KOLAHUN

Couldn't Have Said It Better Myself

An excerpt from Frieden and Mostashari's commentary in this week's JAMA:

"If reforming US health care results only in expanded access to care, costs will increase faster but with limited health benefits. If only cost controls are instituted, even more individuals will be denied access to needed care. Health care must be restructured to make maximizing health the organizing principle. To do this, 3 synergistic changes are needed: (1) payment that offers substantial rewards for disease prevention and effective management of chronic disease; (2) an information system oriented toward prevention; and (3) changes in care management and practice workflows."

The rest of the article continues this non-novel, but well articulated, goal of the future of a good health system.  Moreover, they've got good things to say about the VA and it's EMR.  Well done...and a good read for anyone interested in why each of Obama/Clinton/McCain's plans sucks. 

FEMA Trailers, the CDC and Formaldehyde

This week's Gambit Weekly's cover story does a marvelous job describing the politicization of FEMA and the CDC and the ill-effects on trailer-home residents here in the Gulf Coast post-Katrina.  Months after residents complained and the Sierra Club lobbied, the CDC finally did a study that came to the conclusion that the trailers provided to people who couldn't live in their storm-damaged homes contained um...too much formaldehyde.  Read the Gambit Weekly article - it needs to be digested in whole to really get the "seething quotient" at the appropriate level. 

Of course, going to the CDC website to understand health effects of did little to assuage any anger.  On the one hand, they have a simple health advisory for clinicians (which on whole isn't that helpful).  On the other hand, here's their advice to trailer-residents:

•   Families who live in FEMA-supplied travel trailers and mobile homes should spend as much time outdoors in fresh air as possible.
• Open windows as much as possible to let in fresh air.
•   Try to maintain the temperature inside travel trailers and mobile homes at the lowest comfortable level.
•   Do not smoke, and especially do not smoke indoors.
•   If you have health concerns, see a doctor or another medical professional.
•   Families that include children, the elderly, and those with chronic diseases such as asthma should make a special effort to get as much fresh air as possible, and these families should make relocating to permanent housing a priority. (emphasis added)

WTF?  It would be nice to know which technocrat wrote these suggestions.  Perhaps we could have him/her help us overcome poverty ("make more money"), solve our energy crises ("develop cold fusion"), or end wars ("resolve differences without resorting to violence").  This person's got the right attitude! 

Honestly!   

(pic from flickr.com user SAsqrd)

Depressed? Give Pharmaceuticals Some Money

One needs to do a bit of work to get to heart of the PLoS article showing the relative inefficacy of anti-depressive medications relative to placebo.  First, one needs to overcome the obstacle of reading an article in a pay-for-publication site.  But as we've discussed before in this post, sites like the Public Library of Science (PLoS) have earned stronger reputations for high quality work while using a new business model that relies on researchers funding the Journal rather than subscribers. 

  Then one has to overcome the internalized belief that medicines necessarily help.  We've essentially been sold a bag of goods by big PhARMA that what we need to help our ailing selves is to buy their little pills.  Even way back in the day, the Rolling Stones sang about it.  Then in the 90s, we were inundated by the remarkable effects of Prozac.  Dr. Melfi even prescribes Prozac to Tony Soprano in the pilot episode of the Sopranos.  And what we've got today is that two anti-depressant medicines (though not studied in this paper) rank #5 and #10 in prescription drug dollar value, combining for over $4 billion/annum here in the US.  That's a lot of money for, essentially, sugar pills. 

And finally, though not addressed in the article, we've got to figure out more creative ways to tackle mental health problem.  One of the tangential points in the article is that while they don't believe that anti-depressant medications, per se, help, something does.  While they found no significant effects between anti-depressant medications and placebo, they found that, over a wide range of effects, both did help patients reduce their depression (as measured by their Hamilton score).  The next step in figuring out how to tackle mental health is this something.   

Obama in red tie causes row

The Ministry of Information would like to report that we have received an e-mail from the Clinton campaign, which includes a photo of US Senator Barack Obama wearing a red tie (shown below)– which everyone knows is evidence of his secret, conservative leanings.  The e-mail states that Clinton would not be caught dead wearing a red tie, because she is not now, nor has she ever been a member of the Communist Party – though she cannot say the same for Mr. Obama.  The Obama campaign has yet to deny his known, Communist Party affiliation.

As with an earlier posting, in which our writer described Obama’s Kenyan father as Nigerian, we have not taken the time to check our facts.  And why should we?  And why should you?  Because we wrote it and you read it on the internet, so it has to be true, right?  Just google “Obama Nigerian father” and see how many other people think Obama’s father is Nigerian.  And did you know that Lagos is the capital city of Nigeria?  Well, it is.  Trust us.  We are the internet’s Ministry of Information.  If anyone says it ain’t, you can tell them you read it on the internet – and that makes it true.

Although we have no picture of Obama in a red tie and cannot produce the e-mail we received, it is the hope of the Ministry that other news sources will pick up this story and circulate it ; that both the Clinton, Obama and McCain campaigns will spend time, money and energy discussing this photo and what it means; that you, gentle reader, will pay attention to stories like these, post it on your blogs, talk with your friends about the “necktie scandal”, and be distracted from the more important and informative posts that populate this blog, not to mention the world we live in.

Some bloggers, here, try to entice you with honest reporting on issues that matter (with all their boring facts, tedious attention to accuracy and insistence of informing the public over entertaining them).  But with stories like “Obama in red tie!” and "V47.77 Absence, Penis, Acquired", the Ministry looks forward to the day when we get thousands of hits a day and our blog membership fees are paid for by the advertisements and the logos of our corporate sponsors, found in the empty margins of your screen. $$$$$$$$$$$$$

Our only regret, is that some other “news blog”, beat us to it with “Obama wearing turban”.  Damn that Ministry of Truth and their sucky “Ignorance Is Truth” motto!!!!  Our motto is more cooler.

The Ministry of Information

“more power to the misinformed”

Stories From the Front-Lines - Implementing an EMR

From a loyal reader:

"I am a medical provider at a health clinic that is in the process of implementing an Electronic Medical Record (EMR) system.  For those that are not familiar, an EMR is supposed to bring a lot of benefits to a health clinic.  One of the most commonly referenced is to improve the quality of care provided.  We had our "Go Live" last week in which we were supposed to have all our paper systems disappear into the virtual world.  We have been told by many clinics that this process will be quite painful for about 6 weeks, but then we will begin to see the light at the end of the long tunnel and realize how much easier things have become. 

"I am going to stay positive and try and believe the "experts", but I can honestly say that these past two weeks have left me coming home each night feeling as though I provided anything but quality care.  My eye contact with patients has dramatically decreased- to the point that if it is my first time meeting the patient and I need to finish the chart at the end of the day, I often have trouble remembering what the they looked like!  When I expressed this shocking concern with the IT folks, I was told that there is a file in the EMR that will capture a picture of the patient! 

"The most challenging part of adding an EMR into the clinic has not been making sure everyone has been trained to find each and every pull down menu or move between screens, more so it has been the complete dissolution of the personality that surrounds each and every patient visit.  One of my favorite things of being a medical provider is not the science, not figuring out what medicine fits with what diagnosis, reviewing labs or even seeing success when patients implement changes that improve their overall health.

Perseverance

The British Medical Journal tackles the odious influence of the drug companies on residents training in this week's print edition.  Now, having just written about similar malicious practices in my last post, I was close to saturation on this subject.  Honestly, how often can one topic be beat to death before diminishing and negative returns deem it more than just futile, but harmful? 

Well, as it happens, I'm currently reading a marvelous book, Samantha Power's, A Problem from Hell: America and the Age of Genocide.  Early on, she describes the verbal odyssey of Senator William Proxmire (D - Wisconsin) who spoke out on the failure of the US to ratify the international genocide treaty.  He made a daily speech at every open Senate session for 19 years - well over 3,000 speeches! - urging the body to ratify the treaty (which it eventually did). 

He never repeated speeches.  He tasked his staff to write a new one each night and many times he wrote his own.  He spoke of Jews and Armenians.  He tugged at emotions, commented on landmark anniversaries and did whatever was necessary to slowly wear down his opponents. 

Now obviously drug companies don't compare with genocidal states.  But the creative perseverance of Senator William Proxmire is inspiring.  So expect more posts on the malignant efforts of pharmaceuticals to influence education and prescribing practices.  In the meanwhile, with the daily trickle of drug companies' methodology to infiltrate clinician mindsets - does anyone really trust any article whose author has the slime of a drug company's influence on him or her?   

Physician On The Take

Mrs. Jones (not real name) suffers from chronic knee pain and occasional swelling (not real complaint).  She first came to the public health center after she lost her job because her pain prevented her from her usual work as a tour guide in the art museum (OK, that's true) .  She was in tears because she didn’t know how she would be able to pay for a doctor’s visit or treatment, but she could no longer tolerate the pain and felt she had no other choice but to come in to our clinic.

Because of her low-income, she didn’t have to pay anything for her visit, her medications, her x-rays or the inter-articular injections that relieved some of the pain.  She couldn’t believe that she’d got such great care from a government run clinic, at no cost to her.  She was so happy, she bought me a red necktie – because in her county, red was the color of happiness and good fortune.  She wanted to share hers with me.

About six months later, Mrs. Jones was advised by our social worker to apply for state disability insurance and she brought her application in, on her appointment day, for me to complete.  I filled it out right away, made a copy for the chart and returned the original to her before she left the clinic.  That's when I started thinking...

In my busy clinic, rarely, almost never, do I have enough time to complete forms while the patient waits in the room  - and the rest are in the lobby wondering why it’s taking so long to be seen.  Forms are usually collected and patients are informed that they will be inspected, completed within a week (if error free), or returned to the patient to make corrections before they can be resubmitted for me to be reviewed again.  "Don't expect them to be done early - it gonna take a week, at most.  Forms take one week."  But why did Mrs. Jones get same day service?  The answer came to me as soon as I returned the form to her.  After giving her the form, Mrs. Jones gave me another gift wrapped box; this time, containing an expensive shirt.

The Hagiography of St. Bob of Miami Lakes

My hero, Bob Graham.  Sorry, Barack Obama, to me you're no Bob Graham.

True, in 2003, I did not drop out of my residency to campaign for Bob Graham, as I’d previous declared I would on many occasions. But, I’m still a fan of Graham, not a fanatic. But to this day, I still prefer him over any other politician to serve as our President and hold out hope that the 72 year old two term governor and three term, former US Senator will be on the Democrat’s short list for the vice presidency. (Reagan turned 70 his first year in office!). For over 35 years, Graham served our home state of Florida  as elected official and has earned every bit of the respect he enjoys day.

Check out his portrait, by artist, boxing legend and former personal physician to Muhammad Ali, Dr. Ferdie Pacheco of Ybor City (in Tampa), presently living in Miami.

I support Graham because of his record of accomplishment, not his promises for tomorrow. I like his low-key, intelligent brand of leadership - substance over style.  He fought to create jobs for Floridians, kept oil drilling far from our Gulf and Atlantic coasts, worked to create opportunities from all Floridians, not just the elite. I liked Bob Graham, but he realy became my hero on October 11, 2002.

Low Back Pain

There are a couple of recent manuscripts that deal with the ubiquitous problem low back pain.  In general, there are very few cases of cancer/infections/verterbral compressions requiring immediate attention.  A second category of less acute illness encompasses a larger population - those with radiculopathy or spinal stenosis.  The NEJM review article from this week suggests diagnosis and treatment options for this middle tier group.  Basically, if a clinical exam suggests a neurologic impairment, then they recommend getting a MRI or CT.  However, even if surgery is performed, many patients will end up the same as non-surgical patients by about 2 years.  The final category is for those who have non-specific back pain.  The main recommendation is, well...just keep on walking and take a couple o motrins.  Really.  There's not a lot of things allopathic medicine has to offer these minimal symptom patients.  All these recommendations are encapsulated in the American College of Physicians and the American Pain Society Clinical Guidelines.

All that stuff, while clinically useful, doesn't really make me jump.  What does, however, is that both the NEJM article authors and 2 of the 7 Clinical Guidelines authors reported pharmaceutical company conflicts of interest.  Of all the internists, family practitioners and orthopods around, the NEJM had no one to turn to without a potential conflict of interest?  And the guys writing the GUIDELINES couldn't find two other leading physicians without similar conflicts?  Honestly.

(Picture used from Medline Plus) 

Hagiography

Speaking of Obama hagiography, does our guest blogger remember one Senator Bob Graham 2004 and the possible postponement of a promising medical career?