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Showing posts from May, 2011

Your Tax Dollars Are Being Wasted by Medicare

The title of this post may sound a little Tea Partyish, but stick with me here...

Medicare is projected to go broke by 2024.  We need to do something about it.  Here are a couple of news articles this week that identify some low hanging fruit.

1.  Rita Redberg, UCSF cardiologist and editor of the respected Archives of Internal Medicine, had a terrific op-ed piece in the New York Times this week about overtreatment of older adults, paid for by Medicare.  Some highlights (or lowlights)

40% of colonoscopies are administered to people over age 75 (screening guidelines suggest not screening after 75, and certainly not screening after age 85).  Paid for by Medicare.Kyphoplasty and Vertebroplasty, shown in two terrific randomized trials to be no better than sham procedures, are still funded by Medicare, to a tune of $1 BILLION/year.  Cardiac stents are no more effective than medication management or lifestyle changes in preventing heart attacks or death.  Medicare cost: $1.4 BILLION/year.1/5t…

The confusing morass of medical evidence

Practitioners of evidence-based medicine use published evidence from the medical literature to guide them as they try to provide the best care for each patient. But sometimes the medical literature just feels like a big morass.

The difficulty applying the medical literature to patient care is illustrated by two studies published in the past few months in the very best medical journals. The studies give precisely opposite answers to an important clinical question.

The studies focus on the management of COPD (sometimes called emphysema or chronic bronchitis). COPD, which causes very distressing symptoms such as shortness of breath, is very common, especially in Geriatric patients. It is one of the most common causes of hospitalization, and costs Medicare billions of dollars. One of the studies, published in the NEJM, was recently reviewed on GeriPal. The other study was published in the Annals of Internal Medicine this month.

Patients with COPD are often treated with long acting inhaler…

Watchful Waiting or Surgery for Prostate Cancer?

What should be done in men who have prostate cancer? On first examination, it might seem that the obvious answer would be “take it out of course!” But it actually is not so simple. In fact, the management of early stage prostate cancer (a cancer that has not spread beyond the prostate) has been one of the most difficult and controversial questions in medicine.

On the one hand, prostate cancer is one of the leading causes of cancer death in men. On the other hand, only a fraction of men with early stage prostate cancer are actually harmed by the cancer. In most cases, the cancer will grow so slowly that it will never cause meaningful symptoms. Most men with prostate cancer, especially older men, outlive their prostate cancer and will die of something other than prostate cancer.

Further, the vast majority of men who are treated for prostate cancer (whether by surgery or radiation) will be harmed in some way by treatment. The harms are often substantial. Treatment more often than not le…

Why Should I Have to Choose?

My interest in geriatrics stems from working in a nursing home as a teenager however my exposure to palliative medicine happened during residency. During my training journey, I found that there were many instances where the two fields overlapped leading me down the path to become trained in both fields.

Early on in my journey to combine these fields everyone was so supportive with comments like "that makes sense" or "what a great way to combine your interests". However, now I feel as if I need to choose one field or the other to maintain my own sanity. I mean, how do you even pick which conferences to attend each year? AGS? AMDA? AAHPM? NHPCO? My family says - pick based on the best locations!

As a junior academician at an institution where geriatric medicine has a very nice structured home in the department of medicine and palliative medicine seems more nebulous, I have carved out a job where I continue to do both. Is this a sustainable existence? How do I balanc…

Dying in India: Palliative Care Provides Hope

Imagine you have a terminal illness and were given a prognosis of 3 months...or less.

In a developed country like the United States (US), you may have health insurance coverage and adequate financial resources to choose to die comfortably at home, surrounded by family. But if you’re poor and living in a developing country with few social and health care resources, you may not fare as well.

For many elderly suffering from terminal illnesses in India, Where do I go? and Who will take care of me? are questions they face toward the end of life. A recent BBC news article, "Bringing Hope to Elderly and Terminally Ill Indians," brings to light this reality.


In Delhi, India, Mother Theresa’s Missionaries of Charity runs a shelter where the old and dying can be “abandoned” by family members who are no longer able to care for them.

Although palliative care systems are set up around India, only about 1% of Indians in need actually receive palliative care.

This post will highlight one parti…

Loneliness

2 recent articles have helped me prioritize addressing loneliness of patients.

An opinion piece in this week’s NEJM "The Loneliness of Visiting" emphasizes loneliness in the hospitalized patient during a prolonged hospital stay and how hospitalization is perceived by the family. After 3 months in the hospital, “The problem is the poor chap is lonely” the intern states. The team question why the family has quit coming to the hospital. The situation dramatically changes when the patient develops a stroke. In a delightful change of narrative, the patient changes from Mr. Wilson to Brad. The author, Dr. Ranjana Srivastava has known Brad since medical school and continues to visit daily not as a doctor but as a friend sitting by the bedside. From that perspective, Dr. Srivastava struggles with how to be present with the critically ill. Cell phone and newspapers have to be put aside when she recognizes they are keeping her from being with Brad. Then as a nurse asks what she i…

Undue Influence: Corporate Sponsorship of Professional Society Meetings

There was a great report in one of the most influential medical periodicals today.  Not NEJM, or JAMA, or Annals of Internal Medicine.  I'm talking about the USA Today.  The story concerned corporate sponsorship of medical societies.  The reporting, by ProPublica in conjunction with USA Today editors, is terrific.

The primary expose is of the Heart Rhythm Society, a group that has gone from 38% corporate sponsorship to 50% between 2006 and 2010, totaling $4 million last year.  During this same time we've seen an explosion in the insertion of implantable cardiac defibrillators (ICDs), primarily in older adults.   An ICD can cost more than $30,000.  World sales of ICD's totaled $6.7 billion last year.  12 of the 18 board members of the Heart Rhythm Society are paid speakers or consultants for ICD manufacturers.

At the annual meeting of the Heart Rhythm Society, going on right now in San Francisco, Medtronic has a 12,000 square foot booth, and Boston Scientific has a 8,100 s…

From Twitter to Tenure - The Wrap Up

I have the distinct honor of wrapping up the online prelude for the SGIM Social Media Workshop “From Twitter to Tenure”. So far we have heard from Alex Smith (@AlexSmithMD) from GeriPal, Vinny Arora (@FutureDocs) from Futuredocs, Bob Centor (@medrants) from DB’s Medical Rants, and Kathy Chretien (@MotherinMed) from Mother’s in Medicine.

The previous posts all describe how social media can advance an academic career. Rather than restate many of the same points, I’ll just summarize many of the themes brought up by these clinicians, while highlighting my own personal story.


1.  Learning to write: The most important lesson blogging has taught me is that telling a good story is hard, and that I need a lot of practice to become a better writer. That’s why I love blogging as it forces me to write. As opposed to writing for an academic journal, which often takes more than a year from concept to publication, blogging gives me the opportunity to practice my skills on a weekly basis while rece…

Glycemic Control in Frail Elders: Is There a Happy Medium?

In frail elders, such as those who are disabled and no longer able to care for themselves independently, "less" medical care is sometimes more.


As discussed recently on GeriPal, this may be the case for diabetes. While many guidelines for diabetes recommend tight control of blood sugar, in frail elders this may do more harm than good. For example, many guidelines suggest an HBA1c target of 7%. But frail elders may get little benefit from such tight control, and the risks of hypoglycemic side effects may be substantial. And all the monitoring needed for tight control may have negative effects on quality of life.


But just becasue tight control of blood sugars is not a good idea does not mean that no control is a good idea. It is unlikely that patients with frequent very high blood sugars will feel well. Maybe there is a happy medium.


In 2003, an American Geriatrics Society Guideline Panel tried to find this happy medium, recommending a HBAic target of 8.0% in frail elders. Till r…

The Third Annual Hastings Center Cunniff-Dixon Physician Awards

The Cunniff-Dixon Foundation in collaboration with the Hastings Center and the Duke Institute on Care at the End of Life just announced it will now be accepting nominations for the third Annual Hastings Center Cunniff-Dixon Physician Awards.

The goal of this one of a kind award is to encourage excellent end-of-life care by giving physicians national recognition for their clinical contributions and commitment to the cause of end-of-life medical care.

The 2012 award prizes tops off at $95,000. There will be two unrestricted $25,000 prizes for senior and mid-career physician who demonstrate, through leadership and practice, a serious commitment to end-of-life care. Another three unrestricted awards of $15,000 each will go to physicians early in their careers (less than 7 years in practice) who have made a valuable contribution, through practical research or clinical work, in the field of end-of-life medicine.

As a 2011 award winner, I cannot understate the importance of the award from a…

A New Tool for Estimating Prognosis in the Elderly

"What if your doctor, making use of a Web site that collected a number of tested geriatric scales, could enter information about your history and your health, and then predict with reasonable accuracy your odds of living another year, or four, or nine?What if you, with a slight fib, could log onto that same site and find that information yourself?"
This is the start of Paula Span's most recent New Old Age article in the NY Times titled 'Figuring the Odds'. The question she poses to her audience is whether the general public should have access to geriatric prognostic indexes. This is not some farfetched proposal, but rather a discussion that is coming on anticipated launch a new website created by some GeriPal contributors that will list 18-20 geriatric prognostic indexes.

Why bother with creating a website that can help with prognosticating? Well, although lots of geriatric prognostic indexes have been published, their use has been limited as there is no one plac…