Kermit the Frog at the Doctor's Office

Kermit the Frog at the Doctor's Office
(Source)

Nothing really to say today. I just like this cartoon. Have a good weekend!

Kidney Stones Increase In U.S. Children

Children are being diagnosed with kidney stones much more often these days, according to a piece in the NYTimes "A Rise in Kidney Stones Is Seen in U.S. Children":

To the great surprise of parents, kidney stones, once considered a disorder of middle age, are now showing up in children as young as 5 or 6. 

While there are no reliable data on the number of cases, pediatric urologists and nephrologists across the country say they are seeing a steep rise in young patients. Some hospitals have opened pediatric kidney stone clinics. 

“The older doctors would say in the ’70s and ’80s, they’d see a kid with a stone once every few months,” said Dr. Caleb P. Nelson, a urology instructor at Harvard Medical School who is co-director of the new kidney stone center at Children’s Hospital Boston. “Now we see kids once a week or less.” 

Dr. John C. Pope IV, an associate professor of urologic surgery and pediatrics at the Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, said, “When we tell parents, most say they’ve never heard of a kid with a kidney stone and think something is terribly wrong with their child.” 

In China recently, many children who drank milk tainted with melamine — a toxic chemical illegally added to watered-down milk to inflate the protein count — developed kidney stones. 

The increase in the United States is attributed to a host of factors, including a food additive that is both legal and ubiquitous: salt. 

Though most of the research on kidney stones comes from adult studies, experts believe it can be applied to children. Those studies have found that dietary factors are the leading cause of kidney stones, which are crystallizations of several substances in the urine. Stones form when these substances become too concentrated. 

Forty to 65 percent of kidney stones are formed when oxalate, a byproduct of certain foods, binds to calcium in the urine. (Other common types include calcium phosphate stones and uric acid stones.) And the two biggest risk factors for this binding process are not drinking enough fluids and eating too much salt; both increase the amount of calcium and oxalate in the urine. 

Excess salt has to be excreted through the kidneys, but salt binds to calcium on its way out, creating a greater concentration of calcium in the urine and the kidneys.

Interesting, but not too surprising, especially when you consider how much soda kids drink, the rise in childhood obesity, inadequate water intake, and the link all of these have with kidney disease.

The McCain Healthcare Plan

As I noted in a previous post on the future of healthcare in America, both candidates have dynamic proposals for reforming our healthcare system. Previously, I have discussed the Obama healthcare plan and what I found interesting about it. Today, I will address John McCain's healthcare plan. The entire plan can be found here: Straight Talk on Healthcare Reform

Here are the key points that I found interesting:

• John McCain Will Reform Health Care Making It Easier For Individuals And Families To Obtain Insurance. An important part of his plan is to use competition to improve the quality of health insurance with greater variety to match people's needs, lower prices, and portability. Families should be able to purchase health insurance nationwide, across state lines.
  
  An interesting proposal, but seeing as most families receive their health insurance through their employer, I am not sure how this would be implemented. I assume he means that employers will be able to do this on behalf of their employees. Furthermore, while competition may indeed prove beneficial, health insurance differs from other goods due to the complex nature of what is covered. If policies end up competing primarily on price without regard to benefits, it is not clear how families would be better served.
  
  
  
• John McCain Will Reform The Tax Code To Offer More Choices Beyond Employer-Based Health Insurance Coverage. While still having the option of employer-based coverage, every family will receive a direct refundable tax credit - effectively cash - of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider
  
  Seems like a good idea, except from what I have heard, most plans start around $12,000 per year for a family of four, so I think the credit would have to be expanded.
  
  
  
• John McCain Proposes Making Insurance More Portable. Americans need insurance that follows them from job to job. They want insurance that is still there if they retire early and does not change if they take a few years off to raise the kids.
  
  Makes sense, but how will this be enforced? What if the company fired the employee for poor performance or illicit behavior? This gets to the heart of the problem of tying insurance to employment. Sure, employee pools make for good pseudo-random groups to insure, but it doesn't make sense in the grand scheme of things, especially when one considers that sick people generally are not good workers.
  
  
  
• John McCain Will Work With States To Establish A Guaranteed Access Plan. As President, John McCain will work with governors to develop a best practice model that states can follow - a Guaranteed Access Plan or GAP - that would reflect the best experience of the states to ensure these patients have access to health coverage. One approach would establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs. There would be reasonable limits on premiums, and assistance would be available for Americans below a certain income level.
  
  I don't understand how the government forming a "nonprofit corporation" (NPC) that covers apparently everyone that the insurance companies don't want to cover (ie, the costliest patients) is any different from a bastardized single payer system. If anything, this is worse than single payer, since this NPC would effectively take on the 'worst' patients leaving the insurance companies to cherry pick the lowest risks for themselves.
  
  
  
• CHEAPER DRUGS: Lowering Drug Prices. John McCain will look to bring greater competition to our drug markets through safe re-importation of drugs and faster introduction of generic drugs.
  
  I have the same issues here as I did with Obama's version, namely who is going to regulate this? The FDA? Also, McCain does not address the 2003 Medicare bill.
  
  
  
• TORT REFORM: Passing Medical Liability Reform. We must pass medical liability reform that eliminates lawsuits directed at doctors who follow clinical guidelines and adhere to safety protocols. Every patient should have access to legal remedies in cases of bad medical practice but that should not be an invitation to endless, frivolous lawsuits.
  
  Again, makes sense. However, without any specifics, it seems like empty rhetoric, especially under the current system, this is more a state-by-state issue, rather than a federal one.
  
  
  
• John McCain is very concerned about the rising incidence of autism among America's children and has continually supported research into its causes and treatment
  
  A nice sentiment, but is this really a national issue? Somehow, I feel like McCain has only come to care about this in the last 8 weeks or so...
  
  

Overall, I think McCain's plan has some intriguinig ideas but without more specific details, it is hard to evaluate them. Both plans seem to suffer from a lack of detail in terms of how they will pay for these proposals, implement them, or enforce them. Still, it bothers me that McCain seems to think that the solution lies in putting more power in the hands of patients without many safeguards to ensure that they actually receive adequate care. Having a $5000 tax credit isn't much solace to someone with a new diagnosis of cancer, especially if they are uninsured, since the cancer is now a 'pre-existing condition,' meaning they will not be insured in the future. Perhaps the non-profit corportation would pick up the slack here, but without much detail, who knows how that would work?

In the final judgment, I think both plans have significant deficiencies, but I believe the Obama plan to be the stronger of the two. Still, much change is needed before the U.S. healthcare system truly lives up to its potential. Your thoughts?

The Problem With ERAS

The Electronic Residency Application Service (ERAS) is the system medical students in the United States use to apply to residency programs. While a long ways better than the system that existed before, ERAS still has its frustrating aspects, namely the long delays and lack of coordination.

The system does not have any delays relative to its own timeline. However, the timeline has delays built in. Applicants are able to submit applications usually around September 1 until around November 1. However, most applicants will try to get their materials in by September 1, so that becomes the true deadline. No matter when the applicants submit their materials though, the Dean's Letter (or MSPE in ERAS-lingo) is not uploaded by the candidate's school until November 1.

Why the two month delay? There really is very little reason to not upload the Dean's Letter by September 1. Or, alternatively, let students apply starting on a date closer to November 1, so there isn't that much of a delay.

Particularly frustrating is the fact that some programs have stated policies of not extending interview invitations until after November 1 or even later. One program I applied to will not send out invitations until December! What on earth are they waiting three months for? Some colleagues have noted that this just part of the game that programs play, using these tactics to weed out truly interested candidates from the ones who just applied because it was easy to click the button. Perhaps this is true, but how silly. We are graduate students, training to be professionals, about to enter the field of medicine. Why we have to play such ridiculous games, which ultimately is a waste of time for the students and the programs, is beyond me.

Beyond simply griping about this, I think two easy solutions are possible. One would be to move the ERAS open date later, perhaps to October 1 (or equivalently, move the Dean's Letter release date earlier). The second solution would be to mandate a date for programs to send out invitations so that they cannot play games with their interview slots. Planning interviews would be much easier with an entire slate of invitations, relatively to dealing with the slow trickle that comes in now. This would not change the fundamental workload involved, but it would simplify the situation greatly for applicants. Eventually, hurdles like this one and many others will turn away even the most deserving applicants from careers in medicine, so it behooves the powers that be to make the process of becoming a physician easier while maintaining rigorous academic standards.

Common Things Being Uncommon?

Often in medical school we learn about esoteric things, in order to prepare us for the "once in a lifetime" occurrence when we may see it. The training is important, but sometimes we go too far, to the detriment of more common presentations. Here is an interesting example of things you don't learn in medical school from one ER physician's blog (via KevinMD):

Emergency Medicine is notable as much for its drama as for the pedestrian and mundane things that come through the door. Every time I meet someone new and tell them what I do for a living, I always get the "Is it as exciting as it is on TV?" question, or some variant.

Truth is, of course not. Headaches, abdominal pain, weak & dizzy, etc account for a substantial majority of our cases. In fact, the critical care stuff is generally less than 10% of what we do. Now sure, if I see 16 patients per shift, then yes, I do perform critical care daily. But it turns out that the simplest cases can be the most challenging.

You see, in residency, there's a lot of focus on critical care. I spent months working in the cardiac ICU, the medical ICU, the pediatric ICU, the surgical ICU, the burn ICU, the OR, anesthesia, and on the floors. I could line, intubate, and resuscitate in my sleep (and did, on a few notable occasions). I could recite the Killip classifications for MI and knew the DeBakey versus the Stanford classifications for aortic dissections. So I was well prepared and very comfortable with caring for severely ill and unstable patients, which is an important qualification for the job. Internal medicine also was highly emphasized: complex physiology, the key things not to miss in chest pain, electrolyte management, etc.

All this prepared me very poorly for some of the more mundane elements of my practice in "the real world." Stuff you might call "family medicine," though I don't know if that's the right phrase. For example, I remember the first time I saw a new mother bring in her week-old infant who was vomiting blood. Holy crap but I was scared. I knew all about GI bleeds -- in adults -- and vomiting blood was really bad. I didn't think kids even got GI bleeds. I was wracking my brain over it, wondering if the baby had some sort of vascular malformation in the stomach, and the nurse just stared at me when I told her to put in an IV and draw blood. "Why would you want to do that?" she asked

Keep reading to find out why the nurse questioned the ER doc's actions. You gotta love ER nurses - they've seen everything.

Emergency Medicine / ER Blogs

Lately, I've found myself reading emergency medicine blogs more frequently. The posts tend to cover interesting cases and their initial presentations, including all the confounding variables of 'the real world.' Furthermore, it seems to me that ER physicians tend to share a sort of dry wit that I tend to like.

Here's a list of a few of the blogs I have enjoyed (in no particular order):

• Movin' Meat
  
• ER Stories
  
• WhiteCoat Rants
  
• Edwinleap.com
  
• Emergiblog
  
• Scalpel or Sword?

Have any more Emergency Medicine / ER blogs that I should add to the list? Feel free to add them in the comments.

Toga: Endoscopic Weight Loss Surgery

Weight loss surgery has turned into big business within medicine. Bariatric surgery has gone from the butt of a joke within surgery to a full-fledged subspecialty. Interesting article in the NYTimes today about what might possibly become the latest fad in bariatric surgery: endoscopic stapling.

The product described here, Toga, has not been approved yet in the United States, but it sounds intriguing:

On a recent Wednesday, Karleen Perez lay unconscious on an operating table in Upper Manhattan while her surgeons and two consultants from a medical device company peered at an overhead monitor that displayed images from inside her digestive tract.

The surgeons, Dr. Marc Bessler and Dr. Daniel Davis, had just stapled her stomach to form a thumb-sized tube that would hold only a small amount of food. The operation resembled others done for weight loss, with one huge difference. In Ms. Perez’s case, there was no cutting. Instead, the surgeons had passed the stapler down her throat and stapled her stomach from the inside.

What does the procedure itself entail, you ask?

The operation is not as simple as it might sound. To begin, Ms. Perez was given general anesthesia and put on a respirator. Then the surgeons pushed a dilator, a formidable-looking tube about three-quarters of an inch wide, down her throat to stretch her esophagus.

Next came another wide tube, this one about two feet long, containing the stapler. The surgeons inflated her stomach with carbon dioxide to create space in which to work. Dr. Bessler struggled for 5 or 10 minutes to position the stapler properly, and then activated controls that opened it, like a miniature spaceship, inside Ms. Perez’s stomach.

A sail and curving wire emerged from the stapler to help push aside the folds of her stomach. Then Dr. Bessler turned on a vacuum pump to draw parts of the front and back walls of the stomach into the device to be stapled together.

Three rows of staples were needed, but the stapler holds only one row, so the whole apparatus had to be withdrawn, rinsed, reloaded, pushed back down Ms. Perez’s throat and painstakingly repositioned for each row. The Satiety consultants stood close by to coach, at one point warning Dr. Bessler that if he inflated Ms. Perez’s stomach too much, her first row of staples could pop. The surgery took three hours.

I'm not sure about this whole esophageal dilation. Doesn't that put patients at risk for something like Boerhaave's syndrome (esophageal rupture)? Just wondering. And even if it does work reasonably well, can you say 'turf war'? My guess is that gastroenterologists and bariatric surgeons are going to have at it if this becomes the next big thing in weight loss surgery.

FYI the term 'Toga' comes from transoral gastroplasty.

On a related note, I came across this title and found it funny:

Not only are the readers overweight, but now you're calling them dummies too?! Those poor people!

Update: For more information on bariatric surgery, check out Houston Weight Loss Surgery

The Obama Healthcare Plan

As I noted in a previous post on the future of healthcare in America, both candidates have dynamic proposals for reforming our healthcare system. Today, I look at Senator Barack Obama's proposal for reform. The entire proposal can be found here: Barack Obama's Healthcare Plan (pdf).

If you click, you'll find a broad-ranging plan that is nearly 9 pages long. Here are the key points that I liked:

• Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. They will also phase in requirements for full implementation of health IT and commit the necessary federal resources to make it happen.
  
  I have written previously that electronic medical records need greater support in order to reap potential benefits, and this sounds like the type of commitment the healthcare community has been waiting for. A standards based approach is especially prescient.
  
  
  
• Barack Obama and Joe Biden will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care and costs. Health plans will be required to disclose the percentage of premiums that actually goes to paying for patient care as opposed to administrative costs.
  
  Such transparency is key to forcing hospitals to improve. If the public is more aware of which hospitals are truly good and which are not, they will vote with their feet and their healthcare dollars, forcing underperforming hospitals to shape up.
  
  
  
• Barack Obama and Joe Biden believe we need to eliminate the excessive subsidies to Medicare Advantage plans and pay them the same amount it would cost to treat the same patients under regular Medicare.
  
  Makes sense, doesn't it? Why should the government pay more for what is essentially the same care provision? This is just common sense.
  
  
  
• Barack Obama and Joe Biden will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S.
  
  A good idea in theory (and a free market one, to boot). However, the plan does not provide specifics as far as which countries will be acceptalbe, and how one is going to judge which imported drugs are "safe." The FDA can barely handle monitoring domestic drugs as it is.
  
  
  
• The 2003 Medicare Prescription Drug Improvement and Modernization Act bans the government from negotiating down the prices of prescription drugs, even though the Department of Veterans Affairs’ negotiation of prescription drug prices with drug companies has garnered significant savings for taxpayers.32 Barack Obama and Joe Biden will repeal the ban on direct negotiation with drug companies and use the resulting savings, which could be as high as $30 billion,33 to further invest in improving health care coverage and quality.
  
  Thank you. Finally.
  
  
  
• Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. In fact, the most recent data available reveals that the top five percent of people with the greatest health care expenses in the U.S. account for 49 percent of the overall health care dollar. For small businesses, having a single employee with catastrophic expenditures can make insurance unaffordable to all of the workers in the firm. The Obama-Biden plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers' premiums. Offsetting some of the catastrophic costs would make health care more affordable for employers, workers and their families.
  
  Again, makes sense. This is how insurance is truly supposed to function. Instead of working to deny claims in a patient's time of need, this plan would simply cover catastrophic care. Of course, the obvious question is how much of a liability does this pose to the federal government. Furthermore, isn't this effectively nationalizing coverage anyway since the government would be the 'single payer' behind this scheme for the truly high cost cases? Hmm
  
  
  
• Obama and Biden will require insurance companies to cover pre-existing conditions so all Americans, regardless of their health status or history, can get comprehensive benefits at fair and stable premiums.
  
  A nice sentiment, and definitely something that is necessary, but without details on how this will be enforced or what the limits of "coverage" will be, it's not clear what the true impact of this is.
  
  
  
• They will also create a new Small Business Health Tax Credit to provide small businesses with a refundable tax credit of up to 50 percent on premiums paid by small businesses on behalf of their employees. To be eligible for the credit, small businesses will have to offer a quality health plan to all of their employees and cover a meaningful share of the cost of employee health premiums.
  
  Sounds good, but how much will this cost? What are the cut-offs for 'small business'? Who will enforce that the businesses are actually providing good plans? Again, hmm
  

Overall, I think the Obama plan is sound and has many innovative ideas along with many items that were due for a change. However, without more details on inclusion and exclusion criteria, it is difficult to gauge how much this all will cost. Furthermore, without an enforcement scheme, it is not clear how Obama plans to ensure that all these ideas become reality in a way that protects taxpayers from fradulent claims or plain ol' waste. However, given how competently Obama has run his campaign, I can only hope that his administration would similarly find ways to effectively manage the new healthcare bureaucracies he would be creating. Your thoughts?

I'll have a post soon about the McCain plan too.

Concierge Health Care Service

Concierge health care service is a relatively new concept. The idea is basically one in which the physician cuts out of the middleman and only accepts patients who pay for their care directly, without using insurance. Here is one doctor's concierge healthcare experience (via KevinMD):

This post from about a year ago explored the reasons why my friend and personal physician -- internist Bill Lent, MD -- decided to convert his internal medicine practice to a concierge practice in which he limited his practice to 600 patients who pay $1,500 per year to retain his services. Inasmuch as I am blessed with good health, the only time I see Bill in most years is for my annual physical, which was this past week. As always, it was good to catch up with him and hear his thoughts about the first year of a concierge practice.

In short, Bill's experience has been overwhelmingly positive. The funds generated through his patients' retainer payments have relieved Bill of the financial pressure that had been mounting over the past decade to increase patient visits as Medicare and private medical insurers systematically reduced the amount paid to doctors for such visits. Released from that pressure, Bill is now able to spend more time with each patient, which Bill believes provides the patient with better quality service. The response from Bill's patients has been uniformly positive.

Although Bill's workload has been reduced from the standpoint that he no longer feels compelled to see more and more patients to maintain revenue levels in the face of reduced insurance payments, Bill has had to spend quite a bit of time over the past year in the process of computerizing his patients records. Part of the deal for patients in signing up for the concierge service is that their records are digitized so that the patient, Bill or any other doctor who the patient retains can review the records from anywhere via the Web. That perk has required a considerable expenditure of effort over the past year in digitizing those records, but now that the process is largely complete, Bill will spend far less time in future years as he simply amends a patient's computerized record with each visit.

There have been a number of pleasant surprises in Bill's first year of the concierge practice. For example, Bill was initially concerned that a number of his less affluent patients would opt not to participate because of the retainer payment. Surprisingly, however, his patient base has remained quite diverse from a socioeconomic standpoint -- even a large number of his elderly patients on Medicare elected to participate despite the fact that Medicare doesn't cover any of the retainer payment.

Keep reading for some more interesting observations about the practice. I'm not sure how I feel about the concierge idea yet, but it seems like it has some merit depending on the type of patient the PCP sees. Your thoughts? Comment below!

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Athletes Leaving Brains to Concussion Study

The debate over whether NFL players suffer long-term injuries from playing football seems both silly and sad. Many older NFL players have debilitating injuries but did not make the massive salaries of modern players. From what I've read, the NFL has consistently stone-walled these players when they have sought assistance from the league. Twelve athletes will donate their brains to Boston University to study the effects of conccussions on their brains:

A dozen athletes, including six N.F.L. players and a former United States women’s soccer player, have agreed to donate their brains after their deaths to the Center for the Study of Traumatic Encephalopathy.

On Thursday, the center will announce that a fifth deceased N.F.L. player, the former Houston Oilers linebacker John Grimsley, was found to have brain damage commonly associated with boxers.

The former New England Patriots linebacker Ted Johnson, one of the players who has agreed to donate his brain, said he hoped the center would help clarify the issue of concussions’ long-term effects, which have been tied to cognitive impairment and depression in several published studies. The N.F.L. says that, in regard to its players, the long-term effects of concussions are uncertain.

Hopefully, this new initiative will provide conclusive proof of the effects of football and spur the league into action.

SmartMedTravel: A Website for Residency Applicants

Many 4th year medical students this year are about to embark on the long process of applying and interviewing for residency positions. I've already started to feel the pressure of scheduling multiple interviews in different cities and trying to coordinate with various programs. SmartMedTravel is a site started by a couple of former medical students that aims to make the planning easier. Their mission is:

As medical students we traveled the U.S. interviewing at medical schools and residency programs. We searched the web to find the cheapest options and created this site to be the most comprehensive collection of budget airlines, rental cars, and second option airports compiled in one place.

This site can be utilized by anyone. It is specifically tailored for medical and pre-med students as it is arranged to show the cheapest travel options for every city that has a residency program or medical school

It looks pretty decent. If you use this site, let me know what your experience with it is like. I'll also be sharing my thoughts in a future post.