Wednesday, May 07, 2008
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).
Tuesday, May 06, 2008
medical blog rankings
Monday, May 05, 2008
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.
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.
Sunday, May 04, 2008
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.
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.
Saturday, May 03, 2008
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.
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.
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.
Monday, April 28, 2008
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.
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.
Thursday, April 24, 2008
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.
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.
Monday, April 21, 2008
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).
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).
Sunday, April 20, 2008
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).
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).
Thursday, April 17, 2008
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.
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.
Monday, March 31, 2008
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.
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.
Sunday, March 23, 2008
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.
Saturday, March 01, 2008
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.
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.
Tuesday, February 19, 2008
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.
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.
Monday, January 21, 2008
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
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
Saturday, January 12, 2008
Thursday, January 03, 2008
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.
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.
Monday, December 31, 2007
Saturday, December 22, 2007
Anticonvulsants for Alcoholism
Several studies studies support the use of the anticonvulsant Topiramate (Topamax) for alcohol dependence.
A new study supports the use of Gabapentin (Neurontin) in the early post-withdrawal period:
NEW YORK (Reuters Health) Dec 17 - The anticonvulsant gabapentin reduces alcohol consumption and craving during treatment for alcohol dependence, Brazilian researchers report in the Journal of Clinical Psychiatry for November.
Dr. Fernando A. Furieri, at the Vitoria Municipal Addiction Treatment Center, and Dr. Ester M. Nakamura-Palacios, at the Federal University of Espirito Santo in Vitoria, conducted a randomized, double-blind trial involving 60 subjects, whose average consumption exceeded 35 drinks per week.
After a 7-day treatment for acute withdrawal, subjects were randomly assigned to gabapentin up to 600 mg/day, or placebo for 28 days. Thirty-nine patients had used diazepam during the acute phase; 15 in the placebo group and 13 in the gabapentin continued to do so during the trial phase.
The number of drinks per day, per week, and over the 4-week course of treatment had declined significantly more in the gabapentin group than in the placebo group. Gabapentin was also associated with fewer heavy drinking days and more days of abstinence. The authors note that 20 subjects in the gabapentin group and 13 in the placebo group maintained complete abstinence.
According to scores on the Obsessive Compulsive Drinking Scale, craving for alcohol was also reduced significantly more by gabapentin.
"Gabapentin has shown great potential in the treatment of alcohol dependence and withdrawal syndromes," either as monotherapy or as an add-on pharmacotherapy, the authors conclude.
J Clin Psychiatry 2007;68:1691-1700.
Non-anticonvulsants useful for the treatment of alcohol dependence include antabuse, naltrexone, and acamprosate.
A new study supports the use of Gabapentin (Neurontin) in the early post-withdrawal period:
NEW YORK (Reuters Health) Dec 17 - The anticonvulsant gabapentin reduces alcohol consumption and craving during treatment for alcohol dependence, Brazilian researchers report in the Journal of Clinical Psychiatry for November.
Dr. Fernando A. Furieri, at the Vitoria Municipal Addiction Treatment Center, and Dr. Ester M. Nakamura-Palacios, at the Federal University of Espirito Santo in Vitoria, conducted a randomized, double-blind trial involving 60 subjects, whose average consumption exceeded 35 drinks per week.
After a 7-day treatment for acute withdrawal, subjects were randomly assigned to gabapentin up to 600 mg/day, or placebo for 28 days. Thirty-nine patients had used diazepam during the acute phase; 15 in the placebo group and 13 in the gabapentin continued to do so during the trial phase.
The number of drinks per day, per week, and over the 4-week course of treatment had declined significantly more in the gabapentin group than in the placebo group. Gabapentin was also associated with fewer heavy drinking days and more days of abstinence. The authors note that 20 subjects in the gabapentin group and 13 in the placebo group maintained complete abstinence.
According to scores on the Obsessive Compulsive Drinking Scale, craving for alcohol was also reduced significantly more by gabapentin.
"Gabapentin has shown great potential in the treatment of alcohol dependence and withdrawal syndromes," either as monotherapy or as an add-on pharmacotherapy, the authors conclude.
J Clin Psychiatry 2007;68:1691-1700.
Non-anticonvulsants useful for the treatment of alcohol dependence include antabuse, naltrexone, and acamprosate.
Saturday, December 08, 2007
Different duty of care for psychiatrists and internists
A member of iMedExchange posted about this article:
A general practitioner who slept with a patient's wife -- who was also a patient -- can't be sued for malpractice in Pennsylvania, a three-judge panel concluded, affirming a decision issued by the Philadelphia Court of Common Pleas last year in Long v. Ostroff. Sexual misconduct "may be unethical," the court noted, but state law doesn't recognize such a claim for professional negligence because a general practitioner's duty of care doesn't prohibit that behavior. Unlike psychiatrists, who have a "special duty" to refrain from engaging in sexual relations with a patient's spouse, general practitioners don't have such a duty, Senior Judge Justin M. Johnson explained.
I wonder which standard would apply to me. I am boarded in Internal Medicine and Psychiatry. I primarily practice sleep medicine, which is a subspecialty of both internal medicine and psychiatry. Most insurance plans don't recognize sleep medicine as a specialty, and some list me as internal medicine and some as psychiatry. I took the old sleep boards as well as the new sleep boards (results pending) as an internist. As much as the legal process fascinates me, I guess I better not try to become the subject of a Supreme Court case.
A general practitioner who slept with a patient's wife -- who was also a patient -- can't be sued for malpractice in Pennsylvania, a three-judge panel concluded, affirming a decision issued by the Philadelphia Court of Common Pleas last year in Long v. Ostroff. Sexual misconduct "may be unethical," the court noted, but state law doesn't recognize such a claim for professional negligence because a general practitioner's duty of care doesn't prohibit that behavior. Unlike psychiatrists, who have a "special duty" to refrain from engaging in sexual relations with a patient's spouse, general practitioners don't have such a duty, Senior Judge Justin M. Johnson explained.
I wonder which standard would apply to me. I am boarded in Internal Medicine and Psychiatry. I primarily practice sleep medicine, which is a subspecialty of both internal medicine and psychiatry. Most insurance plans don't recognize sleep medicine as a specialty, and some list me as internal medicine and some as psychiatry. I took the old sleep boards as well as the new sleep boards (results pending) as an internist. As much as the legal process fascinates me, I guess I better not try to become the subject of a Supreme Court case.
Wednesday, December 05, 2007
R.I.P.
LAS VEGAS (AP) -- David "Chip" Reese, a card star who won one of the biggest cash games in the world and three World Series of Poker championships, has died. He was 56.
Reese died in his sleep and was found by his son early Tuesday morning at his Las Vegas home after suffering from symptoms of pneumonia, said poker great Doyle Brunson, his longtime friend.
Despite winning three World Series champion's bracelets over the last four decades, including a $1.8 million HORSE event in 2005 that combines five poker disciplines, Reese focused his attention on high-stakes cash games away from the limelight.
"I've seen him with a million dollars in front of him," said Dalla, describing how Reese would put out racks of $5,000 chips "like he was betting a few bucks."
Reese was part of a generation of players in the 1970s that challenged established greats like Brunson, Thomas "Amarillo Slim" Preston Jr. and Walter Clyde "Puggy" Pearson, Dalla said.
Reese died in his sleep and was found by his son early Tuesday morning at his Las Vegas home after suffering from symptoms of pneumonia, said poker great Doyle Brunson, his longtime friend.
Despite winning three World Series champion's bracelets over the last four decades, including a $1.8 million HORSE event in 2005 that combines five poker disciplines, Reese focused his attention on high-stakes cash games away from the limelight.
"I've seen him with a million dollars in front of him," said Dalla, describing how Reese would put out racks of $5,000 chips "like he was betting a few bucks."
Reese was part of a generation of players in the 1970s that challenged established greats like Brunson, Thomas "Amarillo Slim" Preston Jr. and Walter Clyde "Puggy" Pearson, Dalla said.
Thursday, November 22, 2007
Chantix Linked to Suicide
The U.S. Food and Drug Administration is looking into reports that the anti-smoking drug Chantix may trigger mood swings and thoughts of suicide in patients taking it.
Information provided to the agency by Chantix manufacturer, Pfizer Inc. cited "erratic behavior" in an individual who had used Chantix. The agency is also investigating the death of the person who used the drug, but was also under the influence of alcohol.
The FDA has asked Pfizer for any additional information it has on reports of adverse reactions in people taking the drug. Its Center for Drug Evaluation and Research is analyzing the data and plans to release its findings to the public once the analysis is completed.
In the meantime, the agency recommends that health care providers monitor patients taking Chantix. Patients taking Chantix should contact their doctors if they experience behavior or mood changes, the FDA said.
The FDA also advises that patients taking Chantix use caution when driving or operating machinery due to reports of drowsiness.
From Foxnews
Ultimately, I don't think this is going to pan out. I don't think that Chantix causes suicide. However, in the short term I forsee further declines in Pfizer's stock price. Currently, it's just above its 52 week low. I think Pfizer will be a good buy at around 20, and recommend waiting until then to buy Pfizer.
Information provided to the agency by Chantix manufacturer, Pfizer Inc. cited "erratic behavior" in an individual who had used Chantix. The agency is also investigating the death of the person who used the drug, but was also under the influence of alcohol.
The FDA has asked Pfizer for any additional information it has on reports of adverse reactions in people taking the drug. Its Center for Drug Evaluation and Research is analyzing the data and plans to release its findings to the public once the analysis is completed.
In the meantime, the agency recommends that health care providers monitor patients taking Chantix. Patients taking Chantix should contact their doctors if they experience behavior or mood changes, the FDA said.
The FDA also advises that patients taking Chantix use caution when driving or operating machinery due to reports of drowsiness.
From Foxnews
Ultimately, I don't think this is going to pan out. I don't think that Chantix causes suicide. However, in the short term I forsee further declines in Pfizer's stock price. Currently, it's just above its 52 week low. I think Pfizer will be a good buy at around 20, and recommend waiting until then to buy Pfizer.
Saturday, November 17, 2007
Doctors in Debt
Cnn.com Business Section presents a case study of 2 residents deeply in debt:
It's all supposed to pay off, of course. Once they become full-fledged doctors (attending physicians, in the trade), they'll have six-figure incomes, more reasonable hours, a respected occupation and work that they love.
But for this generation of doctors, and for Meg and Chris in particular, financial security won't come guaranteed with their medical licenses. As health-care economics squeeze physician salaries, rising college and med school tuitions are putting young doctors ever deeper in the hole.
Chris and Meg live frugally, work hard and are making the kind of investments in their future that would make any parent proud. But they're also on track to finish their medical training in the next few years with a staggering $700,000 in debt.
It's all supposed to pay off, of course. Once they become full-fledged doctors (attending physicians, in the trade), they'll have six-figure incomes, more reasonable hours, a respected occupation and work that they love.
But for this generation of doctors, and for Meg and Chris in particular, financial security won't come guaranteed with their medical licenses. As health-care economics squeeze physician salaries, rising college and med school tuitions are putting young doctors ever deeper in the hole.
Chris and Meg live frugally, work hard and are making the kind of investments in their future that would make any parent proud. But they're also on track to finish their medical training in the next few years with a staggering $700,000 in debt.
Tuesday, November 13, 2007
Drug Company Lunches
I once sneezed all over a fresh pan of Olive Garden lasagna multiple times. The big, fat office hogs never noticed. They sucked it down like there was no tomorrow.
Read this site before you eat any more drug company lunches.
( via Kevin MD)
Read this site before you eat any more drug company lunches.
( via Kevin MD)
Monday, November 12, 2007
Getting Spanked
More banks brace for subprime spanking
I saw this headline in the green section of USAToday this morning.
Rather unprofessional language for a major newspaper. Within a few years we'll probably be reading about the Dow being "bitch-slapped" in the pages of USAToday ("bitch-slapped" is probably a good term to describe today's 55 point drop).
I saw this headline in the green section of USAToday this morning.
Rather unprofessional language for a major newspaper. Within a few years we'll probably be reading about the Dow being "bitch-slapped" in the pages of USAToday ("bitch-slapped" is probably a good term to describe today's 55 point drop).
Thursday, November 08, 2007
The death of sleep medicine
Please see my post on sleepdoctor about portable testing for obstructive sleep apnea.
I wish to thank Kevin, M.D. for linking to it.
I wish to thank Kevin, M.D. for linking to it.
Saturday, November 03, 2007
Mississippi's Governor
Mississippi's Governor, Haley Barbour, has been ranked as one of the country's most influential conservatives:
About to be comfortably re-elected as Mississippi governor, Barbour is one of the most accomplished Republican executives in the United States. As a successful Southern governor with immense experience, he is a potential future presidential candidate who would be a clever pick for vice-presidential running mate in 2008. Received national plaudits for his handling of the aftermath of Hurricane Katrina, which devastated Mississippi's Gulf coast, while neighbouring Louisiana's Democratic governor floundered.Barbour, 60, has cut his state's budget deficit in half without raising taxes and used the skills he honed as a Washington lobbyist to good effect in winning over a Democratic-led state legislature. A highly successful chair of the Republican National Committee, Barbour helped lay the foundations for the Republican Revolution and the takeover of Congress in 1994.
(via Drudge)
About to be comfortably re-elected as Mississippi governor, Barbour is one of the most accomplished Republican executives in the United States. As a successful Southern governor with immense experience, he is a potential future presidential candidate who would be a clever pick for vice-presidential running mate in 2008. Received national plaudits for his handling of the aftermath of Hurricane Katrina, which devastated Mississippi's Gulf coast, while neighbouring Louisiana's Democratic governor floundered.Barbour, 60, has cut his state's budget deficit in half without raising taxes and used the skills he honed as a Washington lobbyist to good effect in winning over a Democratic-led state legislature. A highly successful chair of the Republican National Committee, Barbour helped lay the foundations for the Republican Revolution and the takeover of Congress in 1994.
(via Drudge)
Wednesday, October 31, 2007
Atheism
They say that there are no atheists in foxholes. Being unable to sell one's house can also turn a person away from atheism:
The Catholic saint has long been believed to help with home-related matters. And according to lore now spreading on the Internet and among desperate home-sellers, burying St. Joseph in the yard of a home for sale promises a prompt bid.
With the worst housing market in recent years, St. Joseph is enjoying a flurry of attention. Some vendors of religious supplies say St. Joseph statues are flying off the shelves as an increasing number of skeptics and non-Catholics look for some saintly intervention to help them sell their houses.
Some Realtors, too, swear by the practice. Ardell DellaLoggia, a Seattle-area Realtor, buried a statue beneath the "For Sale" sign on a property that she thought was overpriced. She didn't tell the owner until after it had sold. "He was an atheist," she explains. "But he thanked me."
Catholic leaders also say that faith and devotion are necessary, in addition to burying a statue, otherwise the practice amounts to little more than superstition or magic. But they are also enjoying the saint's newfound popularity. "If they have a good result and they think it was St. Joseph, it might inspire them to practice more," says Msgr. Connell.
The Catholic saint has long been believed to help with home-related matters. And according to lore now spreading on the Internet and among desperate home-sellers, burying St. Joseph in the yard of a home for sale promises a prompt bid.
With the worst housing market in recent years, St. Joseph is enjoying a flurry of attention. Some vendors of religious supplies say St. Joseph statues are flying off the shelves as an increasing number of skeptics and non-Catholics look for some saintly intervention to help them sell their houses.
Some Realtors, too, swear by the practice. Ardell DellaLoggia, a Seattle-area Realtor, buried a statue beneath the "For Sale" sign on a property that she thought was overpriced. She didn't tell the owner until after it had sold. "He was an atheist," she explains. "But he thanked me."
Catholic leaders also say that faith and devotion are necessary, in addition to burying a statue, otherwise the practice amounts to little more than superstition or magic. But they are also enjoying the saint's newfound popularity. "If they have a good result and they think it was St. Joseph, it might inspire them to practice more," says Msgr. Connell.
Tuesday, October 30, 2007
Mediocre Care for the Poor Elderly
Vulnerable elderly receive mediocre health care, study finds
The quality of care for vulnerable elderly people on Medicaid and Medicare is “mediocre,” the authors of a new study concluded.
Researchers did a cohort study of 100,528 dual Medicaid/Medicare enrollees from 19 California counties who were age 75 and older in 1999 and 2000. They measured the care provided for 44 quality indicators (QIs) by condition, like heart failure, and intervention, such as medication, using QIs developed by the Assessing Care of Vulnerable Elders project. The article was published in the October Medical Care.
This study, as summarized by the American College of Physicians, found "medicore" care for elderly dual Medicare/Medicaid enrollees. This is the sickest, toughest population to treat. Reimbursement is less than mediocre, though that's no excuse.
The quality of care for vulnerable elderly people on Medicaid and Medicare is “mediocre,” the authors of a new study concluded.
Researchers did a cohort study of 100,528 dual Medicaid/Medicare enrollees from 19 California counties who were age 75 and older in 1999 and 2000. They measured the care provided for 44 quality indicators (QIs) by condition, like heart failure, and intervention, such as medication, using QIs developed by the Assessing Care of Vulnerable Elders project. The article was published in the October Medical Care.
This study, as summarized by the American College of Physicians, found "medicore" care for elderly dual Medicare/Medicaid enrollees. This is the sickest, toughest population to treat. Reimbursement is less than mediocre, though that's no excuse.
Monday, October 22, 2007
Keeping Kids Calm with Video Games
If ritalin isn't enough, child psychiatrists have found a new way to keep children calm- video games. Psychiatric Times presents a case in which playing video games 6-7 hours a day helped a child's self esteem:
Case Vignette: Games and Attention/ Learning Disorders
Alex, a 13-year-old boy, spends 6 to 7 hours a day playing video games. He locks himself in his room, misses meals, and often stays up most of the night, which results in school tardiness. He learns "cheats" (tricks to find quick solutions to game-based problems) online, converses with players in chat rooms, and has accumulated a great deal of knowledge about the intricacies of the many, often violent, games he plays.
Although very bright, Alex has a nonverbal learning disability, social difficulties, poor athletic skills, and attention problems, and he was often made fun of at school. The primary source of his self-esteem, beyond academic achievement, is his video game prowess.
His parents have no understanding of the games, nor of the video games' central importance in his life. Other children in school often come to him for advice about games and strategies and ask to play with him. This has become his claim to fame in and out of school.
While his parents need to educate themselves about the games he is playing and to set limits on his game play, their initial response to curtail them has been modified over time, allowing for an important avenue in the socialization of their son.
Therapy for Alex and his parents involved their appreciation of the role and meaning of games in his life. His parents needed to understand that competence is a crucial component of positive self-esteem—something Alex needed tremendously in order to take on academic and social challenges. Video games provided a means for Alex to feel more confident in moving ahead in these areas. With a greater understanding of the role the games played in his life, his parents were much more tolerant of his game playing.
If your child doesn't play video games, it could be a problem:
Ironically, Seung-Hui Cho's college roommates found it odd that he never joined them in playing video games.
(Seung-Hui Cho was the Virginia Tech shooter)
The full article, Children and Video Games: How Much Do We Know? by Cheryl K. Olson, ScD, Lawrence Kutner, PhD, and Eugene V. Beresin, MD is on the Psychiatric Times website.
I encourage readers of this blog to read the full text of this distubing article. Ritalin and video games... what will child psychiatrists recommend next to control our children???
Case Vignette: Games and Attention/ Learning Disorders
Alex, a 13-year-old boy, spends 6 to 7 hours a day playing video games. He locks himself in his room, misses meals, and often stays up most of the night, which results in school tardiness. He learns "cheats" (tricks to find quick solutions to game-based problems) online, converses with players in chat rooms, and has accumulated a great deal of knowledge about the intricacies of the many, often violent, games he plays.
Although very bright, Alex has a nonverbal learning disability, social difficulties, poor athletic skills, and attention problems, and he was often made fun of at school. The primary source of his self-esteem, beyond academic achievement, is his video game prowess.
His parents have no understanding of the games, nor of the video games' central importance in his life. Other children in school often come to him for advice about games and strategies and ask to play with him. This has become his claim to fame in and out of school.
While his parents need to educate themselves about the games he is playing and to set limits on his game play, their initial response to curtail them has been modified over time, allowing for an important avenue in the socialization of their son.
Therapy for Alex and his parents involved their appreciation of the role and meaning of games in his life. His parents needed to understand that competence is a crucial component of positive self-esteem—something Alex needed tremendously in order to take on academic and social challenges. Video games provided a means for Alex to feel more confident in moving ahead in these areas. With a greater understanding of the role the games played in his life, his parents were much more tolerant of his game playing.
If your child doesn't play video games, it could be a problem:
Ironically, Seung-Hui Cho's college roommates found it odd that he never joined them in playing video games.
(Seung-Hui Cho was the Virginia Tech shooter)
The full article, Children and Video Games: How Much Do We Know? by Cheryl K. Olson, ScD, Lawrence Kutner, PhD, and Eugene V. Beresin, MD is on the Psychiatric Times website.
I encourage readers of this blog to read the full text of this distubing article. Ritalin and video games... what will child psychiatrists recommend next to control our children???
Friday, October 19, 2007
Gray Friday
The Dow Jones industrial average dropped more than 360 points Friday - the 20th anniversary of the Black Monday crash - as lackluster corporate earnings, renewed credit concerns and rising oil prices spooked investors.
The major stock market indexes turned in their worst week since July after Caterpillar Inc. (CAT), one of the world's largest construction equipment makers, soured investors mood Friday with a discouraging assessment of the U.S. economy. In a week dominated by mostly negative results from banks facing difficult credit markets and rising mortgage delinquencies, investors appeared surprised that an industrial name was feeling an economic pinch, too.
The major stock market indexes turned in their worst week since July after Caterpillar Inc. (CAT), one of the world's largest construction equipment makers, soured investors mood Friday with a discouraging assessment of the U.S. economy. In a week dominated by mostly negative results from banks facing difficult credit markets and rising mortgage delinquencies, investors appeared surprised that an industrial name was feeling an economic pinch, too.
The Dow fell 366.94, or 2.64 percent, to 13,522.02. The Dow was down for the fifth straight session and for the week was off 4.05 percent. For the year, the blue chip index is now up 8.5 percent.
Broader stock indicators also fell sharply Friday. The Standard & Poor's 500 index fell 39.45, or 2.56 percent, to 1,500.63, and the Nasdaq composite index dropped 74.15, or 2.65 percent, to 2,725.16.
Broader stock indicators also fell sharply Friday. The Standard & Poor's 500 index fell 39.45, or 2.56 percent, to 1,500.63, and the Nasdaq composite index dropped 74.15, or 2.65 percent, to 2,725.16.
Friday's pullback pales in comparison to what investors had to contend with 20 years ago. On Oct. 19, 1987 - Black Monday - the Dow plunged 23 percent amid concerns about interest rates and slowing economic growth. A decline of similar proportion given the market's current levels would mean a drop of some 3,100 points.
Friday's decline - the third biggest point and percentage drop this year - was the 9th biggest point drop in the Dow since Black Monday.
Friday's decline - the third biggest point and percentage drop this year - was the 9th biggest point drop in the Dow since Black Monday.
via Drudge
Wednesday, October 17, 2007
Winning a Nobel Prize Doesn't make you Right
Al Gore is wrong about the role of humans in global warming. James Watson, one of the discoverers of the mysteries of DNA, is wrong about genes and racial intelligence:
One of the world's most eminent scientists was embroiled in an extraordinary row last night after he claimed that black people were less intelligent than white people and the idea that "equal powers of reason" were shared across racial groups was a delusion.
James Watson, a Nobel Prize winner for his part in the unravelling of DNA who now runs one of America's leading scientific research institutions, drew widespread condemnation for comments he made ahead of his arrival in Britain today for a speaking tour at venues including the Science Museum in London.
The 79-year-old geneticist reopened the explosive debate about race and science in a newspaper interview in which he said Western policies towards African countries were wrongly based on an assumption that black people were as clever as their white counterparts when "testing" suggested the contrary. He claimed genes responsible for creating differences in human intelligence could be found within a decade.
from The Independent
One of the world's most eminent scientists was embroiled in an extraordinary row last night after he claimed that black people were less intelligent than white people and the idea that "equal powers of reason" were shared across racial groups was a delusion.
James Watson, a Nobel Prize winner for his part in the unravelling of DNA who now runs one of America's leading scientific research institutions, drew widespread condemnation for comments he made ahead of his arrival in Britain today for a speaking tour at venues including the Science Museum in London.
The 79-year-old geneticist reopened the explosive debate about race and science in a newspaper interview in which he said Western policies towards African countries were wrongly based on an assumption that black people were as clever as their white counterparts when "testing" suggested the contrary. He claimed genes responsible for creating differences in human intelligence could be found within a decade.
from The Independent
Monday, October 15, 2007
Stark III
Stark version three is apparently out:
In issuing the third phase of the final regulations implementing the physician self-referral rule, also known as the Stark law, the Center for Medicare and Medicaid Services has returned to a stance it held in the first phase.
The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, imaging facilities, or other entities in which they may have an ownership interest.
Under the new rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance, according to several attorneys.
This reversion back to the initial Stark policy is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office.
As a result, “the application of exceptions will be different going forward,” Mr. Melvin said in an interview.
That means most physicians who have referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association. Ms. Nordeng agreed that the return to the “stand in the shoes” view was the most significant component of Stark III.
Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices.
Exceptions to the law were evaluated using an indirect compensation analysis, which ended up being onerous and was the subject of many complaints to CMS. In comments on Stark II, physician groups, hospitals, and other facilities (called designated health services, or DHS entities under the Stark law) urged CMS to revert to the old policy.
CMS itself came to see the indirect compensation analysis as a loophole that allowed potentially questionable investment arrangements to slip through, said Mr. Melvin.
In the Stark III rule, CMS wrote that the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”
There were several other notable changes in Stark III.
The regulations clarify that physicians who administer pharmaceuticals under Medicare Part B (such as chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to get direct productivity credit for those orders, said Mr. Melvin.
The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.
CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far, geographically, that noncompete can extend, he said.
With the new rule, practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, Mr. Melvin said.
“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.
The final Stark rule goes into effect on Dec. 5, 2007.
It's all pretty confusing to me. However, it is my understanding that sleep labs are not considered DHS entities so hopefully Stark III won't affect me too much.
In issuing the third phase of the final regulations implementing the physician self-referral rule, also known as the Stark law, the Center for Medicare and Medicaid Services has returned to a stance it held in the first phase.
The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, imaging facilities, or other entities in which they may have an ownership interest.
Under the new rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance, according to several attorneys.
This reversion back to the initial Stark policy is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office.
As a result, “the application of exceptions will be different going forward,” Mr. Melvin said in an interview.
That means most physicians who have referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association. Ms. Nordeng agreed that the return to the “stand in the shoes” view was the most significant component of Stark III.
Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices.
Exceptions to the law were evaluated using an indirect compensation analysis, which ended up being onerous and was the subject of many complaints to CMS. In comments on Stark II, physician groups, hospitals, and other facilities (called designated health services, or DHS entities under the Stark law) urged CMS to revert to the old policy.
CMS itself came to see the indirect compensation analysis as a loophole that allowed potentially questionable investment arrangements to slip through, said Mr. Melvin.
In the Stark III rule, CMS wrote that the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”
There were several other notable changes in Stark III.
The regulations clarify that physicians who administer pharmaceuticals under Medicare Part B (such as chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to get direct productivity credit for those orders, said Mr. Melvin.
The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.
CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far, geographically, that noncompete can extend, he said.
With the new rule, practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, Mr. Melvin said.
“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.
The final Stark rule goes into effect on Dec. 5, 2007.
It's all pretty confusing to me. However, it is my understanding that sleep labs are not considered DHS entities so hopefully Stark III won't affect me too much.
Mississippi is Number One
Adult obesity is on the rise in 31 states, and no states have experienced a drop in obesity, according to a study from Trust for America's Health.
Mississippi topped the list of the fattest states, with the highest adult obesity rates for the third year in a row. More than 30% of the adult population in the state is obese. Colorado was ranked the “leanest” state with an obesity rate of 17.6%. No state has reached the Health and Human Services department goal of reducing the prevalence of adult obesity to 15% in every state by 2010.
From Clinical Psychiatry News
Mississippi topped the list of the fattest states, with the highest adult obesity rates for the third year in a row. More than 30% of the adult population in the state is obese. Colorado was ranked the “leanest” state with an obesity rate of 17.6%. No state has reached the Health and Human Services department goal of reducing the prevalence of adult obesity to 15% in every state by 2010.
From Clinical Psychiatry News
Go Ahead and Light up a Cigarette
Clinical Psychiatry News reports that cigarette smoking delays the onset of Parkinson's disease:
A pooled analysis of 11 clinical studies has confirmed that cigarette smoking protects against Parkinson's disease in a dose-dependent manner.
Many studies have suggested that smoking may play a protective role in PD, but most have been too small to provide definitive answers. Dr. Beate Ritz of the University of California, Los Angeles, and associates conducted a pooled analysis of eight case-control studies and three cohort studies involving 2,816 subjects who had PD and 8,993 controls. This large data set “enabled us to investigate aspects of cigarette smoking and subgroup-specific associations that could not be addressed adequately in previous studies,” they noted.
The risk of developing PD decreased as pack-years of cigarette smoking increased, so that the average relative risk for the disease dropped 5%–8% for every 10 pack-years of smoking. This dose-response pattern was seen in both men and women, and it was not affected by subjects' educational status.
There was also a strong dose-response trend for the number of years that had elapsed since smoking cessation. Current smokers and smokers who had recently quit showed the lowest risk for PD. People who had quit smoking in the past had a higher risk for PD, but their risk was still lower than that of people who had never smoked (Arch. Neurol. 2007;64:990–7).
Two possible mechanisms for this protective effect have been proposed. Substances such as nicotine in tobacco smoke may promote the survival of dopaminergic neurons, or smoking may alter the activity of metabolic enzymes and thus the production of toxic metabolites.
It is also possible that the same genetic or constitutional traits that raise susceptibility to PD may also deter subjects from smoking. Such traits could be a common cause for both smoking behavior and PD, Dr. Ritz and associates noted.
Tobacco's protective effect appeared to wane in subjects aged 75 and older, another finding that has been reported in previous studies. This is consistent with the hypothesis that smoking delays rather than prevents the onset of PD, the researchers added.
So if you are more scared of PD than lung cancer, COPD, and heart disease, go ahead and smoke!
A pooled analysis of 11 clinical studies has confirmed that cigarette smoking protects against Parkinson's disease in a dose-dependent manner.
Many studies have suggested that smoking may play a protective role in PD, but most have been too small to provide definitive answers. Dr. Beate Ritz of the University of California, Los Angeles, and associates conducted a pooled analysis of eight case-control studies and three cohort studies involving 2,816 subjects who had PD and 8,993 controls. This large data set “enabled us to investigate aspects of cigarette smoking and subgroup-specific associations that could not be addressed adequately in previous studies,” they noted.
The risk of developing PD decreased as pack-years of cigarette smoking increased, so that the average relative risk for the disease dropped 5%–8% for every 10 pack-years of smoking. This dose-response pattern was seen in both men and women, and it was not affected by subjects' educational status.
There was also a strong dose-response trend for the number of years that had elapsed since smoking cessation. Current smokers and smokers who had recently quit showed the lowest risk for PD. People who had quit smoking in the past had a higher risk for PD, but their risk was still lower than that of people who had never smoked (Arch. Neurol. 2007;64:990–7).
Two possible mechanisms for this protective effect have been proposed. Substances such as nicotine in tobacco smoke may promote the survival of dopaminergic neurons, or smoking may alter the activity of metabolic enzymes and thus the production of toxic metabolites.
It is also possible that the same genetic or constitutional traits that raise susceptibility to PD may also deter subjects from smoking. Such traits could be a common cause for both smoking behavior and PD, Dr. Ritz and associates noted.
Tobacco's protective effect appeared to wane in subjects aged 75 and older, another finding that has been reported in previous studies. This is consistent with the hypothesis that smoking delays rather than prevents the onset of PD, the researchers added.
So if you are more scared of PD than lung cancer, COPD, and heart disease, go ahead and smoke!
Psychiatry Residency Training Becomes Even More Wimpy
The Accreditation Council for Graduate Medical Education has reduced the amount of inpatient training necessary for psychiatry residents from a minimum of 9 months to a minimum of 6 months.
At least two psychiatrists who supervise residents say this reduction, which took place in July, “threatens to seriously undermine the quality of training for psychiatry residents.” In a commentary, Dr. Sabina Lim and Dr. Robert Rohrbaugh argue that inpatient training helps foster the development of psychiatry's fundamental skills in indispensable ways, and they note that other specialties appear to place great value on inpatient training (Academic Psychiatry 2007;31:266–9).
At least two psychiatrists who supervise residents say this reduction, which took place in July, “threatens to seriously undermine the quality of training for psychiatry residents.” In a commentary, Dr. Sabina Lim and Dr. Robert Rohrbaugh argue that inpatient training helps foster the development of psychiatry's fundamental skills in indispensable ways, and they note that other specialties appear to place great value on inpatient training (Academic Psychiatry 2007;31:266–9).
Friday, September 14, 2007
Poker and Investing
Sand105 posted an interesting essay on the similarities between poker and investing on the Motley Fool message boards. Here is part of it:
So how are poker and investing similar and dissimilar?
Similarities:1. Most importantly, both games involve incomplete information and randomness. The skill sets developed in one apply directly over to the other. Developing a logic train, calculating odds, and accurately inferring conclusions from incomplete information are exactly what is needed to be successful in both.
2. Both are beatable over the long term. Poker is equivalent to playing one game of chess along with a couple die rolls. Over the short term the die rolls rule – over the long term the chess matches determine the expectation. Equity investing is essentially the same.
3. Both have inherent costs. Poker has rake (5% of each pot, give or take), investing has transaction and frictional costs.
4. Both see black swans occur. No matter the skill set, sometimes the incredibly unusual occurs. Knowing how to recover from these setbacks is a very valuable skill set.
Dissimilarities:
1. By its nature, poker is a negative expectation game if no players are better than one another (due to the rake). Investing naturally has a long term ~10% positive tilt due to the nature of the markets.
2. The inherent costs in investing are lower. As long as the investor doesn’t have huge turnover, transaction costs and frictional costs are well under the cost of rake in poker.
3. More often than not, choosing to do nothing in investing is the right choice. Poker typically requires more risk taking events.
4. The variance in investing is lower than poker. For every $1 I have made in poker over the long haul there has been a ~$10 standard deviation in those results (i.e. for every $1 there is a 67% chance my result will actually be from -$4 to $6 and a 95% chance it will actually be from -$9 to $11.) This type of variance isn’t typical of the equity markets.
5. In poker, to win in the long term a player simply tries to ride out the variance. An investor, however, can use variance to their benefit. BMW has talked about this extensively. Figuring out to what price an equity is likely to jog down to in the short term can greatly juice overall returns.
Lessons Learned:
As a person who has played over 1,000,000 hands of poker in the last few years and been involved in the markets for 15+ years, there are some things that I have learned that I hope folks will find useful.Pretty much in the order I think they are important, these are lessons I think provide for success in both poker and equity investing:
1. Emotional control. Yep, after all the talk about logic trains and odds, I firmly believe emotional control has the most effect on long term results. This is multifaceted. The primary emotion one needs to regulate is tilt (“fear”). Selling in panic is very, very often the exact wrong thing to do. Yet even very experienced investors have it happen. It can’t be stomped out completely – however minimizing it will do wonders for an investor’s return. On the flip side of the coin boredom can be almost as damaging. Playing a hand one shouldn’t or making a trade just because you haven’t had anything enticing float by in a while is usually a mistake. Coincidentally, Whatismyoption has just posted an excellent thread on this subject: http://boards.fool.com/Message.asp?mid=25872875&sort=whole#25876516
2. Recognize that once you buy and equity or put your money into the pot, that money should be treated as if it is no longer yours (in poker it actually is no longer yours). Most people base decisions on selling an equity based on whether or not it has been performing for them. This is wrong! It doesn’t matter if the equity has lost a bunch or gained a bunch since ownership – it is the prospects for the future, the odds that one will see a rise from that price point, that count. In a game sense, when you buy an equity you give your money to Mr. Market. He then takes it and walks around with it – you have no direct control over that walk at all. You are simply betting on the overall direction of his travels. All decisions should be based on that premise. Since most investors feel the loss of money as near physical pain (lots of studies out there on investor psychology), they watch their returns like a hawk and decide to sell based on past performance. Sell decisions should be based on changes in how speculative a stock is, changes in fundamentals, tax loss harvesting, finding a better opportunity, etc. Price by itself, and your buy point relative to that price, is irrelevant.
3. Recognition of high probability situations. Dhandho, in other words. Figure out how to get your money into play with a 60-40 advantage over and over and riches will follow. In investing there are choices every day to hold, buy or sell. Most of the time this will be to hold, but when the high probability situations roll by, grab on and get a piece.
4. The corollary to #3. Don’t bet unless you have lopsided odds. Taking those 51-49 bets, though positive, leads to very high variance. Leave that to the institutional investor who has the bankroll to spread those bets around in enough places to get to the long term. Most individual investors will never get there.
5. Playing games, chess, poker, etc keep the mind agile and greatly assist in both business and investing. Mental cross training. Learning emotional control. Recognizing that both poker, investing, business, and other difficult-but-satisfying-activities are lifelong pursuits and ones in which there is always something new to learn and improvements to be made.
I have found that poker (online Texas no-limit hold'em), stock trading, and sleep medicine are very similar- all three involve long hours staring at a computer screen.
Stock trading and interpreting a sleep study both involve looking at sometimes ambiguous sinusoidal data and trying to interpret the pattern. Online poker and sleep medicine both involve looking at flickering lights/constantly changing patterns on a screen.
So how are poker and investing similar and dissimilar?
Similarities:1. Most importantly, both games involve incomplete information and randomness. The skill sets developed in one apply directly over to the other. Developing a logic train, calculating odds, and accurately inferring conclusions from incomplete information are exactly what is needed to be successful in both.
2. Both are beatable over the long term. Poker is equivalent to playing one game of chess along with a couple die rolls. Over the short term the die rolls rule – over the long term the chess matches determine the expectation. Equity investing is essentially the same.
3. Both have inherent costs. Poker has rake (5% of each pot, give or take), investing has transaction and frictional costs.
4. Both see black swans occur. No matter the skill set, sometimes the incredibly unusual occurs. Knowing how to recover from these setbacks is a very valuable skill set.
Dissimilarities:
1. By its nature, poker is a negative expectation game if no players are better than one another (due to the rake). Investing naturally has a long term ~10% positive tilt due to the nature of the markets.
2. The inherent costs in investing are lower. As long as the investor doesn’t have huge turnover, transaction costs and frictional costs are well under the cost of rake in poker.
3. More often than not, choosing to do nothing in investing is the right choice. Poker typically requires more risk taking events.
4. The variance in investing is lower than poker. For every $1 I have made in poker over the long haul there has been a ~$10 standard deviation in those results (i.e. for every $1 there is a 67% chance my result will actually be from -$4 to $6 and a 95% chance it will actually be from -$9 to $11.) This type of variance isn’t typical of the equity markets.
5. In poker, to win in the long term a player simply tries to ride out the variance. An investor, however, can use variance to their benefit. BMW has talked about this extensively. Figuring out to what price an equity is likely to jog down to in the short term can greatly juice overall returns.
Lessons Learned:
As a person who has played over 1,000,000 hands of poker in the last few years and been involved in the markets for 15+ years, there are some things that I have learned that I hope folks will find useful.Pretty much in the order I think they are important, these are lessons I think provide for success in both poker and equity investing:
1. Emotional control. Yep, after all the talk about logic trains and odds, I firmly believe emotional control has the most effect on long term results. This is multifaceted. The primary emotion one needs to regulate is tilt (“fear”). Selling in panic is very, very often the exact wrong thing to do. Yet even very experienced investors have it happen. It can’t be stomped out completely – however minimizing it will do wonders for an investor’s return. On the flip side of the coin boredom can be almost as damaging. Playing a hand one shouldn’t or making a trade just because you haven’t had anything enticing float by in a while is usually a mistake. Coincidentally, Whatismyoption has just posted an excellent thread on this subject: http://boards.fool.com/Message.asp?mid=25872875&sort=whole#25876516
2. Recognize that once you buy and equity or put your money into the pot, that money should be treated as if it is no longer yours (in poker it actually is no longer yours). Most people base decisions on selling an equity based on whether or not it has been performing for them. This is wrong! It doesn’t matter if the equity has lost a bunch or gained a bunch since ownership – it is the prospects for the future, the odds that one will see a rise from that price point, that count. In a game sense, when you buy an equity you give your money to Mr. Market. He then takes it and walks around with it – you have no direct control over that walk at all. You are simply betting on the overall direction of his travels. All decisions should be based on that premise. Since most investors feel the loss of money as near physical pain (lots of studies out there on investor psychology), they watch their returns like a hawk and decide to sell based on past performance. Sell decisions should be based on changes in how speculative a stock is, changes in fundamentals, tax loss harvesting, finding a better opportunity, etc. Price by itself, and your buy point relative to that price, is irrelevant.
3. Recognition of high probability situations. Dhandho, in other words. Figure out how to get your money into play with a 60-40 advantage over and over and riches will follow. In investing there are choices every day to hold, buy or sell. Most of the time this will be to hold, but when the high probability situations roll by, grab on and get a piece.
4. The corollary to #3. Don’t bet unless you have lopsided odds. Taking those 51-49 bets, though positive, leads to very high variance. Leave that to the institutional investor who has the bankroll to spread those bets around in enough places to get to the long term. Most individual investors will never get there.
5. Playing games, chess, poker, etc keep the mind agile and greatly assist in both business and investing. Mental cross training. Learning emotional control. Recognizing that both poker, investing, business, and other difficult-but-satisfying-activities are lifelong pursuits and ones in which there is always something new to learn and improvements to be made.
I have found that poker (online Texas no-limit hold'em), stock trading, and sleep medicine are very similar- all three involve long hours staring at a computer screen.
Stock trading and interpreting a sleep study both involve looking at sometimes ambiguous sinusoidal data and trying to interpret the pattern. Online poker and sleep medicine both involve looking at flickering lights/constantly changing patterns on a screen.
Monday, September 03, 2007
Bipolar Disorder Overdiagnosed in Children
The New York Times reports on the alarming increase in the diagosis of bipolar disorder in children:
The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.
But others argue that bipolar disorder is overdiagnosed. The term, they say, has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain.
“From a developmental point of view, we simply don’t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness,” he said. “The label may or may not reflect reality.”
Most children who qualify for the diagnosis do not go on to develop the classic features of adult bipolar disorder, like mania, researchers have found. They are far more likely to become depressed.
Others say their children have suffered from side effects of drugs given for bipolar disorder, without getting much benefit.
Ashley Ocampo, 40, of Tallahassee, Fla., the mother of an 8-year-old boy, Nicholas Ryan, who is being treated for bipolar disorder, said that he had tried several antipsychotic drugs and mood stabilizers, and that he had been better lately.
But, she said in an interview, “He has gained weight, to the point where we were struggling find clothes for him; he’s had tremors, and still has some fine motor problems that he’s getting therapy for.”
The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.
But others argue that bipolar disorder is overdiagnosed. The term, they say, has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain.
“From a developmental point of view, we simply don’t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness,” he said. “The label may or may not reflect reality.”
Most children who qualify for the diagnosis do not go on to develop the classic features of adult bipolar disorder, like mania, researchers have found. They are far more likely to become depressed.
Others say their children have suffered from side effects of drugs given for bipolar disorder, without getting much benefit.
Ashley Ocampo, 40, of Tallahassee, Fla., the mother of an 8-year-old boy, Nicholas Ryan, who is being treated for bipolar disorder, said that he had tried several antipsychotic drugs and mood stabilizers, and that he had been better lately.
But, she said in an interview, “He has gained weight, to the point where we were struggling find clothes for him; he’s had tremors, and still has some fine motor problems that he’s getting therapy for.”
Saturday, September 01, 2007
What do you call a nurse practitioner?
Codeblog recently posted on the dilemma of whether a nurse should call a physician by his first name. I frequently encounter a similar problem in my sleep practice: how to address a nurse practitioner in a letter.
For example, suppose a Certified Family Nurse Practitioner named Jane Doe has referred me a patient and I am sending her a consult note. Is it more proper to say "Dear Mrs. Doe", "Dear Ms. Doe", "Dear Nurse Doe", "Dear Nurse Practitioner Doe", or "Dear Jane Doe, CFNP"??
This is how I usually address the letter:
Jane Doe, CFNP
123 Maple Street
Jackson MS 39323
Dear Jane Doe, CFNP
Thank you for referring Mr. Smith for...
If I know the Nurse Practitioner's supervising physician's name, I will usually cc him at the bottom of the letter, esp on Medicare patients. This helps to justify billing the patient as a consult rather than a new patient.
For example, suppose a Certified Family Nurse Practitioner named Jane Doe has referred me a patient and I am sending her a consult note. Is it more proper to say "Dear Mrs. Doe", "Dear Ms. Doe", "Dear Nurse Doe", "Dear Nurse Practitioner Doe", or "Dear Jane Doe, CFNP"??
This is how I usually address the letter:
Jane Doe, CFNP
123 Maple Street
Jackson MS 39323
Dear Jane Doe, CFNP
Thank you for referring Mr. Smith for...
If I know the Nurse Practitioner's supervising physician's name, I will usually cc him at the bottom of the letter, esp on Medicare patients. This helps to justify billing the patient as a consult rather than a new patient.
Saturday, August 18, 2007
Preparing for a career in sleep medicine
Dear Sir,
I am currently enrolling for classes at Brigham Young University - Idaho. I have an interest in sleep therapy and sleep studies. I was wondering if you could offer me some advice as to what kind of Bachelors degree would best suit this line of work. I was thinking that Biology might prepare me the best for medical school. I was wondering if a degree in psychology would be better? I was also thinking about minoring in Health Science. Would this help my occupational and academic choices later on in the field of sleep studies? Thank you for your time.
My response to this letter from a reader:
Sorry about the time to get back to you.
The best type of Bachelors degree would be the one to prepare you for medical school. Any major would be fine, but you will need to take a yr of bio, chem, physics, and organic chem during college, preferably in the first 2 years. Some med schools require calculus. A class in basic statistics would be also be helpful. It would be easiest to fit these pre-med requirements into a bio or biochem major, but you can take any major. Don’t worry about planning for a sleep career until near the end of med school.
Good luck
Michael Rack, MD
I am currently enrolling for classes at Brigham Young University - Idaho. I have an interest in sleep therapy and sleep studies. I was wondering if you could offer me some advice as to what kind of Bachelors degree would best suit this line of work. I was thinking that Biology might prepare me the best for medical school. I was wondering if a degree in psychology would be better? I was also thinking about minoring in Health Science. Would this help my occupational and academic choices later on in the field of sleep studies? Thank you for your time.
My response to this letter from a reader:
Sorry about the time to get back to you.
The best type of Bachelors degree would be the one to prepare you for medical school. Any major would be fine, but you will need to take a yr of bio, chem, physics, and organic chem during college, preferably in the first 2 years. Some med schools require calculus. A class in basic statistics would be also be helpful. It would be easiest to fit these pre-med requirements into a bio or biochem major, but you can take any major. Don’t worry about planning for a sleep career until near the end of med school.
Good luck
Michael Rack, MD
Saturday, August 04, 2007
The AMA is Threatening me
I recently received the following letter from the Mississippi State Medical Association, Central Medical Society (the branch of the American Medical Association covering central Mississippi):
July 18, 2007
Michael J. Rack, M.D.
1006 Treetops Boulevard
Suite 2
Flowood, MS 39232
Dear Doctor Rack:
2007 is well underway and we have not yet received your membership dues. Our records show that you have not paid your local, state, or AMA dues for 2007. I'm sure this is just an oversight, so please use the enclosed envelope to send your check right away. Pease make your check payable to Mississippi State Medical Association.
According to the MSMA Bylaws, physicians who have not paid annual dues by April 1 forfeit membership privileges and must be removed from the membership roster. Membership in the Mississippi Physician (its actually, plural -Physicians, but I have tried to reproduce the letter as closely as possible) Care Network (MPCN) is also in jeopardy.
MSMA continues working to protect the doctor-patient relationship and to enhance the climate in which physicians practice. I encourage you to continue your membership by remitting your dues right away, beause together we are stronger.
Sincerely,
William M. Grantham, M.D.
President
________________________________________________________________
Return this portion with your dues
2007 REQUIRED DUES
Central Medical Society $90.00
MSMA Dues $450.00
AMA Dues $ 300.00
_______
Total Required Dues $840.00
2007 OPTIONAL DUES
MMPAC/AMPAC $150.00
Alliance Dues $90.00
________
Total Optional Dues $240.00
Total Required and Optional Dues $1080.00
The AMA is threatening me with loss of provider status in a key local insurance network, the Mississippi Physicians Care Network (MPCN), if I do not send $840 to the AMA. I will not give in to this corrupt organization. I will probably drop out of the MPCN, though I believe I have the option of sending an amount roughly equivalent to the $840 AMA fee to the MPCN to stay in their network. I would rather that the MPCN get my money than the AMA. I don't give in to extortion. This is one less physician that the tools in the AMA will be representing.
Saturday, July 21, 2007
Crackdown on Juvenile Sex Offenders
Sexual offender registeries, once primarily for adult sexual offenders, are increasingly aimed at teenagers:
Since 1994, federal legislation has required many sex offenders to register with the police, which can aid sex-crime investigations. But Megan’s Law, which went into effect in 1996, mandates that law enforcement also notify the public about certain convicted offenders in their communities. One of the ways states do this is through publicly accessible Web sites. At least 25 states now apply Megan’s Law, also known as a community-notification law, to juveniles, according to a recent survey by Brenda V. Smith, a law professor and the director of the National Institute of Corrections Project on Addressing Prison Rape at American University’s Washington College of Law. That means on many state sex-offender Web sites, you can find juveniles’ photos, names and addresses, and in some cases their birth dates and maps to their homes, alongside those of pedophiles and adult rapists.
However, juvenile sex offenders are different from adult sex offenders:
Adult models, he notes, don’t account for adolescent development and how family and environment affect children’s behavior. Also, research over the past decade has shown that juveniles who commit sex offenses are in several ways very different from adult sex offenders. As one expert put it, “Kids are not short adults.”
while most juveniles who have committed sex offenses are boys around 13 or 14, in other ways they are not a homogeneous population. Though a small percentage — no one knows how many — will become adult rapists or pedophiles, the vast majority, 90 percent or more, will not, Chaffin says. Most have not committed violent assaults or abused multiple children repeatedly. Usually they have had sexual contact — from fondling to oral sex to intercourse — with a child who is at least two years younger than they are. Also, many of the juveniles have been sexually abused themselves, and as a consequence, they act out sexually, typically for a transitory period.
Some, whether they have been abused or not, are what therapists call “naïve experimenters” — overly impulsive or immature adolescents who are unable to approach girls or boys their own age; instead, they engage in inappropriate sexual acts with younger children. Others are generally delinquent juveniles for whom sexual abuse is just one of the ways they break laws, and according to studies, they are much more likely to commit a property crime than they are to commit a second sex offense. They are from working-class, middle-class and upper-middle-class homes, from intact families as well as very broken ones. There are also a number of children — how many is unclear — who are adjudicated for what some therapists would say is “playing doctor” or normative “sexual experimentation.” These are broadly considered to include sexual acts that are spontaneous, intermittent and “consensual” (legally, children under 16 usually cannot consent to sex) between youths within a couple of years age. Similarly, there are the so-called Romeo and Juliet cases, like the highly publicized one in Georgia involving Genarlow Wilson, who is serving an 11-year prison sentence for having consensual oral sex with a 15-year-old girl at a party when he was 17. There have also been court cases of 12- and 13-year-old boys who grabbed girls’ breasts or buttocks in school hallways and were adjudicated as “sex offenders.”
According to the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of pedophilia requires a person to be at least 16 years old and with “recurrent, intense, sexually arousing fantasies” over a period of six months or longer, that he acts upon with a child who is at least five years younger. Many sex-abuse therapists, however, say they’d be wary of diagnosing pedophilia in even a 16- or a 17-year-old. At 16, a teenager’s history of sexual interest is relatively short, notes David Prescott, a therapist and the president-elect of the Association for the Treatment of Sexual Abusers, and it is still subject to change, compared with the history of a 40-year-old who is sexually attracted to young children.
Some of the juvenile sex offenders are being discovered by neigbors and classmates:
Kids Google one another’s names; curious neighbors type in their ZIP codes on sex-offender Web sites. And the problems begin.
Last year, an eighth grader at a Delaware middle school arrived one morning to find kids in the hallway pointing at him and snickering. At first, the boy, Johnnie, who asked me protect his privacy by identifying him by a friend’s nickname for him, was confused. He thought it might be because of his new haircut. Then one kid called him a rapist. Another jeered, “Hey, aren’t you a sex offender?” One teenage boy threatened to beat him up.
Since 1994, federal legislation has required many sex offenders to register with the police, which can aid sex-crime investigations. But Megan’s Law, which went into effect in 1996, mandates that law enforcement also notify the public about certain convicted offenders in their communities. One of the ways states do this is through publicly accessible Web sites. At least 25 states now apply Megan’s Law, also known as a community-notification law, to juveniles, according to a recent survey by Brenda V. Smith, a law professor and the director of the National Institute of Corrections Project on Addressing Prison Rape at American University’s Washington College of Law. That means on many state sex-offender Web sites, you can find juveniles’ photos, names and addresses, and in some cases their birth dates and maps to their homes, alongside those of pedophiles and adult rapists.
However, juvenile sex offenders are different from adult sex offenders:
Adult models, he notes, don’t account for adolescent development and how family and environment affect children’s behavior. Also, research over the past decade has shown that juveniles who commit sex offenses are in several ways very different from adult sex offenders. As one expert put it, “Kids are not short adults.”
while most juveniles who have committed sex offenses are boys around 13 or 14, in other ways they are not a homogeneous population. Though a small percentage — no one knows how many — will become adult rapists or pedophiles, the vast majority, 90 percent or more, will not, Chaffin says. Most have not committed violent assaults or abused multiple children repeatedly. Usually they have had sexual contact — from fondling to oral sex to intercourse — with a child who is at least two years younger than they are. Also, many of the juveniles have been sexually abused themselves, and as a consequence, they act out sexually, typically for a transitory period.
Some, whether they have been abused or not, are what therapists call “naïve experimenters” — overly impulsive or immature adolescents who are unable to approach girls or boys their own age; instead, they engage in inappropriate sexual acts with younger children. Others are generally delinquent juveniles for whom sexual abuse is just one of the ways they break laws, and according to studies, they are much more likely to commit a property crime than they are to commit a second sex offense. They are from working-class, middle-class and upper-middle-class homes, from intact families as well as very broken ones. There are also a number of children — how many is unclear — who are adjudicated for what some therapists would say is “playing doctor” or normative “sexual experimentation.” These are broadly considered to include sexual acts that are spontaneous, intermittent and “consensual” (legally, children under 16 usually cannot consent to sex) between youths within a couple of years age. Similarly, there are the so-called Romeo and Juliet cases, like the highly publicized one in Georgia involving Genarlow Wilson, who is serving an 11-year prison sentence for having consensual oral sex with a 15-year-old girl at a party when he was 17. There have also been court cases of 12- and 13-year-old boys who grabbed girls’ breasts or buttocks in school hallways and were adjudicated as “sex offenders.”
According to the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of pedophilia requires a person to be at least 16 years old and with “recurrent, intense, sexually arousing fantasies” over a period of six months or longer, that he acts upon with a child who is at least five years younger. Many sex-abuse therapists, however, say they’d be wary of diagnosing pedophilia in even a 16- or a 17-year-old. At 16, a teenager’s history of sexual interest is relatively short, notes David Prescott, a therapist and the president-elect of the Association for the Treatment of Sexual Abusers, and it is still subject to change, compared with the history of a 40-year-old who is sexually attracted to young children.
Some of the juvenile sex offenders are being discovered by neigbors and classmates:
Kids Google one another’s names; curious neighbors type in their ZIP codes on sex-offender Web sites. And the problems begin.
Last year, an eighth grader at a Delaware middle school arrived one morning to find kids in the hallway pointing at him and snickering. At first, the boy, Johnnie, who asked me protect his privacy by identifying him by a friend’s nickname for him, was confused. He thought it might be because of his new haircut. Then one kid called him a rapist. Another jeered, “Hey, aren’t you a sex offender?” One teenage boy threatened to beat him up.
Friday, July 20, 2007
Drug Interactions can cause Pregnancy
The Cortlandt Forum describes an interesting malpractice case in which a drug-drug interaction between Tegretol and a birth control pill led to pregnancy:
The 32-year-old woman suffered from bipolar disorder and depression, which she claimed were exacerbated by a divorce and the difficulties of her young son, who had developmental problems. Dr. T referred her to a psychiatric clinic under the care of Dr. P. The psychiatrist started her on bupropion (Wellbutrin) for depression and the anticonvulsant carbamazepine (Tegretol) for her bipolar disorder.
After her discharge from the clinic, the patient continued to see Dr. T. She told him she was “in a relationship” and was taking norethindrone and ethinyl estradiol (Norinyl 1/35) for contraception. Several months later, she announced that she was pregnant despite the oral contraceptive (OC) and had been advised there was a chance of birth defects because she was taking carbamazepine during the first trimester.
The woman decided to have an abortion. During counseling at an abortion clinic, she was told that carbamazepine could interfere with the contraceptive effectiveness of norethindrone and ethinyl estradiol. A plaintiff’s expert later explained that carbamazepine could induce liver enzymes that metabolize estrogen, further reducing the efficacy of the hormone, which is already at a low dose in Norinyl 1/35.
The case proceeded through the depositions and other discovery, then settled for $135,000 a month before trial.
Tegretol (carbamazepine) is a notorious hepatic enzyme inducer. It induces cytochrome P450 3A4, leading to reduced serum levels of birth control pills. Another medication that can do this, although to a lesser extent, is Provigil (modafinil). I warn all my female patients taking Provigil that it can reduce the effectiveness of birth control pills.
Saturday, July 14, 2007
The Quantum State of Cheney
Normally I try to avoid non-medical political commentary on this blog, but I found this Tom Tomorrow cartoon too clever to skip (try clicking on the cartoon or click here if it is too small to read). Although Tomorrow's politics are the opposite of mine, this is one of the best political cartoons I have seen and therefore I'm going to feature it today.
I find the field of quantum mechanics to be fascinating, though my my limited mathematical background only permits a superficial understanding.
If one subscribes to the Many Worlds interpretation of quantum mechanics, one could imagine billions of parallel universes, a few in which Cheney is all executive or all legislative, but most containing a Cheney who is a mixture of executive/legislative. There would also be some in which Cheney is neither, and Gore or Kerry is President- a scary thought.
Thursday, July 05, 2007
Practicing Pelvic exams
A commenter asks:
I've been in practice for 30 years,and teach medical students.I went to med school in Vt and FP residency in Mn. I never heard of practicing pelvic exams in woman under anesthesia. Was this the standard practice in any medical school or an urban myth?
Practicing pelvic exams in women under general anesthesia was not done when I was a medical student (93-97) or resident. Can any older docs confirm if this was ever done??
I've been in practice for 30 years,and teach medical students.I went to med school in Vt and FP residency in Mn. I never heard of practicing pelvic exams in woman under anesthesia. Was this the standard practice in any medical school or an urban myth?
Practicing pelvic exams in women under general anesthesia was not done when I was a medical student (93-97) or resident. Can any older docs confirm if this was ever done??
Learning Pelvic Exams
A commenter on Kevin MD asked:
Is it still true today that anesthesized female patients in the OR provide the opportunity for med students to practice pelvic/rectal exams in secret? Secret from the patient who has no idea this is happening to her? Supposedly the vague consent form the patient signs before the operation is the legal cover teaching hospitals and doctors hide behind to justify this clandestine procedure.I wonder if the surgeon would resent the patient should he or she be asked that the practice not be done. Or might the request not even be honored. The idea of medical students lining up to probe and examine the vagina of an unsuspecting unconscious patient for their own benefit, in my opinion, is nothing short of medical rape.
Medical students are no longer allowed to practice pelvic exams on anesthesized female patients.
Most medical students learn the basics of a pelvic exam from "standardized patients."
Below is a link about standardized patients:
http://uwnews.org/uweek/uweekarticle.asp?articleID=27384
Below is a link about standardized patients:
http://uwnews.org/uweek/uweekarticle.asp?articleID=27384
However medical students still need to practice to get good, and many leave medical school without the ability to do an adequate pelvic exam. Some learn how to do it during OB/GYN rotations, but in many cases the patients on OB/GYN services don't want students to examine them. Therefore many doctors don't become proficient at pelvic exams until residency, if it all.
Subscribe to:
Posts (Atom)
