Waging Health Battles by Fax

I must admit that I am still baffled how U.S. Healthcare has evolved to the point that highly trained medical professionals now spend a tremendous amount of time in doing the kind of tasks described below. This is completely different from my experiences overseas, in which the patient's health is actually the focus of attention, and I can spend 95% of my time helping my patients in terms of direct medical or surgical care.

There is a battle that goes on behind the walls of the family doctor's office every day. We try to get the medications and tests and referrals that our patients need while also seeing patients who require care. The insurance companies don't mind me taking heat from the patients when they don't get the medication I recommend. And they don't have to worry about the liability that I, as a doctor, face for using cheaper drugs that may put the patient at higher risk of complications.

They want me to incur the overhead and frustration that comes with trying to prove to a non-doctor that I know my patient and what I'm talking about. They want to cut costs, and they don't really care about how it affects my patients or my practice. If they make the process hard enough, they hope I'll just give up. There is even a term in the managed care literature for that kind of deterrence: the "sentinel effect."

A 2001 study showed that a doctor seeing 22 patients a day, averaged one insurance hassle lasting for every four or five patients. More than 40% of hassles were reported as interfering with quality of care, the doctor-patient relationship, or both.

I think the hassle factor has doubled in my practice since 2001. Most patients are minimally aware of the battles we fight daily on their behalf. They wonder why the office gets bogged down or why doctors or office staff don't call back.

Crisis of Care on the Front Line of Health

Does your doctor spend time talking to you? Do you see your doctor within 20 minutes of your appointment time? Are you getting the guidance you need to cope with a continuing health problem or multiple overlapping problems? Do you even have a personal physician who monitors your health and treats you promptly with skill and compassion?

A “no” answer to any of these questions — even to all of them — would not be surprising. Finding doctors who know their patients well and who deliver informed medical care with efficiency and empathy has become quite a challenge in America.

There is a crisis in medicine today, and it will not be fixed by any candidate’s proposal to provide health insurance for the 45 million Americans now without it. In fact, an increase in insured Americans could make it worse.
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The problem is that in this era of managed care and reimbursements dictated by Medicare and other insurers, doctors don’t get much compensation for talking to patients. They get paid primarily for procedures, from blood tests to surgery, and for the number of patients they see.

Most are burdened with paperwork and hours spent negotiating treatment options with insurers. And the payments they receive for services have not increased as the costs of running a modern medical practice have risen. To make ends meet and earn a reasonable income of, say, $150,000 a year, many primary care doctors have to squeeze more and more patients into the workday.

“If you have only six to eight minutes per patient, which is the average under managed care, you’re forced to concentrate on the acute problem and ignore all the rest,” said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.

Getting Better Value from Medicine

Maggie Mahar runs an excellent blog on U.S. healthcare. Here is a paper she has put together on Medicare spending. It is worth a read.
(via KevinMd blog)

Somali Pirates Tell All: They’re in It for the Money

Okay, okay so we don't hold people for ransoms here, or do we???

He said that so far, in the eyes of the world, the pirates had been misunderstood. “We don’t consider ourselves sea bandits,” he said. “We consider sea bandits those who illegally fish in our seas and dump waste in our seas and carry weapons in our seas. We are simply patrolling our seas. Think of us like a coast guard.”
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Piracy in Somalia is a highly-organized, lucrative, ransom-driven business. Just this year, pirates have hijacked more than 25 ships, and in many cases, they were paid million dollar ransoms to release them. The juicy payoffs have attracted gunmen from across Somalia and the pirates are thought to now number in the thousands.

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Mr. Sugule said that his men are treating the crew members well (the pirates would not let the crew members speak on the phone, saying it was against their rules). “Killing is not in our plans,” he said. “We only want money, so we can protect ourselves from hunger.”

When asked why the pirates needed $20 million to protect themselves from hunger, Mr. Sugule laughed over the phone and said: “Because we have a lot of men.”

In Financial Food Chains, Little Guys Can’t Win

Ben Stein on the Current Financial Crisis. He correctly points out the looming problem is with credit default swaps..

IMAGINE, if you will, that a man who had much to do with creating the present credit crisis now says he is the man to fix this giant problem, and that his work is so important that he will need a trillion dollars or so of your money. Then add that this man thinks he is so indispensable that he wants Congress to forbid any judicial or administrative questioning of anything he does with your dollars.

You might think of a latter-day Lenin or Fidel Castro, but you would be far afield. Instead, you should be thinking of Treasury Secretary Henry M. Paulson Jr. and the rapidly disintegrating United States of America, right here and now.
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Second, according to what I hear from my betters in the world of finance, the most serious problems are not with the bundles of subprime mortgages themselves — a large but not lethal quantum as far as I can tell — but with derivatives contracts tied to subprime and other dicey debt. These contracts are superficially an attempt to “insure” against risks of default, hence the name “credit-default swaps.” In fact, they are an immense wager — which anyone with lots of money or borrowing ability can enter — about how mortgage-backed bonds, leveraged loan bonds, student loan bonds, credit card bonds and the like will perform.

These wagers entail amounts many times larger than the total of subprime loans. In fact, there are roughly $62 trillion in credit-default swap derivatives out there, compared with about $1 trillion of subprime mortgages. These derivatives are “weapons of financial mass destruction,” in the prophetic words of Warren E. Buffett. (Apparently believing that the worst is over, at least for one big investment bank, Mr. Buffett is now investing in Goldman Sachs.)
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The people whose conduct got us into this catastrophe have not only taken our money, hopes and peace of mind, but they apparently also want a trillion or so more dollars to put into their Wall Street Buddy System Fund. This may be the most dangerous attack on the law in my lifetime. What anarchists even dared consider this plan? Thank heaven that minds more devoted to the Constitution on Capitol Hill are questioning this shocking request.

By the way, if we are actually thinking about tossing the Constitution out the window, why not simply annul these credit-default swap contracts? With that done, the incomprehensibly large liability of the banks would cease, and we wouldn’t need this staggering bailout. Shouldn’t we consider making the speculators pay some of the price?

Irrationally Committed

If I were to tally up the things to which I am "irrationally committed," I wonder if the list would be longer than those things to which I am rationally committed...Perhaps this is another phrase for passion...

The latest from Seth Godin...

My friend Lynn coined this phrase, and it really resonated with me.
Parents or other adults who are irrationally committed to a kid's well being make a huge (perhaps the biggest) difference in that young person's life.

Entrepreneurs who are irrationally committed to their business are far more likely to get through the Dip.

Salespeople and service providers and marketers who are irrationally committed to customer service can completely transform an ordinary experience and make it remarkable.

Is being irrational irrational? Of course it is. That's why it often works.

If you're looking for the sensible, predictable, long-term strategy, this probably isn't it. Except when it is.

Stopping a Financial Crisis, the Swedish Way

This makes sense....

A banking system in crisis after the collapse of a housing bubble. An economy hemorrhaging jobs. A market-oriented government struggling to stem the panic. Sound familiar?

It does to Sweden. The country was so far in the hole in 1992 — after years of imprudent regulation, short-sighted economic policy and the end of its property boom — that its banking system was, for all practical purposes, insolvent.
But Sweden took a different course than the one now being proposed by the United States Treasury. And Swedish officials say there are lessons from their own nightmare that Washington may be missing.

That strategy held banks responsible and turned the government into an owner. When distressed assets were sold, the profits flowed to taxpayers, and the government was able to recoup more money later by selling its shares in the companies as well.

“If I go into a bank,” said Bo Lundgren, who was Sweden’s finance minister at the time, “I’d rather get equity so that there is some upside for the taxpayer.”

Chase Jarvis RAW: Kung Fu

Amazing photography and videography...

Chase Jarvis and Superfad recently teamed up on a campaign for the Kung Fu HD Network. During the 2 day shoot, motion was captured with the Phantom HD camera and stills were shot with the Hasselblad H2D. This video is a brief documentation of this creative collaboration.



via stroboist

The Buck Stopped Then

CRITICS of the administration’s Wall Street bailout condemn the waste of taxpayer dollars. But the taxpayers aren’t the weightiest American financial constituency, even in this election year. The dollar is the world’s currency. And it is on the world’s opinion of the dollar that the Treasury’s plan ultimately hangs.


It hangs by a thread, if Monday’s steep drop of the greenback against the euro is any indication...
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As never before, that trust is being put to the test. In the best of times, the Treasury and the Federal Reserve pretended as if the dollar were America’s currency alone. Now, in some of the worst of times, Washington is treating its vital overseas dollar constituency as if it weren’t even there.

Which failing financial institution will the administration pluck from the flames of crisis? Which will it let roast? Which market, or investment technique, will the regulators bless? Which — in a capricious change of the rules — will it condemn or outlaw? Just how shall the Treasury secretary spend the $700 billion he’s begging for? Viewed from Wall Street, the administration’s recent actions appear erratic enough. Seen from the perch of a foreign investor, they must look very much like “political risk,” a phrase we Americans usually associate with so-called emerging markets, not with our own very developed one.

Are Doctors Treating the Diagnosis or the Patient?

Tara Parker-Pope, author of "The Well" a blog on healthcare at the New York Times has started an effort with Dr. Paula Chen to have a constructive dialogue on patient-doctor relationships. It is always interesting to read the commentary, although the letters are often quite predictable, both from the patient and the doctor side..
Here is a response that I found quite thoughtful, if not profound by Dr. Stephen Taylor (It is number 65):



I was specialist in chronic pain management for 20 years.

Early on in my career I remember one of my first patients with chronic low back pain telling me that he was walking along one day and his legs just “gave out” and he fell. I told him that I didn’t understand what would have caused that and assured him it couldn’t have been his back causing that symptom.
After another 10 patients told me the same thing I began to wonder if there was an association. By the time the 20 or 30th patient described exactly the same event I was wise enough to say “Yes, that will happen in people with your kind of back problem”.
I began practice with the knowledge provided to me by my training doctors and textbooks. That simplistic knowledge lead to many tense interactions with patients because I didn’t empathize with any symptoms I had never heard of (or missed on the tests). As a physician you don’t see what you don’t understand and early on I was so focused on doing what the textbooks said that I forgot to listen to my patients.
Thankfully, over time I learned not only to listen to my patients but to like and respect them as human beings. The majority of them had suffered a great deal of abuse from doctors who were afraid they “just wanted drugs. I learned to be technically proficient and at the same time be a simple human being who understood that they had been through hell and back.
When I reached that human level of understanding of my patient’s experiences my practice became enjoyable and rewarding instead of a draining battle of wills with the people I was supposed to help.
Those poor tortured souls would always have a story to tell. If I interrupted them they would pick up from exactly the point I had interrupted them in their narrative. Early on, witnessing each patient’s compulsion to tell their complete story from beginning to end puzzled me. I thought it was simply a coincidence that every patient did it. Then I came to recognized their compulsion and their emotional urgency as coming from their need to say that they didn’t do anything wrong (which they didn’t) and that their pain was not their fault (which it wasn’t).
In fact, their continued pain was most often the result of misdiagnosis combined with poor treatment or unnecessary surgery. I learned to say, “it’s not your fault”. Frequently they would start to sob when I made that statement. From that point forward we were not just a doctor and patient. Instead, we were a two earnest people trying to find what would work to help them recover their lives.
— Stephen Taylor

Foreign Banks Hope Bailout Will Be Global

Sooo who is asking the hapless taxpayer how much he or she is willing to pay for the reckless ways of the wealthy speculators---hmmm.....?

PARIS — The financial crisis that began in the United States spread to many corners of the globe. Now, the American bailout looks as if it is going global, too, a move that could raise its cost and intensify scrutiny by Congress and critics.

Foreign banks, which were initially excluded from the plan, lobbied successfully over the weekend to be able to sell the toxic American mortgage debt owned by their American units to the Treasury, getting the same treatment as United States banks.

Barefoot College in India

FRED DE SAM LAZARO: The students are mostly women. Some are grandmothers. Hundreds have come through here from villages across India and a dozen other countries to learn how to install and maintain solar energy in rural areas.

Even though it's sophisticated coursework, the only pre-requisite for admission to the Barefoot College is that there are no pre-requisites, not even to speak the language.

Until we arrived with a translator, these Mauritanian women who'd been here four months hadn't spoken to anyone else in Arabic, the only language they know. But language is not a barrier to learning, says the college's founder.

BUNKER ROY (Founder, Barefoot College): Our job is to show how it is possible to take an illiterate woman and make her into an engineer in six months and show that she can solar-electrify a village.

David Foster Wallace on Life and Work

This is a very insightful essay. It must be read in its entirety (at the link). I try to capture the flavor of it in these excerpts below ...

Adapted from a commencement speech given by David Foster Wallace to the 2005 graduating class at Kenyon College. Mr. Wallace, 46, died last Friday, after apparently committing suicide.

Given the triumphal academic setting here, an obvious question is how much of this work of adjusting our default-setting involves actual knowledge or intellect. This question gets tricky. Probably the most dangerous thing about college education, at least in my own case, is that it enables my tendency to over-intellectualize stuff, to get lost in abstract arguments inside my head instead of simply paying attention to what's going on right in front of me. Paying attention to what's going on inside me. As I'm sure you guys know by now, it is extremely difficult to stay alert and attentive instead of getting hypnotized by the constant monologue inside your own head. Twenty years after my own graduation, I have come gradually to understand that the liberal-arts cliché about "teaching you how to think" is actually shorthand for a much deeper, more serious idea: "Learning how to think" really means learning how to exercise some control over how and what you think. It means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from experience. Because if you cannot exercise this kind of choice in adult life, you will be totally hosed.
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if you want to operate on your default-setting -- then you, like me, will not consider possibilities that aren't pointless and annoying. But if you've really learned how to think, how to pay attention, then you will know you have other options. It will actually be within your power to experience a crowded, loud, slow, consumer-hell-type situation as not only meaningful but sacred, on fire with the same force that lit the stars -- compassion, love, the sub-surface unity of all things. Not that that mystical stuff's necessarily true: The only thing that's capital-T True is that you get to decide how you're going to try to see it. You get to consciously decide what has meaning and what doesn't. You get to decide what to worship...

Because here's something else that's true. In the day-to-day trenches of adult life, there is actually no such thing as atheism.

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Look, the insidious thing about these forms of worship is not that they're evil or sinful; it is that they are unconscious. They are default-settings. They're the kind of worship you just gradually slip into, day after day, getting more and more selective about what you see and how you measure value without ever being fully aware that that's what you're doing. And the world will not discourage you from operating on your default-settings, because the world of men and money and power hums along quite nicely on the fuel of fear and contempt and frustration and craving and the worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom to be lords of our own tiny skull-sized kingdoms, alone at the center of all creation. This kind of freedom has much to recommend it. But of course there are all different kinds of freedom, and the kind that is most precious you will not hear much talked about in the great outside world of winning and achieving and displaying. The really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able truly to care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day. That is real freedom. The alternative is unconsciousness, the default-setting, the "rat race" -- the constant gnawing sense of having had and lost some infinite thing.

I know that this stuff probably doesn't sound fun and breezy or grandly inspirational. What it is, so far as I can see, is the truth with a whole lot of rhetorical bullshit pared away. Obviously, you can think of it whatever you wish. But please don't dismiss it as some finger-wagging Dr. Laura sermon. None of this is about morality, or religion, or dogma, or big fancy questions of life after death. The capital-T Truth is about life before death. It is about making it to 30, or maybe 50, without wanting to shoot yourself in the head. It is about simple awareness -- awareness of what is so real and essential, so hidden in plain sight all around us, that we have to keep reminding ourselves, over and over: "This is water, this is water."

It is unimaginably hard to do this, to stay conscious and alive, day in and day out.

The Irrawaddymedia

The best source for all news relevant to Burma here
There was a cyberattack earlier this week on the site, and concern that it would no longer be extant, but it is up and running again.

The Healthcare Hindenberg

Dr. Wes, in a brilliant essay,
points out similarities between what is happening in financial markets currently and the impending implosion of healthcare...


We’re now seeing what happens when the Big Boys and the government worked their Ponzi schemes for keeping the housing bubble inflated. We (the little guys) are seeing what happens to financial markets, the security of our 401Ks and investments, and the economy as a whole after the Big Boys have dropped the ball.

But there is little questioning of the effects of gambling on another high stakes game: people’s health and our nation's economy. Health care is our financial life preserver right now – it is the engine driving the economic survival of towns decimated by manufacturing losses. It is the leading employer for many communities as people fight to re-tool their labor skills into healthcare skills. It is generating a colossal 2.3 trillion dollars of revenue a year: much more than any investment bank – and the philosophy right now? It can’t go under. It will only grow. The future is limitless.

And like homes, we buy it.

So what’s the problem? The problem is there are tremors that the our healthcare bubble is going to burst. A bubble by definition is an artificial inflation based on spending money we don’t have. Healthcare has become so expensive that patients are having trouble paying for it. Employers, too, are having trouble paying for it. Insurers are having trouble paying for it. So guess what, the government is going to have trouble paying for it.

The tremors of an impending healthcare bubble, are like those of our current housing bubble, if we cared to listen: the escalating co-pays, pharmacy, and hospitalization costs. We see the rules change behind the curtain as the Big Boys, ever eager to earn your trust, add millions to our national debt through Medicare drug coverages. We see the employers and insurers in fierce battles for profits as they negotiate plans with hospitals as people are stuck with increasingly larger shares of their bills. And woe to the uninsured, already caught empty-handed in a time of crisis, who suddenly realize their payments exceed those of the more fortunate insured. The once expected mandates for healthcare, too, are beginning to find themselves unfunded and political promises left undelivered. We see the people of Massachusetts in their "New Big Dig" of healthcare, finding that $869 million won't pay their healthcare bill in 2009. And yet we see all this even as the new buildings are going up, even as the spas and Starbucks go into shiny marble lobbies – even now - as we continue to build our healthcare Hindenburg.

Then what happens? Well, Medicare fails. I know, I know. This seems no more possible than the idea that people would ever lose their homes - no way no how.

But when it does happen, then what does the inevitable government bailout look like?

It looks like a national healthcare structure that “comes to our rescue” in ways that no one would have voluntarily chosen. Now we are in crisis. There is no choice in crisis. You must do as we say.

A Professor and a Banker Bury Old Dogma on Markets

A fascinating description of the intense partnership that had developed between Secretary of the Treasury, Paulson and Head of the Fed, Bernancke, in an attempt to prevent global financial collapse...

Just like that, Mr. Bernanke, the reserved former Ivy League professor, and Mr. Paulson, the hard-charging former Wall Street deal maker, launched what would be the government’s largest economic rescue operation in modern times, one that rivals the Iraq war in cost and at the same time may redefine Washington’s role in the marketplace for years to come.

The plan to buy $700 billion in troubled assets with taxpayer money was shaped by two men who did not know each other until two years ago and did not travel in the same circles, but now find themselves brought together by history. If Mr. Bernanke is the intellectual force and Mr. Paulson the action man of this unlikely tandem, they have managed to create a nearly seamless partnership as they rush to stop the financial upheaval and keep the economy afloat.

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Along the way, they have cast aside the administration’s long-held views about regulation and government involvement in private business, even reversing decisions over the space of 24 hours and justifying them as practical solutions to dire threats.

“There are no atheists in foxholes and no ideologues in financial crises,” Mr. Bernanke told colleagues last week, according to one meeting participant.

The improvisational nature of their effort has turned President Bush and Congressional Democrats into virtual bystanders, sometimes uncertain about what comes next and left to wonder about the new power dynamics in the capital. Seemingly every time lawmakers tried to get a handle on what was happening and what role they might play with elections around the corner, Mr. Paulson and Mr. Bernanke would show up again on Capitol Hill for another evening meeting with another surprise development.

Congressional Leaders Stunned by Warnings

The fact that Congressional Leaders are "Stunned by Warnings" I guess is just a reflection of the incredible naivete we Americans have become with regard to our lack of financial discipline and the eventual consequences that would have to ensue...

Mr. Bernanke and Treasury Secretary Henry M. Paulson Jr. had made an urgent and unusual evening visit to Capitol Hill, and they were gathered around a conference table in the offices of House Speaker Nancy Pelosi.

“When you listened to him describe it you gulped," said Senator Charles E. Schumer, Democrat of New York.

As Senator Christopher J. Dodd, Democrat of Connecticut and chairman of the Banking, Housing and Urban Affairs Committee, put it Friday morning on the ABC program “Good Morning America,” the congressional leaders were told “that we’re literally maybe days away from a complete meltdown of our financial system, with all the implications here at home and globally.”

Mr. Schumer added, “History was sort of hanging over it, like this was a moment.”

When Mr. Schumer described the meeting as “somber,” Mr. Dodd cut in. “Somber doesn’t begin to justify the words,” he said. “We have never heard language like this.

Saudi Women Find Unlikely Role Model: Oprah

This article notes how Oprah resonates with Saudi women, which in my experience is true, but misses the larger picture, which is that Saudis have a very special affinity for America. There were many nights that my Saudi techs would ask me if I watched the e.g. 'Lakers vs. Celtics game last night" --broadcast at 2am due to time differences.,...
DAMMAM, Saudi Arabia—Once a month, Nayla says, she writes a letter to Oprah Winfrey.

A young Saudi homemaker who covers her face in public might not seem to have much in common with an American talk show host whose image is known to millions. Like many women in this conservative desert kingdom, Nayla does not usually socialize with people outside her extended family, and she never leaves her house unless chaperoned by her husband.

Ms. Winfrey has not answered the letters. But Nayla says she is still hoping.

“I feel that Oprah truly understands me,” said Nayla, who, like many of the women interviewed, would not let her full name be used. “She gives me energy and hope for my life. Sometimes I think that she is the only person in the world who knows how I feel.”
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Maha al-Faleh, 23, of Riyadh, said, “Oprah talks about issues that haven’t really been spoken about here openly before.

“She talks about racism, for example,” she said. “This is something that Saudis are very concerned about, because many of us feel that we’re judged for the way we veil or for our skin color. I have a friend whose driver touched her in an inappropriate way. She was very young at the time, but she felt very guilty about it — and Oprah helped her to speak about this abuse with her mother.”

Stay or Leave

You tube video of one of my favorite Dave Matthews' songs

We Need Your Vote

In Reno, we already have a tremendous amount of support for the Orbis Pediatric Eye Care Centers in India--if you are an American Express card holder please go to the link and add to our local support for these centers....
From the Orbis Blog...

Nyan and Lehka Pendyala's "Kids for Sight" project to raise money for a pediatric eye care center in India made it to the Top 25 in the American Express Members Project. Now we need your vote so that the project ends up in the Top 5. Those in the Top 5 win anywhere from $100,000 to $1.5 million!

We only need your vote, not your donation. The cash prize comes from American Express.

Voting right now is limited to those with an American Express card. However, anybody can publicize the competition and get out the vote. Please send an e-mail or a widget, which you can find at the bottom of the kids' page, to everyone you know and urge them to vote for Kids for Sight. Please post on your Facebook and Myspace pages, and any other social networking sites you belong to.

Here's the link: http://www.membersproject.com/project/view/8CEPG6

AP IMPACT: Tons of drugs dumped into wastewater

U.S. hospitals and long-term care facilities annually flush millions of pounds of unused pharmaceuticals down the drain, pumping contaminants into America's drinking water, according to an ongoing Associated Press investigation.
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One thing is clear: The massive amount of pharmaceuticals being flushed by the health services industry is aggravating an emerging problem documented by a series of AP investigative stories — the commonplace presence of minute concentrations of pharmaceuticals in the nation's drinking water supplies, affecting at least 46 million Americans.

Researchers are finding evidence that even extremely diluted concentrations of pharmaceutical residues harm fish, frogs and other aquatic species in the wild. Also, researchers report that human cells fail to grow normally in the laboratory when exposed to trace concentrations of certain drugs.

The Sixty-Day War

A fascinating behind the scenes look at the major parties' political strategies and the political operatives behind them from New York Magazine...
With one hastily made decision, John McCain upended the presidential race. An investigation of the bloody new political realities.

The End is Nigh?

"Saudi Jeans" thinks that the latest tirade by Sheik Saleh al-Lihedan may be his undoing...

Saudi Arabia’s top judiciary official has issued a religious decree saying it is permissible to kill the owners of satellite TV networks that broadcast immoral content. The 79-year-old Sheik Saleh al-Lihedan said Thursday that satellite channels cause the “deviance of thousands of people.”

Sen. Grassley Keeps Pressure on Non-profit Hospitals

Here in Reno in the most renowned hospital, it is well near impossible to me get non-insured patients in for surgery--even when I am willing to do the surgery for free...


Sen. Chuck Grassley is pounding on two non-profit hospitals demanding to know whether they restrict the care they give patients based on their ability to pay.

As ranking Republican on the Senate Finance Committee, the Iowa senator has been bearing down on hospital tax breaks worth millions of dollars, saying he is concerned that non-profits are “losing sight of the public service that comes with tax-exempt status.”

The Allure of the One-Stop Shop

An excellent analysis of the ER overcrowding issue here

Jis Gali Mein Tera Ghar

Click here for one of my favorite songs of all time
I don't want to place my foot on those streets
which do not pass by your door

I don't care about the colorful luxuries around me
I don't care about beautiful flower blossoming in every direction
I don't care about the lanes with beautiful spring blossoms
All I know is I don't want to pluck flowers in that garden ...
where your feet got hurt with thorns

Protein Synthesis: Translation 2008

I find this amazingly cool and geeky at the same time...

Bytes of Life

Fascinating or sick?! I am a bit obsessive myself but the folks profiled here are totally over the top in my view!

For Every Move, Mood and Bodily Function, There's a Web Site to Help You Keep Track

A Genetically Engineered Swat

Oliver Judson's articles in the New York Times are without fail informative and entertaining. Here she discusses a promising technique to combat mosquito borne diseases...

Last week, I discussed rewriting the genes of viruses in order to make better vaccines. This week, I’d like to discuss the genetic engineering of mosquitoes as a way to stop the spread of dengue fever.

Dengue is caused by any of four related viruses. The disease can take a number of forms, from a mild sense of feeling below par, to dengue hemorrhagic fever, which can be lethal. Compared to diseases like malaria, dengue is a minor problem. Each year, more than 500 million people are infected with malaria, compared to “just” 50 million people for dengue. As diseases go, it’s not terribly dangerous either: the death rate from dengue hemorrhagic fever is around 2.5 percent.
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Dengue, in other words, is on the rise. It is an up-and-coming virus.

But there is no vaccine and no cure. The only way to reduce the incidence of the disease is to control the mosquitoes that spread it. Which is not working.
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Hence the interest in genetic engineering.

There are several ways that A. aegypti could be engineered so as to interrupt the transmission of dengue. One possibility is to make mosquitoes that are unable to transmit the viruses. The idea would be to release them into the wild in the hopes that they would mate with normal mosquitoes, and resistance would spread.

But I prefer a simpler approach. Here, mosquitoes are engineered to have a built-in flaw: a gene that is lethal when the insect becomes a pupa. Males carrying this gene would then be released. Wild females who mated with one of these males would lay eggs as usual, the larvae would develop as usual — but when they got to the pupa stage, the insects would die. (From the point of view of control, death at this late stage is an advantage, because the animals still occupy the pool as larvae. This is useful because larvae compete with each other for food, so their presence in a pool helps, in and of itself, to keep the population down.)

But if mosquitoes carrying this gene die at the pupal stage, how do you ever manage to rear any males to release? This is the clever part. The mosquitoes are engineered so that whether the gene is lethal depends on what the larvae eat. If their diet contains a certain crucial ingredient, the killer gene does not get turned on. But in the absence of the crucial ingredient, the gene is turned on, and the animals die.

Such a mosquito has been made. In this case, the crucial ingredient is tetracycline, an antibiotic.

Memo From Cairo: 9/11 Rumors That Become Conventional Wisdom

I was in Riyadh, Saudi Arabia when the attacks occurred. From the very get go, Saudis were incredulous that arabs could plan and execute such an attack (as alluded to later in the article)...

However, I think that the conspiracy theories detailed below are not limited to the Middle East but are also felt in the rest of the world, based on conversations I have had with numerous people from Europe, Asia, Africa and Latin America since then...

CAIRO — Seven years later, it remains conventional wisdom here that Osama bin Laden and Al Qaeda could not have been solely responsible for the attacks of Sept. 11, 2001, and that the United States and Israel had to have been involved in their planning, if not their execution, too.

This is not the conclusion of a scientific survey, but it is what routinely comes up in conversations around the region — in a shopping mall in Dubai, in a park in Algiers, in a cafe in Riyadh and all over Cairo.

“Look, I don’t believe what your governments and press say. It just can’t be true,” said Ahmed Issab, 26, a Syrian engineer who lives and works in the United Arab Emirates. “Why would they tell the truth? I think the U.S. organized this so that they had an excuse to invade Iraq for the oil.”

It is easy for Americans to dismiss such thinking as bizarre. But that would miss a point that people in this part of the world think Western leaders, especially in Washington, need to understand: That such ideas persist represents the first failure in the fight against terrorism — the inability to convince people here that the United States is, indeed, waging a campaign against terrorism, not a crusade against Muslims.

It’s not our Fault

The latest from "Musings of a Distractible Mind..."

Dear Patients:

I know you get frustrated with our office. We make you come in for visits when you think we should handle things over the phone. We seem more focused on your chart sometimes than on you. Sometimes you may even wonder if money has become more important than patients.


We are part of an insane system that requires us to do things in a way that makes life harder for us both. We would love to practice medicine differently, but we simply can’t. Here are some examples:

Medical Morale Hits New Low

Dr. Val's commentary on the unbelievable lawsuit in which a doctor is being sued for prescribing painkillers to a patient who crashed her car and killed a man:

"I was catching up on my Wall Street Journal blog reading, when I came across a post about a physician who was sued for prescribing painkillers to a patient who proceeded to crash her car. The crash killed a pedestrian, and the victim's wife is now suing the driver's doctor. Obviously, this case sends chills down physician spines - as it seems that we are now held responsible for patient behavior outside of the the doctor-patient relationship or hospital setting."

Beyond the outrageousness of the case itself, is the sad subtext found in the comments section. Physician after physician respond that they are leaving medicine or have ceased clinical practice. They say that they'd never allow their children to become doctors, and that no amount of compensation is worth the risk and sacrifices of a career in medicine. It's really depressing to read about such low morale.

Original WSJ blog entry here.

Work-life balance

Via Kevin M.D.

It's all the rage in medicine today, especially in residency training. On the other end of the spectrum, doctors who are frustrated with the system can give up and use the desire for balance as an excuse:

Since the income rewards are getting less, the prestige of physician work is diminishing, the autonomy getting harder to even find, and when the pride of being physician gets to some personally determined tipping point, maybe it is more politically correct to say you need more time on the "life" side of work-life balance than to say screw it.

High Technology or Low Vision

Today's Wall Street Journal has an excellent summary of cutting edge devices to help the visually impaired. There is also a video at this link.

Even if you can read this, chances are you know somebody who can't. More than 16 million Americans report some form of visual impairment even when wearing glasses or contacts. That number is expected to double by 2030 as the aging population brings rising rates of macular degeneration, glaucoma, diabetic retinopathy and other eye diseases.

But "low vision" (technically, worse than 20/60 in the better eye) doesn't have to mean darkness and dependence. An ever-growing array of devices can help people maximize their remaining vision and in many cases, compensate for what they've lost. Some of the new offerings: free software that can tailor the text on any Web site to your personal visual needs, and a cellphone that can snap photos of text -- like signs and restaurant menus -- and read it back to you.

Grand Rounds 4.51

Grand Rounds is up at AppleQuack

The Pitfalls of Linking Doctors’ Pay to Performance

This article highlights a conundrum in healthcare.
Doctors are unable to compete in a free-market on the basis of outcomes and receivers of healthcare are unable to accurately assess the quality of the care they receive.

The fundamental problem is that it is extremely difficult to "grade" a process as complex and variable as healthcare delivery--variables that have to be accounted in a single patient encounter may include complexity of disease, other disease interactions, patient compliance, quality of ancilliary health personnel, availability of adequate equipment, decision making processes, technical proficiency, insurance mandated limitations on care etc....

The "pay for performance" title is a complete misnomer (and really rubs me the wrong way) in that it does nothing of the sort. The financial incentive is meaningless except for very large organizations and using very small measures of performances as proxies for quality is potentially fraught with error. Further, I can't see documenting more than I already do. I already an insane amount of time documenting non-relevant details on patient charts for insurance companies and potential adversarial attorneys--which demoralizes me, costs a ridiculous amount of money, and causes patient wait times to continually increase...

(But at least I am not mandated to do preoperative rectal exams for cataract patients as I was during my residency).

Not only that but the pay for performance program in its current iteration is potentially harmful as illustrated below...


The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care.

For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner.

On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences.

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Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons’ numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions.

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Doctors have seldom been rewarded for excellence, at least not in any tangible way. In medical school, there were tests, board exams and lab practicals, but once you go into clinical practice, these traditional measures fall away. At first glance, pay for performance would seem to remedy this problem. But first its deep flaws must be addressed before patient care is compromised in unexpected ways.

Doctors' pay cuts save little in health costs

Excellent editorial by Kevin, M.D. in USA Today
(via The Blog that Ate Manhattan)

"Why should I care if doctors get a pay cut?" my patient recently asked me.
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The number of physicians who do not accept new Medicare patients is dramatic; in states like Texas, this number can exceed 40%. No wonder, as Medicare pays less than half of doctors' fees. This scenario comes as a record number of Boomers approach Medicare age.
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According to the Kaiser Family Foundation, there are more significant drivers of health costs, including new prescription drugs, technology and administrative needs. Princeton economist Uwe Reinhardt estimates that physicians' take-home pay represents roughly 10% of national health care spending. Cutting physician pay by 20% would only reduce spending by 2%.

As Soon as I Landed...

Latest entry from the Orbis blog, written by Dr. Habeeb Ahmad,a third year resident from SUNY Downstate Health Center-- that captures the diversity and spirit of the Orbis team...


As soon as I landed in Beijing, I recalled the awe that I had felt for China during the weeks earlier when watching the 2008 Beijing Olympics. When I arrived in Harbin, China my eyes were opened to why I was there. Here, I am in a remote corner of the world in China, here to help an indigent population in need of eye care. My first encounter with the individual members of ORBIS was quite interesting. Here I thought, were people of all different backgrounds, cultures, religions and language with a common passion for saving sight worldwide. On Monday, I witnessed firsthand this passion during the screening for oculoplastics, glaucoma and medical retina clinics at the number two affiliated Hospital at Harbin Medical University.

Heavy Snoring as a Cause of Carotid Artery Atherosclerosis

The prevalence of carotid atherosclerosis was 20% with mild snoring, 32% with moderate snoring, and 64% with heavy snoring (P < 0.04, Χ2). Logistic regression analysis was used to determine the independent effect of snoring on the prevalence of carotid and femoral atherosclerosis. After adjustment for age, sex, smoking history, and hypertension, heavy snoring was significantly associated with carotid atherosclerosis (odds ratio 10.5; 95% confidence interval 2.1-51.8; P = 0.004) but not with femoral atherosclerosis.

Maasai Warrior Hairdressers Break Taboos

MOMBASA, Kenya (Reuters) - Maasai warrior Lempuris Lalasho went to Kenya's tourist haven Mombasa to find a white woman to marry, but he ended up working as a hairdresser, a profession that is taboo in his culture...

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Maasai warriors are not allowed to touch a woman's head: it is regarded as demeaning in the patriarchal culture. Moran who become hairdressers risk a curse from the elders, or could even be expelled from the community.

read on...

Dare Not Speak Its Name

The latest entry from the always excellent Doc Gurley blog:

Doc Gurley Pop Quiz!*

“Dare not speak its name” refers to (choose one):

1) Traditional Jewish law about the four-letter name for God
2) George Carlin’s send-up of TV censorship [WARNING: definitely R-rated video]
3) The CIA’s role in Guantanamo Bay interrogations
4) Homosexuality - Lord Alfred Douglas’ description of his relationship with Oscar Wilde
5) The pharmaceutical drugs Chantix and Ambien

Answer: all of the above. Chantix and Ambien (oops, was I not supposed to say those names?) have joined the ranks of God, gays, torturers, and seven kinds of profanity. How can that be?

Most Sung-About Body Part? The Eyes Have It

The Eyes win!


Visual artists Fernanda Viégas and Martin Wattenberg analyzed over 10,000 songs to find out which parts of the human body were mentioned the most and broke down the resulting data by genre. The result: An interactive graphic work called "Listen" that correlates musical genres with the body parts they mention the most, as part of their ongoing Fleshmap project. Clicking on each genre brings up a more detailed representation of its chief bodily concerns.
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So, what do the results tell us? Across all of the categories, the eyes are most frequently mentioned body part (Hall & Oates, "Private Eyes"), with the exceptions of hip hop, which places a firm emphasis on the posterior (Sir Mix a Lot, "Baby Got Back") and blues (Louisiana Red, "Keep Your Hands Off My Woman") and gospel music (The Gospel, "Put Your Hands Together"), which are respectively focused on the keeping off of one's hands and the clapping or raising of one's hands.
(via The Happy Hospitalist)

About Death, Just Like Us or Pretty Much Unaware?

MOURNING OR CONFUSED? Gana held her dead baby, Claudio, for days

Last week the Internet and European news outlets were flooded with poignant photographs of Gana, an 11-year-old gorilla at the Münster Zoo in Germany, holding up the body of her dead baby, Claudio, and pursing her lips toward his lifeless fingers. Claudio died at the age of 3 months of an apparent heart defect, and for days Gana refused to surrender his corpse to zookeepers, a saga that provoked among her throngs of human onlookers admiration and compassion and murmurings that, you see? Gorillas, and probably a lot of other animals as well, have a grasp of their mortality and will grieve for the dead and are really just like us after all.

Nobody knows what emotions swept through Gana’s head and heart as she persisted in cradling and nuzzling the remains of her son. But primatologists do know this: Among nearly all species of apes and monkeys in the wild, a mother will react to the death of her infant as Gana did — by clutching the little decedent to her breast and treating it as though it were still alive. For days or even weeks afterward, she will take it with her everywhere and fight off anything that threatens to snatch it away. “The only time I was ever mobbed by langurs was when I tried to inspect a baby corpse,” said the primatologist Sarah Hrdy. Only gradually will she allow the distance between herself and the ever-gnarlier carcass to grow.

Vogue’s Fashion Photos Spark Debate in India

NEW DELHI — An old woman missing her upper front teeth holds a child in rumpled clothes — who is wearing a Fendi bib (retail price, about $100).

Vogue India’s August issue presented a 16-page vision of supple handbags, bejeweled clutches and status-symbol umbrellas, modeled not by runway stars or the wealthiest fraction of Indian society who can actually afford these accessories, but by average Indian people.

Perhaps not surprisingly, not everyone in India was amused.
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There’s nothing “fun or funny” about putting a poor person in a mud hut in clothing designed by Alexander McQueen, she said in a telephone interview. “There are farmer suicides here, for God’s sake” she said, referring to thousands of Indian farmers who have killed themselves in the last decade because of debt.