DB’s Medical Rants

 
Dr. RW provided a link to Dr. Wachter’s excellent article reviewing the 4 hour rule and why it failed.  For those who do not have access to the Annals of Internal Medicine, here is the abstract:

The administration of antibiotics within 4 hours to patients with community-acquired pneumonia has been criticized as a quality standard because [...]

 
Doctors Say Medication Is Overused in Dementia

Nevertheless, many doctors say misuse of the drugs is widespread. “These antipsychotics can be overused and abused,” said Dr. Johnny Matson, a professor of psychology at Louisiana State University. “And there’s a lot of abuse going on in a lot of these places.”
Dr. William D. Smucker, a member [...]

 
The debate appears in the current issue of the Archives of Internal Medicine - subscription needed to read the text.
Hospitalists and the Hospital Medicine System of Care Are Good for Patient Care
Mark V. Williams, MD
A Hospitalist Inpatient System Does Not Improve Patient Care Outcomes
Robert M. Centor, MD
Rebuttal
Mark V. Williams, MD
Rebuttal

Robert M. Centor, [...]

 
Birmingham VA cardiologist fishes blockages from plugged arteries

Interventional cardiologists working with minimally invasive techniques have long wrestled with the problem of exactly how to handle blood clots that often plug the diseased coronary arteries of heart-attack patients.
Cardiologists typically run tubes and wires from a patient’s groin up to blocked heart arteries. They inflate tiny balloons [...]

In today’s NEJM -
Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure

Background It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure. This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure [...]

 
Our colleague, RW sees the world without rose colored glasses.  SHM must focus on hospitalist career satisfaction.

The specialty will be stronger if it can attract career hospitalists, but, as I wrote last week, it will be manned increasingly by transient labor unless leaders provide a stronger vision for career satisfaction. According to an article [...]

 
Medscape has a provocative discussion occuring - More Physicians Abandon Hospital In-Patient Care.  A few excerpts:

Primary Care Internal Medicine is DEAD - at the hands of Medicare and the Insurance monopoly - the body is still twitching but it’s dead. By the time our leadership both political & medical, realize this it will already be [...]

 
I have been writing about the importance of accurate diagnosis throughout the 6+ years of this blog’s existence.  I frequently opine that the quality movement has ignored diagnostic accuracy because it is not easily measured.
Maggie Mahar tries to address this issue in two recent blog entries - The Silence Surrounding Diagnostic Errors; Part I and [...]

 
I often rant about performance indicators - Exploring the concept of stratification - implications for performance measures
Yesterday, the NEJM released several important articles which challenge blood sugar tight control as a means of decreasing complications.  The NY Times covers these articles very well - Tight Rein on Blood Sugar has no Heart Benefit.
At the SGIM [...]

 
The state of primary care
The authors list four things which are damaging primary care:

A population health agenda - which pulls patients away from their primary care physician
Perverse incentives from P4P
Access
Restricted work hours for trainees

A couple of excerpts for those who do not have access to this journal.

The second matter is perverse incentives.Targets have their place, [...]

A loyal reader writes:

You have been, rightfully so in my opinion, a loud critic regarding current P4P schemes and the perverse effects they have.
With 15-25% of medical home payments to be determined by how well these homes meet certain “benchmarks” (likely similar to those in current P4P plans), this must be a serious concern, right?
Do [...]

 
Better care is primary

Medicare, the largest single payer of healthcare services in the country, inadvertently encourages uncoordinated, excessive care. In 1992 Congress established a physician payment system intended to limit costs, but the federal government gave advisory authority to a committee weighted in specialists’ favor. This committee offers payment recommendations for more than 7,000 different [...]

 
A comment:

t has become apparent to me that the organizations that really count, the government and large insurers, don’t want to fix primary care. If primary care as it is now practiced had value to them, they would increase payments to primary care physicians and only primary care physicians for the most common CPT codes [...]

Conflicts noted - both organizations in which I have had leadership roles have endorsed and advocated for testing the medical home.
I attended an excellent discussion of the medical home yesterday.  The idea combines several concepts:

Patient care benefits from coordinated care
Physicians will provide better systems of care if they receive some compensation for that provision.  By [...]

 
One of my favorite quotes comes from Abraham Maslow - "If you only have a hammer, you tend to see every problem as a nail."
Recently I saw a 74 year old man admitted for a GI bleed.  We appropriately got a GI consult.  The consultant scheduled a colonoscopy, but called (without letting us [...]

 
Many readers know that I work part-time at the VA hospital, making ward rounds 2 months each year.  Today I want everyone to think of the veterans.  Many medical students and residents make light of the veterans’ contribution to this country.  We see them later in life, after many of them have lived hard lives [...]