1. Credit vs. Refund
2. New Characteristics
3. Placebo Journal Update
4. Gorback’s Thoughts by Michael Gorback MD
5. Vaginal Rejuvenation
6. Maybe They Were Wrong?
7. Joke of the Week
8. Ridiculous TV Reporting of the Month
9. Bacharach’s Beliefs by Ted Bacharach MD, retired
10. Affordability
11. LIFER
12. EMR vs. Paper
13. Maria’s Media Spotlight by Maria Simbra MD
14. Feedback About The Placebo Gazette

1.  Credit vs. Refund

As pointed out in the WSJ, Congress is returning to work and will start the health care debate once again.  The hot topic of possibly creating an individual based insurance system will be up for discussion.  Bush wants one that includes a credit or deduction of $15, 000 for a family or $7500 for an individual that would apply against both the income and payroll tax.   Romney and Giuliani also like this idea. The other option is a refundable tax credit.  A family would receive $5400 and an individual would get $2160.  Now here is the laughable part.  The refund would even go to those who pay no taxes at all making it basically a handout.   It would require $800 billion over 10 years to subsidize the health care for lower earners.  As the article states, once embedded in the tax code, this “entitlement” would never go away.  Both plans are basically Republican but what is still confusing to me is that it seems to just be redistributing wealth.  As we all know, these kinds of plans never truly work.  Robin Hood is just a fable.  So is the lesson of teaching people to fish versus just giving them the fish.  Hey, what happened to all those $3000 VISA debit cards they gave out after Katrina? 

2. New Characteristics

A recent Newsweek article points out how medical schools are looking more kindly on students in the humanities majors believing they are likely to become well-rounded and caring doctors.  The author, unfortunately, seemed to have missed other characteristics that potential medical students should have:

• Martyrdom
• Self-masochism
• OCD
• Self-flagellation
• Depression
• Mania
• Poor taste in clothes
• Lack of humor

The October issue of the Placebo Journal is about done.  For those that read this Placebo Gazette and watch our Placebo Television, the Placebo Journal is something a little different.  It is all humor with a pinch of truth.  It will make you laugh and feel that you are not alone out there.  It also financially drives all that we do.  I appreciate any interest you may have and hope you would consider subscribing to some “idiopathic wit and wisdom”

SUBSCRIBE

4. Gorback’s Thoughts by Michael Gorback MD

Coercive Care

Managed care was nothing. Wait until you meet Coercive Care. Presidential candidate John Edwards (who made his personal fortune as a malpractice plaintiff's attorney) has announced that under his proposed health plan everyone in the country would be "required" (i.e., FORCED) to get regular medical examinations. Women will be "required" (forced) to undergo mammograms. He really said that.

The underlying principle seems to be "If you want health care, you must submit to health care. We Know What's Best For You. Trust Us. We Are From The Government. What we will force you to undergo will make wish you drew the line at fluoridation of public drinking water. We own your body because you have entrusted it to us."

Think about it. You MUST get a colonoscopy after reaching a certain age. If pathology is found you MUST undergo treatment. There would be an EBM (evidenced based medicine) feeding frenzy as various stakeholders (equipment and drug manufactories, etc) try to make their scientific findings the law of the land. If you can "scientifically prove" that X drug is the treatment of choice for Y disease, then by law anyone with Y disease MUST submit to taking X drug. The patient does not have a choice. If you reap the benefits you must submit yourself to treatment. And if you own stock in the company that makes X drug, you will get very rich. And any doctor who can help generate the right kind of data supporting X drug will get very rich as well.

Actually, you do have a choice. You can opt out of the coverage and buy private insurance instead. You will be able to opt out. I have no doubt about this whatsoever because the rich will insist on preserving their right to accept or refuse medical treatment. If you don't have the money but still want to have control over your body, go uninsured. Why would you want to do something like that? You'd have to be insane. Or maybe -- maybe -- the government decided that you were too old or too frail for childbearing and demanded that you undergo an abortion or be dropped from the health care system. But you didn't want an abortion so you told the government to screw off and went without insurance. I guess you don't have to be insane to opt out; maybe you only have to be 40 years old and pregnant.

That pretty much closes the loop doesn't it? In the end you have people with private insurance, government insurance, or no insurance. All that has happened is that more people were forced through the health care system.

A system under-equipped and understaffed to accommodate the tidal wave of patient encounters force-fed into the system.

A system that will break under the strain.

A system that will be increasingly prone to errors in geometric progression.

A system where people will be injured or killed by medical negligence in record numbers.

A system that will generate a phenomenal amount of . . . . malpractice suits. The trial lawyers will preserve that when the law is written.

So there you have it. A shit sandwich, with the super-rich as one slice of bread, the lawyers as the other slice of bread, and us, my friends, as the part in middle. 

The American College of Obstetricians and Gynecologists recently came out against the cosmetic procedure called vaginal rejuvenation or what has been nicknamed “designer vaginoplasty”.  This has been billed as a way to tighten the areas altered by aging and childbirth.  The controversy is whether this procedure is truly medically indicated because there are no studies supporting it not to mention the risk of infection, scarring and nerve damage that may occur from its use.  The attention on this procedure has skyrocketed because of the general population watching the physician on the show Dr. 90210 doing it.  Is it cosmetic?  Does it improve sexual fulfillment?  Are the medical claims about its benefits exaggerated?  Who knows?  I am just offended by their TV commercials.  You know the ones.  Hot Pockets.

6. Maybe They Were Wrong?

If you haven’t heard, the suicide rate for children and young adults aged 10 to 24 rose 8% in 2004.  This was the largest annual increase in more than 15 years.  The CDC report did not speculate on a reason but it just happened to coincide with the black box warning given by the FDA to be placed on antidepressants.  Remember the uproar when the SSRIs were thought to increase the suicide risk?  A lot of us physicians who used these drugs to treat teenagers felt that this was garbage science and just another capitulation by the FDA.  It also opened up major doors for lawyers to sue.  So now what?  The bottom line is that we should never let the media dictate our care.  That is unless we want to work in a retail clinic.

7. Joke of the Week

With the help of some of the newest fertility technology, a 65-year-old woman was able to give birth to a baby recently.  When she was discharged from the hospital and went home, the relatives came to visit.
 
“We came to see the new baby?" one of the relatives said.

 "Not yet," said the mother. "I'll make coffee and we can visit for awhile first."
 
Thirty minutes had passed, and another relative asked, "May we see the new baby now?" 

"No, not yet," said the mother.
 
After another few minutes had elapsed, they asked again, "May we see the baby now?" 

"Not yet," replied the mother.
 
Growing very impatient, they asked, "Well, when can we see the baby?"  

"When he cries!" she told them.  

"When he cries?" they demanded.  "Why do we have to wait until he cries?"  

"Because, I forgot where I put him..."

This is a little twist on our normal “Ridiculous Study of the Month”.  I want to thank the good folks at healthnewsreview.org for this one. Good Morning America did the piece on what they describe as the medical mystery plaguing thousands of Americans supposedly coming down with Chronic Lyme Disease every year.  You can check out the entire transcript here:

http://www.healthnewsreview.org/review/transcript.php?rid=1016

As we all know, many times these programs have no idea what the hell they are talking about.  In this piece, they highlighted just one patient's diagnosis and her treatment for Chronic Lyme Disease.  Unfortunately, they failed to mention a few things:

• Conflict of interest – the patient is a board member of an organization that raises money for this supposed disease and advocates experimental treatments for it. She is also a paid motivational speaker who has appeared before two pharmaceutical companies and several health groups.
• Lack of details - the story didn’t mention her other prior illnesses and that while she was battling the disease she reportedly was able to hold a variety of corporate management positions and work as a model and TV reporter.
• Lack of evidence – “The story shows no evidence that the reporters attempted to verify the facts of her case, get independent commentary on her diagnosis and treatment, explain the risks and benefits of the treatment or even identify the physician who provided it. “
• Lack of context – Nothing was mentioned about the controversy of the existence of Chronic Lyme disease. 

As stated on the website cited above, “this story was sensationalized, unreferenced, biased and incomplete.”

The good news is that there is going to be a rush by patients to be treated for Chronic Lyme Disease around the country.  Fringe physicians will have a whole new slew of patients trying to cure all their ills which means more money in their pockets.  Who needs hard, irrefutable facts when you have Good Morning America?  

9. Bacharach’s Beliefs by Ted Bacharach MD, retired

Medicare and government tactics have often backfired.  I believe the first prize for self defeating programs is undoubtedly HIPAA. This program has caused far more harmful results and has prevented nothing. The communication channels impeded have far outweighed any possible benefit. Access to those who need is adversely affected and access for those who shouldn’t get it is unimpaired. The score does nothing for the patient, nothing for the physician, but preserves the right of insurance companies, financial institutions etc. to get full access to whatever they might like to know about you. {Most people have signed the authorization for the insurance company to review their medical records. This authorization is usually in print smaller than what most people can see.} The nurses and doctors have found that their interchange of information is
severely impeded by roadblocks of all types, often to the detriment of quality
patient care.

Medicare, in their desire to cut the cost of medical care, has also frequently failed to accomplish what they intended. The result of some of their policies has resulted in adverse effect on patient care.

The payment of a global fee to the hospital for certain procedures has resulted in several new problem areas. Since the hospital gets paid for the procedure and what the government felt was the average needed length of stay hospitals have found that to maximize their reimbursement they can cut the length of stay. The first thing is to admit the patient on the day of surgery. Admittedly this can be accomplished in many patients without adverse effect. Unfortunately relying on the patient’s statements that he did not eat breakfast or did or didn’t take his or her pills can lead to some errors. Since the last observation the patient may have contracted an infection or there may have been some change in his status. Hospitalizing patients the day before surgery was not a luxury but did provide an added measure of safety.

In the desire to cut the number of days in the hospital patients can be discharged 48 hours after admission. This cuts the number of days of hospitalization and maximizes hospital profits but often results in patients being discharged to nursing homes or other facilities so that new charges can be developed. Unfortunately these discharges often result in the patient being placed in an environment where follow-up is not too good and adverse results happen. One of the patients who was sent home after a hip replacement was brought back to the emergency room with a joint filled with wall splattering pus. The nursing home stated that the area had looked normal the day before.

The fact that Medicare does not pay for “routine physical exams” has encouraged many insurance companies to do likewise. The result is that preventive care and early detection are becoming obsolete concepts.

The care for the chronically ill can also be adversely affected by limitation of the number of visits to the physician’s office. Unfortunately all patients are not alike
and vary by age, concurrent conditions and ability to conform and take their
medications.

The gap in affordability for medical insurance has also had some dire
consequences. Since the cost of medical insurance is greatest for the patient
approaching Medicare age coverage, it has become increasingly common for
patients to defer needed procedures or treatment for a year or two when they will become eligible for Medicare coverage.

I am sure I have missed many situations in which Governmental decisions and
implementations have led to adverse results. As physicians we do bear some
responsibility and should use all of the means at our disposal the change what we can. Unfortunately we lack unity on most issues thus making our voice a very weak one and the result of the problems created will be seen as a valid reason for “universal healthcare” in which case the number of problems may well increase and be compounded. Physicians can influence the future of medical care and should do more than just say “I don’t like Universal Healthcare”.

10. Affordability

In an article in the WSJ, Michael Cannon of the Cato Institute states that letting Americans own their health care dollars and making them care about costs would be the answer in fixing our healthcare problem.  He points out that as many as 75% of the uninsured could afford to buy insurance but still don’t.   Part of the reason is that health insurance premiums have risen 87% since 2000.  We are a wealthy country.  The Census Income Report showed that the percentage of Americans living below the poverty line fell to 12.3% which is the first significant drop in a decade.  We also know how to price shop.  Unfortunately, many Americans have no problem skipping on getting health insurance thinking that they just won’t get sick.  Wouldn’t it be a good idea to make it mandatory that we all have insurance just like we do for auto insurance?  If the answer is yes, which I believe it is, then wouldn’t be a good idea to make insurance companies truly compete for our money.   I want the future commercials to show a family having 30 or 40 representatives coming to their house offering different insurance products like they do know for mortgage loan commercials.  To accomplish this we need to stop the insurance companies from consolidating and merging.  We need to be able to choose insurance products from ANY state and not just our own.  And we need to allow the individual to deduct health insurance off their taxes and not just let the employers do it.  The real problem is, just because most of us in this country can afford health insurance doesn’t mean it is truly affordable. 

11.  LIFER

Due to the large amount of requests, we have decided to open up our LIFER section again.  We will not accept more than 100 more LIFERS and cannot guarantee when we will open this up again.  If you are interested, here is what you will get:

• A lifetime subscription to the Placebo Journal
• A full set of posters $75 value
• A back issue package of your favorite 6 issues from our back issue online selection. $42 value
• A PJ pen $6 value
• 10 free slides for your lectures $75 value
• Your name on our website with any info or picture you want

Hurry, this will not last long!

http://www.placebojournal.com/shopexd.asp?id=74

12. EMR vs. Paper

In another epic battle, technology took it on the chin as electronic medical records (EMR) showed no significance difference in quality as compared to paper charts.  The Archives of Internal Medicine published a study in July that in 14 out of 17 guideline-based quality metrics, physician offices that used paper charts did just as well.  Chalk one up for old school!

I’m really not gloating too much about this for many reasons.  The term “quality” is very difficult to define.  Second, I hate these guideline-based metrics and have said before that I feel it is crap.  Third, this is probably another example of gaming the system.

The question is, however, why do all doctors have to switch to EMR when the evidence isn’t there?  The pressure is still on all docs to switch yet no one is taking into account the high cost of implementation, the technology which still isn’t that great, and the time to use these damn EMRs is extremely destructive to productivity in the office.  This begs another question.  Are we doctors still going to be penalized for not switching to EMR based on faith and prayer?  Just like P4P, the answer is a resounding YES.

13. Maria’s Media Spotlight by Maria Simbra MD

Here were my assignments.

8/01/07           "CDC Expects Worst West Nile Virus Season in Years"

8/03/07           "Changes Ahead for Back-To-School Vaccinations"

8/06/07           "Researchers Learn More About Rosacea"

8/06/07           "New Exercise Guidelines Released"

8/07/07           "Humidity Makes Hot Weather Feel Even Worse"

8/07/07           "Heat and Humidity Put Old, Young at Risk"

8/08/07           "Doctor Explains Do's and Don'ts in the Heat"

8/10/07           "Health Hazards to Watch for When Cleaning After the Flood"

8/14/07           "MRIs Can Be Helpful in Breast Cancer Detection"

8/15/07           "Toy Recall Has Parents, Doctors Concerned"

8/15/07           "Doctors See Spike in Football Related Injuries"

8/17/07           "Doctors: 3 Factors Impact Miners' Well-being"

8/20/07           "Now Drug Helping in Battle Against Osteoporosis"

8/20/07           "Study: Pain Medicine Use Has Nearly Doubled"

8/22/07           "High Blood Pressure Goes Undiagnosed for Many Kids"

8/24/07           "Bill Would Require Parents' Permission for Tanning"

8/28/07           "Report Shows Nearly a Quarter of Pennsylvanians Considered Obese"

8/31/07           "Bedtime Routines a Must For Back-To-School"

To see these reports, go to KDKA.com, click on the word "Video" at the top of the large box (top right), open the drop down menu and click on "Health," look for the headlines mentioned above.  They're organized by date, the most recent reports up top.

Top of the A.  The second week in August was blistery hot and swampy humid.  The first part of the week I was part of the "A block," going live, covering "the heat and your health."  Then a major storm came through on Thursday that week, leaving a Pittsburgh neighborhood flooded.  So I was covering "flood clean up and your health."  Every now and then it's great to be part of the big story(ies).  You find yourself rising to the occasion and doing your best work.  The icing on the cake was a compliment from my news director saying that my pieces were "nicely done."

Great idea lost in translation...or editing.  I loved the concept I had for the "Do's and Don'ts" piece.  It was going to be me and the E.R. doctor spying on people from the news jeep a la "What Not to Wear," commenting on people's behavior in the heat.  While we had interview sound in the car, the camera was on the scene, and not on us.  So we did a formal sit down interview later to make sure we had all the necessary sound bites.  In the editing, I envisioned only seeing the doctor out in the field, and only hearing his comments from the indoor interview under the b-roll.  After editing, it appeared as if the doctor hadn't really gone out with us...oh, but wait, he did...or did he?  Unfortunately, we were editing in the field, preparing to go live with a storm approaching.  The time and environmental pressures were such that we couldn't go back and finesse the editing.  As a result, the piece was a bit confusing, and did not do my idea justice. 

Bungled web headline.  The story was not about the young and old in the heat!  A completely different group of people was the whole point of the report.

Milestone moment.  This particular August, I celebrated my 40th birthday.  It's a little weird being able to see both ends of the tunnel from here.  But I'm grateful to have found a satisfying professional niche at this point in my life.

14. Feedback About The Placebo Gazette

I WANT TO KNOW WHAT YOU THINK.  Please go below and post your thoughts under the WRITE A REVIEW section.  You can also see some one of these articles on our blog:

Until next time, keep smiling, keep laughing and keep out of the sample closet.

Doug

King of Medicine