Tuesday, June 12, 2007

AHRQ: Overall Health Care Quality Performance in Pennsylvania

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Sunday, June 10, 2007

Pennsylvania Doctor Trap Number Two Proposed

Pennsylvania has chosen an interesting strategy to keep doctors from leaving the state. Rather than fix the current jackpot medical malpractice system they've decided to try to trap doctors that are already here.

The first example of this was something called the MCARE abatement program. The Medical Care Availability and Reduction of Error (MCARE) Act replaced an existing catastrophic coverage fund with a new fund to cover awards which exceeded the primary coverage provided by professional liability policies. Each physician must pay into the fund a percentage of their primary premium to sustain the fund.

The MCARE abatement program (or Health Care Provider Retention Program) provides some financial relief from paying premiums to the fund. How much relief a physician gets depends on the practitioners specialty. And here we come to trap number one. If you accept the abatement, you agree to practice in the state for the year in which you receive the abatement AND the next year. If you leave early, you have to pay back the full amount of the abatement.

The legislature is now working on trap number two--a physician loan forgiveness program. For a period of ten years, for every year a physician practices in Pennsylvania after completing training the state will pay off ten percent of their student loan debt. If they leave early (say, after five years), they have to pay the state back ALL of the money the state paid toward their loans.



Saturday, June 9, 2007

Why I'm Not Buying The (First) iPhone

With only three weeks to go until the release of the iPhone the frenzy is peaking. What features will it have? What is the twelfth icon? Will it have a SIM tray? Where will be the best place to buy one? I decided to today that I don't care. Let me explain why I won't be buying Apple's iPhone.

I've learned not to buy the first of anything Apple puts out. Though I love the company and have been buying their computers and other devices since the beginning, I think that (especially recently) there's good reason to be patient and let other people help Apple work out the kinks.

I ordered the MacBook on the day it was announced....and had the heat-sink problem. I ordered the 24" iMac the day it was announced...and had it up and die on day four of owning it. There are other examples of released hardware that was flawed initially but improved with each revision that, thankfully, I didn't experience myself. The bottom line is that being first has a price and that it's worth giving Apple a chance to learn from the initial release and improve the hardware with subsequent revisions. That doesn't mean waiting for the next model. Apple revises hardware between new releases, too.

The second reason for waiting is that the device you really wanted is usually the second one in the model line, not the first. But you compromise, tell yourself it's still worth getting the first one, but it's not. Because as soon as the second version comes it, you decide you should have waited. That's what happened to me with the Newton. I bought each new model as it came out (and still have a 2100).

What do I expect in the second version of the iPhone that I think makes it worth waiting for? Better-than-EDGE speed, for one thing. A camera that's better than 2 megapixels for another. GPS for a third. And many fewer problems.

Today, I put down my own good money for a Nokia N95. Five megapixel camera, built-in GPS, and a mature OS that has lots and lots of third-party apps. With iSync and the release of Nokia Media Transport yesterday (nice write-up here), adding contacts, calendars, iTunes music, photos, and videos just got a lot simpler.

ReaderMini: Google Reader On-The-Go

I track about one hundred news sources with Google Reader. By subscribing to a site's RSS feed, I can see updates as they happen without having to visit the web page itself. Very efficient.

Google has a mobile version, too. Thought this stripped-down version is excellent for cell phones, the interface is too simple for someone with a more capable internet device such as a PDA, UMPC, smartphone, or Nokia N800 internet tablet.

From reading the forums at internettablettalk.com I just found ReaderMini:

"Reader Mini is a light-weight alternative to Google Reader. Reader Mini uses the Google Reader API to access your feeds. It is a compromise somewhere between the power of the main interface and the too-limited mobile version."



Friday, June 8, 2007

Pennsylvania's Lawmakers Could Learn From Texas

Texas enacted tort reform in 2003, capping damage awards at $250,000. In an article titled "Insurance companies, doctors flock to Texas" David Hendricks passes along some facts I hope Pennsylvania legislators take to heart:

  • Malpractice insurance rates have fallen an average of 21%
  • The number of companies offering malpractice insurance in the state has risen from four to thirty
  • Malpractice lawsuits have fallen 50%
  • Doctors are coming to Texas, as evidenced by 2,250 pending applications for medical licensure

[Kevin, MD]



Thursday, June 7, 2007

At risk: vaccines - The Boston Globe

The Boston Globe

"Certainly there is plenty of evidence to refute the notion that vaccines cause autism. Fourteen epidemiological studies have shown that the risk of autism is the same whether children received the MMR vaccine or not, and five have shown that thimerosal-containing vaccines also do not cause autism. Further, although large quantities of mercury are clearly toxic to the brain, autism isn't a consequence of mercury poisoning; large, single-source mercury exposures in Minamata Bay and Iraq have caused seizures, mental retardation, and speech delay, but not autism.  

Finally, vaccine makers removed thimerosal from vaccines routinely given to young infants about six years ago; if thimerosal were a cause, the incidence of autism should have declined. Instead, the numbers have continued to increase. All of this evidence should have caused a quick dismissal of these cases. But it didn't, and now the courthas turned into a circus. The federal and civil litigation will likely take years to sort out."


[Via PointofLaw.com]


Thursday, May 24, 2007

Pennsylvania CRNA's Are After Independent Practice (Again)

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Currently pending in the Pennsylvania Legislature is House Bill 1256 to amend the state law that currently requires CRNA's to be supervised by physicians. If enacted, Certified Registered Nurse Anesthetists would no longer be 'supervised' but 'shall administer anesthesia in collaboration with a physician or dentist' (emphasis mine). Furthermore, such collaborating physician only needs to be available electronically (i.e. a phone call away). I'm told that this new language would essentially give CRNA's the ability to practice independently in the State of Pennsylvania.

I think this is a very, very bad idea. In a year when the Governor has made patient safety a centerpiece of his legislative agenda, telling CRNA's that they can practice without supervision seems to me to be a step in the wrong direction. CRNA's are nurses. Highly trained (and the most highly paid) advanced practice nurses, yes, but still nurses. The proposed legislation seeks a substantial change in the status quo and should not be enacted without clear proof that the quality of care Pennsylvania's residents receive will not be adversely affected.

The CRNA lobby is arguing that you really only need anesthesiologists in teaching institutions. I hope our legislators will pause to consider how silly this assertion is. I know a lot of CRNA's. A few of them are very, very good. I would let any one of my physician colleagues (that's about forty people) give my family members an anesthetic. I would only let a handful of CRNA's do the same, and then only with physician supervision immediately available.

Perhaps we should amend this bill so that only the Governor, and members of the legislature and their families will receive anesthesia only from CRNA's and without physician direction for, say, the next ten years and see how good an idea they think this is.

Pennsylvania's citizens are aging. They need physicians to evaluate them before, during, and after their surgery and anesthesia. If you're in favor of this bill, you're probably also in favor of RN First Assistants doing routine cholecystectomies and other surgeries. Those performing surgery have to try really hard to kill a patient. We just have to not pay attention for one minute.



Saturday, May 19, 2007

"Not All Hyperglycemia is the Same"

One of my almost daily frustrations is the imprecise description of what kind of diabetes patients have. I'm often told, or see written, that a patient has 'insulin dependent diabetes' just because they are taking insulin. Dr. RW points to the second in a series of articles on diabetes in the journal Clinical Diabetes. It's a good review for me that I may use as the basis for a 'refresher' for the nurses...

[Dr. RW]



Monday, May 7, 2007

Another Obstetrics Ward in Philadelphia Plans To Close

The Philadelphia Inquirer published an article over the weekend titled Demise of maternity wards is inducing . . . The Baby Scramble
"Blaming financial losses and a deluge of patients who previously might have gone to other, now-defunct maternity wards, Jeanes Hospital is closing its obstetrics unit May 31. Chestnut Hill Hospital is reviewing its obstetrics program as well and has not ruled out closure."

Lots of other good data in that article, too, such as the time-line for closure of other OB units in the greater Philadelphia area:

  • Medical College of Pennsylvania (1997)
  • Nazareth (1998)
  • Germantown (1999)
  • City Avenue (1999)
  • Roxborough (1999)
  • Warminster (2000)
  • Elkins Park (2001)
  • Episcopal (2001)
  • Mercy Philadelphia (2002)
  • Methodist (2002)
  • Mercy Fitzgerald (2003)
  • Parkview (2003)
  • Frankford-Torresdale (2006)
  • Jeanes (2007)

Pennsylvania Physician Supply Back In The News

A recent Health Affairs article titled Changes In Physician Supply And Scope of Practice During A Malpractice Crisis: Evidence From Pennsylvania has gotten a great deal of national media attention. It's conclusion was as follows:

"...This study found that the proportions of physicians restricting their scope of practice and exiting practice in Pennsylvania were similar during and before the malpractice crisis for most high-risk specialties. The overall supply of high-risk specialists did not decrease during the crisis except in obstetrics-gynecology."

I've been thinking about this article for a while now. I've written to the lead author asking about the inclusion of medical residents-in-training in their statistics but have yet to hear back. Including residents may hide important trends. For example, new residency programs may have opened during the study period. Trading doctors who are fresh out of internship for experienced specialists is not a good deal, but the numbers as used wouldn't show this.

Another question I have is 'compared to what?' What has happened in other states during this time? According to the Dauphin County Medical Society, among the twenty most populous states, only Pennsylvania and California saw their physician supply drop during the study period. All others saw an increase of 10-20% in physician supply.



Sunday, May 6, 2007

I'm a Better Anesthesiologist Today Than A Year Ago

At the end of this busy week I began to reflect on how this week was different than an average week would have been even a year ago.  It was different both for me and for a significant number of my patients.  Hopefully, it was as good for patients as it was for me.

For the first ten years after I finished my training I did not believe nerve blocks for extremity surgery were worth doing.  Surgeons didn't want to wait for me to do them or for the blocks to 'set up.'  Blocks failed a certain amount  of the time. There were complications that just didn't happen when 'numbing the big nerve.'

My thoughts on all this changed, not because of a journal article or discussions with a colleague, but because of an article in Wired magazine.  The Painful Truth was an article on the use of regional anesthesia to improve medical care to our wounded soldiers in Iraq and Afghanistan:

Now Buckenmaier is leading a group of army doctors and nurses determined, as he puts it, "to drag the military kicking and screaming into the 21st century." His team believes the future of wartime pain control is a new form of anesthesia called a continuous peripheral nerve block, which takes a more targeted approach by switching off only the pain signals coming from the injured limb, leaving patients' vital signs and cortical functions unimpaired.

The applicability to civilian anesthesia was obvious.  In my hospital, when someone gets a knee replaced, the surgeon usually blindly injects a large amount of local anesthetic in the general vicinity of the femoral nerve and we dope them up with morphine.  Patients are in the hospital for three days largely for pain control issues, all the while at risk for nausea, vomiting, respiratory depression, etc.

I took a second look at regional anesthesia and decided to use it in my practice again.  This week two elderly ladies had total shoulder replacements after having interscalene blocks. They were pain free for the rest of that day.  Six of my patients had knee replacements after femoral and sciatic blocks.  They had no pain until the next morning.

With catheter techniques, these pain-free intervals will be measured in days instead of hours.  The surgeons are giving us the time to do these techniques because they are hearing about how good they are for patients at their own national meetings.  My colleagues who 'didn't do blocks' have learned to do simple femoral nerve blocks and want to learn others.

It was a good week for me because I love seeing patients do well. It was a good week for my patients (whether they knew it or not) because they trusted me enough to let me poke them with a needle once or twice to make their recovery that much easier.  By next year I hope to be placing catheters and doing infusions.  Thanks, Trip Buckenmaier.


Friday, April 27, 2007

Pennsylvania Malpractice Numbers Ignored?

I composed a polite letter to the editor of our local paper, the Patriot-News. It went something like this (exactly like this, actually):
"Title: Is Pennsylvania's Malpractice Crisis Solved? Maybe for trial lawyers.

Dear Editor,

Data just published by the non-profit, non-partisan Kaiser Family Foundation at http://www.statehealthfacts.org/ provides facts to consider in our discussion of health care reform in Pennsylvania.

Based on data from the National Practitioner Databank, Pennsylvania ranks third in the nation in the number of paid malpractice claims per thousand physicians (http://tinyurl.com/22mppw). Pennsylvania ranks second only to New York in total payments for claims made during 2006--over $300,000,000 (http://tinyurl.com/26hh9p).

Please consider passing these facts on to your readers so that they may form their own conclusions about the state of Pennsylvania's malpractice system. I submit that being ranked second and third in the nation in two objective measures of malpractice payouts does not support those who contend that our malpractice crisis is 'over.'"

Was it published? Nope. Oh, well.


It WAS published on Sunday, April 29th, 2007,
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