely immobilized to protect the graft site.
•    Her left arm has a heplocked IV in it.
•    Half her head is shaved because the surgeon took the donor skin from the scalp.
•    She’s vegetarian and the cafeteria sent her chicken for lunch.
•    Dinner was vegetarian but she can’t really cut up a baked potato with only one hand.
•    The hospital has double rooms and is running at capacity, so the staff is harried.
•    Her roommate is an elderly, demented woman who keeps trying to get out of bed by herself and objects to the TV being on. So far, all she’s said to us is “Mind your own business!”

Did You Or Someone You Know Break the Health Care System?

Tom Daschle and Barack Obama’s transition team have asked that Americans – interested in the subject of healthcare reform – lead community meetings to create a list of ideas for the new administration. So my husband took the invitation to heart and has decided to lead a group in our home right here in DC. Please respond if you’d like to join us. Here’s a copy of the email he’s been sending to friends:

###

Did You Or Someone You Know Break the Health Care System?

Has our health care system failed you personally?  Is it broken?  I don’t want to hear about it….

….come join me for a Health Care Community Discussion (http://video.yahoo.com/watch/4122939/11107417) about what’s right with the U.S. Health Care System.

Be prepared to discuss one experience in which your interaction with the health care system was positive.

The goal will be to gather those observations and submit them to the Obama-Biden Transition Health Policy Team to be applied as best practices across the entire industry.  Why do we always have to approach reform by looking at what’s wrong?  Let’s discuss what’s right.

If you would like to attend this event, please RSVP to szlotkus at yahoo.com

Date: December 30th
Time: 7-9pm
Location: Dupont Circle, Washington DC (I will provide the exact address to attendee’s via e-mail)
Total attendance will be limited to 15 people.

Bring a friend, or pass on this web page to someone you think might be interested in coming.

Steve Z

Should The FDA Deny Access To Promising Cancer Drugs Under All Circumstances?

I was reading a good blog post about ethics violations in clinical trials in India, and was reminded of an interesting case in the U.S.  Several years ago a 21-year-old woman (Abigail Burroughs) with terminal cancer (who had exhausted all treatment options) was denied the option of purchasing a drug that was in the final process of receiving FDA approval. The FDA ruled that terminally ill patients should not be permitted to purchase drugs until the drugs have completed the approval process, citing safety concerns. Their arguments also included that:

1. Patients cannot make a truly informed decision regarding whether or not to try a medicine that has not yet been fully tested.

2. Allowing access to drugs before they are FDA approved would undermine the clinical trial process.

3. If terminally ill patients could buy treatments, others would soon expect health plans to cover these costs for others.

4. Allowing access to drugs before they were proven effective would add to the public’s general confusion about evidence-based medicine and promote magical thinking.

I don’t know how you feel about this, but it makes me squirm a little bit. Although I appreciate the FDA’s position (and my colleague Dr. Jim Sabin has blogged about his support for the ruling) it just seems a little heavy-handed, especially in light of the details of the Abigail case. Here’s what I wrote to Dr. Sabin:

About the Abigail case… I think they were trying to get access to Erbitux for Abigail, and it was in phase III trials at the time (so there was mounting evidence for its efficacy – their request to purchase it wasn’t scientifically unreasonable.)

I have very mixed feelings about the FDA ruling. I understand that we don’t want to 1) set a precedent that would lead to insurers having to pay for expensive experimental therapies 2) discourage people from entering clinical trials 3) allow drug makers to profit from “false hopes” in terminal cases. However, couldn’t we add enough caveats to make it reasonable to allow patients who have exhausted all other options to purchase (with their own money) drugs that have shown promise but are not yet FDA approved?

What if we said that the drugs had to be in phase III trials, with enough evidence to suggest a plausible benefit for the patient? Terminal patients are rarely good candidates for clinical trials (I don’t think we’d be poaching from the CT pool), few can afford to buy monoclonal antibodies (and the like) on their own so if there were trials for terminal patients, they’d still have great incentive to join, and I’m not sure that just because a patient can buy a treatment that insurance will HAVE TO follow suit.

Something about limiting personal choices (for those who have the means to make them) seems un-American to me. There are very low risks of harm in monoclonal antibody treatments (so the argument that the FDA must err on the side of patient safety doesn’t really fit the Abigail case). Yes, it’s sad for those who can’t afford to buy every possible therapy – but why should we deny access for those who can? With the right caveats, I think we could allow people like Abigail to try every remaining option. But of course I agree that phase I drugs are just not far enough along the research pipeline to make educated choices about them.

Maybe Abigail was a casualty of the one-size-fits-all, population-based rules that are appropriate most of the time, but fail in exceptional cases. I predict that this sort of thinking (where evidence-based protocols are applied in a cook book manner to all patients with a given disease) will dominate the healthcare landscape in the coming years as we seek to reign in costs and do the best thing for most. I just wish there were a way to bend rules on the edges a bit. What do you think?

The Friday Funny: Omega 3 Fatty Acids

America’s New Export: Hospitals And Medical Schools

Photo of Presbyterian Church

I often cringe when I see charts displaying parallel growth lines of these two variables: the number of American fast food restaurants in a given country and local obesity rates. The bad news is that our unhealthy eating habits have been exported successfully to foreign countries. The good news is that we’re going to export hospitals and health services next.

I spoke with Emme Deland, Senior Vice President of Strategy at New York Presbyterian Hospital, about the globalization of healthcare and the exportation of American health technology and expertise. You may read my summary of our discussion, or listen to the podcast here:

[Audio:http://blog.getbetterhealth.com/wp-content/uploads/2008/12/deland.mp3]

Dr. Val: Where does New York Presbyterian Hospital stand in terms of the global marketplace for medical tourism?

Deland: We’ve spent the last couple of years reviewing our strategy regarding medical tourism because we want to be a part of the global healthcare economy. There is a growing market for hospital development overseas, particularly in India, the Middle East, Eastern Europe, and China. The US offers the most advanced medical care in the world, and it’s only natural that other countries want to begin importing it. Whether it’s minimally invasive surgery, infertility techniques, or prenatal diagnostics and care – America is among the global leaders in health technology and services.

Dr. Val: What do these countries want to import exactly? Providers, infrastructure, physical plants, data systems, consultants who can advise on ways of doing things to reduce errors and improve quality?

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