Saturday, April 23, 2005


The New York Times Magazine has a good article about autopsies.
The rate of autopsies has declined markedly in the last 40 years, partly due to economic pressures:
Hospitals say the problem is money. An autopsy can cost from $2,000 to $4,000, and insurance won't cover it. Most patient families blanch if asked to pay for it, and many can't afford to after paying medical and funeral bills. So the hospital gets the tab. For most of the postwar period up to 1970, hospitals generally paid it, essentially because they had to: the Joint Commission on Accreditation of Healthcare Organizations required hospitals to maintain autopsy rates of at least 20 percent (25 percent for teaching hospitals), which, then and now, is the rate most advocates say is the minimum for monitoring diagnostic and hospital error. The commission eliminated that requirement in 1970. Lundberg says that this happened because hospitals, which had already allowed the rate to drop to close to 20 percent since its 1950's high of about 50 percent, wanted to let it drop further and pressured the commission. The commission's current president, Dr. Dennis S. O'Leary, says it eliminated the standard because too many hospitals were doing poor autopsies -- and often only the cheapest, simplest ones -- just to make the quota. In any event, few hospitals have paid for autopsies since then. Money is too scarce, they say, the needs of living patients too great.
Improvements in medical technology have not eliminated the need for autopsies:
Perhaps the most troubling reason for the decline of the autopsy is the overconfidence that doctors -- and patients -- have in M.R.I.'s and other high-tech diagnostic technologies. Bill Pellan of the Pinellas County medical examiner's office says: ''We get this all the time. The doctor will get our report and call and say: 'But there can't be a lacerated aorta. We did a whole set of scans.' We have to remind him we held the heart in our hands.'' In fact, advanced diagnostic tools do miss critical problems and actually produce more false-negative diagnoses than older methods, probably because doctors accept results too readily. One study of diagnostic errors made from 1959 to 1989 (the period that brought us CAT scans, M.R.I.'s and many other high-tech diagnostics) found that while false-positive diagnoses remained about 10 percent during that time, false-negative diagnoses -- that is, when a condition is erroneously ruled out -- rose from 24 percent to 34 percent. Another study found that errors occur at the same rate regardless of whether sophisticated diagnostic tools are used. Yet doctors routinely dismiss possible diagnoses because high-tech tools show negative results. One of my own family doctors told me that he rarely asks for an autopsy because ''with M.R.I.'s and CAT scans and everything else, we usually know why they died.''
The bottom-line is that autopsies, though useful for quality control and for the detection of emerging pathogens, will not make a comeback unless 1) Medicare directly pays for each autopsy done or 2) the Joint Commission or Medicare requires a certain autopsy rate for hospitals.

Tuesday, April 19, 2005

Bankruptcy Reform (a comparison of doctors and lawyers)

An article at talks about the bankruptcy reform legislation recently passed by Congress. An interesting part of the article mentions the probable effect of the legislation on bankruptcy lawyers:
Ehrenberg sees another change in the new bankruptcy law that could affect women. Attorneys will now be liable for inaccuracies in a debtor's bankruptcy papers."They're going to have to investigate their own clients," he says. "It's widely believed in the bankruptcy community that many attorneys who provide moderate-cost legal services will pull out because they can't afford to do the case for that amount of liability for the same price. It would not be surprising that women would be adversely affected by not being able to find affordable legal representation."
So for bankruptcy lawyers who provide services to poor/lower middle class clients, the liability may outweigh the payment received for the services. Sounds similar to the situation that doctors who see Medicaid/uninsured patients are in. Of course, most doctors continue to provide these services, at least on a limited basis. It will be interesting to see if the lawyers do.

Friday, April 15, 2005

Teaching Psychotherapy

Ten things to avoid when teaching psychotherapy (from an interview with Dr. Glabbard in Psychiatric News).

Teach psychotherapy as though it is isolated from the rest of psychiatry
Use "straw man" arguments to denigrate psychotherapeutic approaches that are different from your own
Teach psychotherapy as a discipline that demands theoretical purity rather than creative eclecticism
Assign nonpsychiatrist faculty to teach psychotherapy to residents
Avoid illustrating theory with clinical examples
Avoid letting them see you sweat
Teach professional boundary issues and ethics as rigid rules isolated from clinical struggles
Ignore all psychotherapy research
Worship at the altar of evidence-based therapies
Protect residents from the "dirty business" of patient fees

Most psychiatry residency programs are guilty of using psychologists and social workers to teach residents psychotherapy.

Tuesday, April 12, 2005

Tips on Preparing a Living Will

A living will is a legal document that provides directives for your medical care in the event that you are physically unable to express them. Here are some things to keep in mind while creating a living will:
Specify which flavor of feeding-tube nutrient you prefer. Otherwise, you may get stuck with cream of mushroom day in and day out.
Leave at least one reasonably flattering photo for the press. This point cannot be emphasized enough.
Explain in no uncertain terms that, should you die and return as a zombie, loved ones must shoot you in the head without hesitation.
Research medical life-support technology and specify whether you'd prefer to be hooked up to a Danninger Continuous Passive Motion device, an Emerson suction unit, or a Slushee machine.
Comatose people have been shown to exhibit a brainstem-level response to music, so prepare a decade's worth of mix tapes in advance.
A living will is a great way to meet a notary public, if notaries public are your thing.
A health-care agent is the person assigned to make your medical decisions in the event you are unable to. A talented, aggressive health-care agent will score you the absolute best medical care available, but will charge you a 15- to 20-percent commission.
Telling your friends while you're drunk that it would suck to be on life support doesn't constitute a living will. Make sure to write it on the back of a coaster.

From the Onion, with some of the more tasteless tips edited out.

Friday, April 08, 2005

Repeat Residency Training??

A letter to the editor in Medical Economics states:
"I believe most of us are under the impression that organizations that oversee professional behavior are extremely reluctant to take genuine disciplinary actions. While I agree that only substantiated charges should be made public, I'd like to see stronger punishment than a meaningless letter of censure, yet less than revoking a license. Perhaps physicians could be required to repeat residency training to re-establish their skills."
I would rather lose my medical license than to repeat residency.

Thursday, April 07, 2005

Peer Review

Does peer review of submissions to journals work?? Slate discusses the lack of evidence for peer review.

Wednesday, April 06, 2005

Physician of the Year

Kevin, MD writes about the Republican "Physician of the Year" award, which is discussed in this article. Basically, by donating money to the National Republican Congressional Committee, a doctor can become a "Physician of the Year." It is not an award of merit, but a reward for party donors.
Last year I donated some money to the Republicans. This year I got the same fax as in the article, except that they wanted a little more than $1,250 from me (I decided not to pay for the award). It's pretty obvious that this is not a genuine award for merit. The article mentions that "on the Internet, ABC News found physicians across the country doing just that — listing NRCC's Physician of the Year among their honors and credentials." It's fine to donate money to a political party that you believe in. I have nothing against the Republican party for offering this "award" to their physician donors. But any physician who would list this phoney award on his CV is pathetic. The fault in this case lies not with the Republican party, but with dishonest physicians. To reiterate, there is nothing wrong with having a "Physician of the Year" plaque hanging in your home to demonstrate your loyalty to the Republican party, but to list this on your CV among your credentials is unprofessional and in my opinion any physician who does this should be investigated by their state medical board for unprofessional behavior.

Friday, April 01, 2005

Problems with the Mental Status Exam

A letter in Psychiatric News discusses the problems with the mental status examination:

The MSE, often characterized as psychiatry's equivalent of the physical exam, is in fact a mixture of historical information, observations, and conclusions. "Thought process" is known from examination, but what we describe as "thought content" is history—phobias, compulsive behavior, and suicide ideation, for example. Hallucinations occurring at the time of the examination are "current mental state"; yesterday's hallucinations are history. "Judgment" is an evaluation.

The MSE is flawed because of a lack of agreement about the meaning of some of the terms. "Mood" and "affect" are often confounded. "Orientation to person" refers to the patient's awareness of his or her own identity, but some take it to mean recognition of the examiner, while "orientation to situation" is not a standard question. "Judgment" may reflect the patient's answers to test questions, or it may reflect recent conduct, such as fighting with a police officer or giving money to a con man. Some describe a patient as having impaired judgment if he or she has a drug habit or stops taking prescribed medication.

Note to medical students: the mental status examination is an examination of the patient's complete mental state, including mood, organization of thoughts, abnormal perceptions (hallucinations), cognition, etc. This is different from the Folstein Mini-mental status exam, which is a 30 point scale that measures only cognition.