Wednesday, October 20, 2010

Public Health Survey

This evening I received a call from the Boston Department of Public Health, conducting a survey about my level of healthiness.  Well, to be honest, this is the second call, but the last one was post-call mid afternoon on a weekend, so I got off the phone quickly.  Understanding my civic duty as a health care and public health professional (and I knew they would keep calling), I undertook the litany of questioning. 

There were approximately 50 questions in topics moving in an orderly progression from demographics to general health to diet (vegetables, fruits and soda), exercise, mood/depression & social support, workplace smoking, walking & biking, neighborhood safety and availability of healthy food, smoking and program awareness.  Notably absent were alcohol related questions.  There were probably more questions if I had answered yes, but that is only conjecture.  (No, I have never smoked a cigar, cigarillo or mini cigar that looks like a cigarette, not even a few puffs.  No, I have not served active duty in the military).

The gentleman calling me had no idea that I was a health professional, and so some of the questions were awkward to answer:  "How often have you felt nervous/jittery/hopeless in the last 30 days?"  I am in the ICU, so the answer is sometimes.  "Has a health professional asked you about smoking in the past 30 days?"  Yes, because my colleagues and some patients are health professionals.

All in all it was an interesting but quite tedious experience.  Given my experience in public health, the data from this survey will inevitably be used as evidence to increase "awareness" funding to various health related programs.  I find this to be unfortunate, because the libertarian in me still thinks that if a program works, it should be so popular as to be self-sustaining and not require an ever enlarging "awareness" budget, culled from the earnings of the citizens it purports to help, but do not voluntarily give over their money.  But alas....

Sunday, October 17, 2010

In Support of Overnight call

One of the greatest fictions in medicine (if you look at how we staff) is that somehow people are less sick on the nights or weekends.  At the same time, continued political pressure without good evidence to support is shortening resident work hours, now to the point of ludicrous 16 hour shifts.  While this seems long, a 30 hour shift requires 1 commute to work each way, and 1 sign-in and sign-out, a 16 hour shift doubles these requirements. Depending on how far away one lives from the hospital, this can be hours out of each day wasted in minimally productive activities that are neither educational or providing a service to patients.  The mentality of a resident on overnight call is different than one going home that day.  When we are trying to get out, anything and everything that happens to delay our exit (and eventual return) to the hospital increases stress.  Our goal becomes to provide the care that we need to provide so we can finish our day.  There is less time to delve into interesting findings, spend time with patients, and think. Education time gets squashed out.  When on overnight call, we know we aren't going anywhere.  This produces a relaxed atmosphere.  Rather than the always intense pace of a normal day with an uncertain end, intensity varies.  There is time to teach, learn and discuss. It is frankly more fun to do the job all the way and stay overnight, than do it almost all the way, but just as stressed and tired, but without the benefit that comes at the cost of the few extra hours.

But most importantly, as one of my great attendings once said, all of the good things happen at night.  While on call this past week I was able to spend several hours observing an attempt to *cure* a stroke by direct removal of clot in the brain... through a catheter placed in the groin.  I had only heard/read about this before, but I got to experience every minute of it.  This took place between 9pm and 2am.  If I had the choice of whether or not to stay, knowing a full day was ahead of me, would I?  Was it worth it?  These are questions each of us have to answer for ourselves, but I am certain I would not have had this amazing experience if not on overnight. 

The decision to continually and arbitrarily limit work hours for all specialities of medicine equally, without individual program flexibility is inherently a political one.  The root decisions all stem from the tragic loss of a politically connected young woman in New York.  There is not nor has there ever been evidence that spending less time with patients as a result of limited work hours would have saved that girl's life.  And yet we keep moving in that direction, for fear that if we, as a profession, do not appear to be regulating ourselves, that some worse bogeyman of the government will do it for us.  I ask if we really have self-determination if we regulate ourselves to appease regulators waiting in the wings.  And I ask if it does anybody- patients, residents, any good.

There is another way to ensure that residents have fair and equitable hours in which to work, learn and live... but that is another post!

Thursday, October 14, 2010

On Medicine Shortages

We received an interesting e-mail yesterday that there is a nationwide shortage of a medicine called furosemide, or Lasix (no relation to the eye-surgery).  Without going to much into detail, Lasix is a mainstay generic/old medication in the treatment of any condition in which a patient has too much fluid and we'd like to get it off of them.  Conditions such as heart failure, kidney failure and liver failure are commonly treated with Lasix.  More acutely, Lasix is a mainstay drug for patients on cardiology or intensive care services.  It just so happens that I am spending this month in the Coronary intensive Care Unit, hereinafter referred to as CCU.  In the CCU, we use Lasix commonly and on nearly every patient.  There are other medications that work similarly or accomplish the same thing, but rarely at such nice dosing intervals or at low cost. 

We received the following information via email:
furosemide 40mg is $0.30

bumetanide 1mg is $0.68
Torsemide 20mg IV is $6.55
Ethacrynic acid 50mg IV is $511.58

These are all per dose costs.  Note that Lasix, the least expensive, is on shortage.  How could this have happened?  According to a Bulletin from the American Society of Health-System Pharmacists, there is no available reason for the shortage.  According to the FDA it is due variously to manufacturing delays and increased demand. So no factory burnt down, or was contaminated, or at least not to public knowledge.  It does appear that one manufacturer will no longer be making the drug.  And therein lies the issue.

Why does Lasix cost $0.30 per dose?  It would seem as though this price is too low.  In a reasonably free market, when supply diminishes and demand remains constant, suppliers will raise prices and demanders will either pay the higher prices or substitute where available.  Our hospital plans to substitute. However, when prices are not allowed to rise to signal the market that supply is decreasing (because of government price controls or regulation) shortages just happen, without the clear warning that a price increase signals.  I will not pretend to justify the logic behind price controls, but I will clearly present such controls as a cause of shortages.  Shortages can only happen in the presence of government intervention....  See the Philippines as a case study.  We do not have direct price controls in the US, but in order to participate in Medicaid maximum drug prices must be adhered to.  Even if Lasix is not price controlled, the decreased price of other medicines made by the same manufacturer may force them to scrap production of margin generics.  Combined with exceedingly high barriers to entry for pharmaceutical manufacturers and it is surprising that there not more shortages.

I return now to the hospital where I am curious as to how this will play out.  We are told that we have ample supply for several weeks and that more is coming to replenish our supply.  The question is, will we physicians prescribe as usual, not believing the shortage, or will we change our behavior.  It is a classic issue within medical training of individual patient vs. systemic thinking.  My prediction is that nothing will change unless pharmacy begins to dictate our prescribing habits, which will cause mild grumbling but no real outburst from the physicians.  Then we will return to prescribing as regular once the shortages ends.

Tuesday, October 12, 2010

4 Stages of Creativity

This weekend I had the pleasure of travelling home to NJ for my brother's birthday.  On a walk through the woods Sunday morning with my wife, my father and two family friends, (one of whom has become clinically addicted to wood turning) and the topic of creativity came up.   Mostly this was a way to get our wood turning friend to shut up about wood turning for just a few minutes.  Given my designs as a medical entrepreneur, the creative process is something that I have thought and read on greatly. It appears to me that creativity comes in 4 stages:

1.  Copying.  Everyone has to start somewhere.  We all learn our first skills by copying those around us.  It is frowned upon to submit your copied work as original, but copying itself allows us to reverse engineer the creative process.  Even though we know the "solution" that we are copying, the manner in which we arrive begins to define a personal style.  I started writing by copying sentences painfully out of grammar books.  Any great band starts as a cover band.

2. Mixing.  Once we have copied enough different people, we begin to put granular elements of their style together.  Mixing is a crude form of creation, and the borrowed components are often easy to identify. 

3. Amalgamation.  The difference between mixing and amalgamation is the easy recognition of the underlying parts.  Mixed copied styles are easy to sort out, but amalgamated styles are subtle.  It is likely that only experts could tease out the components beneath, but there may not be true creation.  It is also here that the line between plagiarism and original work is blurred.

4. Creation.  Perhaps a semantic argument, but true creation occurs when the artist develops something new and novel.  It is not just a mixing or rearranging of underlying parts, but rather a new form that has not been seen before.  Notice that our artist has been producing for quite some time before this phase, and most people fail to create just because they give up to soon.  So don't give up. 

In the case of our wood turner, he is convinced that he has no talent but just works really hard, I really cannot see the difference.

A fair disclaimer, it is possible that the thoughts within this post are copied, mixed, or amalgamated from others, not actually created.  Special thanks to Malcolm Gladwell and Marc Andressen for their writing on the matter that has inspired this piece.  And thanks to Alan... when am I getting that pen?

10/23/2010-- The pen arrived, and it is fantastic!
Thanks Alan!