- Perfection
- Accountability
- Placebo Journal Update
- Gorback’s Thoughts by Michael Gorback MD
- Hot Water
- Walmart Is Now My Enemy
- Joke of the Week
- Ridiculous Study of the Month
- Bacharach’s Beliefs by Ted Bacharach MD, retired
- How Valuable Is The Chest X-Ray?
- Future Medical News
- Another Quality Setback
- Turnout
- Feedback About The Placebo Gazette
1. Perfection
“But they were undefeated!” exclaimed my 9-year-old daughter as she wept in bed.
“I know. I know. But it is really hard to be perfect. It was a great year and they did their best. Remember, it’s just a game,” I told her as I kissed her goodnight.
I am a family physician in my forties who is also a father of three. My wife, kids, friends and I watched in disbelief as the Patriots lost a shocker last week to the New York Giants. It was such a sad moment to see Tom Brady throw that last incompletion of the night knowing that there will be no tomorrow. Or is there?
I am by no means a perfect father. The expletives being thrown around the living room were hardly all coming from me as my 14 and 15 year old boys couldn’t hold back as well. Putting them to bed with some kind of pep talk was no easy task either. Unless you live under a rock, you would know that teenagers aren’t enthralled with speeches from their parents. I just knew there was a lesson in all this. As Patriot fans, we invested months watching our team run their record to 18 and 0. But it was not to be. The truth is that perfection is unattainable for us human folk and keeping this in perspective was the only really way to get my boys to understand this defeat. This was just a game; there will be bigger losses in life.
This past week a study came out showing the incidence of depression being higher in our mid-forties. Also this past week a 43 year old family doctor who recently left our call group and medical organization committed suicide. He had two young boys. I am sure the touchdown pass to Plaxico Burress at the end of the game meant little to them. This is what I told my sons and I think it helped them just a bit to see the bigger picture.
Maybe the lesson of this game was to show the world that some things are out of man’s reach. There is nothing wrong in trying to be perfect but the journey and the lessons along the way may be a little more important. Though I feel horrible for Brady, Moss, Seau, Bruschi and the gang, I had always felt a sense of sadness for Tom Coughlin and Eli Manning as they were continually berated by the pundits over the past few years. There was something almost perfect in their vindication last night.
My Dad, who died a few years back, was a rabid Giants fan and we would have had a great two weeks ribbing each other before the big game if he were alive today. As I tossed and turned trying to sleep, I thought he was probably smiling down on me, glad that his “men in blue” pulled one of the biggest upsets in sports history.
No, using perfection as an end all, be all is a mistake. The 72 Dolphins can keep it. The rest of us will have to work through middle age, parenting our kids, keeping our jobs, paying our mortgages, and pursuing happiness as best as we can. The only way to accomplish the last one, I am convinced, is with a little perspective. Football is just a game. Life is just a little more important. At the end of the day, even Tom Brady is human and has to go home to Giselle. And though she may seem perfect, I’ll still take me wife. What? It’s close to Valentine’s Day. Do you know how many points I would score by getting that printed in a major newspaper? I may not be perfect but I am sure as hell not stupid.
2. Accountability
I enjoyed the Grammys the other night but I found it really disturbing how they kind of glorified Amy Winehouse. This artist may be talented but she has a terrible polysubstance addiction for which she almost mocks in her hit song. It just bothered me how the other singers made it seem like she is the victim. Where is the accountability? Speaking of which, let’s talk about Heath Ledger for a minute. He was another talented artist who lost his life to drugs in a terrible overdose “accident”. Accident? Are you kidding me? The cause of death was described officially as "acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine”. That is an accident? No doctor knowingly prescribes all these drugs to the same person.
Ledger’s case could have been used as a way to teach the youth about the dangers of abusing prescription drugs. Not going to happen. Here is what his family says:
“While no medications were taken in excess, we learned today the combination of doctor-prescribed drugs proved lethal for our boy. Heath's accidental death serves as a caution to the hidden dangers of combining prescription medication, even at low dosage.”
So not only are they in denial of this being due his drug addiction but they are now placing the blame on someone else. Who may that be? Hmm, let me guess, how about the doctor? Mark my words, the lawsuit is on its way.
3. Placebo Journal Update
The February edition of the Placebo Journal is out. If you haven’t received it then it should get to you shortly. It is also available as a back issue.
At this time we are putting our energy into writing our 40th edition that will come out in April. If you have some true stories about pharmaceutical companies or insurance companies, I would love to see them.
If you are interested in subscribing to the only journal that will make you laugh, click below. Isn’t it time you had a guilty pleasure?
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4. Gorback’s Thoughts by Michael Gorback MD
On Friday February 8 the Wall Street Journal ran a sickening piece written by minions of the health insurance industry. In it they whined that they are too heavily regulated, there are too many mandates, and that they do not contribute to the rising cost of health care.
At first I thought the opinion piece by Bunce and Wieske on health insurance mandates was a satire because no one could possibly think that the regulations and mandates faced by health insurance carriers are anything but self-inflicted. The reason there were so few insurance mandates in the 1960s and so many today is something the insurance industry asked for with its irresponsible behavior. These companies hijacked American health care in the 1990s, essentially placing themselves in control. This is a very highly scrutinized and regulated field. We are not talking about refusing to pay for a dented fender; we are dealing with human lives. You cannot insert yourself into the process without coming under greater scrutiny and regulation. If you insert yourself into the health care process as intrusively as the managed care companies did you should not be surprised to find yourself being highly regulated.
The managed care companies also implemented a plethora of restrictive and draconian policies that produced a huge backlash from the citizens of this country, forcing their legislators to respond. Have they forgotten so soon the drive-through mastectomies and new mothers being sent home from the hospital the day after delivery? And who can forget that watershed moment when Helen Hunt let fly an obscenity-filled rant about HMOs in "As Good as It Gets" and movie audiences stood up and cheered?
Equally difficult to believe is the insurance carriers' assertion that they are not responsible for rising health care costs. Many of them seem to be reporting double-digit earnings increases on a regular basis. Aren't the costs of these earnings increases passed through to the consumer, or would they have us believe that each year they get 10% more efficient at making a profit? Using compounded rates of return, it is only a matter of a few years before they become so efficient that they can make money without doing any business at all.
Who can fail to see the irony of a managed care company complaining about micro-managing? Insurance companies routinely override physicians' orders and ignore their clinical decisions. I have a letter on my desk right now denying an analgesic prescription for a patient in terrible pain because it falls outside the arbitrary limits set by the insurance company. I will have to spend a fair amount of time - without compensation - writing a letter of appeal on behalf of this patient, and it will not be the only such letter that I write this week. The managed care companies are the last people on this planet who should complain about micro-managing. Pot, meet kettle.
This article was little more than self-serving propaganda from an industry that wants to cherry-pick low-cost, low-risk health care services and be free from other, more expensive, obligations. They don't want to insure sick people. They don't want to pay for mental health services. Medicine doesn't work that way; there are problems that are easy and inexpensive to treat and others that are not. It is not uncommon for a physician or a hospital to take a significant loss on certain types of services in certain patients. Who pays the surgeon who operates on an uninsured drug dealer with a gunshot wound? Nobody. It comes with the territory. If you want to manage the health care system in this country to the extent the managed care companies do, you're either in or you're out. There is no in-between.
The managed care industry has raped and pillaged the health care system for its own handsome profits for 20 years, and they are simply reaping what they have sown. They deserve no sympathy.
5. Hot Water
Dr. Robert Jarvik, the man more known for his Lipitor commercial than anything else, is now in a little hot water. I am sure you have seen the spots where he talks about "When diet and exercise aren't enough, adding Lipitor significantly lowers cholesterol." I actually did a bit on him in a recent Placebo Television. You can check it out here. http://youtube.com/watch?v=tat9YxprZls
Anyway, though Dr. Jarvik does have a medical degree it seems he doesn’t practice clinical medicine and he is not a cardiologist. In other words, he cannot even prescribe the stuff. Even funnier to me is the part of the commercial where he is rowing a boat. It turns out that it was a body double! According to his friends, Dr. Jarvik doesn’t row.
I think it is hilarious that some actor had to put on a Jarvik wig for the shoot. Maybe Dr. Jarvik should start selling that and stop worrying about completing and perfecting the artificial heart he has been working on for decades. It would sell a lot more and no one could get heart. Okay, maybe some.
6. Walmart Is Now My Enemy
I know, I know, we have heard this all too many times before. Walmart comes to town and shuts down the Mom and Pop stores. I read Sam Walton’s story a few years back and to tell you the truth, it really is a wonderful tale. He was an amazing man. Now that Walmart, however, truly wants to put me out of business I am starting to understand what others have complained out for so long.
In late January, the New York Times reported that CheckUps, which was a clinic in Walmart in some southern states, was shutting down all 23 of their sites. I was elated.
http://www.nytimes.com/2008/01/29/business/29clinic.html?_r=1&ex=1202274000&en=eb4ddd274a2a7685&ei=5070&emc=eta1&oref=slogin
It seems they fell behind in paying the nurses and staff. Hooray, I thought. But my excitement would not last long. About a week later the New York Times put out another piece where Walmart announced plans to open several hundred clinics in their new stores. http://www.nytimes.com/2008/02/07/business/07clinic.html?ex=1203051600&en=1ae3530e247b3366&ei=5070&emc=eta1
These “Clinic at WalMart “walk-in centers are going to form alliances with local hospitals or other walk-in clinic businesses as they push forward to conquer this business.
If there is a positive, maybe there will be some transparency on the pricing for some of the services we provide in medicine. That would be a good thing especially when someone is paying cash. It also may make doctors aware that we need to get our “acutes” in the office in a more timely manner.
That being said, I believe Walmart and its partners are in for a world of hurt as they try to cater to that certain crowd who want what they want and want it now. They are the same ones who don’t have money or real insurance. In other words, Medicaid will eat Walmart alive.
7. Joke of the Week
A male patient is lying in bed in the hospital, wearing an oxygen mask over his mouth and nose. A pretty, young, student nurse appears to give him a partial sponge bath.
"Nurse", he mumbles, from behind the mask. "Are my testicles black?"
Embarrassed, the young nurse replies, "I don't know, Sir. I'm only here to wash your upper body and feet."
He struggles to ask again, "Nurse, please check. Are my testicles black?"
Concerned that he may elevate his blood pressure and heart rate from worry about his testicles, she overcomes her embarrassment and pulls back the covers. She raises his gown, holds his manhood in one hand and his testicles in the other.
Then, she takes a close look and says, "There's nothing wrong with them, Sir!
The man pulls off his oxygen mask, smiles at her and says
very slowly:
"Thank you very much. That was wonderful, but, listen very, very closely......
"A r e - m y - t e s t - r e s u l t s - b a c k ??"
8. Ridiculous Study of the Month
A study by Gary S. Becker PhD in the Journal of Economic Perspectives comes to the conclusion that paying for people’s organs would cut wait lists. He estimates that a $15,000 payment for kidneys would increase the number of transplants by 44%. Well, no sh%t, it would. Of course, there is that little snafu involving ethics. How ridiculous is this concept? Thankfully, there has been push back against Dr. Becker because his plan, others feel, would exploit the poor. No it wouldn’t. You just need to tell them they will grow another kidney back. Seriously, here is what happens when this kind of thing goes on. http://www.nytimes.com/2008/01/30/world/asia/30kidney.html This NY Times piece describes how 500 Indians had their kidneys removed by a team of doctors running an illegal transplant operation to supply kidneys to rich Indians and foreigners. As the article states, many of the donors were day laborers who were picked up from the streets with the offer of work, driven to a well-equipped private clinic, and duped or forced at gunpoint to undergo operations. The only positive spin from this, however, is that these clinics are doing wonderfully in their quality indicators.
9. Bacharach’s Beliefs by Ted Bacharach MD, retired
Physician’s Interacting
In numerous situations we are placed in a position where it is necessary to work with others. Physicians interact with their patients as well as nurses and often find it necessary to interact with other physicians. It is in the latter situation where difficulties ensue quite frequently. Personally I have a problem, I would rather let a fly escape out the window than swat her with a flyswatter. I suspect that this failing has not been of any great benefit when dealing with fellow physicians.
The first instance in which I learned about this failing was in the Army. Stationed at a small post we had two doctors. For a short period I was alone but it did not take long before a second doctor arrived. I was somewhat alerted to possible danger when he introduced himself and immediately added the fact that he did not drink, smoke or swear and did not like being around people who did. He was also a part time preacher and was an active member of an Evangelical church. When I told my wife about my new acquisition she tried to reassure me that things will work out alright, I was not entirely reassured. Our new physician had arrived by himself and had left his wife in Texas where his new born son had just been born.
Three weeks after his arrival he informed me that his wife was arriving by air in Washington DC. He asked if he could borrow my car to pick her up. I realized in spite of misgivings that I was a “soft touch”. Realizing that he had no place for his wife to stay I offered him temporary shelter at the small cottage my wife and I had rented.
The result of these actions was a threesome of houseguests that lasted six weeks. During this period my wife and our child had to move to a porch so that our guests could occupy the bedroom with their new child. Fortunately it did not get too cold. Because of his new small child he insisted on keeping the house warm. I think his concept of warm differed from mine just a little. He was from Texas and I was from upstate New York. We burned a ton and a half of soft coal in our kitchen stove to keep the house warm and got several new blankets for
my wife and I who slept on the porch.
Eating, even back in those good old days, was still something that was needed. Since it was our house our guests felt it was necessary for us to supply adequate food. Food was cheaper back in those days but so were salaries and income. By scrimping on everything else as much as possible we managed to keep our guests well fed. I tried desperately to get him to look for a place to live with little success. Finally after six weeks he found an apartment in a nearby town. He was a little upset when he was told by the landlord that he could not cover the hole in one wall with a picture as the hole was a Civil War remnant.
He had moved out the week before, when his wife called and asked my wife to take her to the commissary which was 40 miles away. My wife figured that she probably wanted to repay her for some of the groceries they had consumed while at our place. This was not the case. After returning from the Commissary my wife helped to carry her groceries into the house and returned home without thanks of any kind.
Any sensible individual would think that this experience would have taught me something— it did not. Over many years and a long career I made the same or similar mistake at least five more times. My advice to all colleagues is be as tough as you can when dealing with fellow physicians as they are just as likely to take advantage of you as anyone else.
10. How Valuable Is The Chest X-Ray?
For those not following the story, the lawsuit over the death of John Ritter is now in full force. If you don’t remember, he died over a year ago after having a dissecting aortic aneurysm. The family already has received $14 million from the hospital but they want $87 million more from the physicians involved in the case. Personally I don’t have coverage over $3 million for my malpractice so the question is where would the rest come from? Well, if the plaintiffs win the case I guess they would take the physicians personal assets. Can you imagine? You spend your whole life training to be a physician and all of a sudden it is gone in a second. I really don’t know if these docs were negligent. They certainly didn’t try to hurt him. Their case is built upon the fact that Ritter was in the throes of an MI due to the dissecting aneurysm when they arrived on the scene. Since “time is muscle”, we are trained to treat that MI as soon as possible. Unfortunately, that treatment is not good for the aneurysm. Since a chest x-ray was not done they did not see that. I wonder whether a portable chest x-ray would even see the aneurysm? Lastly, since he was having the aneurysm and an MI, I doubt he would have even made it through surgery.
What is interesting is that Ritter had all the symptoms of an MI and none of the symptoms of a dissecting aneurysm, though to be honest, there can be some crossover there. There is evidence that he had body scans prior to that day showing a normal size aorta. So, in unstable chest pain, does a chest x-ray have to always be done? And the key word is unstable. The answer, in the future, will be based not on science but on the awards in this case.
11. Future Medical News by Michael Gorback, MD
2055 - APReutersAOLWSJ.
Wal-Mart Hospital Corporation (Hong Kong Stock Exchange, WMHC) announced today it has completed its acquisition of Tenet Healthcare Corporation, creating the country's largest hospital chain. Wal-Mart, which began as a humble Five and Dime in Bentonville Arkansas in 1950, became an economic retail powerhouse during the latter part of the 20th century.
In the early 21st century, experiencing difficulty with expansion and increasing retail competition, Wal-Mart placed small in-store medical clinics in its stores. By 2021, the wave of aging baby Boomers and the collapse of Medicare drove older people to find less expensive medical care and the medical side of its business exploded as retail returns began to shrink. In 2029 Wal-Mart spun off its retail business to focus on medical care and embarked upon a series of strategic acquisitions.
Prior to this deal J.C. Penney MedCorp (New Delhi Stock Exchange, JCPM) was the nation's largest hospital chain. With Wal-Mart taking the lead, J.C. Penney will fall to second place, which also happens to be last place due to consolidation of the hospital industry in the past decade.
Physician reaction was mixed.
"Personally I don't see a problem," said Dr. Krishna Ramamurthy, who is chief of the medical staff, treasurer of the medical staff, secretary of the medical and the entire medical staff of Tenet's flagship Lucky Five Star Hospital and Gas 'n' Go. "Do you want some Lotto tickets?"
"This is a travesty," said Dr. Wen Yun Fat of Happy Panda Oncology Clinics of America, "We have no choices now as to where we send our patients who need hospitalization. Last year we had 5 people with failed nanobot therapy that we had to hospitalize. Our only choice was Wal-Mart's Gandhi Memorial Hospital because J.C. Penney's was out of network. There has to be more competition."
Jesus Valdez, M.D., President, Vice President, Treasurer, and Secretary of the AMA, said that the nation's 1,000 doctors will not stand for this. AMA plans to spend half of its 2056 $100,000 budget lobbying Congress to break up what it considers a monopolistic system.
12. Another Quality Setback
A recent diabetes study called Action to Control Cardiovascular Risk in Diabetes was halted early because more patients died when they had their blood sugar strictly controlled than those who were on a less intensive regimen. You read that right. Getting diabetic patients under tighter control, what we have been taught for so long, may be worse for them! The significantly higher death rate should throw a huge monkey wrench into the whole P4P garbage which is trying to base bonuses on how low a patient’s HbA1C is (average blood sugar over the prior 3 months). Unfortunately, it won’t.
13. Turnout
The big news this weekend is the incredible turnout in Maine to vote in the Maine Democratic Primary. For some reason the media thought it was amazing because there was a snowstorm the same day. It was described as “incredible” as “Democrats overlooked the snowy weather and turned out in heavy numbers for municipal gatherings”. Listen, we don’t have much in Maine. We are a very poor state and we are freezing our asses off here but what we do have is resilience. I guess the best way to explain that is this little vignette. I recently came back from Walt Disney World where the temperature was 78 F. We knew we were home in Maine when we were awakened the next morning with a weird sound. Looking out the window I could see my neighbor using a blow torch to melt the ice all over his driveway!
14. Feedback About The Placebo Gazette
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Until next time, keep smiling, keep laughing and keep out of the sample closet.
Doug
King of Medicine
