30 March 2008

Grim Irony

The Chief Complaint read "Defibrillator shocks."

The patient, an eighty-something year old man, had an ICD, an implanted cardioverter/defibrillator, due to a history of cardiomyopathy (enlarged heart) which presumably had predisposed him to abnormal and dangerous irregularities in the heart rhythm and even sudden death. A small computer packet implanted in his chest wall monitored his heart rhythm and could regulate or even shock the heart if it detected certain abnormalities. He reported that he'd had half a dozen shocks from the thing in the previous eight hours.

ICD discharges are really uncomfortable. They feel, I have been told, like the proverbial "kick in the chest."

Usually, an ICD discharge is not a big deal -- it's the device working as designed. You watch the cardiac monitor, or interrogate the device's memory, and verify that the shocks were appropriate. If the thing is malfunctioning, it can be reset. Mostly, you have to ensure there's no underlying reason that the patient is having arrhythmias -- a new heart attack, or heart failure, dehydration, infection, etc. -- and treat the cause, if possible.

For this guy, the cause was actually pretty obvious. He admitted that he'd been feeling poorly, and in the ER he had a fever of 102° and was clearly septic from a UTI. His blood pressure was low, and while examining him, I saw two short episodes of ventricular tachycardia (VT) on the monitor, one of which resulted in yet another shock.

So the device was working appropriately, and we instituted standard treatment for sepsis -- antibiotics and all that good stuff -- and posted him for an ICU bed, even though he wished to be DNR. But predictably, he did not do well, and while in the ER he began to show signs that he was unlikely to survive this illness. Family assembled at the bedside and we had "the talk." They were tearful but accepting, and slowly but peacefully, the patient departed the land of the living.

Except nobody remembered to tell his ICD. The damn thing just wouldn't give up! Long after the patient had basically expired, long after his heart had lost the ability to beat in any sort of functional pattern, the silly thing kept pacing away and periodically issued a shock, which caused the patient's body to twitch in a manner most distressing to the family.

A frantic search ensued for a magnet. Placing a donut-shaped magnet over the device deactivates it, and we keep one in the ER for just such an occasion, but it was missing -- stolen, it was darkly intimated, by the ICU. They couldn't find it either. Eventually I got a cardiologist from the building next door to send one over, and we shut it off for good.

As this was transpiring, I was at the bedside talking with the family. The patient's wife pulled out his wallet and showed me the manufacturer's card for the ICD -- It was a "St Jude" model. While I know nothing about the company, St Jude Medical, I endured sixteen years of Catholic education and I know my catechisms: traditionally, St Jude is the patron saint of lost causes.

No wonder the damn thing wouldn't give up.

25 March 2008

Fluorescent Therapy: Corollary

One corollary to the Fluorescent Therapy outlined in my previous post is what is commonly called "Boredom Therapy." This is most commonly applied to patients with complaints which are factitious or derived from personality disorders, or those with complaints most likely related to drug-seeking behavior, or other presentations in which there is clearly little to no medical urgency coupled with a patient interaction which is likely to be difficult, complex, and confrontational.

Theses cases differ from fluorescent therapy in that there is no obligatory time delay built in by reasonable and justifiable medical tests. Patients view such a time interval and its attendant fluorescent exposure as valuable and itself therapeutic.

Boredom therapy is that in which the physician provider simply ignores the patient and leaves them neglected in the room for an extended time, while nothing happens. Although this may seem callous or even abusive, it is usually not, nor is it even deliberate in most cases. For example in a typical busy ER, the doctor is likely juggling coordinating the care of several critically ill patients, and simply does not have the spare time to sit down and explain to the patient with Chronic Recurrent Abdominal Pain why, in this the seventh ER visit in two months, we will not be able to provide a definitive diagnosis for their pain. Or perhaps the doctor is simply scared of what is certain to be a challenging confrontation and "ducks" the problem patient, paying attention instead to all his other patients until the nurses, who cannot avoid the increasingly annoyed glares from the patient, who is now standing in the doorway of their room, force the doctor out from his hiding spot to go discharge the patient.

In some rare cases, with patients who clearly are abusing the ER, deliberate boredom therapy is applied, with the intent of making the patient understand that the ER is not a fun or productive place to be, and to negatively reinforce the behavior that brought them in.

In all cases, "Boredom therapy" facilitates the discharge of the patient, by wasting enough of their time that they simply don't want to be in the ER any more and want to go home. The value is that these patients would otherwise be resistant to discharge, either because they had unrealistic expectations of what could or would be accomplished in the ER, or because they somehow enjoy coming in. The cost, which must be balanced, is that the patient, who really didn't need to come into the ER in the first place, ties up a bed for several hours, and makes your nurses hate you. If the waiting room is full, it's generally better to forgo the boredom therapy and just discharge them directly, even though that usually means an ugly fight.

[Please note: if you ever came in to the ER as a patient and had to wait a long time, it was most likely because ERs are busy and inefficient. Boredom therapy as described above is reserved for patients who are clearly abusing the ER. This is in all likelihood not you. Please don't rant in the comments about how long it took when you went in for "x" -- I've heard it a million times, and really, we're sorry about it, but it's off-topic. On the other hand, if you are a malingerer or psychologically disturbed person who has been abusing the ER, then by all means, go right ahead and flame on! (dons asbestos underpants)]

A Novel Application of Phototherapy in the ER

Anybody who has cared for premature infants or neonates with jaundice is familiar with the Bili-Blanket, a form of phototherapy in which blue light at about 450nm isomerizes bilirubin into a form which is water-soluble and more easily excreted.

Similarly, those in the frigid North of Alaska and Canada are aware of the value of phototherapy for Seasonal Affective Disorder. The long nights up there can induce depression, so very intense light sources are used to stimulate the pineal gland, which can ameliorate the depressive effect of the prolonged darkness.

In our ER, we have many times noted the efficacy and value of a type of phototherapy, which we call "fluorescent therapy."

A typical application would be a patient who presents with a number of vague, constitutional symptoms which appear on the initial examination not to herald any serious medical condition, but are serious enough to justify a work-up, perhaps with labs or some sort of time-consuming imaging study. The patient, during this evaluation, is placed in a room illuminated by a standard industrial fluorescent tube bulb, and there they remain for several hours, bathed in its flickering, blue-ish glow, while awaiting the results of their tests.

After completion of a non-standard time course of this phototherapy (150-210 minutes in most cases), a high frequency of spontaneous remission of symptoms is noted, and without further intervention, the patient reports feeling better and wanting to go home. Outcomes indicate that the one-month mortality for patients treated with and responding to fluorescent therapy is exceedingly low, approaching zero.

Further research is needed into other potential applications of this novel form of phototherapy.

24 March 2008

I am no longer smug

My MacBook Pro is infested with a virus -- or some sort of malware; I can't quite figure it out. The browsers (Safari and Firefox) periodically get hijacked. I'll try to load a common site (say this one, or Google) and get involuntarily redirected to some site which purports to provide traffic tracking services or the like.

I called Apple Care and they thought I have a virus, so I shelled out some cash for McAfee's VirusScan, scanned the drive, and found nothing.

The hijacking is frustratingly intermittent, which of course makes it harder to diagnose.

Oh, well, it could be worse. I could be running Vista.

Well, go figure. Turns out I'm still smug. Never mind.

(amusing on-line Apple ad courtesy of The Unofficial Apple Weblog)

4,000


Just sayin'

(Image credit: Mark Wilson/Getty Images)

23 March 2008

Irresponsibility

I met with my tax guy the other day. I'm tragically a victim of my own success; this year I will pay enough in taxes to fill the tanks of an F/A-18 with enough Jet-A fuel for a single mission. (And yet the damn Navy won't let me ride along! It's only fair -- I paid for the gas, I should get to ride back seat.) So we go through the whole rigamarole, determining which exclusions and deductions are reasonable and lawful and which are not.

While doing so, I cast my mind back a month or so to a blog post by Edwin Leap, in which he opined that "if we [elect] a Democratic president, that president, he or she, will surely raise taxes. I explained that I was really unhappy with that idea, and that I like the current tax cuts." Well, I can't entirely disagree; I too like low taxes, and my taxes, as a fraction of my overall income, are the lowest they have ever been.

Edwin runs in a different direction with his thoughtful post, and I refer you to read it for yourself. He touches on what most of us would consider a reasonable area of discussion -- whether government should be large or small and how far the scope of government should extend into the private sphere. There's a lot of vibrant debate taking place on these topics at both the national and local levels, and there are valid points on both sides.

What bothers me about the government's policies of the last seven years, and the virulent strain of conservatism, commonly described as "anti-tax activism," is that it conveniently ignores the reality that, once the government we are debating actually exists, once the money is spent, whether for good or for ill, that government must be paid for. "Anti-tax" is not a valid governing philosophy. "Small government" is a valid philosophy, though I don't particularly subscribe to it, but whether the government is big or small, it has to be paid for. The only way to pay for the government is taxes. Taxes today are unpleasant. Deficit spending inevitably results in higher taxes, with compounded interest, to be paid in the future, by us and by our children.

And this is what I find the most reprehensible about the Bush government's policies: they have expended federal entitlements enormously, quadrupled earmarks and pork-barrel spending, and engaged in a very expensive war, while pretending that it simply does not need to be paid for. You probably know that I, like almost two-thirds of Americans, think going into Iraq was misguided. The most recent estimates I have seen indicate that the direct costs of the war exceed $500 Billion. Even though I opposed and oppose the war, I do acknowledge that it has got to be paid for! But not the republicans.

Dick Cheney famously growled that "deficits don't matter. Reagan proved that." Perhaps, in the narrow sense that an administration can max out the national charge card without paying an electoral price; Bush's re-election seems to have confirmed this tenet. But do deficits really matter? Is the dollar's recent collapse in some part related to the national debt? What other real world consequences are there to this debt? There are a lot of really smart economists out there who debate this passionately and in terrible, mind-numbing, boring detail; I'm humble enough to admit that I don't have any claim to expertise or authority in this field. But the common-sense conclusion is inescapable: large structural deficits, escalating over time, are unsustainable in the long term.

In addition to the economic risk of a national debt that exceeds 40% of GDP, there are strategic risks. China's central bank owns about $1.3 Trillion in US Treasury notes, and has threatened to liquidate these, should the US try to impose any sanctions. I don't know about you, but I find it very unsettling that a not-exactly-friendly power like China has, should it choose, the ability to devastate our economy and trigger a collapse in the value of the dollar.

In response to this point, Edwin wondered if we couldn't balance the budget just by cutting spending. Unfortunately, about $2.1 Trillion of the $2.9 Trillion budget is off the table -- national defense, social security, interest on the existing debt, medicare, etc. There doesn't seem to be room in the remaining budget for cuts to offset the $500 Billion-ish annual deficit. Bush has been content to run out the clock on this fiscal catastrophe. McCain disingenuously promises more tax cuts. The Democrats, mindful of Walter Mondale's fate, studiously say nothing.

I think Edwin is right: if we elect a Democrat, taxes will go up. I'm not jazzed about that. On the other hand, I went through some pain to pay off my credit cards and I am glad I did. Now I've got more discretionary income to play with. Bill Clinton stared down the republican congress, raised taxes, and balanced the budget. It can be done, though with some pain. It's necessary -- if any politician has the stones and the maturity to do it. If we put it off, we just hasten the day of reckoning.

Bill Clinton bequeathed to Bush and America a budget that was balanced and solvent. Bush and his enablers in the Republican congress squandered that. I'd be pretty pissed, if I were Clinton, since the balanced budget was his most tangible and important legacy. Of all Bush's many crimes against the American people and the Constitution, his recklessness and irresponsibility with the nation's future may not be the worst, but may ultimately prove to be the most intractable.

The national budget must be balanced. The public debt must be reduced; the arrogance of the authorities must be moderated and controlled. Payments to foreign governments must be reduced, lest Rome become bankrupt.
Marcus Tulls Cicero, 63 BC

20 March 2008

On the bandwagon

OK, everybody else is doing it, so I might as well indicate my awe at Obama's reframing of the racial question with the greatest American political speech of the past thirty years, by providing a link to what was this morning the most-viewed item over at YouTube:


I won't gush too much over the speech itself. Enough has been said elsewhere, and it's inarguably a great speech delivered by a great orator, whether you agree with his politics or not. But Lars, a previously unknown-to-me diarist over at DKos pointed out in whimsical fashion what may be the most remarkable aspect of this speech:

He Wrote It Himself.

I spent the last five hours in my woodshop with a lathe and sandpaper and an awl, carving this beautiful oak chair that I now present to you.

I did it because you will need something to sit down on when the full measure of what Ambinder wrote crashes upon you like all the heavens and the stars above.

Let me repeat it.

Because it bears repeating.

That speech today? The one that has pundits--from the liberal David Corn at The Nation ("This is as sophisticated a discussion of race as any American politician has sought to present to the public") to the conservative Charles Murray, of National Review Online ("it is just plain flat out brilliant—rhetorically, but also in capturing a lot of nuance about race in America. It is so far above the standard we're used to from our pols."), and those in between--noting the brilliance, sophistication, sincerity and candor of the words spoken by Obama? That speech?

He wrote it himself.

Once more, with feeling:

He wrote it. Himself.

Barack Obama did. He wrote it.

Now, if you are like me, and I pray for your soul you are not, you had the normal reaction to finding out this piece of information. You rushed right to the Library of Congress to determine exactly the last time that a President or a presidential candidate wrote a major speech alone, by himself or herself.

And, of course, what you discover is that other than the speeches Obama has written for himself, the last time a major speech was written without the aid of a speechwriter by a president or presidential candidate was Nixon's "Great Silent Majority" speech delivered on October 13, 1969.

Now that was a good speech. Evil, no doubt, to its very core, and designed to proliferate the feelings that allowed the great Southern Strategy success, but a good speech nevertheless.

In other words, not in my lifetime. And I am oldish. I have kids and wear dark socks with slippers and complain about the quality of my lawn and get hungover way too easily. But in the last 37 years there hasn't been a speech like this written by the man himself. Not like this.

Here is a chair. Regardless of who you support, or what you think of Obama, I want you to sit here, right here on this chair and consider something wonderful. To wit:

It is possible that we will have a President who not only will speak in full, complete sentences, but who will do so in a manner that is eloquent, and who will also be articulate and eloquent in delivering words he is intelligent enough to know, understand, and use in a speech he is capable of writing himself.

This chair, it is oak.

Sit and think about that.

After seven years of the worst crumble-bumblings of the nattering nabob from Crawford, think about that.

He wrote that speech. He wrote it. He, himself.


Amen.

It's supposed to be funny

From Bill in Portland Maine:

Democrat Eliot Spitzer was forced to resign for hiring prostitutes because he seemed to be such an upstanding public figure. Senator David Vitter, on the other hand, wasn't forced to resign for hiring prostitutes because, well, that's what America has come to expect from Republicans.

More humor, political and otherwise, after the jump. Your mileage may vary.

19 March 2008

Why do people go to the ER?

Skimming the billing reports -- usually I just look at the financial metrics, payor analysis, etc. -- the important stuff. For some reason I was caught by the list of most common diagnosis codes used in our ER, in order:

  • 786.50 UNSPEC CHEST PAIN
  • 789.09 ABDOMINAL PAIN OTHER SITE
  • 465.9 ACUTE UPPER RESP INFECTIONS UNS
  • 847.2 SPRAIN/STRAIN LUMBAR REGION
  • 558.9 OTH NONINFECTIOUS GASTROENTERITIS
  • 486 PNEUMONIA ORGANISM UNS
  • 466.0 ACUTE BRONCHITIS
  • 780.99 OTHER GENERAL SYMPTOMS
  • 784.0 HEADACHE
  • 346.90 UNS MIGRAINE NOT INTRACT
  • 847.0 SPRAIN/STRAIN OF NECK
  • 079.99 UNSPECIFIED VIRAL INFECTION
  • 599.0 URINARY TRACT INFECTION UNSPEC
  • 724.2 LUMBAGO
  • 338.19 OTHER ACUTE PAIN
  • 780.2 SYNCOPE/COLLAPSE
  • 780.97 ALTERED MENTAL STATUS
  • 786.09 RESPIRATORY ABNORMALITY OT
  • 428.0 CONGESTIVE HEART FAILURE UNSPEC
  • 787.03 VOMITING ALONE
  • 381.00 UNS ACUTE NONSUPPUR OTITIS MEDIA
  • 491.21 OBSTRUCT CHRON BRONCHITIS W EXAC
  • 493.92 ASTHMA UNSPEC W ACUTE EXACER
  • 625.9 UNS SYMPTOM FEMALE GENITAL ORGANS
  • 780.4 DIZZINESS/GIDDINESS
So there you have it. There's a lot of duplication, though. There are no fewer than ten different "Chest pain" codes. Gotta love coder-speak: "Other General Symptoms." What the heck does *that* mean? (Other than the coder couldn't figure out what the heck the doctor meant).

17 March 2008

Completers

Suicidal patients are an everyday part of life in the typical American ER. For a variety of reasons, the vast majority of the "suicide attempts" are not particularly serious, by which I mean that the methods most commonly seen are not terribly lethal, and the patients attempting usually didn't actually want to die. For example, consider a patient who impulsively grabs a knife and makes a few superficial cuts in his or her wrist while arguing with their spouse, who then dutifully calls 911, or one who downs a whole bottle of prozac and then immediately calls a friend to tell them what they have done. These are the "suicide attempts" we routinely care for.

These patients are often a huge pain in the ass. They are usually intoxicated, often combative and agitated, may require extensive workups to ensure that no actual life threats exist, and wind up spending hours and hours in the ER, weeping and wailing, puking charcoal all over and annoying staff with their dramatic and manipulative behavior. Occasionally a non-serious gesture winds up being more dangerous than the patient intended. ("You mean tylenol is dangerous?") Many a time an irritated nurse has approached me and grimly suggested that we publish an educational flier titled "Suicide: getting it right the first time."

If this makes it sound like we don't take suicide attempts awfully seriously, then you're right. Mostly it's due to the preponderance of minor suicidal gestures over real attempts. Don't think we're not professional about it -- we know how to rule out the serious threats and make sure that a safe disposition is accomplished. But we are not overly impressed with the low-level stuff we usually see. I think the relative absence of "serious" attempts in the ER may be due to the fact that the numerical incidence of real suicidality is low, compared to the gestures, and the selection bias that those people who really do want to end it all tend not to make it in to the ER.

They are called "completers," in the jargon, as they "complete" their suicide attempt. When a would-be completer comes into the ER, it changes the whole tone of the evening. A pall settles over the department; the place is unusually quiet and staff uncommonly grave. This guy really meant it. It's a weird feeling.

Like the guy I saw the other day. A classic completer: middle-aged male, rather heavy drinker, recently lost his job and losing his marriage. His wife came home to find him in the garage with the engine running, unconscious, with an empty vodka bottle and pill bottles in his lap. Only she came home earlier than he expected.

He came in intubated with a carboxyhemoglobin level greater than 40%, which means that 40% of his red blood cells were saturated with carbon monoxide and incapable of carrying oxygen. This starved his brain of oxygen and resulted in a loss of consciousness, and would have progressed to death if not interrupted. The outcome in this case was good; we "dove" him in a hyperbaric chamber. Oxygen in higher-than-atmospheric concentrations can rapidly displace CO from the blood, allowing for full or near-full recovery if brain damage has not already occurred. This individual had a short stay in the ICU and was discharged to a voluntary psychiatric hospitalization.

This was an uncommon case with a reasonably happy result; many serious-but-unsuccessful suicide attempts wind up causing devastating consequences, especially when the method is violent: handgun, hanging, and certain poisonings can cause permanent brain damage, spinal cord injuries, or other organ failures. It's all very sad. I probably feel more empathy for these folks and their families than I do for almost any other patient. How terrible must their perceived suffering have been to drive them to actually pull that trigger?

I am glad we don't see them too often, because it's a hard thing to stare in the face:

This guy really meant it.

I'm Back and I'm Bald

I never realized how temperature sensitive my scalp is! It's not uncomfortable, it's just that I usually don't perceive the sensation of temperature up there. If I walk under an unshielded lightbulb, I can sense it clearly. A slight gust of wind is easily perceptible. Weird. I'm gonna need some hats.

Oh, yeah, right. You all want pictures. Here you go:

Enjoy, and remember, if you enjoy looking at these pictures, you are ethically obligated to go to the St Baldrick's web site and donate. They're still accepting donations, of course.

Here's a more complete photo gallery for your enjoyment.

Oh, and Nathan's Network wound up with over $36,000 raised, and I brought in somewhere around $16,000, once a few last pledges straggle in. Not too bad.

Cheers!

10 March 2008

Nearly there

Four more days to go. On Friday, I'll be going bald for children's cancer research. So far, through the wonderful efforts of my friends, family, co-workers, and the incredible readers of this blog, I've raised nearly $15,000! Nathan's Network has raised over $30,000, which I find just incredible.

So, if you wanted to give, but never got around to it, you've got four more days. You can click on the link below, or call 888-899-BALD to make your secure, tax-deductible donation.

I'll be traveling, so pics of my shorn scalp may not show up till monday.

Don't delay any longer! Click the link and help cure pediatric cancers today!

DONATE

Oh yeah, and while you're at it, stop by ScrubsGallery.com to pick up some high-quality medical fashions... They're also sponsoring me with a challenge grant. So buy some stuff and know it's going towards kids' cancer research!

I get emails

from my in-box:

Kandahar Afghanistan

ED docs, or non-ED docs with significant ED experience, wanted for Medical Crash Crew service in Kandahar, Afghanistan. Rotations 10 weeks on/ 5 weeks off. Medical evac insurance, travel, accommodation and life support provided. Safe base, no work outside the base, and team is part of NATO support staff.

Pay is in Euro, tax free, with bonuses and superannuation ( pension plan) payment of 9% extra. Locum enquiries welcomed. We have an urgent need for a physician to deploy and be in location for 10 weeks from 3 May 2008. ( As the applicant pulled out-his wife, who wears the pants, was watching CNN too much and had a very active imagination) Lesser locum periods are possible but will definitely need to be negotiated.

Salary expectation is: EUR 48,000 for 10 weeks tax free. This is approximately USD$74,000 for 10 weeks at present exchange rates.
Yow. Suffice it to say with a new baby in the house I am not heading overseas any times soon. I'm not endorsing or promoting this offer, by the way. Just, yow.

This is not medical

But it is awesome. Have you ever been confused about this whole complex sub-prime mortgage meltdown? Here's a hysterical -- and reasonably accurate -- presentation of how it all went down, crudely animated with stick figures.

[h/t Greg Mankiw, who also points out that the language is not safe for young children, but then it's economics, which is never safe for young children.]

07 March 2008

Resistance... weakening

With the release of the iPhone SDK, the iPhone now has epocrates running native on it, according to Mac Rumors.

The epocrates site implies that it's still a browser-based interface; maybe they just haven't updated the web site.

I use epocrates all the time. I used to use it on my Sony Clie (Palm OS), then on my BlackBerry Pearl, but I always found the sync features buggy and since our ER now has an EMR, I spend a lot of time at a PC workstation and so I just have the free on-line epocrates bookmarked. But it's insanely useful, and if it were available for the iPhone, and worked well, I'd go back to putting it in my hip pocket, even if that meant paying for it.

When I don't use epocrates, I get a lot of phone calls from bemused pharmacists, saying tactfully, "Doctor, you didn't really mean to prescribe this, did you? You know the more common dose is..."

Damn I want an iPhone. Five more months until my t-mobile contract expires, and hopefully by then the next-gen iPhone will be out, with the faster EDGE 3G web browsing.

Five months.

Damn.

05 March 2008

Health policy wonkery round-up

Things I've been reading lately:

From the Washington Post: The Healthy Americans Act, sponsored by Senators Wyden (D-OR) and Bennett (R-UT) is still alive and kicking. It's an innovative proposal to "blow up the existing health insurance system," and replace it with a public-private partnership providing universal coverage administered largely by private insurers. Best of all, it eliminates Medicaid (!), which feature alone makes me want to support it.

According to Ezra, Sen Wyden spoke today at the American Health Insurance Plan's conference, speaking to the insurance industry executives, with a surprisingly warm reception. "If your profession decides – as it did in 1993 and 1994 – to go out and spend millions of dollars fighting to preserve the status quo, you may delay reform for awhile but you will increase the likelihood of a government run health system with no role for the private sector.” There is growing support from unlikely industry sources for this sort of health care reform, including large employers like GM, the small business associations, and the SEIU and other labor organizations. If the insurance industry's opposition is co-opted by mandates (which would greatly increase the size of their customer base) and subsidies, that would go a long way towards removing obstacles to reform.

DemFromCT over at Daily Kos published a thoughtful and surprisingly non-partisan, neutral diary on the prospects for reform and the dueling priorities that different players have. Kevin will be pleased to see that single payor was preferred by only 15% of respondants to a survey.

And while we're perusing the Great Orange Satan, jd in nyc has an insightful post on how multipayer universal healthcare works in other countries and the lessons we might draw for US healthcare. Key graf:

The first wave universal healthcare system in the U.S. will expand, not shrink, private health insurance. You have nothing to fear from this, so long as ... a few simple rules are followed.
  1. All individual insurance is guaranteed issue: no insurer can turn you down for coverage based on pre-existing conditions, nor can it drop you once you get sick. When the insurer can't get drop you, it immediately has a much stronger incentive to take care of you. A stitch in time saves nine, and all that.
  2. All individual insurance is community rated: insurers can't charge you 10x as much as your neighbor because you are 50 and have diabetes, whereas she is 25 and has no illness. Large risk pools are created so that the healthy subsidize the sick.
  3. The cost of insurance is determined by ability to pay: the poorest get it for free, and lower income individuals have a sliding scale of subsidization.
  4. Individual and/or employer mandates: if a substantial number opt out of the system, they are disproportionately likely to be healthy and/or poor. each group causes its own escalating problems if allowed to opt out, so this must be strongly discouraged by making it never to one's financial advantage to do so. Penalties must be higher than the cost of coverage for your income bracket (or firm size).
  5. Universal, standard basic insurance package: this has the benefit of ensuring everyone has real health coverage and not crap insurance, and it also lets every provider know a large range of things that are going to be covered no matter what. It dramatically reduces bureaucratic complexity from what we have now, even if it isn't as simple as single-payer.
  6. Some means of comparing and purchasing insurance options in a straightforward and transparent way: self-explanatory, I think. This was the national insurance exchange in Clinton's 94 plan, and is the Health Connector in Massachusetts' current system. Universal access to FEHBP fills that role in Clinton's new plan.
  7. Some additional set of mechanisms for rewarding insurers for helping people to be healthy, but not for enrolling a disproportionate number of people who are already healthy: the idea is to discourage cherry picking, which is hard to do in a guaranteed issue system but possible, and encourage wellness and disease management activities on the part of insurers. There are several options here that I won't go into.
The counterpoint to that is Ezra's op-ed piece, Why health insurance doesn't work, which describes the current perverse market incentives which drive bad behavior by insurers. Key insight:
Health insurance ... is a form of risk pooling that individuals use to smooth out lifetime healthcare costs. Heath insurance does not insure us against risks so much as it insulates us against costs. We pay regular premiums so we don't have to directly pay for irregular care.
'nuff said.

04 March 2008

I almost forgot to link this

WhiteCoat over at the eponymously named WhiteCoat Rants has struck a deal with Scrubsgallery.com to sponsor my St Baldrick's day shave!

The deal is this:

ScrubsGallery.com has offered to donate $10 to ShadowFax’s efforts, up to a total of $500, for each purchase made at the ScrubsGallery.com web site. Buy a scrub top for $15 and $10 of your purchase goes to St. Baldricks. Buy a lab jacket for $18 and $10 of your purchase goes to St. Baldricks. Buy a stethoscope for $9.95 and St. Baldricks still gets $10. Even better is that you get free shipping on orders more than $29.

I can't thank ScrubsGallery.com and WhiteCoat enough for this creative collaboration -- all their idea -- I had nothing to do with it! So, if you happen to be in the market for some new scrubs in the next ten days, get thee over to ScrubsGallery.com and peruse some of their fine merchandise.

And if you haven't yet, there's still plenty of time to donate to St Baldrick's. Click the image below to help me get to my new, improved goal of $20,000, crush JimII and his lawyer friends, and contribute to curing kids' cancer!

DONATE

03 March 2008

Women are Dumb

Time for a little non-partisan outrage.

From the Onion:

From the Washington Post (I swear to God I'm not making this up):

The Onion is a joke newspaper. The Washington Post is not, or didn't use to be, anyway. The headline in the above screenshot was subsequently softened a bit, but, frankly, is a fairly accurate summary of the article's main thesis.

But it's OK, because it was written by a woman, and is supposed to be "tongue in cheek," you see? Next week, they'll have the "Jews are scheming misers" feature, written humorously by Jon Stewart, followed by "N----rs just don't float," penned by Chris Rock.

Seriously, what the hell was the editor thinking, running a piece like this? No such thing as bad publicity, I guess.

You can let the editors know what you think of their decision by writing: outlook@washpost.com Be polite.

Raising the bar

One of my supporters for St Baldrick's offered me a conditional contribution. (As if shaving my head was not conditional enough!) The terms: since it's a St. Patrick's day event (in Chicago, no less) I need to dye my hair green before going under the razor. So there it is: I hereby commit and pledge that I will go green and post the pictures of my verdant locks prior to shaving!

So, if you haven't, c'mon, click the link and pony up a couple of bucks for kids' cancer research.

As it happens, faithful reader and personal friend EMH (M/N 977) is a pediatric oncologist who is applying for a grant from St Baldrick's! I have been lucky enough to get a perspective into kids' cancer from the fundraising side, from sharing the experience of cancer patients like Nathan and Henry, from the clinical side in my training, and now from the research side.

EMH (M/N 977) is currently working on medulloblastoma, the very same cancer that Henry is fighting as you read this. She describes her work thusly:

As a pediatric oncologist, I am acutely aware of the need for more
effective, less toxic drugs for kids with cancer. Our lab's focus is
medulloblastoma, which is the most common malignant brain tumor in
children. While cure rates can be up to 80% for standard risk
patients using a combination of neurosurgery, chemotherapy, and
radiation, patients under the age of three have only about a 30%
chance of cure. Kids who are cured typically have significant side
effects from therapy, such as deafness, difficulties with walking,
speech difficulties, and growth failure.

Our lab is looking for better drugs for medulloblastoma. We have
developed a transgenic mouse model in which the mice get metastatic
medulloblastoma. This is really important, because nearly all
children who die of medulloblastoma die of metastatic disease. If the
candidate drugs we're testing work to treat medulloblastomas in our
mice, we will move the drugs toward clinical trials. We have a great
track record in moving drugs from the lab bench to the bedside. At
present I believe that there are five national clinical trials open
for pediatric brain tumors. Our lab initiated four of them. I hope
to initiate one of the next ones.

Sadly, it is harder than ever to get research funding. Fewer than 10%
of NIH grants are funded. Companies that develop drugs typically
focus their research on common adult cancers, since they need to be
able to recoup their research and development costs through drug
sales. Since pediatric cancer is rare, there will never be profit in
developing drugs for this small but very important group of patients.
Thus, private funding is critical to finding cures for childhood cancer.

The St. Baldrick's Foundation is a group that is making big strides
towards curing childhood cancer. Private groups raise money by
sponsoring "shavees" to shave their heads in solidarity with children
undergoing treatment for cancer. These funds are granted to doctors
and scientists doing cutting-edge research in pediatric oncology.
Like many physician scientists, I rely on private funding to move my
work forward. Children with cancer rely on all of us to find cures
for them, fast.

Thank you for supporting the families you know who have been touched
by childhood cancer, the brave souls who are shaving their heads for
the cause, and the St. Baldrick's Foundation for uniting our efforts
across the country.
I can't add much to that sort of testimonial. Help her out by making a small (or large) gift. And, if you feel up to it, head on over to Henry's site and send them some love. They could use it right now.

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