Healthcare Update — 01-07-2013


Colorado Medical Society files suit to prevent chiropractors from administering medications. The Chiropractic Board of Examiners created a rule permitting such actions after chiropractors complete 24 hours of study and a certification exam.
I go against the grain on this one. Let chiropractors prescribe medications. After patients start experiencing bad outcomes because the 24 hour course chiropractors take doesn’t teach them about drug interactions or side effects, patients will learn to appreciate doctors a little more. Then throw a few chiropractors in jail for administering too much pain medication and see how many of them want to continue administering medications.Vermont Supreme Court rules that physicians are liable for the negligence of a physician assistant but not liable for unprofessional conduct of a physician assistant when physician assistant found to be inappropriately prescribing narcotics without physician’s knowledge.
Docs be aware that when you agree to supervise PAs and NPs, there can be significant liability in doing so.

Taiwan considers imposing limits on medical malpractice claims after penalties for physicians and proliferating lawsuits have driven physicians away from fields such as surgery and emergency medicine and there is now a “dwindling pool of qualified physicians in the key departments”. But think of how safe the patients must be as Taiwan sues its way to better health care.
Flu map
Influenza is rampant throughout most of the country. CDC site shows that influenza is either regional or widespread throughout the country. With school starting for many children today, look for additional illness to be spread.
All you doctors make sure to do sepsis workups and immediate sepsis treatment on everyone that comes to the ED with influenza so that some misinformed journalist doesn’t misuse sepsis guidelines to plaster your name and your hospital all over a national newspaper while trying to hide the fact that he misused the sepsis guidelines on the outside chance that there is a bad outcome with one of your patients.

How to stop heroin overdoses? One Annals of Internal Medicine study suggests freely distributing kits with the reversal agent Naloxone in it. Not much help if someone overdoses alone, but that’s beside the point.

The government thinks it is going to save money by paying for “results” not paying fee for service. Boy are they wrong.

EP Monthly snags another thought leader in medicine. Seth Truger (@MDaware) is now one of EP Monthly’s premier Twitterers. If you aren’t doing so already, you can follow EP Monthly on Twitter here @EPMonthly. If you’re really a glutton for punishment, you can also follow me at @WCintheED

Get well soon, honey. Washington man walks into emergency department to visit his wife, whips out an 8 inch kitchen knife, hands wife a suicide note, then walks out of hospital. Police find him sleeping somewhere else on hospital grounds and find knife stashed four blocks away. Man then gets brought back to the ED … this time as a patient.
Something about being found “somewhere else on hospital grounds” and them happening to find a hidden knife four blocks away just doesn’t seem right to me.

Indiana hospital fires eight staff members who refuse influenza vaccination. Wonder how long it will be before an employee at hospital mandating influenza vaccination gets Guillian Barre and then whacks the hospital for a multimillion dollar judgment.Remember how everyone called the NRA crazy for recommending that armed guards be present in every school (like the 11 armed guards present in the school for President Obama’s kids)? The American Academy of Pediatrics has now created a policy recommending that all school districts have a school physician to oversee health services and that such physicians be “experts in key school health topics” who will “collaborate with their AAP chapter” to understand the laws regarding their roles in schools.

Anatomically correct vomiting robot helps scientists study spread of norovirus.
I don’t get this. Think about it. If someone vomits, other people are not going to stand in place and say “British scientists used an anatomically correct robot to prove that I won’t become sick if I’m more than 7.2 feet from your mouth.” They’re going to jump out of the way and run the opposite direction. If aerosolized vomit can spread disease, then those who clean up the aftermath can rest assured they need to use a face mask and wash their hands well. We don’t need a puking robot to prove that.
In addition, the robot is in a stationary upright position. How many adults stand up straight and just let the vomit blast forward from their mouth and dribble down their nose when their tossing their cookies? People bend over and splat over the floor … or into the toilet if they’re lucky enough to make it to the bathroom.
Not sure that the money spent on Hurling Harry (or Barfing Billy) was worth the enlightening conclusions from the study.

Can you help a patient find his doctor to thank her? 40 years ago a man was injured in Israel when Syrians attacked. Shrapnel injured his eyes and blinded him. Normally, the patient would have no access to an eye specialist. However, an American doctor adept at eye surgery just happened to be doing clinical rotations at the small hospital where the injured soldier was brought. The doctor was able to remove the shrapnel and the patient regained his eyesight. However, he never got the chance to thank his doctor.
Be interesting to see just how powerful social media is in tracking down this surgeon. Female probably late 50s/early 60s in age. Worked in Israel in 1973 during the Yom Kippur War. Know anyone who might fit the description?


  1. Pay-for-results has obvious weaknesses, mainly arbitrage: providers will only treat those patients where the expected pay is greater than the expected expense. In principle, it’s possible to set up the pay so that the pay and costs match up, but in practice this isn’t possible even without all the lobbying.

    But it also has a fundamental problem, which in my opinion rules it out even if the “in principle” objections can be dealt with. The problem is the variance. Suppose that pay scales exactly match up with costs, so that on average over the whole system, the expected future pay at any point of the treatment exactly matches the expeted future costs. Even then, this is only an average statement — there’s no reason for the two nubers to match for individual patients.

    Now for an institution that sees many many patients per year, this will average out. But smaller institutions see fewer patients, so (relatively) they will face larger variance (roughly, the deviations scale as one over the square root of the number of patients). Actually, this understates the problem, since it’s usually rare conditions that are expensive to treat. So can the hospital afford to do heart transplants? Most hopsitals do only a few a year, so the probability of a “bad flucutation” where all patients do badly is not that low. Of course, there is also a “good fluctuation” possiblity where all patients do better than expected, but hospitals are not supposed to be a “high-risk / high-reward” kind of business.

    This is a similar problem with requiring hospitals to treat indigents and cover the costs by treating other patients — on average over the whole system it’s not a bad way to do it, but for specific hospitals the costs and revenue don’t have to match.

  2. In 2011, I seem to recall that there were potentially 176 reports of GBS and 99 were confirmed in roughly 100 million doses.

    But, alas, you are right. If a hospital requires it, this crap will surface.

    • I work in the same hospital system (but a different hospital) in Indiana that required the flu vaccine this year. I haven’t heard any serious complaints about the mandatory flu vaccines.

      A general question, though. To work at the hospital, we have to show proof of hepatitis B vaccination as well as varicella vaccination/positive antibody titers/documentation of chickenpox. I have heard no one complain about these mandatory vaccinations. What’s the difference?

      • I work in a large 5 hospital health system which requires ALL employees to receive the Flu Vaccine, volunteers too. All office employees, accountants, clinical staff, engineers, housekeeping, physician, everyone. If you do not provide proof of vaccination or exemption you lose your job. Thousands and thousands of employees and all have complied by January. No complaints and we have been working toward this over the past 3 years. It is good for the patients and keeps staff healthy.

  3. Hahaha, love the continued digs at the misinformed quarter-backing power of hindsight expert medical Dr. Google read up on the Internet journalist… 😉

  4. Re: chiropractors. Could not agree more, WC. Same for psychologists and prescribing. They know not what they do. But they’ll find out soon enough.

  5. WC, as you rush to your usual misguided judgment so you can repeat your meaningless line of “sue your way to better healthcare”, you misread the Taiwan article.

    Key paragraph: “The bill, which is pending review in the Legislative Yuan, would make medical personnel liable for criminal punishment only if they acted with “malicious intent” or in violation of duty.”

    This has nothing to do with malpractice cases. It has to do with criminal liability. These people would not be sued as in a civil case. The state would bring charges (assuming some similarity between their system and ours). I realize you’ve got a line to spew, but at least read your own links before hopping on the Jump to Conclusions Mat. I normally wouldn’t expect someone who isn’t a criminal or an attorney to catch the civil/criminal distinction, but you’ve put yourself out as such an expert on these matters it’s surprising you missed it.

    But maybe it’s not your fault – maybe the tort reform newsletter the “reformers” sent you and you cut and pasted from wasn’t clear either.


      – this is a detailed plan of what the Taiwanese government is going to do. As far as I can see, it is a no-fault compensation scheme, a patient’s ombudsman and extra-judicial “arbitration” by some government official.

      All of these things have already been tried in Norway and Sweden and have failed dismally. Difficult to see why the Taiwanese want to go down that road as well.

    • Logic gene powers … ACTIVATE!

      Go back and click on the article and read *why* the Taiwanese government is considering the bill. Actually, don’t bother. I wouldn’t want you to get more confused. Key paragraph:

      “Malpractice claims proliferate in Taiwan and can result in severe penalties for medical personnel. As a result, domestic physicians tend to avoid fields such as surgery and emergency room treatment, according to the bill drafted by the Department of Health (DOH). The DOH developed the bill after the premier called for solutions to Taiwan’s dwindling pool of qualified physicians in the key departments.”

      So in other words, Taiwan was suing its way to such good health care that it couldn’t find sufficient qualified physicians … because those “severe penalties” it was imposing are so good at improving quality and availability of health care.

      Now Taiwan is trying to backpedal to attract more physicians. We’ll see if it works. Or maybe they can hire more lawyers. After all, trial lawyer Gerry Spence believes that trial lawyers are more important than doctors, anyway.

      We’re heading down the “penalty” path in medical care in this country, also.

      Watch to see how the availability of medical care is affected.

      Glad I’m a doctor.

      • A criminal action is not a suit at all similar to a medical malpractice civil suit (assuming we can compare legal systems between our country and theirs). So your comparison fails, per usual. It’s unlikely that Taiwan’s system has much in common with our system with its roots in the British. Moreover, their healthcare system is single payer, which also makes comparisons between the motivations of physicians between our country and theirs pretty suspect. But I realize the conclusions drive the evidence with you, rather than vice versa.

        Quick primer on Taiwanese Healthcare:

        Note the section on Problems.

        We are not heading down the penalty path in this country any more than we are trying to “sue our way” to better healthcare in this country. As you well know, the majority of malpractice doesn’t result in a claim. And when you look at the number of doctor/patient interactions and the number of criminal charges against physicians, it’s minimal.

        The availability of medical care is, has been, and always will be a function of the wealth of a community. Poor people will always have fewer, and there will always be plenty of physicians to serve wealthy communities. Your hysterical pronouncements will not change that.

  6. As a pharmacist I don’t want prescribing practices expanded to chiropractors. In some circumstances I carry a liability along with the prescriber. I have found the less a prescriber knows about a medication the more adamant he/she is in prescribing it.Can you imagine a chiro trying to prescribe adalimumab or methotrexate?

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