Patrick Kennedy Would Have Survived

Fifty years ago, Patrick Kennedy was born, lived 39 hours, and died.

... Five and a half weeks premature, delivered by Caesarean section on Aug. 7, 1963, at Otis Air Force Base on Cape Cod, Patrick weighed a relatively robust 4 pounds 10 1/2 ounces.

.. Patrick died just 39 hours after his birth, a victim of what was then the most common cause of death among premature infants in the United States, killing an estimated 25,000 babies each year: hyaline membrane disease, now known as respiratory distress syndrome.

Complain all you want about the US healthcare system and infant mortality, but neonatology has advanced tremendously in the last fifty years. In today's NICU, almost certainly, Patrick Kennedy would have survived.

Patient Engagement: I Do Not Think It Means What You Think It Means

Jessie Gruman, PhD has an important post on Dr.Kevin Pho's Blog - Patients and clinicians don’t have the same goals in mind. Patients have a different view of what active patient engagement in healthcare means from that of clinicians, insurers, employers, or policy wonks.

... This divergence of aims between patients and those who organize, deliver and pay for our care doesn’t alarm me on most days. Each stakeholder is working to standardize incentives, processes and programs that they believe will provide the best chance for the greatest number of us to get care that is safe and effective. On average, I am grateful.

But I know that these stakeholders don’t view patient engagement as an expression of our individual needs and preferences. Rather, for most of them patient engagement is synonymous with our compliance with our clinicians’ evidence-based recommendations to lose weight, control our blood sugar, use prescription medications as directed and abstain from frivolous use of the ER. For them, our engagement in our care is the expected consequence of believing that scientific evidence shows – and our clinicians know – that certain behaviors and treatments will produce the best outcomes for most people. They are convinced that any rational individual will act consistently with that understanding. Many narrow-minded economists would agree.

Some professionals have sounded alarms about this conflict between the goals of patients and the goals of health care. 

Real patient engagement begins with the doctor - patient relationship or perhaps more aptly stated, the patient-doctor relationship. Individualization is critical to this concept. The problem is that tailoring of therapy to fit the patient's needs often runs counter to protocol-based medicine. While the evidence should be a jump off point, protocols are just that - the beginning not the end of the discussion. What works for the area under the curve might not be appropriate for the patient under the examination gown. This is the quandary we face today as conflicting megatrends of Best Practices butts heads with real Patient Engagement. Fasten your seatbelts.

I Can't Get No Satisfaction

Dr. Robert Centor of the db's Medical Rants blog points to this article in The New Yorker, When Doctors Tell Patients What They Don't Want To Hear, highlighting the linkage of payment for physicians' services to Patient Satisfaction Scores.

Will our patients still like us if we tell them things they don’t want to hear? The challenge of communicating unpleasant, possibly profoundly upsetting information to patients is timeless. What has changed, however, is that physicians are now being judged, and compensated, based upon their ability to do it.

In October, 2012, Medicare débuted a new hospital-payment system, known as Value-Based Purchasing, which ties a portion of hospital reimbursement to scores on a host of quality measures; thirty per cent of the hospital’s score is based on patient satisfaction. New York City’s public hospitals recently decided to follow suit, taking the incentive scheme one step further: physicians’ salaries will be directly linked to patients’ outcomes, including their satisfaction. Other outpatient practices across the country have also started to base physician pay partly on satisfaction scores, a trend that is expected to grow.

We all hear the stereotype - Doctors are rude, egotistical bullies who don't listen to patients. There's a post on today's Dr. Kevin Pho blog on Doctor Bashing as a national sport. Yes, there are times when a physician can seem gruff and tactless. There's little excuse for that. However, telling someone what they do not want to hear is not always easy nor is it usually especially well-received. This is the one area where the customer service model falls flat on its face. Face it, the customer aka patient is not always right. Now while a patient with advanced cancer understands the grim prognosis after hearing the bad news, someone with Type 2 Diabetes might not well appreciate that in order to ameliorate the disease process, he would have to stick to the program - often, for life. People don't wish to hear that they need to lose weight or give up old habits, even if intellectually, they know it. Should the messenger be penalized for the message?

For myself, I realize that I too need to face reality - Patient Satisfaction Scores are not going away anytime soon. So I need to remember that the patient is as human as I am and needs to be "handled with care." For my part, I will try to deliver the bad news in a professional and caring manner. I would ask all of you kindly to not shoot the messenger.

Too Much Of A Good Thing

In today's NY Times Well Blog, Gretchen Reynolds asks if there is such a thing as too much exercise.

... But the newest Vasaloppet-related study, published in June in The European Heart Journal, is worrisome. For it, researchers from Uppsala University and other institutions examined the health records of almost 53,000 race participants and found that the more races that someone had completed between 1989 and 1999 or the faster they had finished, the more likely they were to require hospitalization in the next 10 years for an abnormal heart beat, a condition known as arrhythmia.

For some time, exercise scientists, as well as a few highly committed exercisers and their spouses, have wondered if there might be an upper limit to the amount of exertion that is healthy, especially for the human heart. While the evidence is overwhelming that exercise improves heart health in most people and reduces the risk of developing or dying of heart disease, there have been intimations that people can do too much. A 2011 study of male, lifelong, competitive endurance athletes aged 50 or older, for instance, found that they had more fibrosis — meaning scarring — in their heart muscle than men of the same age who were active but not competitive athletes.

Now the latest Vasaloppet study and a separate study of rats running the equivalent of several rodent marathons that was published this month in The Journal of the American College of Cardiology are likely to further the debate about possible upper limits to safe exercise.

Women's health experts have known the hazards of too much exercise for years, given the increased incidence of menstrual disturbances in marathon runners. And remember that Jim Fixx, the author of The Complete Book of Running, died of a massive heart attack after his daily run.

So by all means exercise, but listen to your body. It may be trying to tell you something.

Medicine Swings Like A Pendulum Do

In 2002, the NIH Stopped the Women's Health Initiative (WHI) Study of the use of estrogen and progestin in postmenopausal women because of a small increase in breast cancer incidence and a lack of overall benefit. The study's findings were thought controversial at the time for many reasons, among them being the use of a study group comprised mostly of older women who wouldn't have benefited from hormones anyway. Moreover, this group did not reflect the standard of care at the time.

Today, we learn the results of an updated WHI analysis. Its conclusion -

Thousands of postmenopausal women have died prematurely over the past decade because they avoided estrogen therapy after hysterectomy, a new analysis of a landmark study showed.

The most conservative estimates placed the total number of deaths at 18,601, and the toll could be as high 91,610.

What happened here? This new analysis was limited to the use of estrogen only in younger women who had undergone hysterectomy.

The updated analysis was limited to younger women (50 to 59) who had undergone hysterectomy. In that subgroup of patients, unopposed estrogen significantly reduced the mortality risk, Philip Sarrel, MD, of Yale University, and co-authors reported online in the American Journal of Public Health.

"The finding is so dramatic -- reporting thousands of women dying every year -- if this gets the attention that it deserves, we hope it will change clinical practice," co-author David Katz, MD, the Yale-Griffin Research Center, said in an interview. "We hope that clinicians will start routinely talking to their patients who have had a hysterectomy and bringing up the issue that taking estrogen may save your life. We have data to show that it can save your life.

"Frankly, our paper should do that. It's not every paper that has the potential to change clinical practice. This one should. It occurs in the context of a growing awareness of the damage we have done by talking women out of all forms of hormone replacement."

Props to the researchers for going back and re-evaluating the data, bucking the tide of conventional wisdom. This happens more than people realize in medicine. It's called the Sleeper Effect, after an early scene in the Woody Allen film Sleeper.

Medicine Swings Like A Pendulum Do.

Winning the #WarOnVaccines

ABC's The View tabbed Jenny McCarthy to replace Elizabeth Hasselbeck. Yes, Jenny McCarthy whose claim to notoriety has been the debunked notion that vaccines are causally linked to autism. In fact, the most damning paper by Wakefield et al, published in 1998, was retracted by The Lancet in 2010. Undeterred, Ms. McCarthy has soldiered on, backed by such scientific luminaries as Oprah Winfrey.

The problem is not one of facts or science. Medicine has that in spades. The problem is audience. Jenny McCarthy, last seen on ABC's New Year's Rockin' Eve, and her junk science now has exposure to a large segment of the American people on The View. When was the last time anyone saw the AMA President on TV? And can anyone name the AMA President? (Dr. Ardis Hoven)

Ms. McCarthy's exposure goes way past television. Jenny McCarthy has over 900K followers on Twitter. To put things in perspective, the owner of the most followed medical blog on the net, KevinMD.Com, Dr. Kevin Pho has 50K followers. See the problem?

There is one solution. There is one physician with a larger presence than Jenny McCarthy. That physician is none other than cardiac surgeon Mehmet Oz, MD. With over 2M Twitter followers and a large national audience on The Doctor Oz Show, @DrOz has the juice, the voice and the following to get the word out there. Make no mistake - this is a war. Our children's lives are at stake. Old childhood diseases are coming back. Dr. Oz, the time is now. How about it?

Cover Your Assets

A CT Gyn has had his personal assets seized to satisfy a plaintiff's verdict of $5 million which exceeded his liability insurance policy limit of $1 million. 

... An even more important lesson may be that a $1 million malpractice insurance policy limit may be inadequate for some specialties.

Regardless of the facts of the case, there is something terribly wrong here. And they wonder why defensive medicine exists.

Prenatal Sonograms and Autism

An article in The Daily Beast wondered about a connection between the more frequently used prenatal ultrasound examinations and autism. Dr. Roy Benaroch's post in Dr. Kevin Pho's widely read medical blog tries to shine some light to an evironoment filled with entirely too much heat.

... This is what’s actually reported in the article, in order of appearance:

1. References to a study showing that among low-risk pregnancies, routine ultrasounds don’t improve outcomes. This is true. It’s irrelevant to the title or thesis of the article, but it’s true. Media lesson #1: if you don’t have a study to prove your point, talk about a different study that says something else entirely.
2. Ultrasounds drive up the cost of care. Again, correct. Again, irrelevant. See point #1.
3. Women who undergo frequent ultrasounds are more likely to have a pregnancy where the baby is found to have growth restriction. Well, this is true. It’s also true that if you look outside you’re more likely to know if it is raining. Fetal growth restriction is diagnosed by ultrasound. If you don’t look, you don’t know it’s happened. But looking outside doesn’t make it rain; and looking at an unborn baby with an ultrasound doesn’t cause the baby to be small. And, in any case, this is again irrelevant to autism. See point #1.
4. The author of the article has written a book in part about her assertion that ultrasounds are to blame for what she calls “an astronomic rise in neurological disorders among America’s children.”
5. The mice studies I referenced before—those come up now, several paragraphs in, the first even remotely relevant material. The lesson here: if you are a mouse, do not get seven hours of ultrasounds a day.
6. A neurologist named Manuel Casanova shares the author’s concerns, and says he and colleagues have been testing the ultrasound-autism hypothesis for three years. However, and this is important: after several technical paragraphs about his ideas, he’s uncovered zero evidence to support this claim. What he’s saying are generalities about brain development that are true, and he’s juxtaposing this against information about ultrasounds and information about autism, but he doesn’t in any way refer to any of his or anyone else’s actual research establishing a connection. These are ideas. Ideas are not evidence.

That’s it. The whole article.

Obstetrician Dr. Jacques Abramowicz has also looked at this issue, concluding in the Journal of Ultrasound in Medicine:

...analysis of in utero exposure (to prenatal diagnostic ultrasound) in humans has failed to show harmful effects in neonates or children, particularly in school performance, attention disorders, and behavioral changes. There is no independently confirmed peer-reviewed published evidence that a cause-effect relationship exists between in utero exposure to clinical ultrasound and development of ASDs in childhood. 

Personally, after being bombarded nightly by various cable news pontificators, I'd suggest that the proliferation of cable news might be associated with autism. Of course, that's just my opinion. I could be wrong.

Blaming The Obstetrician

The Maryland Court of Special Appeals overturned a multimillion-dollar judgment against Johns Hopkins Hospital  in a case that accused its doctors of causing severe and irreversible brain damage to a baby born at the hospital. 

The judges ordered the case sent back to a lower court for retrial. They ruled that Hopkins should have been allowed to give more testimony about the role a midwife might have played in the baby's injuries.

Dr. Amy Tuteur has already posted on the rest of the story.

Enzo’s case was detailed in the suspension order issued by the Maryland Board of Nursing:

On or about April 14,2010, the Board received a complaint from … Director of Labor and Delivery and … Director of Gynecology and Obstetrics, at Hospital B. According to the complaint, between March 25th and 26th, 2010, Respondent failed to follow the standard of care in her management of an attempted home birth by:

I. Utilizing Intramuscular Oxytocin to stimulate labor in a term pregnancy;
II. Using fundal pressure in the second stage of labor to attempt to cause descent of
the fetus;
III. Using vaginal chlorhexadrine, rather than intravenous penicillin, in labor to treata known group B beta hemolytic strep vaginal carrier to prevent early onset GBS neonatal sepsis;
IV. Misdiagnosing fetal station resulting in an unnecessary episiotomy. The physical exam on admission to Hospital B was a fetus impacted in the vagina at + 1 station which was incompatible with the report that the fetus had been crowning when the episiotomy was performed…

… Patient B delivered a male infant (“Baby B”) by LSTCS, with a vertex fetal presentation and occiput posterior (“OP”) position at birth. The APGAR scores were 1 at 1 minute and 5 at 5 minutes and cord/Initial blood gas was ph 7.1; pC02 63; p02 10; BE -13. Baby B was limp and cyanotic on delivery with nuchal cord x 1, required PPV for 3 minutes before being transitioned to CPAP. Baby B was transported to the NICU on CPAP with diagnoses of Hypoxic Ischemic Encephalopathy and Seizure disorder.

Baby B was transferred to a pediatric rehabilitation hospital on April 21, 2010.

In other words, Muhlhan was horribly negligent in caring for this women and the hospital saved Enzo’s life. Enzo’s parents know this and do not dispute it. They insist that the hospital didn’t save Enzo’s life fast enough, contending that there was a delay in performing the necessary C-section.

How did the jury decide that it was a purported delay at the hospital that resulted in Enzo’s injury and not the egregious malpractice of Evelyn Muhlhan? It was easy. Enzo’s parents’ lawyers successfully argued to disallow any evidence of Muhlhan’s negligence.

As the court records show:

Plt [Plaintiff's] motion in limine to preclude any refence [sic], testimony or argument that ceritified nurse-midwife Evelyn Muhlhan Deviated from the standard of care and to preclude Loraal Patchen, CNM and Carolyn Gegor CNM from testifying is hereby heard and granted.

Clearly, the Hospital was sued as the one with "deep pockets." But is this right?
The Maryland Court of Special Appeals' decision seems a step in the right direction in righting a wrong. Justice should be about the truth, the whole truth, and nothing but the truth. But as Oliver Wendell Holmes famously observed, "This is a court of law... not a court of justice."

Further, the case speaks volumes about how we deal with the future care of neurologically impaired infants and their parents' facing serious financial strain. The Tort System isn't geared toward care, merely at judging fault. Some get compensation, others get nothing. This needs to change. It's way past time to have that adult conversation.

It's A Jungle Out There

Thinking of consulting Dr. Google? Best heed the advice of Dr. Kenneth Lin.

A recent survey found that 60 percent of adults have gone online at least once in the past year to look up health information. Unfortunately, finding high-quality health websites is a challenge. Several years ago, a review of 79 studies published in the Journal of the American Medical Associationconcluded that online health information for consumers is frequently flawed, inaccurate, or biased. Based on my experience, the situation isn’t any better today.

Why do some health websites contain misleading information? One reason is that the group or organization running the site may have a hidden agenda. Drug companies often create consumer demand for expensive new drugs by financing groups that promote awareness of a previously unrecognized health condition, a sales tactic known as “disease mongering.” (For example, Dartmouth Medical School researchers have argued that restless leg syndrome became a disease only when a drug was developed to treat it.) Unfortunately, a study published in 2011 in the American Journal of Public Health found that most health advocacy groups that receive drug-company funding don’t disclose that on their websites.

Another reason that websites may contain misinformation is that some groups willfully disregard scientific evidence to promote certain health beliefs. For example, even though the U.S. Institute of Medicine found in 2004, after an exhaustive review of the medical literature, that there is no relationship between childhood vaccines and autism, it’s easy to find websites that claim otherwise. Similarly, although most researchers have concluded that Morgellons disease—a bizarre skin condition that sufferers believe to be caused by an undiagnosed parasitic infestation—is likely to be a psychiatric delusional disorder, you wouldn’t know it by simply Googling “Morgellons.”

Read the whole thing. It's a jungle out there.

Law of Unintended Consequences

In 1984, Libby Zion died following an emergency admission to a New York hospital. Concluding that her death was the result of a medical error by exhausted housestaff, her well-connected father launched a crusade which ultimately led to resident work hour restrictions prescribed by the ACGME.

Now, we learn that restricting work hours for PGY 1 housestaff to 16 hours leads to a significant decline in surgical experience.

... Compared with the four academic years before the change, the year immediately following the restriction saw significant declines in total operative cases (by 25.8%), major cases (by 31.8%), and first-assistant cases (by 46.3%) performed by the interns (P≤0.008 for all), according to Christian de Virgilio, MD, of Harbor-University of California Los Angeles Medical Center, and colleagues.

The drops were seen across most types of surgery, the researchers reported online in JAMA Surgery.

"If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume," they wrote, noting that the reduced experience of interns entering postgraduate year two "may have a domino effect on subsequent competence."

While errors caused by sleep deprivation must be kept at an irreducible minimum, we must acknowledge the threat of unacceptable errors caused by inexperienced doctors. Perhaps, before instituting guidelines, august bodies should base their decisions on evidence, not eminence. 

Of course that's just my opinion. I could be wrong.

Liability Reform IS Healthcare Reform

And now a word from your humble blogmeister:

Letter: Doctors harmed by liability costs

To the editor

Published 3:18 pm, Tuesday, July 9, 2013

The Times Union recently published an Associated Press report on an impending need for primary care doctors ("Provider gap predicted," June 23). But to those practicing medicine in New York, physician shortages are hardly news. For years, doctors have been driven from the state, in large part because of enormously high medical liability insurance premiums.

New York has the highest medical insurance payouts and premiums in the country by an astounding margin. Physicians in parts of the state pay nearly $200,000 per year for insurance. Yet, this is hardly an indictment of our doctors and hospitals. Indeed, New York physicians are among the safest and most skilled in the nation. The reason for this disconnect is our legal system, which incentivizes a steady stream of lawsuits. In fact, a series of studies (http://bit.ly/WaG8sT) of closed claims by the Harvard School of Public Health found that more than half of medical malpractice claims were either "frivolous" or of "uncertain merit."

It's so bad the state has been forced to intervene. Last year alone, New York taxpayers' paid $127.4 million (http://bit.ly/19I1qTF) to subsidize medical-malpractice insurance. But this is treating the symptom, not curing the disease.

The fact is our doctors are leaving (http://bit.ly/qooT4l) for states where measures have been passed to curb litigation. Those who remain must wonder every day whether the next time they see a patient it will be in the courtroom. New York doctors should be allowed to focus on saving lives, not fighting lawsuits.

Arthur C. Fougner, MD

Having health insurance is not the same as having access to a doctor. Once more time - Liability Reform IS Healthcare Reform.

Behind The Veil

Today's NY Times highlights an important issue for patients - finding the price hospitals charge for inpatient admissions. Most will use some variation of what Medicare pays per diagnosis or DRG. The kicker is that the Medicare payment system is arcane bordering on unfathomable. In the NY Times illustration, the DRG for uncomplicated vaginal delivery is 775. Some states, NY included, use Medicare payments - yes, Medicare in some instances of disability pays for childbirth - as the model from which all other payments are calculated. But try consulting Dr. Google for this one - you come up empty. I know I did. Here's a thought for the AMA - garner some karma points by compiling all Part A payments per locale per DRG and link this to the AMA website. Perhaps State Medical Societies and Specialty Societies should compile similar lists as well. A little good will would go a long way. Remember, it's not a free market when nobody knows the price.

CMV Alzheimers Link?

Alzheimer's could be triggered by by common CMV virus.

Contracting a common virus may play a role in the development of Alzheimer’s disease, a new study has found.

The study of the brains of older adults found an association between patients’ immune responses to cytomegalovirus (CMV) and signs of Alzheimer’s disease. “More studies are still needed to understand how an active CMV infection might be related to this most common form of dementia,” said study researcher Dr Julie Schneider, of the Rush University Alzheimer’s Disease Center in Chicago.

A cure? Faster Please.

The Soul Killer

Cytomegalovirus (CMV) is the most common viral infection of newborns in the US. About 30,000 infants are born with CMV infection annually. About 5000 infants are born with or develop serious disability.

Since most infected with the virus don't know they carry it, it's important to identify carriers during pregnancy. It's also more important to minimize exposure to infection. The CDC suggests the following:

• Wash your hands often with soap and water for 15-20 seconds, especially after
  • changing diapers
  • feeding a young child
  • wiping a young child’s nose or drool
  • handling children’s toys
• Do not share food, drinks, or eating utensils used by young children
• Do not put a child’s pacifier in your mouth
• Do not share a toothbrush with a young child
• Avoid contact with saliva when kissing a child
• Clean toys, countertops, and other surfaces that come into contact with children’s urine or saliva

For more information,do  discuss this infection with your Obstetrician - sooner rather than later.

America's Founding Doctors

Jacob Goldstein from the WSJ Health Blog:

Who knows better than a doctor — witness to birth, sickness and death — that all men are created equal? So it is fitting to recall, this Fourth of July, that the signatures of five physicians are scattered among the 56 names at the bottom of the Declaration of Independence.

Here are the basics on the Founding Doctors. Facts not otherwise attributed come from the book Physician Signers of the Declaration of Independence(Yes, there’s really a book with that title, and we were able to get our hands on a copy.)

Benjamin Rush was a Pennsylvania doc who served as a high-ranking surgeon in the Continental Army and was later treasurer of the U.S. Mint in Philadelphia. He is known as the Father of American Psychiatry, and his book Medical Inquiries and Observations upon Diseases of the Mind was the standard psychiatry textbook for much of the 19th century, the NIH says.

Matthew Thornton practiced for years in rural New Hampshire. When he went to Philadelphia for the Continental Congress, he had himself innoculated against smallpox and wrote of the ensuing ordeal. His satire described a Dr. Cash (“we saw no more of him, till I paid his bill of 18 dollars”); Dr. Critical Observer (“told me he would critically observe every stage … came once in two or three days, and stayed about a minute”); and Dr. Experience (“a merchant, who had the Small Pox, visited us every day, and gave a much truer account of the Small Pox, than all the doctors.”)

Josiah Bartlett was a practicing physician who became governor of New Hampshire and was one of the framers of the Constitution. But the practice of medicine remained important to him. In 1793, two years before he died, he wrote a letter to the New Hampshire state medical society (which he helped charter) expressing his hope that the group would crack down on quackery by “discouraging ignorant & bold pretenders from practizing [sic] an Art which they have no knowledge.”

Lyman Hall worked as a minister until, for reasons unknown to history, he was charged with “immoral conduct” and dismissed. He became a doctor, left his native Connecticut and ultimately landed in Georgia, where things seemed to improve for him — in 1783, he became governor of the state.

Oliver Wolcott was the son of a Connecticut governor who trained as a physician and may have practiced briefly, but spent most of his life in public office. For a while, he held the appealing sounding title of “high sheriff” in Litchfield County.

“And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.”

They didn't worry about third party payors, trial lawyers or SGR. They stood up for America against the tyranny of the crown. 

There are presently 20 physicians in Congress. It'd be a good idea for the Doctors Caucus of the House of Medicine to unite with the Doctors Caucus of the Houses of Congress. We'd all be better off.

Turning Point: A Sesquicentennial

One hundred fifty years ago, the Army of Northern Virginia stumbled upon the Army of the Potomac at Gettysburg, Pennsylvania. George Will shares some thoughts:

... Studying history serves democracy by highlighting contingencies: Things did not need to turn out the way they did; choices matter. Since Hegel, Marx and other 19th-century philosophers decided that history is History — a proper noun, an autonomous force unfolding an inner logic — humanity has been told that vast, impersonal forces dictate events, nullifying human agency.

But they don’t. Choices matter. They certainly did during the first three days of July 1863 at the town of 2,390 people seven miles north of the Mason-Dixon line. In “Intruder in the Dust,” William Faulkner famously invoked the tantalizing power of possibility:

“For every Southern boy fourteen years old, not once but whenever he wants it, there is the instant when it’s still not yet two o’clock on that July afternoon in 1863, the brigades are in position behind the rail fence. . . . That moment doesn’t need even a fourteen-year-old boy to think This time. Maybe this time with all this much to lose and all this much to gain: Pennsylvania, Maryland, the world, the golden dome of Washington itself.”

But Lee's gamble failed at the decisive moment and, inexorably, the South's fate was sealed. Without those three days in July of 1863, slavery might still exist and Lincoln would never had the opportunity to utter those few words that now, as Stanton put it, "belong to the ages." As in the Rubayat, "the moving finger writes and having writ, moves on." 

Now They Come For The Obstetricians

First they came for the Orthopedists. Today, the NY Times slams the cost of Maternity Care.

...  Despite its lavish spending, the United States has one of the highest rates of both infant and maternal death among industrialized nations, although the fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures.

Some social factors drive up the expenses. Mothers are now older than ever before, and therefore more likely to require or request more expensive prenatal testing. And obstetricians face the highest malpractice risks among physicians and pay hundreds of thousands of dollars a year for insurance, fostering a “more is safer” attitude.

But less than 25 percent of America’s high payments for pregnancy typically go to obstetricians, and they often charge a flat fee for their nine months of care, no matter how many visits are needed, said Dr. Robert Palmer, the chairman of the committee for health economics and coding at the American College of Obstetricians and Gynecologists. That fee can range from a high of more than $8,000 for a vaginal delivery in Manhattan to under $4,000 in Denver, according to Fair Health, which collects health care data. 

According to the NY Times, the main issue is "a la carte" billing and payment. The solution is predictably bundled payments.

There are two problems with the NY Times analysis. The first issue gets barely a mention and, of course, is buried. That is cost of medical liability. While the US leads the world in healthcare costs, it also leads the developed world in liability costs as well.

Moreover, medical liability costs have risen faster than all other tort costs and healthcare inflation.

While the article mentions the high rate of liability insurance for obstetricians, it conveniently neglects the mention of the costs of liability insurance for what often is the deepest pocket - the hospital. Moreover, the article does not examine defensive medicine at all.

Finally, the article neglects to mention another, more troubling issue - the financing of graduate medical education. With the present emphasis on healthcare belt tightening, the costs of the training of our future doctors always seems to get the short shrift. This needs to be addressed asap and cannot be seen as an afterthought.

I look forward to future NY Times articles focusing on these two issues: graduate medical education and medical liability reform. Our lives may depend on it.