Vol. 100 November 1, 2013 Paranoia and Other Scary Bits

November 1, 2013

Cheney cartoon

“Just because you’re paranoid doesn’t mean they aren’t out to get you.”
– Joseph Heller, Catch 22

Even the powerful can get paranoid
Former Vice President Dick Cheney recently said during a “60 Minute” interview that he had his cardiologist turn off the wireless function in his implanted pacemaker “in case a terrorist tried to send his heart a fatal shock.” Years later, he saw that scenario played out in an “Homeland” episode. (1) We knew that his DC residency was pixellated in the Google satellite view. We wondered if he was on the NASA phone surveillance list, but then we remembered that he ordered that.

Sometimes “They” are right
Surveys of over a million people nationwide revealed that Northeast people were described as “irritable, impulsive, and quarrelsome”. Ever drive in Boston? Midwest and Deep South people were considered “conventional, friendly, sociable, compliant, and emotionally stable”, while the West weighed in as “creative and relaxed, reserved, and perhaps somewhat distant.” Well, California IS distant from Boston and New York. (2)

“Whenever physicians are talking about quality, they are talking about money”
From 2005 to 2010 the urology practices that owned a new radiation technology (IMRT) for treatment of prostatic cancer used IMRT twice as much as urologists who did not own the machine so had to refer patients to others for IMRT. Treatment of prostatic cancer with IMRT cost about $31,000 as compared to about $16,000 for surgery or implantation of radioactive seeds. (3)

“I can’t find a primary care physician!”
In 2006 the Association of American Medical Colleges (AAMC), fearing a future doctor shortage, recommended a 30% increase in medical school slots. That goal may be reached by 2016. BUT, there has been no federal support for increased residency training slots. The AAMC states that there is currently a 15,000 shortage of residency training slots. Medicare funding of Graduate Medical Education (GME) is the major support of residency training, and it was reduced by $11 billion during the ACA debates. It is unlikely to be restored during the 2014 budget debates.  “Physician shortages may become more apparent as the ACA’s coverage expansion takes hold.” (4)

“Not another new flu?!”
Chinese health officials announced in March that a “novel” influenza A virus (H7N9) had infected 132 people and that 37 of them had died. BUT, there has been no evidence of human-to-human transmission and very few of the 20,000 Chinese with flu-like illness actually showed infection with H7N9.  A new element in the tracking of the virus was the recognition of huge spikes in tweets containing the word “H7N9” in both Chinese and English. “Digital Disease Surveillance” is the new term.

Why does a state refuse federal money via Obamacare to subsidize its Medicaid program ?
The New England Journal of Medicine says there are 33 such states, and John Stewart says there are 26. These states are declining to set up health insurance marketplaces (“exchanges”) under Obamacare (ACA) and have acquiesced to the federal government to do so. As a result these states will NOT receive the ACA federal subsidy (up to 100%) of their Medicaid costs for the next three years. John Stewart’s incredulous search for a common denominator of why these states would “bite off their nose to spite their face” came up with only one, a Republican governor and/or a Republican-controlled legislature. (5)

“Umpires are always ruling against my team!”
A study of a million pitches in or near the strike zone, but not swung on, revealed that umpires are less likely to call close ones against batters who are catchers. Presumably due to the rapport that the two develop over long hours of being in close proximity.  Also, the strike zone for the next pitch when the count is no balls and two strikes is apparently 26% smaller than the strike zone when the count is 3 balls and no strikes.(6)

There is no free lunch…or free drugs.
Coupons for free prescription drugs were available in 2011 for nearly 400 brand-name drugs or about 11% of all brand-name prescriptions. 75% of the coupons were for drugs treating chronic conditions (those needing six months or more of treatment), and 58% of those brand-name drugs had lower-cost alternative drugs available. By the time the brand-name coupons expire or run out, the pharmaceutical companies seem to hope that the patient has developed a loyalty for it or resists a change to a lower cost equivalent because of its perceived effectiveness.(7)

“I could be killed by lightning playing golf in the rain.”
Who would think otherwise with all those golfers out there swinging metal golf clubs under big antenna-like umbrellas in the rain? It turns out that anglers, campers, and boaters account for more of the 152 fatal lightning strikes over the past seven years than golfers.  About half of the anglers and boaters were struck while seeking safety. The others were clueless and presumably victims of a “bolt from the blue.”

Fear of terrorism
Polls taken in Boston after the Marathon bombings indicate that more people think that “such attacks are likelier, but fewer live in dread of them.”…”In the United States since 9/11 Islamic terrorism has resulted in the deaths of 37 people. During that same period, ten thousand times that many have been killed by guns wielded by their countrymen or themselves.” (8)

“Will my baby’s flat head harm the brain?”
The American Academy of Pediatrics 1992 recommendation to reduce sudden infant death (SIDS) by having the infant sleep on his/her back has worked. The incidence of SIDS has dropped by 50%, but referrals to subspecialty clinics for plagiocephaly (flat head) have increased.  In a recent study of four Canadian communities 47% of 440 infants had observable plagiocephaly (a flat side of the head). Most were mild and needed no treatment, but the mothers probably stayed worried until time and normal activity rounded things out. (9)

References:
1. Boston Globe, 10/26/2013, report from interview on “60 Minutes”
2. Boston Globe, 10/27/13, report from Journal of Personality and Social Psychology
3. NEJM, 369;17,  October 24, 2013
4. NEJM, 369;4,  July 25, 2013
5. NEJM, 369;13, September 26, 2013
6. Boston Globe, 7/122/13, report from “Social Pressure at the Plate: Inequality, Aversion, Status, and Mere Exposure”
7. NEJM 369;13,  September 26, 2013
8. The New Yorker, May 20, 2013, p. 36
9. Pediatrics 2013 Aug; 132:298


Vol. 53 October 15, 2011 The Heart of the Matter

October 14, 2011

Imagine that you are over 65 years old and you have a failing heart. Your doctor tells you that you are at “maximum medical treatment” and are not eligible for a heart transplant because of your age and other medical conditions.  Then the doctor mentions that a pump could be implanted in your body to help your heart pump more blood; a left ventricular assist device or LVAD.

Imagine a small device put into your chest during open heart surgery that could help you pump enough blood around so that some of your old energy would return and you could resume some, but not all, of your usual activities.

Imagine that Medicare would pay for the operation, device, and medical follow-up. Then try to imagine what the $228,039,342 Medicare paid for about 1500 of these operations would look like if spread out on a table in hundred-dollar bills.

Imagine what it would be like to be one of the 55% (815) of patients who survived the operation and left the hospital alive after receiving this pump. Imagine how even happier you would be if you were one of the 43%  (350) discharged alive who was still alive 2 years later. Imagine your relief when Medicare pays the average $1,000 a day hospital rate for the 56% of pump recipients who have to be rehospitalized at least once in the 6 months after implantation.

Imagine your perplexing thoughts when a statistician tells you that your life extension cost about $60,057 “per quality-adjusted life-year”.

Imagine that your psyche and your family can handle the burdens of multiple medical visits, utter dependence on the infallibility of a medical device, 24/7 family care and vigilance, strict adherence to medication regimens, worries about medical and financial complications, and alteration of body image perceptions that can lead to depression and anxiety.

Imagine how your life might actually end. If you turn off the pump it is suicide. If your doctor or family member turns off the pump it is either euthanasia, assisted suicide, or ethical withdrawal of therapy depending on the status of your permission (and maybe the State you are in).  Perhaps you will develop a new fatal condition from which you will die with the pump running. Imagine if you lived long enough to require a pump replacement.

Imagine that part of the pre-operative process before the pump is implanted is a detailed discussion with your physician (and your family hopefully) about how and when YOU would want the pump turned off.

NOW … IMAGINE THAT YOU ARE DICK CHENEY. *

Then imagine how a “rationing” process to cut medical care costs under Medicare might work in this situation.

Imagine how it might work if you were the patient rather than Mr. Cheney.

Blogs have already appeared making the argument that Steve Jobs would not have lived his “extra” two years with a liver transplant under U.K. or Canadian health systems.

Medical ethics are about “where you draw the line”. Remember that in the beginning of this scenario your doctor said you were “ineligible” for a heart transplant. That was a drawn line, a rationing decision. Our current dilemma and sometimes heated discussion is really about WHO draws the line. (Medicare, Medicaid, private insurance or pharmaceutical company, Congress, professional specialty societies, health care lobbyists, medical ethics committees, Comparative Effectiveness Research in the U.S., NICE in the U.K., individual physicians and patients, or God)

*shamelessly copied from Matthew McConaughey’s dramatic closing speech to the jury
saving Samuel L. Jackson’s life in A Time To Kill  by John Grisham.

References;
Journal of Medical Ethics, Spring 2011, Vol.18, issue 2, published by Lahey Clinic; LVADs as destination therapy: difficult ethical decisions.

Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System, Daniel Callahan, 2009, Princeton  University Press


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