Thursday, May 7, 2009

Lines Drawn on Comparing Medical Treatments -

A back-pain researcher, Dr. Richard Deyo recalls the uproar the last time federal officials tried to suggest how doctors should practice their profession.

It was in the mid-1990s, when Dr. Deyo helped develop federal guidelines urging surgeons not to perform spinal fusions to treat acute pain. The reason was simple: There was little evidence that the fusions worked in many patients.

Spine specialists quickly attacked the report, calling it flawed. One medical device maker, Medtronic, sued unsuccessfully to block its release. Republican lawmakers tried to kill the agency that issued the report. It survived, but its funding was drastically cut, and it decided to stop issuing guidelines.

Now, 15 years later, the Obama administration is entering this same medical minefield. And once again, opponents are gearing up for a fight.

The administration plans to spend $1.1 billion over the next few years on studies like the one conducted by Dr. Deyo, to compare the effectiveness of competing treatments for common conditions like back pain, heart disease and prostate cancer. The studies will be publicly released, to help doctors and patients decide which treatment options they want to pursue.

Supporters include many medical researchers, consumer groups, unions and insurers. They say such studies are essential to curbing the widespread use of ineffective treatments and to helping control health care costs, which totaled $2.2 trillion in 2007, or 16 percent of the nation's gross domestic product.

The New England Journal of Medicine published several articles Wednesday supporting the federal effort and rebutting arguments raised by critics.

But potential opponents — which include medical products companies, some doctors and their political allies — warn that the comparative effectiveness movement could lead to inadequate treatment for some patients and even the rationing of health care.

"It is not difficult to see how you can get on a slippery slope very easily," said Tony Coelho, a former Democratic congressman who is head of a new industry-backed Washington group called the Partnership to Improve Patient Care, formed to lobby on the comparative effectiveness effort.

The group's backers include major trade organizations that represent producers of drugs, medical devices and biological treatments.

Critics like Mr. Coelho also point to a British government agency, the National Institute for Health and Clinical Excellence, or NICE, which considers costs in judging a treatment's effectiveness. Based on NICE's findings, the British government has denied some patients access to costly drugs like those used to treat cancer.

Whether cost should be a factor in this country was a hot-button issue during the Congressional debate in February, when the comparative-effectiveness funding was approved as part of the economic stimulus package. A legislative report by Congressional lawmakers who negotiated the final version of the bill said that they did not intend the research money to be used to "mandate coverage, reimbursement or other policies for any public or private payer."

Despite that assurance, even supporters of the effort say one goal in identifying effective medical treatments is to stop wasting money on those of little value.

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Giving birth 10,000 miles from home. - By Rachel Louise Snyder - Slate Magazine

An enormous nipple bobbled slightly on the TV screen in front of me. Beside it was a set of tiny heart-shaped lips belonging to a newborn, pecking birdlike around the nipple's circumference. The lips failed to find their prey. This poor child's first grand failure in the world is, I was told, the unfortunate result of a mother on drugs. "Damn crackheads," I thought.

But the drugs in this case, said our placid wide-mouthed instructor, were your regular old garden-variety epidural. "Damn epidural-heads," I thought, then I realized I was in all likelihood referring to myself.
The next scene showed a similar bull's-eye teat, a similar heart-shaped mouth, only this time the lips hit upon the nipple almost immediately. A few of us students offered up a quiet Hooray! to the tiny nonverbal hero. It was as if we'd been given a glimpse into this child's blessed future … an alternative Montessori-style education where he would excel at dodge ball and four square, followed by a stint in high school as class president and homecoming king, valedictorian at Harvard (perhaps Cambridge), after which he would land a six-figure-a-year job right out of B-school. Eventually, his golden journey would culminate at his deathbed, where he would be surrounded by children and grandchildren, cooing back all the powerful lessons of morality and ethics he taught them. And all because his brave mother grimaced through labor sans epidural.

A small crowd of couples, including my husband and me, watched the video. We were sitting in an arctic room just off the women's health center of Samitivej Hospital—that's "Sa-mitt-i-vay"—in Bangkok, Thailand. Only tropical cultures can make air conditioning this cold. (Citizens of Hong Kong routinely come down with colds from the frigid subways and office buildings.) I am American, and my husband is British. There was also a Belgian couple, two Australian couples, one Japanese-American couple, two couples from India, and the rest a combination of gorgeous Thai women with unremarkable Western men. Generally speaking, we were not the medical tourists one hears about so often these days; we were, more accurately, medical expatriates (except the Thai women, of course). Most of the women were a month or so from their due dates and were taking this class as one in a series of prenatal preparation courses offered by the hospital. Other classes covered topics like breast-feeding, exercise, hormones, newborn care, and discipline. Only one woman was 24 hours away from her due date.


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Epocrates Online - Physicians' reference

Provide the best possible patient care with Epocrates Online - a free, fast, and effective way to find clinical information at the point of care.

Unlike other online medical references, Epocrates Online organizes practical, peer-reviewed content with a unique patient-centered approach, providing you with answers, not more questions.

  • Continually updated, integrated drug and disease information
  • The most relevant information, by clinicians, for clinicians
  • Easy-to-use expandable menus that let you go from concise to comprehensive
  • Look up a monograph directly, or find specific information through an open-text search

BMJ Learning

BMJ Learning is the world's largest and most trusted independent online learning service for medical professionals. We offer over 490 peer reviewed, evidence based learning modules and our service is constantly updated. Train and test your knowledge and skills today.

doc2doc - Doctors Community, Forums and Doctors Networking

doc2doc has a range of tools to help you network with other doctors on a professional and social level. On our clinical forums you can discuss interesting or puzzling cases and discuss any aspect of medicine. You can also create your own forum and build a community around your own interests or place of work. You can find people you work with, used to work with or want to get to know through our people search.

FluTracker - Tracking the progress of H1N1 swine flu

This map and the data behind it were compiled by Dr. Henry Niman, a biomedical researcher in Pittsburgh, Pennsylvania, using technology provided by Rhiza Labs and Google. The map was compiled using data from official sources, news reports and user-contributions.

Monday, May 4, 2009

Health Care Law Blog

Keeping an eye on health care law. Thoughts and comments on the
health care industry, privacy, security, technology and other odds
and ends.

Health Blogs Observatory

Health Blogs Observatory is an online research lab devoted to examination of the health blogosphere. Our main goal is to conduct annual surveys of health bloggers and their blogs to gain better insights into the state of health blogging.


My name is Bertalan Meskó. I'm a last year medical student (currently doing clinical rotation) at the University of Debrecen, Hungary. Here is my LinkedIn profile.

I plan to become a clinical geneticist specialized in personalized genomics. I believe that the future of medicine belongs to this field.
On this blog, my aim is to make medicine, genetics more readable even for those who are not too interested in them. That's why I mostly write about genetic testing, personalized genetics, the most important news of clinical genetics and, of course, popular medicine.

I also work on the relationship between web 2.0 and medicine. I try to provide useful content; tools and services that could ease the work of physicians, medical students, nurses or medical librarians.

The Health Care Blog

The Health Care Blog (THCB) has acquired a reputation as one of the most respected independent voices in the healthcare industry. The Wall Street Journal calls us "among the most widely read insider publications in the field. Web MD calls us "a free-wheeling discussion of the latest healthcare developments."

The Health Care Blog: Op-Ed: Patients first. Doctors second.

Op-Ed: Patients first. Doctors second.


As part of the recently enacted stimulus bill the federal government is spending $19 billion to promote the adoption of electronic medical records by physicians.  Yet, with all the focus on doctors, lawmakers have forgotten the most critical piece of the puzzle -- patients.

Take the case of Joe (not his real name), a patient who came to see one of us recently. Joe is a thirty-something year-old with type 1 diabetes. After a rebellious few decades that included dozens of hospitalizations, he was finally re-engaged in his care. His most recent request -- to access his electronic medical record. Joe wanted to track his hemoglobin A1c, an important marker of his diabetes, follow his blood pressure and take a closer look at his cholesterol. After all, it is his information in the clinic's commercially available electronic medical record.  Sadly, his request couldn't be honored. Patient-access features simply hadn't been built in.

Health information technology offers great promise to patients. Patients can access their medical information online, communicate with doctors by email, schedule appointments through the web and take advantage of numerous tools to manage their own illnesses. They can become equal partners in their care.

But without further intervention from policy makers, many of these tools will remain unavailable to patients. Doctors may adopt electronic health records, but those health records will be just as inaccessible to patients as today.

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e-Patients: How they can help us heal healthcare, because healthcare professionals can't do it alone.

Medical Student Blog | Following the journey of a mature student from pre-med to medical school.

Twitter Doctors, Medical Students and Medicine related | Medical Student Blog

Below is a list of Doctors, Medical Students and Medicine related tweets and blogs/websites.

Health News Review - Objective Ratings of Health and Medical Journalism

Schwitzer health news blog

Gary Schwitzer has been recognized and awarded many times for his work in health journalism in various media, including television news, interactive multimedia and the Internet. Professor Schwitzer worked in TV health/medical news in Milwaukee, Dallas and at CNN. He produced groundbreaking decision-making videos at Dartmouth Medical School in the 1990s. In 2000, he launched as editor-in-chief. Professor Schwitzer teaches courses in health journalism, ethics and electronic news reporting. He is also publisher of

Doctors, Students, & Health Care Professionals - FriendFeed

Twitter feeds, blog postings, and links shared by doctors, medical students, and other health care professionals.

J. Schwimmer (KidneyNotes) on Twitter

  • Name J. Schwimmer
  • Location New York City.
  • Web
  • Bio Medical Blogger, Internist, Nephrologist, and Tech Enthusiast.

Google Health: helping you better coordinate your care

We continue to learn a tremendous amount since launching Google Health in the spring of 2008. We're listening to feedback from users every day about their needs, and one issue we hear regularly is that people want help coordinating their care and the care of loved ones. They want the ability to share their medical records and personal health information with trusted family members, friends, and doctors in their care network. I can relate to this.

Just a few years ago, my father suffered a minor heart attack and was sent to the ER. I arrived on the scene in a panic, and was asked what medications he was taking. To my surprise, I had no clue. If my father had a Google Health account, and had shared his profile with me, I would have been up-to-date on his current medications.

I'm happy to announce today Google Health has addressed this issue with the release of a new "Share this profile" feature enabling Google Health users to invite others they trust (whether it's a family member, a trusted care network provider, friends, and/or a doctor) to view their medical records and personal health information.

Log into Google Health, click on "Share this Profile," and type in the email address of the person with whom you'd like to share your profile. Google Health will send an email to them with a link to view your profile. The link will only work in connection with the email address of that person — your profile can't be accessed if the link is forwarded on. You can stop sharing at any time, and you can always see who has access to your information. Those who are viewing your profile can only see the profile you share — not any other one in your account. We've also built in some extra protections to make sure your health information stays safe, private, and under your control.

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The Efficient MD - Life Hacks for Healthcare

Pipes: Doctors and Medical Students on Twitter

Clinical Cases and Images - Health News of the Day

Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day. News of the Day

Clinical Cases and Images - Blog

"One of the best blogs in medicine is Ves Dimov's Clinical Cases and Images - Blog. It contains a rich collection of "presurfed" material for busy clinicians and features interactivity and timely discussion. Dimov is also a supporter of medical librarian bloggers. Why waste time fumbling with search engines when you can consult this blog for timely updates? As well as case discussions, Ves provides links to today's medical headlines from Reuters and clinical images via a dynamic, free photo sharing tool called Flickr. One of his slide presentations "Web 2.0 in medicine" is available on Slideshare (itself a fantastic new 2.0 tool). Clinical Cases and Images is a virtual laboratory for doctors and medical librarians interested in Web 2.0."

Oxford University Press: When Doctors Become Patients: Robert Klitzman

For many doctors, their role as powerful healer precludes thoughts of ever getting sick themselves. When they do, it initiates a profound shift of awareness-- not only in their sense of their selves, which is invariably bound up with the "invincible doctor" role, but in the way that they view their patients and the doctor-patient relationship. While some books have been written from first-person perspectives on doctors who get sick-- by Oliver Sacks among them-- and TV shows like "House" touch on the topic, never has there been a "systematic, integrated look" at what the experience is like for doctors who get sick, and what it can teach us about our current health care system and more broadly, the experience of becoming ill.

The psychiatrist Robert Klitzman here weaves together gripping first-person accounts of the experience of doctors who fall ill and see the other side of the coin, as a patient. The accounts reveal how dramatic this transformation can be-- a spiritual journey for some, a radical change of identity for others, and for some a new way of looking at the risks and benefits of treatment options. For most however it forever changes the way they treat their own patients. These questions are important not just on a human interest level, but for what they teach us about medicine in America today. While medical technology advances, the health care system itself has become more complex and frustrating, and physician-patient trust is at an all-time low. The experiences offered here are unique resource that point the way to a more humane future.

When doctors become patients by Robert Klitzman - Review

Robert Klitzman's book When doctors become patients records the experiences of 70 "wounded physicians" (to use Carl Jung's term). Through these stories, the author seeks new insights into being a physician, being sick, and the functioning of the health care system in the United States in the early 21st century.

In the introduction, Klitzman writes "Though the early states of doctor's careers have been examined . . . much less attention has been given to the latter stages of medical careers and the exact boundaries of the 'doctor role.' Little is known about how they travel back to the lay world from that of being a doctor, what stages comprise their journeys, and whether their two roles change, blur, or conflict, and if so, how." Klitzman uses qualitative methods to illuminate this journey. He initially conducted 20 interviews of physicians with HIV and then recruited other physicians through the Internet, e-mail announcements, websites, word of mouth, and advertisements in newsletters. The 70 contributors lived in several cities in the United States, practiced a wide variety of specialties, ranged in age from 25 to 87 years, and had a range of medical diagnoses, including HIV infection, cancer, heart disease, Huntington disease, and bipolar disorder. The author hopes that "the lessons these doctors gained can help patients and families, current and future physicians, other health care professionals, and policymakers."

The book is organized thematically into three sections that describe the experience of becoming ill (becoming a patient), the experience of returning to work as a physician after being a patient, and how the experience of being a patient changed the ways in which these physicians practiced medicine. Thus, aspects of each physician's story surface, usually, in multiple sections. Appropriately — because the method is qualitative — Klitzman lets these physicians tell their own stories. The text is dominated by excerpts from each physician's interviews, usually 2- to 3-paragraph segments that illustrate specific points. The book's chapters are thus a series of vignettes woven together to illustrate specific themes, such as Chapter 3, "The medical self: self-doctoring and choosing doctors," Chapter 8, "Being strong: workaholism, burnout, and coping," and Chapter 11, "Us versus them: treating patients differently."

Above all, this is an honest book. To his great credit, Klitzman was able to get these physicians to talk bluntly about their experiences, how those experiences changed them, and how they tried to doctor differently as a result. While there is nobility, generosity, and kindness in these stories, there is also frustration, selfishness, resentment, and anger. Everyone will bring something different to the reading of this book, and as a result, each will take something different away.

For example, I was particularly moved — and upset — by Chapter 4: "Screw-ups: external obstacles faced in becoming patients." Physicians describe the ways in which their symptoms were ignored, particularly psychiatric symptoms such as depression and anxiety; how their dignity and identity were diminished; the various incidences of poor communication that left them confused and upset; and the arrogance of treating physicians. As a practicing physician, I could only cringe as I read, thinking about the times I had been guilty of all of these same sins. For patients and their family members who read this chapter, there will be much that is all too familiar, and perhaps there will be some small reassurance that even doctors, when ill, experience these indignities.

This book, as intended, raises far more questions than it answers. This is illustrated, for example, as these wounded physicians describe how they think about their responsibilities toward their patients. On the one hand, there are condition-specific issues such as what types of care physicians with HIV should and should not participate in (i.e., should they do procedures in which there is some finite risk of bleeding and consequent infection of a patient?). But in addition, there are broader issues related to physicians' implicit commitment to "be there" for patients over time when they themselves may have, for example, a metastatic cancer. What kinds of conversations should physicians have with patients about this difficult topic? What are physicians' ethical and legal responsibilities? Here the issues faced by physicians are in some ways no different from those faced by other personal service professionals, such as lawyers or accountants, and some discussion of or reference to norms in other professions would have been helpful.

While Klitzman works hard to extract lessons for physicians and patients from these accounts, the beauty of the book for me was the directness and humanity of its stories. For that alone it is worth reading. The only aspect of these physicians' stories that I was still waiting for when the book ended was family. A theme that wove its way through every chapter was the powerful way in which the identity of "physician" shaped and often dominated these doctors' lives. I was left wondering how that identity competed with that of son, daughter, father, mother, parent, and grandparent. This is a thoughtful and carefully written book. Read it. You will not come away unaffected.