The 7 Deadly Sins

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 This physician's license was revoked and he was also criminally convicted of fraud.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

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

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

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

Vitamin D

Vitamin D has recently become a hot area of research.

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

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

Are Psychiatrists Real Doctors?

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

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

ER call ethics

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

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

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

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

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

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

Iowa floods

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

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

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

More on the Primary Care Shortage

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

Never-Never-Land

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

Medical Ethics

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

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

Doctor Etiquette

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

medical blog rankings

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

CON Opposition in the South

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

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

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

My Predictions for the US Dollar

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

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

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

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

American Psychiatric Association caves in to gay activists

Bob Unruh reports in WorldNetDaily:

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

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

My Solution for the Primary Care Shortage

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

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

The Abuse of Nonprofit Status by some Hospitals

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

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

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

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

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

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

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

Perhaps all hospitals should be required to pay taxes:

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

Managing Psychiatric Patients in Medical Hospitals

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

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

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

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

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

Here are some possible solutions:

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

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

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

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

Hospital Medical Staff Should not be Treated like Employees

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

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

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

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

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

Mississippi Psychiatrist Disciplined

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

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

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

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

Soccer is a dangerous sport

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

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

The Dalai Lama is now a Psychiatrist

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

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

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