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Comment Re:Proper rest (Score 1) 332

""We brought a two-minute checklist into operating rooms in eight hospitals," Gawande says. "I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things: Make sure that blood is available, antibiotics are there."

You do realize that pre-op antibiotics and such are pushed by anesthesia, blood availability is a blood bank and nursing issue. None of these "checklists" really apply to the operating surgeon.

Comment Re:Some doctors in my hospital do cancel elective (Score 1, Funny) 332

I am an anesthesiologist. When I am on overnight call I am always off the next day. Our group of Anesthesiologist strongly believes this is the right thing to do. On overnight call I don't come in until 3pm because 24 hours it too tiring. The motto of the American Society of Anesthesiologists is "Vigilance" You can not be vigilant if you are sleep deprived.

On several occasions I have seen heart surgeons who are up at night with emergencies call off scheduled, elective cases in the morning. Perhaps we just have a good bunch of surgeons here, but all of the OR team (nurses, perfusionists, Anesthesiologists...) think it is the right thing to do.

Respectfully... the reason why anesthesiologists need stricter work hours, "breaks" during their cases, etc., is because their job is so f'ing boring that even the well-rested often fall asleep at their anesthesia consoles.


Comment Re:Proper rest (Score 1) 332

The medical world should borrow two things from military aircraft maintenance... CHECKLISTS.

Pilots, who are at least as studly and narcissistic as physicians, KNOW ignoring checklists is a great way to fuck shit up. That's why it is PUNISHED.

As to the civilian custom of working interns to exhaustion, that's just stupid. The military can train enough folks for wars, the civilian side of the house should "militarize" medical care (including quality control and open chain of command for complaints) and get shit done.

Checklists for surgeons are a silly idea. Why? You know an aircraft's blueprints. You know that the aircraft has been through a rigorous certification procedure whereby each and every maintenance technique has been methodically tested and examined.

My patient? I don't know how my patient is built. I don't know how he or she will react to this medication or this surgical procedure. I don't know for a fact their anatomy. That nerve I see, is it a vital cranial nerve or an anatomical variant of a meaningless or redundant nerve?

Medicine and surgery is, and remains, an art. If you spend a week in the OR with different surgeons performing the same procedure, you will see that each surgeon does things differently. From the type of incision, to the order of the steps of the surgery, to which vessels are taken and which ones are preserved, to the type of suture that is used. There's no rhyme or reason besides the fact that it "works" for this surgeon. Checklists? You'll be forcing square surgeons into round surgeon holes, and the outcomes aren't pretty.

And most importantly-- every surgery that is commonly performed was "new" at one point. There's no reason to think that my way of doing, say, a thyroidectomy is better than the way they do it in, say, Japan, where axillary endoscopic dissections are more common. What if I want to try that in the US, saving my patient a large anterior neck scar. What? No checklist for that? Oh, too bad. There's no room for innovation in medicine, I guess.

Comment Re:an institutional illness (Score 1) 332

The health care system in the USA gets a larger share of the richest economy in the world than any other health system anywhere. If the problem is lack of money, I must ask...where is the money going, then?

The health care expenditures of the US increase on a yearly basis, and average physician salaries decrease on a yearly basis.

On the other hand, hospitals are happy to hire new nurse managers, paperwork associates, EHR czars.

Oh, and not to mention the lawyers. Always need more lawyers....

Comment Re:an institutional illness (Score 2) 332

Part of the problem is the medical profession's method of "training" physicians by putting them through an extended period of hazing: working around the clock, being awakened at random intervals, etc. Many of the ones who get through it develop the delusion from it that they can do the work properly under any conditions, especially sleep deprivation. It's a badge of honor for them, and they will engage in all sorts of denial and rationalization to keep at it.

Respectfully disagree. I'm a resident in a surgical subspecialty, a subspecialty I chose in no small part because there aren't nearly as many surgical emergencies compared to general surgery. That being said, residents don't go through "hazing" as much as "trial by fire." For instance-- awakened at random intervals. It's not as though residents got woken up for the fun of it (well... depending on the nurse.). It's because there's an issue for a patient that needs attention-- be it a new consult in the ER, a trauma being choppered in, or issues on the inpatient floor. Now, there's certainly (many) instances when I'm woken up for a completely nonsense page-- my favorite example is getting a page at midnight because the nurse thought the patient needed "butt paste." There should be mechanisms for limiting the amount of sleep disruption to the on-call staff; limiting work hours, IMO, raises as many problems as it solves. Particularly the new ACGME regulations for interns starting next July which limits you to 16 hours in-hospital and rules for "strategic napping." And there's no badge of honor. I value my sleep. When I finish my training, I don't intend to operate beyond the hours of 7am and 6pm. But I know that there will be instances where I have to. Even more so for general surgery, vascular surgery, neurosurgery, etc. And the problem is worse in rural settings where there might be one surgeon on call for weeks at a time. Do you tell them not to book any OR cases for a month or two? Ridiculous. As a resident, this is my time to learn how to become a surgeon. It's my time to learn habits that I need to use when I'm an attending, when I don't have a supervisor who can step in and tell me that I'm doing something wrong or can offer suggestions on how to improve my technique and habits.

Comment Re:If not us, who? (Score 2, Informative) 131

So the question is, if they can channel 'huge' amounts of water from the Red Sea, why don't they use that for irrigation?

That's what they're planning to do; they're going to desalinate the Red Sea to provide water to communities instead of using the Jordan River. What's left-over from the desalination process will be pumped into the Dead Sea to increase it's level. It's, you know, all in TFA.

Comment Re:Way to go, NASA! (Score 4, Interesting) 181

As spectacular as some of its failures have been -- like slamming a probe into Mars because one group failed to convert the units the other group was using -- it's important to recognize that NASA is capable of equally spectacular successes. These rovers have done way more than anyone expected and helped us learn a tremendous amount about Mars. We definitely got more than our money's worth on this project, and the scientists and engineers whose hard work made it happen deserve some serious accolades.

I think it's also important to note that NASA is something like 5/6 in Mars landings.... no other agency in the world has even landed 1 successfully. People (correctly?) shit on NASA for its perceived failings in manned spaceflight but it has an unbeatable record in interplanetary exploration.

Comment Re:Nurse != Secretary (Score 1) 406

That's why healthcare is a market failure. There is not perfect access, or anything even approaching it. You cannot make informed decisions based on quality of service and cost and all that when you think you might be dying. You'll go wherever's closest, no matter HOW badly they do their job, if you think that they're at least basically competent WRT lifesaving.

That may apply to emergency situations, but healthcare >>> emergency room. Consider, for instance, that you want to get Lasik, or you need to have an angioplasty, or you have a mass in your oral cavity. These are 3 different instances, of varying levels of exigency, in which a free market allows you to choose a health care provider based on not only geography, but skill, experience, ratings by other patients, cost, personality, etc. etc.

Yes, it's true that if you're shot in the chest, you're going to whichever trauma service is closest to you. But those are extraordinary circumstances.

Comment Re:Test it with the military first (Score 2, Insightful) 170

But do you really think the ER is going to look up your name (if they have it), find your record and spend the time looking at it before they treat you? And heaven forbid if the file is the wrong one or their is some important inaccurate information (and there always is).

I do. I always look up a patient's medical record when I admit a patient. Why? Because, almost invariably, when I ask the patient a question about their medical history, they will either forget to mention something or will just tell me to "look in the damn chart." It also helps me to formulate a battery of questions to ask when I end up seeing the patient.

Does that mean that the medical record is accurate? No, of course not. And that's why I always ask the questions to confirm. Usually I'll say something like, "I looked in your record and I saw that you were in the hospital last year for .... and that you have a history of .... and ..... Is there anything else?" And if you've ever tried to take a history and physical on a cantankerous patient, you'll be glad that there's a record in the computer because more often than I care to admit, that's the only information I have to go on when patient's refuse to cooperate.

Comment Re:So much for not sacrificing ideals for safety. (Score 1) 906

Insurance for my family (me, wife, 2 kids) through my employer would cost $1,200/month. I make 30k/yr. Do the math. That's half my salary BEFORE taxes.

So if they are against people like me, an educator and a community-oriented person who goes out of their way to help people having access to health care then FUCK THEM.

I really hope you're not a math teacher.

Comment Re:This is untenable (Score 1) 136

That's great for employees of LMC, but you're overlooking two things:

(1) LMC was able to negotiate that kind of blanket coverage with their insurance provider because, well, they're Large. Smaller business don't have that kind of leverage.

(2) There's absolutely nothing to stop the insurance provider from telling LMC, "Right now you're paying $x million per year for blanket coverage. We can offer you the same coverage for 0.9$x million per year [which will actually cost us 50%, not 90%, of what it does now, although we're not going to mention that] if you accept our suggestions about which types of employees you might want to ease out the door." Nor is there anything to stop LMC's management from thinking this offer is a really good idea.

If you think there's a way to solve either of these problems without serious government regulation, please feel free to make a suggestion.

Well, it has been suggested. Read Matt Miller (a liberal political commentator) and his book The Two Percent Solution.

In response to your points, in Pt 1, my response to that is that issues like this are precisely why Barack Obama's plan to force companies to provide health care to their employees is biased in favor of big business. A company with 100,000 employees can negotiate far better insurance terms and rates than a company with 10,000, or 1,000, or 100. In fact, my "ideal" solution to universal health care (and the one championed in "The Two Percent Solution") would be to offer a mandatory tax rebate/tax credit which must be used to buy health insurance. As a condition of receiving this tax rebate, insurance companies must cover anyone for the same rate and offer the same exact policy.

This works for the insurance companies because they get to spread out their risk over 300 million rather than over 1 individual. It vastly multiplies the advantage that Large Multinational Corporation has in terms of buying insurance, and distributes that advantage over the entire country instead of one company. It works for the populace, because they now not only get insurance, but because any insurance company can cover you, the insurance companies must compete on coverage. This last point is precisely why single payer socialized health care will be a net negative for health care in this country. A government run organization has no impetus for innovation, whereas multiple companies competing in the same field do.

As far as pt 2, that issue is moot under Matt Miller's plan. Ignoring that, that's walking a fine line towards employment discrimination, and I'm sure the Large Multinational Corporation's lawyers would have something to say if management were inclined to accept such an offer.

Comment Re:Microsoft has done some good work on this so fa (Score 1) 136

Doctors who can't accept that the patient is in the driver's seat are obsolete.

OK, so as a doctor, if a patient is asking for narcotic pain meds, I should accept that the patient is the driver's seat and acquiesce? If a patient is asking for antibiotics and the doctor is sure that the patient's symptoms are due to a virus, I have to accept what the patient is demanding?

You do understand the concept of audit trails, right? ...digital signatures to keep track of who is updating the record is exactly that.

So when I'm admitting a patient to the hospital, I have to now second-guess the entries in a patient's medical record to see if the patient mucked around with the records or whether it was genuine?

It is fundamentally irrelevant whether I can regurgitate a specific definition. What matters is that the record is the property of the patient and the patient bears the ultimate responsibility for its contents.

I'm asking this because I suspect you don't know what a medical record exactly entails, and why it would be absolute foolishness to allow it to be modified in any way other than by appending to it.

Comment Re:Microsoft has done some good work on this so fa (Score 1) 136

Gee, I don't see any words to the effect of "haphazrdly edit" anywhere in "MS is taking the position that patients should be able to see their own records, and even correct their own medical records. (But with digital signatures to keep track of who is updating the record.)" Perhaps you can point them out?

I make the assumption that most patients, without medical training, aren't qualified to make edits to their medical record. I equate that with haphazardly edit.

Look, legally, even a patient's physician isn't supposed to "edit" a medical record. It's like a file that you only have append privileges to. Why does it make any bit of sense to allow someone with no medical knowledge whatsoever to make edits?

I'm still waiting for an answer. do you even know what a medical record is?

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