Buying a Senate Seat

Those in the know are saying that Caroline Kennedy won't get appointed to the empty New York Senate seat because she hasn't donated that much to New York politicians.

On the other hand, Illinois governor Blagojevich is fighting to keep his job and stay out of prison after being accused of trying to sell Obama's former Senate seat.

I guess the lesson here is that if you want to buy a Senate seat, you need to start spreading the money around far in advance of the seat being open, and you can't just give money to the governor who will be appointing you, you need to spread the money around to other state officials in the governor's party. I guess it's illegal to directly buy a Senate seat, it has to be done indirectly and there can't be a quid pro quo.
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One of the main problems with medicine today is that the rules are made by corrupt lawyers and politicians, and not by doctors themselves. Why is it considered improper influence if a pharm rep gives a doctor a pen (this practice will stop Jan 1, 2009), but it's perfectly fine for a lobbyist to give $1000 to a politician's re-election campaign?

Opioids and Testosterone

Although I mainly practice sleep medicine, I have been treating patients with opioid dependence at Somnus Sleep Clinic for the last year. I prescribe suboxone. Several of my male patients have complained of decreased libido and erectile dysfunction. After checking a testosterone level and finding it to be low in several of these patients, I referred them to an endocrinologist for testosterone therapy.

Opioids can cause hypogonadism, probably by interfering with the hypothalamic-pituitary-luteinizing hormone (LH) axis.

Unfortunately, for most of these patients I checked testosterone levels after they had been taking suboxone for several months, so it wasn't clear if suboxone was causing the effect or if it was due to prior opioid abuse.

When I see male patients for their initial visit prior to initiating suboxone therapy, I think I am going to start ordering baseline testosterone levels if there are symptoms of hypogonadism present.

Shredding of the Constitution

President-elect Obama, who allegedly is not a natural born citizen and would therefore be ineligible to be President, has nominated Hillary Clinton to be Secretary of State. Hillary Clinton is ineligible to be Secretary of State due to the Constitution's emoluments clause.

Unethical Psychiatrists

An editorial in the NY Times today discusses the unethical activities of two prominent psychiatrists:

The company also drafted a scientific abstract on Risperdal for Dr. Biederman to sign — as if he were the author.... And it sought his advice on how to handle the uncomfortable fact, not mentioned in the abstract, that children given placebos, not just those given Risperdal, also improved significantly.
Dr. Biederman’s work and reputation have helped fuel a huge increase in the use of powerful, risky and expensive antipsychotic medicines in young people... Now it is hard to know whether he has been speaking as an independent expert or a paid shill for the drug industry.

The editorial also discusses Dr. Frederick Goodwin.

The Democrats are still trying to Steal the Election

It's been a while since I last posted; I have been busy.

The Presidential election is over and Americans have gotten the President they deserve.

The votes are still being counted for a few Senatorial and Congressional races. The Democrats are putting a big effort into stealing the Minnesota Senate seat:

http://news.aol.com/political-machine/2008/11/12/im-good-enough-im-smart-enough/?icid=100214839x1212508863x1200805879


It increasingly seems Al Franken, Mark Ritchie, ACORN, and a whole host of Democrats across Minnesota have a plan to put Mr. Franken in office, be it the will of the people or not. There needs to be a recount in Minnesota, that's true. But someone needs to step in and make this thing happen clean. So far, it's just plain dirty.

The Democrats are trying to steal the election

The liberal group ACORN, which has been engaging in massive voter fraud across the country, tried to register Mickey Mouse to vote in Florida.

Obama criticizes America

Obama vs. America

Obama Youth II

http://www.youtube.com/watch?v=wy09UpI60F8



The previous video of Obama's paramilitary troops is no longer available; here is another copy:

The Carnage Continues

While world leaders announce rescue measures to fix the crumbling global financial system, Israel stocks drop 7.68%:

Israel's main stock index dived 7.68 percent on Sunday when the Tel Aviv Stock Exchange opened after a four-day holiday weekend and a 45-minute delay enforced after a sharp drop in preliminary trading.

Recommendations for your Investments

I think the broad market indices are going to decline approximately 15% more before hitting bottom. I believe this will happen near the end of October. Once the Dow drops below 7500, I would recommend gradually moving your money into a stock market index fund or ETF.

Given the recent strength of the US dollar and its likely future decline, moving some of your money into international fund is also reasonable (once the Dow drops below 7500).

How to Ruin the US Economy

Scare Americans into putting up $750 billion of their hard earned money to bail out the billionaires and their friends who created the market for loans to poor credit risks (The "subprime" market) and the unbelievably large side bets on those loans, promising that such a bailout would save the retirement savings of Americans, then allow the immense hedge funds to make the market crater immediately afterwards.
by Ben Stein

Time to Get Out of the Stock Market

According to Jim Cramer, it's time to get out of the stock market:
“Whatever money you may need for the next five years, please take it out of the stock market right now, this week. I do not believe that you should risk those assets in the stock market right now.”

The Cure for Psychiatric Illness

CASH:

Based on our findings, the clinical utility of monetary incentives in the form of cash deposits or lump sum payments directly to patients should be reappraised as a viable alternative therapeutic modality for the treatment of mild, moderate or severe cases of anxiety with or without co-occurring depression. Cash payment should also be considered the treatment of choice for all major depressive disorders including mild, moderate and severe clinical or sub-clinical depression, depressed moods, or any and all dysthymic, cyclothymic or depressive symptoms appearing with or without comorbid anxiety disorders.

from the Bonkers Institute for Nearly Genuine Research

The Bailout Tax

US House Speaker Nancy Pelosi wants a "Wall Street tax" to fund the $700 billion bailout:

... the fee could be assessed after five years if the non-partisan Congressional Budget Office determined taxpayers had lost money in the bailout.
"If after five years ... the CBO decides that the American taxpayer has lost money in this, then there would be a fee on financial institutions," Pelosi said...

I find it interesting that Democrat Pelosi is proposing this, since the Democrats, especially New York Senator Schumer, receive a majority of Wall Street's political contributions. Schumer and other Democrats blocked the Republican's attempt earlier this year to increase the tax on hedge fund managers (I guess Democrats could claim that hedge funds aren't technically part of "Wall Street", since most are now headquartered in Connecticut). Because of the Democrats, hedge fund managers pay only a 15% tax rate on their earnings, rather than the usual tax rate. I think increasing this tax rate would be a great start to paying for the bailout.

Democrats responsible for the Financial Crisis

Bloomberg has a collumn today, written by Kevin Hassett, explaining why the Democrats are responsible for the current financial crisis:

Alan Greenspan warned Congress about the coming financial crisis in 2005:
... If Fannie and Freddie ``continue to grow, continue to have the low capital that they have, continue to engage in the dynamic hedging of their portfolios, which they need to do for interest rate risk aversion, they potentially create ever-growing potential systemic risk down the road,'' he said. ``We are placing the total financial system of the future at a substantial risk.''
Republicans tried to act:
For the first time in history, a serious Fannie and Freddie reform bill was passed by the Senate Banking Committee. The bill gave a regulator power to crack down, and would have required the companies to eliminate their investments in risky assets.

But Democrats opposed the reform bill:

But the bill didn't become law...... Democrats opposed it on a party-line vote in the committee..... Republicans, tied in knots by the tight Democratic opposition, couldn't even get the Senate to vote on the matter.

If only the Senate Democrats hadn't obstructed the Republicans in reforming Fannie Mae and Freddie Mac, we wouldn't have the serious financial crisis that we are in today.

Ben Affleck at the Democratic Convention

Ben Affleck will be doing the samething I will be doing over the next several days, playing poker:
Ben Affleck is upping his stake in politics – with poker. The Oscar winner, 36, will be in Denver this week for the Democratic National Convention, where he'll be celebrating at more than one political party. Among his official duties: performing at a roundtable event for SeaChange Ideas Forum, packing food for the needy and playing poker to benefit paralyzed veterans.

Of course, I won't be in Denver- I'll be playing in Vicksburg.

Another Narcissist

Maureen Dowd has a great collumn today on the Breck Girl (aka John Edwards):

The stunning admission Edwards made to ABC’s Bob Woodruff, and in a written statement from Chapel Hill on Friday afternoon, was that he’s a narcissist.
He admitted that wallowing in “self-focus” out on the trail and thinking you’re “special” can result in a solipsism that “leads you to believe you can do whatever you want, you’re invincible and there’ll be no consequences.”
Even in confessing to preening, Edwards was preening. His diagnosis of narcissism was weirdly narcissistic, or was it self-narcissistic? Given his diagnosis, I’m sure his H.M.O. would pay.
The creepiest part of his creepy confession was when he stressed to Woodruff that he cheated on Elizabeth in 2006 when her cancer was in remission. His infidelity was oncologically correct.

I'm glad Edwards lost the Democratic primaries, bad things can happen when a narcissist comes into power. On the other hand, maybe someday he'll bring balance to the country.

Neuropsychiatric explanation for Alien Abduction

Current Psychiatry has an article about Alien Abduction Experiences, which can be caused by several pscyhiatric and neurological conditions. Some cases are hypothesized to be secondary to sleep paralysis combined with hypnagogic or hypnopompic hallucinations:

Full-body paralysis normally accompanies rapid eye movement (REM) sleep, which occurs several times a night. Sleep paralysis is a transient state that occurs when an individual becomes conscious of this immobility, typically while falling asleep or awakening. These experiences can be accompanied by hypnagogic (while falling asleep) or hypnopompic (while awakening) hallucinations. An estimated 30% of the population has had at least one sleep paralysis episode. In one study, 5% of sleep paralysis patients had episodes that were accompanied by hallucinations.

During sleep paralysis episodes, individuals typically sense a threatening presence. Patients have reported beastly and demonic figures of doom: devils, demons, witches, aliens, and even cinematic villains such as Darth Vader and Freddy Kruger. Others have described this presence in terms of alien visitations or abductions.

Sleep paralysis and associated hallucinations can sometimes be treated by treating any underlying sleep disorders. Treatments for cataplexy, such as tricyclic antidepressants, are often effective for sleep paralysis.

Die Endlosung

This comment was posted on the Wall Street Journal Health Blog today:


Die Endlösung must be applied to individuals who chronically do not participate in the production and consumption of commodities.
Comment by DM - August 4, 2008 at 9:42 am

I posted this comment 11 hours later:

I’m surprised that the first comment promoting The Final Solution (Die Endlosung) hasn’t been removed by the moderators of this blog yet. I would think that a statement arguing that the chronically unemployed should be killed would be considered offensive.
Comment by Michael Rack, MD - August 4, 2008 at 8:56 pm

DM's comment, in addition to being offensive to both Jews and the chronically unemployed, doesn't make sense. While not everyone produces commodities, everyone consumes commodities.
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Update (8/5) DM's comment has been removed from the Wall Street Journal Health Blog. Mine has been too- I guess the Wall Street Journal is trying to cover up the lax monitoring of their blog.

Woo in Psychiatry II

In response to my "Woo in Psychiatry" post, an anonymous poster advised:
read work by Steven Sevush MD

A quick google search reveals that Dr. Sevush is a geriatric psychiatrist, that he's done some work on Alzheimer's, and that he is written on consciousness. I am not sure if this essay is by him, but it came up when I googled "Steven Sevush MD and quantum".

Now quantum mechanics has some interesting philosophical implications, though it takes several years of advanced college mathematics (which I lack) to have even a basic understanding of quantum mechanics. Quantum mechanics has some interesting implications for the concept of consciousness. There has been some research looking at the speed of neural transmission, and whether an action can begin before the person makes the decision to carry out the action (I am probably butchering the concept, see Roger Penrose for more details).

I maintain my assertion that quantum mechanics has nothing to do with psychiatric treatment. I have no problem if a psychiatrist is interested in quantum mechanics and its philosophical implications. However, if a psychiatrist starts talking about "energy fields" to his patients, that psychiatrist is a quack.

At the last Psychiatric Congress (an annual CME seminar), I suffered through an hour session on psychotherapy in which a psychiatrist who thought he knew much more than he actually did about quantum mechanics erroneously said that quantum mechanics is about energy fields and that we are all connected by energy fields (quantum field theory has nothing to do with us all being connected). I had to restrain myself from telling him that he was a fool.
The only "energy" or "energy field" relevant to psychiatric treatment is the energy generated by an electroconvulsive therapy machine.

Autism is not a mental illness (according to Dear Abby)

DEAR ABBY: I just finished reading your June 9 column and am shocked at what I read. Your response regarding autism was way off base. You said, "Autism is a mental health disorder ... some people consider ... to be shameful."
Autism is a neurological disorder, NOT a mental health disorder......
DEAR MELISSA: My thanks to you -- and the many other readers -- who wrote to correct me..... autism is often considered a mental health disorder because it affects behavior, cognitive ability and social skills. However, it is genetically predetermined -- biologically based.
Experts clearly agree that autism is a neurologically based condition. The current criteria used to diagnose autism are contained in the Diagnostic and Statistical Manual of Mental Disorders, a publication of the American Psychiatric Association. However, this does not mean that autism is a "mental illness." Autism is most accurately described as a "neurodevelopmental disorder."

Most psychiatric conditions have at least some biological basis. Schizophrenia can also be considered a "neurodevelopmental disorder," though it has a later onset than autism. There is no clear dividing line between what is considered a neurological brain disease and what is considered a mental illness.

Psychiatrists in the News

A famous psychiatrist has been featured prominently in the news headlines this week:
(CNN) -- Radovan Karadzic, whose Interpol charges listed "flamboyant behavior" as a distinguishing characteristic, was a practicing psychiatrist who came to be nicknamed the "Butcher of Bosnia."
Twice indicted in 1995 by the U.N. International Criminal Tribunal for the former Yugoslavia, Karadzic faces charges of genocide, complicity in genocide, extermination, murder, willful killing, persecutions, deportation, inhumane acts, terror against civilians and hostage-taking.
While president of the so-called Serbian Republic of Bosnia-Herzegovina, Karadzic's troops were reported to have massacred over hundreds of thousands of Muslims and Croats during a campaign of "ethnic cleansing." Early estimates of the death toll from the 3-year war ranged up to 300,000, but recent research reduced that to about 100,000.
Karadzic was born on June 19, 1945, in Petnjica, Montenegro. He studied psychiatry and medicine at the University of Sarajevo during the 1960s and took courses in psychiatry and poetry at Columbia University from 1974 to 1975.

Poker in Mississippi

Those living in Jackson MS no longer have to drive to the coastal region to play No Limit Texas Hold'em. Vicksburg (45 minutes from Jackson) now has 2 poker rooms. The room at the Horizon casino, though, is of low quality and sometimes only has Limit games. I recommend the Ameristar casino- not as good as the Imperial Palace in Biloxi, but Ameristar does usually have several No Limit tables going.

Woo in Psychiatry

Alternative medicine quackery is spreading throughout medicine, but is especially common in psychiatry:

Complexity theory, quantum mechanics, and quantum field theory are conceptual frameworks that have been largely overlooked by Western medicine as potentially useful explanatory models of illness and healing. These nonclassical paradigms may eventually lead to models or research methods that will clarify the nature of putative informational or energetic phenomena related to health, illness, and healing. Phenomena regarded as legitimate subjects of inquiry in nonorthodox paradigms that have been largely overlooked by Western biomedical research include the role of intention in healing and the putative beneficial effects of “subtle energy” on health.

Quantum brain dynamics is a nonclassical model that uses quantum field theory to explain subtle dynamic characteristics of brain functioning, including postulated influences of nonclassical forms of energy and information on the brain. It has been suggested that healing intention operates through nonlocal energetic interactions between the consciousness of the medical practitioner and the physical body or consciousness of the patient. Conventionally trained physicians generally regard reports of beneficial outcomes following “energy” treatments as examples of the placebo effect because contemporary Western science is not able to substantiate the role of postulated forms of nonclassical energy when these modalities are employed.

If you hear a psychiatrist using the word "quantum" or if you hear him talking about "energy fields", that psychiatrist is a quack and you should run out of his office as fast as possible. Quantum mechanics has nothing to do with psychiatric treatment.

suicide nation

USA Today reports on the Japanese suicide epidemic, which is being fueled by economic hard-times as well as Japanese cultural traditions promoting suicide:

"Suicide is not considered a sin," says sociologist Masahiro Yamada of Chuo University in Tokyo. "We've made it a bit of a virtue."
A decade of weak economic growth and the unraveling of Japan's system of lifetime employment have left many middle-age and elderly men unemployed and in financial ruin. Among Japanese suicides, nearly 71% are men, more than 73% are 40 or older, and more than 57% are jobless.
For an unemployed, former "salaryman," suicide can be "a rational decision," Yamada says. When a man commits suicide in Japan, his beneficiaries can still collect his life insurance. And insurers pay off Japanese home mortgages when a family's breadwinner dies — even if the death is a suicide. "If he dies, the rest of the family gets money," Yamada says. "If he continues to live without a job, they will lose the house."

Should Pre-meds have to take Organic Chemistry??

The Wall Street Journal Health Blog discusses this issue. Here is the comment I posted:

I am all for weeding out people, but I think that the 2nd semester of O chem is a waste of time. Instead of a 2nd sem of O chem, I would require a semester of med-school level Biochemistry (and use this as a weed out course, in addition to the 1 semester of Ochem). I disagree with the previous comment of getting rid of physics. A basic knowledge of physics is helpful for many areas of medicine - neurophysiology (EEG/sleep studies), radiation oncology, nuclear radiology, and ophthalmology.

Psychiatry and the Pharmaceutical Industry

Congress is accusing the profession of Psychiatry and its leading organization, the American Psychiatric Association, of prostituting themselves to the pharmaceutical industry:

But now the profession itself is under attack in Congress, accused of allowing this relationship to become too cozy. After a series of stinging investigations of individual doctors’ arrangements with drug makers, Senator Charles E. Grassley, Republican of Iowa, is demanding that the American Psychiatric Association, the field’s premier professional organization, give an accounting of its financing.

“I have come to understand that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions,” Mr. Grassley said Thursday in a letter to the association.

In 2006, the latest year for which numbers are available, the drug industry accounted for about 30 percent of the association’s $62.5 million in financing. About half of that money went to drug advertisements in psychiatric journals and exhibits at the annual meeting, and the other half to sponsor fellowships, conferences and industry symposiums at the annual meeting.

Here is the Consumerist's take on the issue:

Psychiatry is nothing more than a well-funded front for big pharma, according to lawmakers investigating the field's premier organization, the American Psychiatric Association. Unlike psychologists, psychiatrists can write prescriptions, giving pharmaceutical companies a powerful incentive to lavishly subsidize both their lifestyle and profession.
A psychiatrist's office is a "safe space," where it's ok to ask any question, including: "have you received any compensation from any drug company?"
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My practice is mainly sleep medicine- largely osa and cpap. Unless you count hypnotics like Ambien and Lunesta (I typically start off with generic Ambien before trying Lunesta or Ambien CR), I prescribe less psychotropics than the typical internist and much less than the typical psychiatrist. I resigned my membership in the APA over a year ago. I am not in the pay of the pharmaceutical companies.

The Disadvantages of having a doctor for a mother

I haven't had much time to blog recently, and I don't really have anything original to say today. I did come across an interesting post, via Kevin MD, on the Mothers in Medicine blog. In the post "Second generation", a mother/resident discusses her current situation and how it was like for her to grow up as a child of a doctor:

"I really adored my nanny (who coincidentally had the same first name as my mother), and that was a good thing since she was the adult I spent the most time with."

Every day when I leave in the morning, she reaches out for me and cries. And I think to myself, "What kind of mother am I to leave her like this?" But when I go to work, I’m earning the money that pays the rent and building a career that hopefully someday she’ll be proud of.

The 7 Deadly Sins

The Medical Board of California lists the seven deadly sins that can cost a doctor his license.
Often its possible to committ more than 1 sin at a time:
Each Medical Board investigator probably can recount three or four outrageous cases of sexual misconduct that they have investigated. For me, one was a renowned psychiatrist who had a seven-year affair with a schizophrenic patient. Their sexual relationship began in the library of a university medical school. Their relationship culminated with the psychiatrist using the patient to procure prostitutes with whom he, and the patient, would have group sex. Instead of paying money for the prostitutes' services, he bartered by providing them with prescriptions for Klonopin or other controlled substances. Not to be limited to a mere one or two violations of law, he would then bill Medi-Cal for group therapy (definitely one of the more creative liberties I've seen taken with a CPT code). This physician's license was revoked and he was also criminally convicted of fraud. Lust and Greed.
Not everyone agrees that Greed is bad:
"The point is, ladies and gentlemen," Gordon Gekko pontificated in the movie "Wall Street," "that greed - for lack of a better word - is good. Greed is right. Greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms - greed for life, for money, for love, knowledge - has marked the upward surge of mankind."

In my opinion, Pride is probably the most common deadly sin among physicians:
There are a lot of doctors out there who are brilliant practitioners, but they have no business acumen. Being too proud to admit it, they are lured into contracts and obligations due to their business naiveté and end up being cited for all kinds of violations (failing to have a fictitious name permit, aiding/abetting the unlicensed practice of corporate medicine, advertising violations). I hate to be the bearer of bad news, but ignorance is never a valid defense.

Pride is also known as Vanity:
Vanity, definitely my favorite sin.

For those of you who don't watch movies much, that last quote is from The Devil's Advocate- A great performance by Al Pacino.

Vitamin D

Vitamin D has recently become a hot area of research.

Low vitamin D- 25(OH)D- has been linked to depression.

Low Vitamin D levels have also been linked with a poorer prognosis in women with breast cancer.

Are Psychiatrists Real Doctors?

Dr. Moffic attempts to answer this question in Clinical Psychiatry News:
A flight attendant came down the aisle asking whether there was a doctor on the plane. My wife must have thought I was one, and told the flight attendant so. She then woke me and told me of the concern.
Was I a “real” doctor? After all, hadn't I been writing about how psychiatrists' medical backgrounds should distinguish them from psychologists, even to the extent that I suggested that our next diagnostic manual should only be for us? But being a “real” doctor in real life is far different from just writing about it. Was this some sort of cosmic test for me?
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My wife, who is a psychiatrist, has volunteered my medical services on a flight before.

There are some inaccuracies in Dr. Moffic's article:
These days, a medical internship is the first of the 4 years of psychiatric residency training, and consists exclusively of medical rotations, including neurology.
A psychiatric internship is not the same as a medical internship. A typical psychiatry internship consists of 4 month of medicine, 1-2 months neurology, and 6-7 months of psychiatry. Most psychiatrists are ill-prepared to treat medical illness.

ER call ethics

I was recently asked to comment on this article written for the blog Brain Blogger (shortened version below, I encourage you to read the full article):

In a fit of rage, a thirty year old otherwise healthy man punches a hole through his window.

Unfortunately, there is no hand surgeon in the community that takes on-call service for the ER. Thus, the ER doctor calls various community hand surgeons to see if they will take care of the patient.
Finally, the ER is able to get a hand surgeon who will answer his pager. The hand surgeon agrees to get involved with the care of the patient. He listens to the story over the telephone and feels in his best judgment that the patient will need an exploration of his hand in the operating room. Studies show that there is no difference whether this happens sooner or later as long as it is done within 24 hours. Thus he explains to the ER doctor that he is out to dinner with his family and won’t be able to see the patient until the morning. He tells the ER physician to either discharge the patient and have him come to his office in the morning, or to admit the patient and that he will see the patient in the morning.

Several ethical issues are raised later in the article and by commenters to the article, and I will only address a few of them, but I encourage comments.

1. I do not think that physicians have an ethical obligation to provide hospital/ER call. I think this is a matter of negotiation between hospitals and the doctors who apply for medical staff privileges. Hospitals have the right to refuse medical staff privileges to doctors who don't want to meet the hospitals' call requirements. Doctors have the right not to apply for privileges at hospitals that have onerous call requirements. To attract physicians of certain specialties, some hospitals may need to pay the doctors for taking call, though this is a legally tricky area.

2. Regarding the specific case, once the surgeon "agrees to get involved with the care of the patient", I think he is obligated, at least from a medicolegal perspective, to go in and see the patient that night. If he wasn't prepared to go in that night, he should have told the ER doctor that in general that type of injury requires surgery within 24 hours, but that he couldn't comment on the specific patient. If I was in that surgeon's place, I would have offered to see the patient in the morning, but made clear that the ER doc was responsible for the patient until then and that no doctor patient relationship would exist until and unless the patient arrived at my office. I would tell the ER doctor that if he was uncomfortable with that disposition, he could always send the patient to a university hospital/tertiary care center (if the ER doc thought the patient was stable for transfer).

Iowa floods

Fifteen years ago I arrived in Iowa City, Iowa to begin medical school, just as the great flood of 1993 was ending. It looks like this year's medical students will have a similar experience.

Here's a link to more information about the situation in Iowa City.

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edit (6/15): The University of Iowa makes it's last stand.

More on the Primary Care Shortage

Medical Economics magazine reports that graduating primary care doctors are getting more job offers than previously. This is in a large part due to the decreasing number of physicians going into primary care.
So why the continuing shortage in primary care? In a word, money, despite a boost in financial incentives for new recruits beginning last year. Even today, medical graduates shouldering huge debts survey the practice landscape and see a real disconnect between the hours PCPs put in and their incomes, at least compared with specialists and surgeons. Compounding the problem is graduates' perception that, as PCPs, they'll occupy a lower rank in the medical pecking order. No wonder, then, that primary care practice still isn't a big draw, at least not for US medical residents.

Never-Never-Land

Over the last several months, much has been written on the medical blogosphere and on medical websites about "never events":
In August 2007, Medicare announced that, starting October 2008, it will no longer reimburse the treatment hospitals must provide to redress eight medical errors, a list likely to lengthen in the future. In fact, CMS has already announced its plan to add ventilator-associated pneumonia and deep vein thrombosis to its list in fiscal year 2009.
Some of the events on the list are expected complications of treatment rather than true medical mistakes.
For now, the Medicare decision affects only hospitals. So why should physicians worry?
Although under the never-event rule physicians may still bill for their services when a mistake on Medicare’s list occurs in the hospital, Gosfield says those days are numbered. “I think at some point that will change,” she says. “There’s going to be more and more emphasis on shared clinical responsibility for patients — that you should pay attention to where you are referring to and who you’re taking referrals from.

Medical Ethics

The current issue of Medical Economics magazine has an interesting article about medical ethics:
A consequence of fewer physicians accepting Medicare and Medicaid recipients, of course, is that those who continue to treat these patients will be forced to see a disproportionate share of them, and suffer the economic consequences.
FP Patricia Roy of Muskegon, MI, proposes a middle ground. "Nobody can make a living caring for these folks exclusively," she says. "But I think ethically, and in the interest of fairness, we all have to takesome." Turton agrees. "Physicians work within a system," he says, "and, ethically speaking, the burden of caring for uninsured and underinsured patients must be distributed evenly throughout the physician population."

Medicare and Medicaid reimbursement will continue to decline in inflation-adjusted dollars, and possibly also in nominal dollars as well. As a sleep specialist, I will continue to see most patients referred to me by my primary care colleagues, including patients with Medicare and Medicaid.
I disagree that primary care patients have an obligation to work within a broken system and take Medicare and Medicaid. Until PCP's show some backbone, Medicare reimbursement will continue to decline.

Doctor Etiquette

I'm too lazy to summarize the WSJ Health Blog post on doctor etiquette, my comment on the matter is #3. I also entered a comment around #24 (which may not be up yet if you reading this around 12:30 am May 8).

medical blog rankings

Medical blog rankings for the month of April are up. This blog is # 340, right behind "A Chance to Cut is a Chance to Cure," which has no new posts this year. Doing somewhat better is my other blog, "sleepdoctor," at #236.

CON Opposition in the South

David Rosenfeld at Medical News, Inc reports on the controversy regarding Certificate of Need laws:

Florida Governor Charlie Crist is mounting an aggressive campaign this year against the state’s certification process for new hospitals, commonly known as Certificate of Need (CON). And he’s not alone.
CON laws face a battery of opposition in states across the South. Yet few believe that the laws will change.
Although most CON laws are slightly different, each represents the efforts of individual states to limit growth and ensure that healthcare facilities are constructed only where they’re needed.

Existing hospitals, in an attempt to decrease competition, tend to support these laws.

My Predictions for the US Dollar

Although the long-term trend of the US dollar has been to weaken, especially against the Euro, for the last 2 weeks the US dollar has strengthened.

Warren Buffett predicts further weakening of the US Dollar (Bloomberg.com):

The U.S. dollar will keep weakening and Buffett feels ``no need to hedge'' against currency risk when buying large companies outside the U.S., he said.

Who am I to disagree with the legendary Buffett? He takes a long-term view on investments, and I agree with him that in the long-term the US dollar will continue to weaken. However, I believe that the US dollar will (mildly) strengthen against the Euro over the next 4 to 6 months. The Fed rate cuts are over, and there will probably be a rise in the Federal Funds rate this summer, which will have a strengthening effect on the dollar. The economic slow-down will also tend to strenghten the dollar. On the other hand, current inflationary pressures will have a weakening effect. I expect the dollar to resume its long-term trend of weakening late in 2008, as increasing inflation and economic expansion will cause the US dollar to fall to new lows against the Euro.

American Psychiatric Association caves in to gay activists

Bob Unruh reports in WorldNetDaily:

A discussion on religion, homosexuality and therapy that had been scheduled during the American Psychiatric Association's annual meeting in Washington has been shut down following an attack by a "gay" publication on some of the people planning to participate.

But the event, scheduled Monday, has been yanked from the schedule, according to the APA, because of the "misinformation and rhetoric" that was circulating about the issue.

My Solution for the Primary Care Shortage

In an attempt to alleviate the coming physician (particularly primary care) shortage, states are increasing the size of their medical school classes, and a few are even building new medical schools. As pointed out by the WSJ Health Blog, this will make little difference in the total number of licensed, practicing physicians since the number of practicing physicians is determined by the number of residency slots. The primary effect of increasing the number of US medical students will be to increase the proportion of US graduates to foreign medical graduates in residency programs, and ultimately the proportion of US grads to foreign grads in the ranks of practicing physicians.

Many states, including Mississippi, are foolishly increasing the size of their medical school classes in an attempt to increase the number of primary care doctors in their state. If the goal is to increase the number of primary care doctors within a particular state, a better way to accomplish this goal would be to increase the number of primary care residency slots in that state. Since CMS (Medicare) is not adding new subsidized residency slots (approximately 100,00 dollars per year), states should subsidize these slots themselves. If the goal is to increase primary care docs in a state, subsidizing primary care residency slots is a much better investment than increasing the number of medical students, many of whom will end up leaving the state or practicing a subspecialty. Since many internists go on to subspecialize, the best investment value would be to increase the number of family practice and pediatric slots.

The Abuse of Nonprofit Status by some Hospitals

The Wall Street Journal has an interesting article today By Barbara Martinez about nonprofit hospitals. It seems that some nonprofit hospitals are demanding payment up front and refusing treatment to patients who can't pay:

When Lisa Kelly learned she had leukemia in late 2006, her doctor advised her to seek urgent care at M.D. Anderson Cancer Center in Houston.
The Kellys arrived at M.D. Anderson with a check for $45,000 on Dec. 6, 2006. After having blood drawn and a bone-marrow biopsy, the hospital oncologist wanted to admit Mrs. Kelly right away.
But the hospital demanded an additional $60,000 on the spot. It told her the $45,000 had paid for the lab tests, and it needed the additional cash as a down payment for her actual treatment.

Once, Mrs. Kelly says she was on an exam table awaiting her doctor, when he walked in with a representative from the business office. After arguing about money, she says the representative suggested moving her to another facility.

It seems that M.D. Anderson gouged Lisa Kelly:

On one bill, Mrs. Kelly was charged $20 for a pair of latex gloves. On another itemized bill, Ms. Wallack found this: CTH SIL 2M 7FX 25CM CLAMP A4356, for $314. It turned out to be a penis clamp

When a for-profit hospital acts like this it is understandable. These hospitals are, after all, in business to make a profit. What excuse do nonprofit hospitals, which pay no taxes, have?

According to the American Hospital Directory, 77% of nonprofit hospitals are in the black, compared with 61% of for-profit hospitals. Nonprofit hospitals are exempt from taxes and are supposed to channel the income they generate back into their operations. Many have used their growing surpluses to reward their executives with rich pay packages, build new wings and accumulate large cash reserves.

Perhaps all hospitals should be required to pay taxes:

"When you have that much money in the till and that much profit, it's kind of hard to say no" to sick patients by asking for money upfront, says Uwe Reinhardt, a health-care economist at Princeton University, who thinks all hospitals should pay taxes. Nonprofit organizations "shouldn't behave this way," he says.

Managing Psychiatric Patients in Medical Hospitals

Today's Hospitalist Magazine discusses the challenges of managing psychiatic patients in (medical) hospitals (via Dr. RW):

a young, depressed woman who presents to the ER after a suicide attempt with an overdose of benzodiazepines. The woman is often uninsured, and because there’s no bed at the county mental health facility, she is admitted to—and stays in—the medical ward.

The woman discussed in the above example may languish weeks on the medical ward waiting for a psychiatric bed (at a private psychiatric hospital or at a government psychiatric hospital) to open up- if she's lucky. If she's unlucky and committment paperwork has been filed, she may wait in jail for a psychiatric bed to open up. Assuming she's lucky and she gets to wait in a medical bed, who takes care of her? This role typically falls to the hospitalist (internist), who is often unprepared:

“some hospitalists are not comfortable prescribing the initial dose of certain psychiatric medications, like the newer antipsychotics.” While most hospitalists may be comfortable starting patients on antidepressants, “much further beyond that and their comfort level goes away.”

Of course, a psychiatrist (if available) is usually consulted, but he may only see the patient and leave a note several times a week.

Here are some possible solutions:

1. Reopen psychiatric wards in general hospitals. only 25% of general medical hospitals still have dedicated psychiatric units. Not profitable, so probably won't happen.

2. Open up Med/Psych wards in general hospitals. Not profitable, so probably won't happen. In addition, there are huge insurance issues with Med/Psych wards- mental health care is often covered by a mental health carve out, so the medical insurer and the psychiatric insurer will sometimes each try to deny responsibility for covering the hospitalization.

3. Give psychiatrists admitting/attending privileges at general hospitals and have them be the attending for the patient (after medical stablization). To get psychiatrists to do this, they will have to be subsidized by the hospital like many hospitalists are. Not profitable, so probably won't happen. In addition, there are the insurance issues discussed in #2.

4. The hospitalist groups could hire psychiatric nurse practitioners to help them manage these patients (using some of the subsidy they get from the hospital). Probably the most viable solution.

Hospital Medical Staff Should not be Treated like Employees

Bob Wachter recently wrote about the different disciplinary treatment of doctors and nurses, when both committ a HIPPA violation (in this case, looked at Britney Spears medical records):

of the 53 people caught snooping, 18 of the non-doctors resigned, retired, or were dismissed, while no physicians left the staff.

Wachter acknowledges that nurses, therapists, etc are hospital employees, while physicians have traditionally in private practice and have not been in an employee/employer relationship with the hospital:

These forces quite logically led hospitals to develop two parallel systems of governance, rules, and enforcement: one for physicians, and another for everybody else.

He is in favor of peer review for matters requiring clinical judgement, but feels that
for violations of unambiguous rules and policies...there is no reason that the standards for physicians and other staff should be different.
----------------------------------------------
Here are my thoughts on the matter:
While not excusing the actions of the doctors who looked at Britney's records, I do not think that doctors should be treated like employees (except for the rare cases in which they are actually employees of the hospital). I personally would resign from the medical staff of any hospital that tried to treat its staff physicians in such a matter. Treating doctors the same as hospital employees makes about as much sense as a law firm treating its partners the same as its secretaries. It would make more sense to treat hospital CEO's like the hospital's maintenance staff than to treat doctors like nurses.
Doctors are the ones who send their patients to hospitals. If a hospital doesn't treat me well, I will send the patients who have entrusted themselves to my care to a different hospital (for those who are wondering what type of patients I send to the hospital, given that I am mostly an outpt sleep doc, let me just say that hospitals today do much more than inpatient care- they provide outpt lab testing, imaging studies, sleep studies, etc. I do occasionally help cover a local psychiatric hospital).

Mississippi Psychiatrist Disciplined

The Clarion Ledger (Mississippi's main newspaper) reports:

A Brandon psychiatrist (Dr. Stanley Russell) who has been scrutinized over three decades for allegedly prescribing large quantities of addictive narcotics should not be allowed to continue practicing even with new restrictions, the mothers of two former patients say.

The board found in its most recent investigation of Russell that he had again violated rules and regulations. It agreed, however, to restrict him from writing prescriptions for any narcotic or habit-forming drugs and to limit him to working at the Region 8 Mental Health Center in Brandon, where he had been a part-time staffer. The consent agreement also calls for his work to be reviewed and his care of patients evaluated.

Dr. Russells's private practice has been closed down and he has been limited to working at the local community mental health center, without the ability to prescribe controlled substances. I have several patients who were previously being treated for their psychiatric problems by Dr. Russell and their opioid addiction by me, in my suboxone clinic. I have ended up taking over the psychiatric care of some of these patients.
(in case any prospective patients are reading this, let me mention that I am no longer accepting new psychiatric and/or suboxone patients, but I am seeing new patients with sleep problems).

Soccer is a dangerous sport

New research shows that soccer is a dangerous spectator sport:
Dr. Ute Wilbert-Lampen and her associates studied cardiovascular (CV) event rates in the Munich area during the month-long World Cup soccer tournament held there in 2006, and compared them with the rates for the same area during several control periods. On days when the German national team competed, CV event rates spiked, particularly among men and among people with known coronary disease.

I'm going to have to stop going to my kids' soccer games.

The Dalai Lama is now a Psychiatrist

Psychiatric Times reports that "His Holiness" participated in a conference on depression:

The conference focused on the role that meditation might play in promoting cognitive, emotional, and physiological states that are protective against depression. This issue was examined within the broader context of whether developing mindfulness and greater compassion through meditation training in adulthood might help individuals compensate for the depressogenic effects of adversity, trauma, and lack of nurturance early in life, all of which are primary environmental contributors to major depression.
During the conference, researchers presented data that suggested that mindfulness practices may help prevent the recurrence of major depression and that meditation practices specifically designed to promote compassionate cognitions and emotions toward others may have effects on the brain and body that are directly relevant to depression.
The Dalai Lama opened the conference by acknowledging the unique relationship that exists between Emory University and several leading institutions of higher education within the Tibetan exile community, a relationship that has culminated in the Dalai Lama joining the Emory faculty as a Distinguished Presidential Professor. He expressed his conviction that Western physical sciences and Buddhist traditions of studying the mind have much to offer each other in better understanding mind-body interactions relevant to health.

It's no wonder that other medical specialties look down on psychiatry.

eHealthTech

The billing for my outpatient sleep practice as well as for Somnus Sleep Clinic (sleep studies) is done by eHealthTech. eHealthTech is stationed in MS, but handles medical billing and physician practice management across the country. I highly recommend eHealthTech to physicians of all specialties.

The government is watching you

The AP reports:

In coming weeks, private audit companies will begin scouring mountains of medical records. Their mission: Determine if health care providers erred when billing Medicare and require them to return any overpayments to the federal government. The auditors will keep a tidy percentage for their services.The contractors have shown they're pretty good at their work. In just three years, they've returned more than $300 million to the federal government - and that's just from three states. That experiment is winding down. But a larger, national program will soon take its place.The rollout of "recovery audit contractors" will be gradual. They'll monitor health care providers in 19 states beginning this spring. In October, an additional five states will join.

Health care providers are nearly unanimous in their dislike of the program's continuation, much less its expansion. Many lawmakers have similar sentiments, though it was Congress in 2006 that made the program permanent. A bill sponsored by Rep. Lois Capps, D-Calif., calls for a one-year moratorium.The program's critics say that contractors have too much incentive to question as many claims as possible. That's because they get to keep about 20 percent of the overpayments."What we have here is bureaucrats and government contractors coming in and trying to second guess what doctors and nurses have done in a hospital setting," said Don May, vice president for policy at the American Hospital Association. "They're playing Monday morning quarterback."

While the contractors are often described as overzealous, that's a compliment as far as one watchdog group is concerned."A little zealotry is what were looking for on the part of the taxpayers," said Leslie Paige, spokeswoman for Citizens Against Government Waste.

When the program goes national, all contractors must have a medical director on staff. The agency also is limiting how far back auditors can look when reviewing patient records. The limit will be three years, but under no circumstances, before Oct. 1, 2007.Finally, the agency is working on regulations that would defer repayment until after the appeals process is completed. Currently, the money is taken back regardless of the appeal status, which providers say is a financial burden and akin to guilty until proven innocent.But what gets health care providers most upset is when auditors determined a procedure or hospital admission was not medically necessary.May said that there's a "lot of gray area" when it comes to whether a patients needs to be admitted to a hospital or rehab facility. Often the patients have diabetes or other complicating factors that prompt a physician to want closer monitoring."You need a physician looking at these daily if not more so to make sure the patients are being managed effectively," May said.

Primary Care is Growing (sort of)

The American College of Physicians reports that fewer American physicians are entering primary care specialties. However, the overall number of primary care providers is increasing due to nurse practitioners, physician assistants, and IMG's:
Although fewer Americans become primary care physicians, primary care providers increased per capita thanks to international medical graduates and the growth in physician assistants and nurse practitioners. And the overall growth in primary care provided more efficient and less expensive health care, according to testimony given to Congress last week.
The Government Accountability Office (GAO), Congress' research arm, provided testimony to the Senate Health, Education, Labor and Pensions Committee. In the past decade, the per capita number of primary care doctors, including internists, pediatricians, family practitioners and general practitioners, rose an average of 1.17% annually.
The per capita number of primary care physicians grew faster than that of specialty physicians, 12% vs. 5%, respectively. The Associated Press reported from the GAO's testimony that fewer American medical graduates choose primary care, but international medical graduates (IMGs) covered the gap. GAO figures show that in 2006 there were 22,146 American doctors in residency programs in the U.S. specializing in primary care, down from 23,801 the previous year. IMGs made up 1 in 4 new U.S. physicians, according to the AP.

Robert E Lee/MLK day

LITTLE ROCK, Ark. (AP) -- While the nation honors the Rev. Martin Luther King Jr. on Monday, three states celebrate another man as well. In Arkansas, Alabama and Mississippi, the slain civil rights leader shares a state holiday with Robert E. Lee, commanding officer of the Confederate Army.
Here's Huckabee's position on the holiday:
In 1997, a spokesman for then-Gov. Mike Huckabee said that both men should be honored. Huckabee, currently running for thr Republican presidential nomination, in 1999 signed the bill that gave the Legislature a holiday on King Day

Number 385

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Fallling Knives

Slate has a nice article today about the dangers and rewards of trying to catch a falling knife:
One of the nice things about being a billionaire, or a private-equity magnate, or the CEO of a gigantic bank is that you don't fret about paying retail. If you see an object you desire—a plane, a mansion, a car, a suit—you don't wait for it to go on sale. You just buy it.
In their professional lives, however, such players are attracted to marked-down merchandise like post-Christmas shoppers are drawn to Macy's. Picking through the discard bin and sifting through marked-down inventory of formerly hot products is a highly respected investment strategy. But efforts to catch such falling knives depend on perfect timing. Stick your hand out too late, and you get nothing. Grab the handle at precisely the right moment, and you've got yourself a set of Wüsthofs on the cheap. Stick your hand out too early, and you're simply impeding the blade's fall to earth. Today, several savvy financial operators who tried to catch falling knives in the formerly hot housing and credit sectors are walking around with huge gashes in their hands.
On Aug. 22, Bank of America decided things couldn't get worse for Countrywide Financial, the massive mortgage firm whose stock had been halved since the beginning of the year. Bank of America boldly announced a $2 billion investment in the form of a security that pays a 7.25 percent annual interest payment and "can be converted into common stock at $18 per share." In the months since then, Countrywide, stung by a deteriorating housing market, has fallen another 50 percent. Today, its stock trades at about $9. Bank of America, which is already licking its wounds from an ill-timed plunge into investment banking, is already out several hundred million dollars on its investment in Countrywide.
In the fall, Bear Stearns, the mortgage-dependent Wall Street firm that soared to dizzying heights as the credit market boomed only to crash back to earth, attracted an international cast of falling-knife catchers. In September, Joseph Lewis, one of Britain's wealthiest men, spent $860 million on a 7 percent stake in Bear, paying an average of about $107 per share, according to the Wall Street Journal. In December, he boosted his stake twice. Today, with Bear's stock trading at close to $85, Lewis has turned his massive fortune into something slightly smaller. He's likely lost about 15 percent of his investment. In October, Bear agreed to a complicated deal with CITIC Securities, in which the Chinese firm would invest $1 billion in Bear Stearns for a stake worth at least 6 percent. Since then, Bear's stock has fallen about 20 percent.
Some investors have suffered deeper wounds. On Dec. 10, Warburg Pincus—a very sharp private-equity firm—agreed to invest up to $1 billion in struggling bond insurer MBIA, which had lost 55 percent of its value in the previous two months. Warburg bought 16.1 million shares at $31 a share and committed to fund another $500 million. (The deal also included warrants to buy several million shares of the company's stock at $40 per share.) Within days, as MBIA dealt with questions about its exposure to collateralized debt obligations and other exotica, the company's stock plummeted to $19. In less than two weeks, Warburg lost nearly 30 percent on its investment in the shares, or about $183 million. And that was before deep-pocketed investor Warren Buffett said he might start his own bond insurer to compete with MBIA.
Of course, it's early days, and these investments could well turn out to be genius moves. But the experience of these knife-catchers highlights a significant difference between the denouement of the dot-com bubble and the real-estate/credit bubble. In the former, the end came swiftly and violently. Since the bubble activity was concentrated in highly liquid, publicly traded stocks, investors—mutual funds, hedge funds, individuals—were all able to flee at the same time. The NASDAQ Composite—the epicenter of the bubble—fell 37 percent in two months in the spring of 2000, and nearly 75 percent between late March 2000 and April 2001. In some instances, this herdlike behavior created overreactions that set the stage for smart Dumpster-diving investors. In April 2003, Apple's stock traded for a split-adjusted $6.60; today it's at $198.
This time around, the bubble activity was concentrated in comparatively illiquid assets—like mortgage-backed securities, collateralized debt obligations, and houses. It may seem obvious now, but homes don't trade with the same speed and lack of friction that stocks do. And when housing prices fall, builders don't respond by slashing prices with alacrity; they respond by keeping prices the same and throwing in amenities, or, as the Wall Street Journal reported, by funneling cash back to buyers through third parties. The housing bubble popped, but between October 2006 and October 2007, according to the Case-Shiller index, housing prices fell only 6.1 percent. Housing prices may need to fall 30 percent or 40 percent before they bottom out, but it will take years—rather than months—for that process to play out. And as the market continues to slump, companies whose business models rest on making mortgages—and on buying, selling, and insuring securities based on mortgages—may face a string of losses.
Not all knife-catchers have been hurt, though. Goldman Sachs was one of the few Wall Street firms to prosper during the subprime tsunami, as it used its own cash to make bearish bets on subprime securities. By late December, First Marblehead, the student-loan company, had lost about 75 percent of its value over the course of 2007, as investors fretted over loan defaults and rising financing costs. On Dec. 21, Goldman's private-equity unit stepped in and agreed to buy up to 20 percent of the company for $260.5 million and offer a line of credit. With First Marblehead's stock having rallied from $11 to about $15 today, Goldman is solidly in the money on its investment. Many analysts already believe the sharp traders and risk analysts at Goldman have superhuman powers. Its ability to overcome the force of gravity and halt a plummeting financial-services stock may only add to the firm's legend.