January 10th, 2011 by DrRich in Better Health Network, Health Policy, Opinion
Tags: Arnold Kling, Covert Rationing Blog, Doctor Patient Relationship, Dr. Donald Berwick, Dr. Rich Fogoros, Dr. Troyen Brennan, Healthcare Policy, Healthcare Politics, Remote Third Parties
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From the ominously-titled book “New Rules” by Donald Berwick, M.D., and Troyen Brennan M.D.:
“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care…is to constrain decentralized individualized decision making.”
Unfortunately, Dr. Berwick’s straightforward formulation of the appropriate role of the individual physician in our reformed healthcare system is not isolated to thinkers of the Progressive persuasion. The notion that most clinical decisions can be usefully made by a centralized authority is attractive even to some conservatives.
For example, a few years ago the noted economist Arnold Kling strongly defended the idea. “My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.”
Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he is now with the Cato Institute, and before that he taught economics at George Mason University. So he has earned his conservative and/or libertarian chops.
And to be fair, he is not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will know, is as abhorrent to DrRich as it probably is to you.) Kling is saying: Trust patients, armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves. Read more »
*This blog post was originally published at The Covert Rationing Blog*
January 10th, 2011 by KevinMD in Better Health Network, Opinion
Tags: American College of Surgeons, Anesthesiology, Dr. Kevin Pho, Elective Surgery, Fatigued Surgeons, General Anesthesia, General Surgery, KevinMD, Medical Errors, New England Journal of Medicine, Patient Safety, Regulation For Doctors, Shortage of General Surgeons, sleep deprivation, Sleep-Deprived Surgeons, Tired Doctors, USA Today, Wall Street Journal Health Blog, Work-Hour Restrictions For Doctors, WSJ
1 Comment »
In a recent New England Journal of Medicine, a perspective piece on what to do with fatigued surgeons is generating debate. The issue of work-hour restrictions has been a controversial issue when it comes to doctors in training, something that I wrote about earlier in the year in USA Today. But once doctors graduate and practice in the real world, there are no rules.
As summarized in the WSJ’s Health Blog, the perspective piece argues for more regulation for tired surgeons:
… self-regulation is not sufficient. Instead, “we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived,” they write. For example, elective procedures wouldn’t be scheduled for the day after a physician is due to be on all-night call.
And the authors suggest that patients be “empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.”
It’s a noble goal, and indeed, data does show that fatigued surgeons tend to make more errors. Patients, once confronted with a choice of being operated on by a tired surgeon, may choose to postpone surgery. Read more »
*This blog post was originally published at KevinMD.com*
January 10th, 2011 by Richard Cooper, M.D. in Better Health Network, Health Policy, News, Opinion, Research
Tags: Dartmouth, Dr. Richard Cooper, Geographic Variation, Geographical Comparison, Healthcare Policy, Healthcare Utilization, HHRs, Hospital Referral Regions, Medicare Expenditures, MedPAC, Metropolitan Statistical Areas, MSAs, Poverty, The Poor, U.S. Healthcare System
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MedPAC has released another report in which they have tried to explain variation in healthcare utilization among metropolitan statistical areas (MSAs), of which there are approximately 400. MSAs more-or-less correspond to Dartmouth’s 306 hospital referral regions (HRRs), and the conclusions reached by the Dartmouth folks and MedPAC tend to correspond. In commenting about MedPAC’s last report, issued in December 2009, I noted that the major variation was caused by high Medicare expenditures in seven southern states, where patients are poorer and sicker and use much more care.
In their new report, MedPAC went a step beyond measuring expenditures, which they adjusted for prices and other factors in their last report, to measuring the actual units of service, a far better way to assess the healthcare system. MedPAC’s new findings on the distribution of service use in MSAs are graphed below:
Based on this new approach, MedPAC concluded: “Although service use varies less than spending, the amount of service provided to beneficiaries still varies substantially. Specifically, service use in higher use areas (90th percentile) is 30 percent greater than in lower use areas (10th percentile); the analogous figure for spending is about 55 percent. What policies should be pursued in light of these findings is beyond the scope of this paper, which is meant only to inform policymakers on the nature and extent of regional variation in Medicare service use. However, we do note that at the extremes, there is nearly a two-fold difference between the MSA with the greatest service use and the MSA with the least.” Read more »
*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*
January 8th, 2011 by DrWes in Better Health Network, Health Tips, Humor, Opinion
Tags: Bra, Cardiac Device, Cardiac Electrophysiology, Defibrillator, Dr. Wes Fisher, Heart Disease, Magnets, Medical Device Interference, Pacemaker
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This comment [with a specific photo] was posted on my blog earlier:
“I was reading one of your old posts about magnets and I was wondering if a magnetic front closure on a bra would be a problem? There’s a warning on the label but I know part of that is just due to liability. What about this bra that has a magnet clasp on the front? If the magnet hits right in between the breasts would it be close enough to the device that it could interfere? Also does having a magnet that close change the settings or turn off a defibrillator/pacemaker early? I’m sure most doctors would say just wear another bra but this bra in particular is very comfy! I’ve tried it on but not worn it for extended periods of time. Luckily this is one of the only major complaints I’ve had about having heart disease and a [medical] device at such a young age.”
First, let me say thank you for asking this question. Who knew research could be so, er, entertaining! Second, this question reinforces why medical blogging is so great: You learn something new every day.
Now, as I slap myself back to a bit more professional stance, I’ll summarize by saying I think you’ll be okay to use such a bra with some precautions. Given the picture and the clasp’s location, this bra is more likely to interfere with the pacemaker of the partner you hug rather than yourself, provided your pacemaker was implanted over three centimeters from the magnetic clasp. Since most pacemakers and defibrillators are implanted just below the collar bone, the chance of the magenetic clasp to interfere with your device is remote. Read more »
*This blog post was originally published at Dr. Wes*
January 7th, 2011 by Debra Gordon in Better Health Network, Opinion
Tags: Debra Gordon, Dying Well, Dying With Dignity, Elderly Family Members, Elderly Loved Ones, End Of Life Care, End-Of-Life Decisions, End-Of-Life Planning, End-Of-Life Preferences, End-Of-Life Wishes, Fear Of Death, Health Affairs, High Cost Of Dying, Julie Appleby, Keeping Dying People Alive, Medicare, Mortality, Quality of Life, USA Today
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My cousin’s mother-in-law is in her late 90s. She had horrible osteoporosis and can barely move. She has little cognitive function left. She requires nearly 24-hour care and no one would even attempt to say she has any quality of life left. She told her son years ago that she was “ready to go,” and had had enough.
And yet when I asked my cousin’s husband if his mother had any do-not-resuscitate orders, or had ever completed an advanced director outlining her wishes of what kind of end-of-life care she wanted, he said no. His sister, he said, just wasn’t ready for that yet. So what, I asked, will you do when/if your mother gets pneumonia? Will you treat it with antibiotics? Will you put her on a respirator? If she is no longer able to eat, will you feed her through a tube?
He couldn’t answer. And he was clearly uncomfortable with the questions. Read more »
*This blog post was originally published at A Medical Writer's Musings on Medicine, Health Care, and the Writing Life*
