Wednesday, June 22, 2016

The last refuge arguments for central planning find a home in health care discourse

The economist and historian Dierdre McCloskey put it this way ( my paraphrasing). If some one glanced at what happened in the twentieth century and still believed in the value of central planning, they were not paying attention.

The Marxian dreams and even the subsequent efforts of the market socialists such as Oscar Lange ended badly or sometimes never really got off the ground. Things ended   badly in the case of the USSR and Communist China wherein the promises of greater prosperity and equality ended in mass starvation and mass murder.The 1917-1991 gigantic social experiment was a failure.

 The contrast between East and West Germany and North and South Korea could not be more striking and devastating to the devotees of socialist planning and their advocates  had to find arguments not based on economic success.

The economist Anthony de Jasay in his book Political Economy,Concisely  discusses what he considers to be   the two last refuges of the socialist central planner;the plea for social justice and the doctrine of unequal exchange.

We can find versions of both in the rhetoric of the defenders of the Affordable Care Act (ACA) and in the pronouncements of the medical progressives whose major premise is that medical care is too important and complex to be left to the individual physician and patient and that we must have wise leaders with ideas to replace the traditional "dyad" of the patient and physician as the deciders of medical care .


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Tuesday, June 21, 2016

Exercise associated collapse

The term exercise-Associated Collapse (EAC) as used by Dr. Tim Noakes of Cape Town South Africa refers to athletes collapsing after completing a marathon or longer event, though the term more generally could refer to anyone collapsing during or after an endurance event.
Noakes writing specifically about the endurance race event collapse is describing a runner who typically finishes the event and then feels lightheaded, possible nauseated and may indicate that he feels like he will faint. The blood pressure is low in the 100 to 110 range with a mild tachycardia in the 110 range. Noakes emphasizes that the appropriate intervention is to elevate the legs or low the head below leg level. This maneuver, in his vast experience will bring about recovery fairly quickly without the use of IV fluids. This approach received some documented support from a small randomized trial recently published by Noakes and co workers. See here for abstract.

Although the runner will be to varying degrees dehydrated, or volume depleted, Noakes indicates that the faint is not due to the volume status per se. Rather the mechanisms he postulates is as follows:

The post exercise collapse ( as opposed to the collapse that may occur while exercising which brings to mind a number of other more serious possible causes ) is due to postural hypotension related to several factors.

With exercise in the heat there is increased blood flow to vessels near the skin leading to a redistribution of blood to the peripheral veins ,more so as the ambient temperature increases.

Next the action of the calf muscles, while exercise continues, will reduce the volume of blood stored in the lower limbs and maintains an adequate venous return to the heart. When exercise stops, the calf muscle mechanism for venous return decreases and blood accumulates in the dilated venous system leading to decreased venous return and hypotension in the upright position.He also suggests that in the trained athlete there is a blunted compensatory increase in heart rate in response to a lowered blood pressure further increasing the likelihood of faint or near fainting.

So the treatment is the standard treatment for what used to be called vaso-vagal faint namely the Trendellenberg position. He believes that dehydration is not the cause and volume repletion is not the treatment, although obviously volume replacement is appropriate but can be done orally.

Noakes in his book ,Lore of Running, 4th edition, says that approach has worked well in his vast experience in the medical tent after the Comrades ultramarathon in South Africa.

Key information to management of the collapsed athlete is the following;

Location of collapse (i.e. while running versus after the race)
Level of consciousness and cognition (altered states suggest something more ominous that benign post exercise hypotension-particularly exercise associated hyponatremia )
Rectal temperature greater than 40C ( 104 F) means heat stroke.

Noakes and others have emphasized the importance of prompt measurement of serum sodium and blood sugar. Serum sodium less than 120 plus altered mental status should lead to administration of 3 % NaCl.





Friday, June 17, 2016

This preventive medicine stuff is not easy

Case in point  is in regard to hormone replacement therapy (HRT) for menopausal women.It has not been easy to get that right.

The stylized facts of the history of that effort briefly are:

Use HRT widely as heart disease will be prevented plus the usual listing of such things as better skin,lessened hot flashes,improved mentation and all of the advantages of being younger rather than older.

Give HRT to almost no one as actually it increases not decreases incidence of heart disease.Yeah we got the sign wrong.And then there was the issue of increased blood clots and cancer risk.

Then  a study demonstrates decreases incidence of clinical heart disease if the HRT is given early after the onset of menopause.The earlier data that demonstrated increased heart disease was derived from a study of older women who received HRT later after the onset of menopause. This suggests that a major determinant of outcome is timing.

See here for the more recent study on HRT in which women received HRT soon after the onset of menopause which demonstrated a decrease in the incidence of clinical heart disease.

Preventive medicine is not rocket science. The rocket scientists know with impressive accuracy where the rocket will come down as the law of physics applicable to that application are pretty well worked out. Preventive medicine is much harder.

Information voltage drop-not just a hospitalist issue

I recently read that hospitalists have a term for one type of failure to communicate namely "information voltage drop"

This refers to the information relevant to the patients discharged from the hospital not reaching the outpatient "health care entities", eg the nurses at the nursing home and/or the doctors who don't go to hospitals doctors doing the primary care. This would obviously was a problem if the physician in the hospital and the physician in the office were the same person as it was typically in the heyday of the general internist.

It is , of course, a multi-two way street, information from the primary care docs do not always get to the hospitalists in a complete accurate form. reports from tests in the hospital may not get to the chart in time for discharge, etc etc.

 A google search yielded 131,000 hits for that term in quotes. The blog "notes form dr.rw" recently discussed the important issue of the drop of key information from the hospital setting to the post hospital care. I has seen it repeatedly in my mother-in-law as she veered  from nursing home  to the ER and then hospitalization..One one occasion her Remeron  was not given for weeks in the nursing home due to nursing oversight and then started back in the hospital at the dose the docs thought she was taken resulting in near coma and a neuro consult.

Voltage drops can occurs in very short times and distances. I informed at least 6 different medical personnel prior to a invasive cardiac procedure , one not fifteen feet and four minutes before an IV bag was hung containing the same mediation regarding which  I had repeatedly mentioned a personal  allergy.Fortunately the dose of Versed I had received  was low and I  could protect myself.

Monday, June 06, 2016

Does the Conflict of Interest statement in medical journal articles really mean anything?

 I am beginning to think that the answer to the question in the heading is no.Thinking about a article in the NEJM published at the time of the run up to the passage of Obamacare and who the authors are probably shaped my opinion.

In the August 1,2013 NEJM a special report is published entitled "Prescription for Patient-Centered Care and Cost Containment" The authors are Thomas Daschle, Pete Domenici,William Frist and Alice Rivlin.The article predictably is in favor of the Accountable Care Organization and opposes fee for service in medicine. The article is not remarkable  for its content.That could have been predicted from the names of the authors. What I find remarkable- but not unusual or atypical- is that one of the authors who is a principle in a venture capital firm that invests  in health care businesses states that he has no conflicts of interest and that his business interest would not even possibly be conceived as such.

Dr. Frist's credentials are well known as he is an accomplished cardiac and transplant surgeon and former US Senator.His family's association with Hospital Corporation of America is also well known and Dr. Frist is not now associated with that organization. A few minutes of effort on the web yields considerable information about his current business interests at the time of the article's publication.

He is a partner in a venture capital firm, Cressey and Company,which specializes in health care related investments.These following are listed under partnerships on their website: 1)equity partnership in US Renal Care,a large private dialysis enterprise,2)Encompass Home Health,a provider of hospice  and home health care with over 100 locations in 12 states 3)Jazz Pharmaceuticals 4)Select Medical which owns rehab and long care facilities, 5) Spine Wave Inc  6)Strategic Heath Care Program 7) Wound Care Specialists.

Section 5 of the ICMJE form , which authors of articles are obliged to complete and  which can be accessed for all of the authors on the NEJM website states:

"Are there other relationships or activities that readers could perceive to have influenced or that give the impression of potential influencing what you write in the submitted paper?" (my underlining)

Dr. Frist and the others all answered no to each of the questions.

At the very slight risk of appearing cynical I suggest that his relationship with Cressey just might " give the impression of potential influencing" to some readers.  The words potential and impression seems to make that question one that would be hard to answer in the negative if someone were involved in just about any aspect of health care.

 I wonder how many readers might consider the article in a different light if following the article there was a statement that Dr. Frist was a partner in a firm whose income stream is dependent  on various health care entities. I'll bet more than a few readers might just think about the potential of influencing even though Dr. Frist is not on the actual boards of the companies in which he invests nor is he likely to be involved in anyway with the day to day operations of these businesses.Is the ICMJE form and the manner if which the form is answered really provide any useful information to journal readers ?  Do the editors of medical journals need to have any oversight over the ICMJE form answers?Does the COI statements appearing regularly in medical journal mean anything at all?

I am not suggesting that Dr.Frist's views on the various topics covered in the NEJM article were determined or even influenced by considerations of what the author's  recommendations would have on the income streams of the various health care business entities in which he is invested.But it is certainty possible that readers of the article just might get the impression of potential influence if they were informed about them in the COI statement.



Managed Care and "learned helplessness" and medical professionalism

Health Care Renewal in the Sept.22,2006 posting referenced comments by the editor of The British Medical Journal,Leona Godlee, suggesting that physicians in the British NHS may have been so beaten down by their increasingly dysfunctional system that they seem unable to stand up and fight back as their medical professionalism demands. Roy Poses then links their behavior and some he has witnessed in physician's seeming inability to push back at the administrative forces that are squeezing the life out of American medical case to the concept of "learned helplessness."

From that reference and Google I learned that "Learned helplessness" is a term born in the 1960 psychology experiments in which animals "learned" that they had no control over a given experimental situation. Later, when the animals were placed in a different situation in which they had control, they remained passive and were unable to act . Actually only about 2/3 of the animals learned helplessness in that way, the others were able to solve a simple problem to escape a electric shock.(About 5 % of animals seemed to be rather helpless even before the conditioning.) That work by Martin Seligman lead to a theory of depression.

I have written before about some of the ways that Managed Care has damaged medical professionalism in this country. Examples abound. No longer are consultations routinely arranged by physicians based on their personal knowledge of the clinical expertise of the consultant but rather to someone on the patient's insurance plan. Medications sometimes are chosen more on the basis on the insurance company's pharmacy management's arm formulary than on the basis of the physician's judgment. Time pressures directly or indirectly shaped by HMO and Managed Care have placed physicians in the untenable situation of not having time to deal with the patient's problem(s). Approval for testing and procedures have to be pleaded for.

In an earlier posting, I considered the notion that not only have the practices of managed care-which would not have occurred if we had not agreed to go along with them-seriously eroded the physician-patient relationship but also the relationship between physicians.

Dr. Godlee's editorial was aimed at the British physicians but are U.S. physicians far behind in the areas of learned helplessness and diminishing professionalism? To not speak out against the practices and structures of managed care that clearly are detrimental to patient care, and to go along to get along would be about as antithetical to medical professionalism as anything I can think of. Some of the current behavior of physicians may well be characterized as learned helplessness but in the early days of managed care our failure to act must have had other origins as we had not yet had time to learn to be helpless Moreover  the new Professionalism, as envisioned by the ACP and the ABIM and the Robert Wood Johnson Foundation  meshes neatly with the learned helplessness . By following guidelines physicians can work for the common good and further social justice all the while not feeling helpless at all. 

Note: Obviously the reference to the BMJ article is not breaking news. In reviewing drafts of earlier blog commentaries I realized I had neglected to post this one.

Sunday, June 05, 2016

Worried about your health care?Do not fear, the Medical Platonic guardians are gearing up

Plato envisioned a utopian society ruled by philosopher kings,leaders with ideas. Brilliant and knowledgeable, logical and devoted to the good of the crowd. Even back then the question was raised, "who will guard the guardians?" or "Quis custodiet ipsos custodes?"

The platonic ideal has persisted through the years since Plato pontificated.Currently those whose world view echos Plato are called progressives or [modern day]liberals as opposed to the classical liberals who hold the opposite view.Also, from what I've read the neo-conservative Leo Straus was a bit enamored with some of Plato views on government.

A apparent modern Plato fan is H.J.Aaron who has had three commentaries in the Perspective sections of the NEJM in the last year. He seems to be their go-to guy for his Platonic mindset and particular for  IPAB issues.Here is a link to  a sample of his views.


He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." ( Well, that would be a first) He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition  to what James Madison envisioned but a major feature of the administrative state.

He likens the creation of IPAB to the creation of the Fed Reserve which was to be an entity not subject to congressional control set up a governmental entities largely not controlled by Congress.

IPAB is not much in the news currently as the legislative trigger for its activation has not been pulled  but be aware it is still on the books and is available to be the mechanism by which selfless, wise leaders will direct health care miraculously immune to pressure from  lobbyists representing interests that Madison referred to as factions.




Friday, June 03, 2016

Politicalization of medical ethics-you have to ask why and by whom

The politicization of medicine is cogently  discussed  by Dr. Thomas Huddle. See here for an abstract of his article.

First, with the publication of the Charter, Professionalism in the New Millennium in 2002 the notion of social justice was injected into the listing of attributes and behaviors that physicians should exhibit to act professionally.Rather than a well reasoned and documented  argument for such action being presented by the authors, we saw a series of gratuitous assertions.

Subsequently a commitment to social justice was declared to be an ethical imperative in the American College of Physicians'  (ACP) ethics manual. Other professional organizations followed suit pledging at least rhetorical support of the inclusion of social justice into their ethical propositions.

 Dr Huddle, who teaches at University of Alabama Medical School at Birmingham, says in part:

1) civic virtues are outside the professional realm, (2) even if civic virtues were professionally obligatory, it is unclear that civic participation is necessary for such virtue, and (3) the profession of medicine ought not to require any particular political stance of its members.

"Advocacy on behalf of societal goals... is inevitably political".

" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Requiring a commitment to social justice is clearly  political and requires physicians to take a particular political stance and a particular philosophical position..Advocacy for social justice is one feature of the modern liberal or progressive political stance.Such advocacy is not typically part of the conservative political viewpoint or the libertarian ( aka classical liberal) position.

The notion of justice upon which which the country was founded  was that of the justice embodied in the rule of law,i.e. treating everyone equally under the law. The foundational notion of the social justice line of thinking is essentially that treating folks who are unequal equally is unfair and unjust and therefor there must be societal  effort to mitigate inequality by redistributional  and other coercive  efforts of the state.

The physicians who authored the Charter and the ACP's new ethics would appear to be of the progressive persuasion while there are many physicians in the country who are not. A small group of what I have labeled as the "medical progressive elite" have seemingly captured the conversation and are attempting to  profoundly alter traditional medical ethics.To the extent that they and similar minded individuals set the agenda of major medical professional organizations and medical students education they may have succeed. but I wonder how many practicing physicians are even aware of the views that they pretend to be a settled issue.

Why would such an effort be launched and well funded ? Who gains from efforts  to bring about a sea change in traditional medical ethics? The answer to that may be found in the plan that the elite medical progressives later introduced to enable practicing physicians to on  a day by day basis practice social justice.Simple they just had  to follow guidelines .In that way there would be an alleged greater benefit to the collective -although sometimes as the expense of the individual patient-and presto we have a utilitarian form of social justice with the collective and of course third party payers benefiting.Is this the "why"?


Note: An shorter version of this essay had been published previously. I redo it now because sadly a version of social justice seems to be firmly appended to medical ethics,on paper if not in practice and few voices are heard in opposition.I find physicians believing that they should work for the good of the group or the collective or society a very frightening notion one with a slippery slope  as evidenced by what went on in collectivist societies in the last century.

Thursday, June 02, 2016

Presidential Election 2016-the wisdom to choose.

Thomas Sowell laments the choice that we are likely to have in the upcoming presidential election.In a recent commentary entitled "Grim Choice" ,he writes that the November election will offer a choice between a "thoroughly corrupt liar and an utterly irresponsible egomaniac".



"More than any other time in history, mankind faces a crossroads. One path leads to despair and utter hopelessness. The other, to total extinction. Let us pray we have the wisdom to choose correctly.” 

 Woody Allen

More thoughts on correction of severe hyponatremia

In adults electrolyte issues have traditionally been the arena in which internists ( and I guess now mainly hospitalists) earn their fees. Here is an interesting take on the correction of severe hyponatremia.

Severe ( often defined as less than 120) hyponatremia is typically considered as an medical emergency. Discussions regarding it usually consider acute hyponatremia ( as in runner's hyponatremia) and chronic. In the former some urgency exists in regard to treatment as the concern is brain swelling and catastrophic brain herniation. In chronic, too rapid correction runs the risk of osmotic demyelination.

Beer potomania is part of the differential diagnosis of hyponatremia. This article provides gives data on alcoholic patients with hyponatremia and explains several mechanisms for the low sodium other than what is usually thought to occur in beer potomania syndrome.