May 17th, 2009 by DrRob in Better Health Network
Tags: CDC, H1N1, Influenza, Internal Medicine, Overreaction, Pediatrics, Swine Flu, virus
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Before you get too “conspiracy theory” on me, let me assure you that I am not going to talk about how the influenza virus pandemic is the work of terrorists (unless the Napoleon and Snowball are trying to take over our farm). I am also not suggesting that children are terrorists (although some do raise my suspicion).
The virus that brought such worry and even panic seems now to be “fizzling out” and people are now questioning if the authorities and the press overreacted to the threat. Will this be a replay of the “boy who cried wolf” and have us complacent when a real threat comes? One writer questioned if the flu “overreaction” was “more costly than the virus itself.“ Another article cites an Australian professor (of what, the article did not say) who stated that “the country would be better off declaring a pandemic of some of the real health problems it has, like diabetes and obesity.”
The real din, however is in the countless letters to the editor and calls to radio talk-show hosts mocking the “alarmism” put forth by the WHO and others about this flu. This does appear to be in the minority, as one poll said that 83% of Americans were satisfied with the management of the outbreak by public authorities. Still, I suspect the volume of the dissent and sniping at the non-serious nature of the pandemic so far will only increase over time. The number of people who know better than public health officials will multiply.
This pandemic is a catch-22 for public health officials, as an excellent article on the subject states:
The irony is that the overreaction backlash will be more severe the more successful the public health measures are. If, for example, the virus peters out this spring because transmission was interrupted long enough for environmental conditions (whatever they are) to tip the balance against viral spread, CDC and local health officials will be accused of over reacting.
Which brings me to the connection to terrorism. If public authorities somehow thought there was a 10% chance that New York City would be hit with another major terrorist attack, how big should their reaction be? If they suspected that there was a reasonable probability, say 5%, that the subways would be flooded with sarin gas, should they shut them down? I would certainly hope they wouldn’t leave that many people open to the chance of death.
And what is the best outcome? The best outcome is that this is an overreaction. The best outcome is that the terrorists, in fact, have reformed and are instead joining the Professional Bowling tour. I would welcome this outcome (not to mention the exciting infusion of young talent to the tour). The problem is, the officials have no idea how it will play itself out. Truth be told, since 9/11, there have not been any major terrorist attacks in the US. Does this mean that the money spent on the department of homeland security has been wasted?
As a pediatrician, I am very accustomed to overreaction. If you bring in your 20 day-old child to my office with a fever of 102, I will do the following:
- Admit them immediately to the hospital
- Draw blood tests looking for serious infection
- Check a urinalysis to make sure there isn’t an infection (using a catheter to get the sample)
- Start IV antibiotics as soon as possible
- Perform a spinal tap to rule out meningitis.
This seems a little over-the-top, doesn’t it? The child just has a fever! The problem is that children this age with a fever caused by a virus look identical to those who have meningitis. By the time their appearance differentiates, it is too late. This forces me to do the full work-up on every infant with fever and treat each one as if they have meningitis or some other serious infection. I do this despite the fact that the cases of meningitis are far outnumbered by that of less serious problems.
If this is your child, don’t you want me to do that?
Knowing what we know about pandemics, the same caution was, in my opinion, absolutely the right thing to do. If the virus turns out to be nothing serious, hallelujah. I don’t want my patients (or family members) dying at the rate that some of the previous H1N1 viruses caused. I want this to be a lot of worry for “nothing.” Please let it be so.
But I still don’t think it is time to relax. As one commenter on an earlier post I wrote about this pandemic stated:
It’s still a bit early to relax. The 1918 flu went around first in the spring and was very mild – kinda like this. Then it came back in the fall after incubating and mutating and was a killer.
I think the CDC and WHO probably will be concerned about this until next year, at least. Just to be on the safe side.
Remember that that flu, which was mild in the spring, went on to kill 20-100 million people.
For this reason, I hope the voices of reason win out over the armchair quarterbacks that don’t have to make these decisions that could mean the life or death of millions. Will you tell me that evacuating the NY subways wouldn’t be a good thing on the threat of Sarin gas? Would you criticize me for “overreacting” if your infant with a fever turned out to just have an upper respiratory infection? I hope not.
If you would, then that gives us ample reason to ignore your opinions on how this flu was handled.
*This blog post was originally published at Musings of a Distractible Mind*
May 17th, 2009 by Paul Auerbach, M.D. in Better Health Network
Tags: Discharge Instructions, Emergency Medicine, Patient Education
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When a healthcare provider takes care of a patient, he or she usually completes the episode by explaining something to the patient. For instance, if I treat a wound, before I leave the patient, I explain how to change the dressing, take care of the wounds, signs and symptoms of infection, how to take any suggested medications, when to return for a recheck, etc. But in thinking about how I make the communication, I don’t always write everything down for the patient, or even quiz the patient to determine if they comprehend what I have told them. Undoubtedly, some do not.
A recent study performed in the emergency department setting indicates that at least three quarters of patients do not fully understand the care that they have been given, or even comprehend when they do not understand their discharge instructions. Dr. Kirsten Engel and colleagues (Annals of Emergency Medicine 2009; 53:454-461) found that, “not only do the patients not understand the care instructions from their doctors, but the vast majority are also unaware that they have not fully understood what the doctor has told them.” One can always be critical of any study’s methodology – in this case it might have been more effective to include more patients and caregivers in the analysis – but even if the findings were not so dramatic, there is an important message in the results.
There are many reasons why a patient might not understand what has been accomplished for him. These include lack of an explanation, an explanation that exceeds the patient’s educational level (comprehension), language barrier, and distraction of the patient (by being ill, in pain, having altered consciousness, or other medical/social situation). Doctors are sometimes poor communicators, and are even caricatured as such. During a rescue situation, or when there are multiple victims, there may not be time to be a superb communicator. However, whenever possible, at least the basics should be covered, and this certainly applies to situations of medicine in the outdoors.
If the situation allows, take the time to explain what you are doing for/to your patient while you are doing it. This begins with preparing him or her for the event, particularly if it will be painful, like wound cleansing, manipulating an injured body part, realigning and splinting a broken bone, etc. After you have accomplished your medical intervention, if you need for the patient or anyone else to be responsible for assessing/monitoring the patient, then be very precise about what it is that is to be observed, how frequently to check on the patient, and whom to tell if there is a problem. Explain all medications, including purpose, doses, frequency of administration, and common side effects. To the extent possible, write everything down, so that the patient and other caregivers have a record of what they are supposed to do. If time allows and you have the patience for it, ask the patient and caregivers if they understand what you have told them, and ask them to repeat your advice and instructions. Do not assume that because you have told someone something one time in an awkward and rushed moment, that they heard and understood everything you said. “Medical speak” can be complicated or confusing, and what seems simple and logical to you may require more than a quick run-through. The time that you take to be clear, straightforward, and understood will pay large rewards later in terms of better patient outcomes and fewer problems down the road.
Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.
Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.
This post, Understanding Instructions, was originally published on
Healthine.com by Paul Auerbach, M.D..
May 16th, 2009 by EvanFalchukJD in Better Health Network
Tags: Billing, Canada, Canadian Healthcare, Coding, Healthcare System
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Why paying for health care is so difficult:
a gigantic, complex raft of billing codes which are seemingly designed to haunt you in your sleep. With thousands of codes, and with frequent revisions to the fee schedule, it’s difficult to imagine a bureaucratic system. . . more challenging to decipher.
American health care? No, Canadian.
Some problems are inherent to health care, regardless of who pays for it.
*This blog post was originally published at See First Blog*
May 14th, 2009 by DrRob in Better Health Network
Tags: Costs, Dr. Rob, Finance, Health Policy, Healthcare Rationing
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I met a urologist from another city recently. Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.
“I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely.”
When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red. “That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare. It was a flawed study and should not be taken as the final say on the matter.” He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.
I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst. I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced. My view is one that sees a non-diseased general public, and not worst-case scenarios. I also didn’t point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: “Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives.” (1).
But I digress. What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare. It is regularly used as a scare tactic for those who advocate a “free market approach” to healthcare. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis. Rationing healthcare seems a universal evil, and any step that is made toward controlling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.
So what exactly is so bad about rationing? The word itself refers to an individual being given a set amount of a limited resource, above which none will be available. In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves. Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it. This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others. I certainly understand this fear.
But are all limitations put on care really a step toward rationing? Are limits put on care a bad thing? The answer to that is simple: DUH! Of course not! Of course there need to be limits on care! Without control over what is paid for, the system will fall apart. Here’s why:
- Limited Resources – Not only are our resources limited, they need shrinking. The overall cost of our system is very high and has to be controlled somehow. Different interests are competing for resources, and by definition whoever doesn’t win, doesn’t get paid. This means that someone needs to prioritize what is a necessity and what is not.
- Lack of personal culpability by patients – with both privately and publicly funded insurance, the actual cost to the patient is defrayed. They are not harmed by unnecessary spending, so they don’t try to control it. Only uninsured patients are painfully aware of the cost of unnecessry tests.
- Lack of personal culpability by doctors – If I order an unnecessary test or expensive drug, I am not harmed by the waste. For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever. Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted. Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).
- Incentives for other parties – As I just said, hospitals and radiologists have incentives to have wasteful procedures done. The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him. Drug companies want us to order their more expensive drugs than the generic alternatives. This doesn’t mean any of them are wrong, but they sure as heck won’t fight waste if it harms them financially to do so.
When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed. At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies. When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type. Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient. But when I changed there was really no negative effect on my patients.
One of our local hospitals just built a huge new cardiac center. Statistically, our area is a very high-consumer of coronary artery stents compared to the national average. Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization. Logically this may make sense, but the data do not suggest that these people are helped at all. Do you think that the hospital wants these procedures halted? Do you think the cardiologists do? Yet if they are truly unnecessary, shouldn’t they be stopped? Couldn’t the $200 million they spent on their state-of-the-art facility be used in better ways? Someone has to be looking at this and making sure the money spent is not wasted.
Without cost control a business will fail, and the same goes for our system. Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing. Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing. The end goal is to spend money on necessary procedures instead of waste. I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed. I doubt that the American Cancer Society is in favor of rationing.
Let’s just spend our money wisely. It’s just common sense; not an evil plot.
*This blog post was originally published at Musings of a Distractible Mind*
May 14th, 2009 by GruntDoc in Better Health Network
Tags: Blood, Dr. Allen Roberts, Emergency Medicine, Gurney, Image, Photo
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So typical a colleague remarked on it.
*This blog post was originally published at GruntDoc*
