Family Medicine Notes

Here's the lancet article (or here in pdf) being cited in the news today.  Free login to The Lancet is required.

Here's the summary:

Les Roberts, Riyadh Lafta, Richard Garfield, Jamal Khudhairi, Gilbert Burnham

Summary

 

Background In March, 2003, military forces, mainly from the USA and the UK, invaded Iraq. We did a survey to compare mortality during the period of 14·6 months before the invasion with the 17·8 months after it.

 

Methods A cluster sample survey was undertaken throughout Iraq during September, 2004. 33 clusters of 30 households each were interviewed about household composition, births, and deaths since January, 2002. In those households reporting deaths, the date, cause, and circumstances of violent deaths were recorded. We assessed the relative risk of death associated with the 2003 invasion and occupation by comparing mortality in the 17·8 months after the invasion with the 14·6-month period preceding it.

 

Findings The risk of death was estimated to be 2·5-fold (95% CI 1·6-4·2) higher after the invasion when compared with the preinvasion period. Two-thirds of all violent deaths were reported in one cluster in the city of Falluja. If we exclude the Falluja data, the risk of death is 1·5-fold (1·1-2·3) higher after the invasion. We estimate that 98000 more deaths than expected (8000-194000) happened after the invasion outside of Falluja and far more if the outlier Falluja cluster is included. The major causes of death before the invasion were myocardial infarction, cerebrovascular accidents, and other chronic disorders whereas after the invasion violence was the primary cause of death. Violent deaths were widespread, reported in 15 of 33 clusters, and were mainly attributed to coalition forces. Most individuals reportedly killed by coalition forces were women and children. The risk of death from violence in the period after the invasion was 58 times higher (95% CI 8·1-419) than in the period before the war.

 

Interpretation Making conservative assumptions, we think that about 100000 excess deaths, or more have happened since the 2003 invasion of Iraq. Violence accounted for most of the excess deaths and air strikes from coalition forces accounted for most violent deaths. We have shown that collection of public-health information is possible even during periods of extreme violence. Our results need further verification and should lead to changes to reduce non-combatant deaths from air strikes.

We appropriately consider the 3000 New Yorkers who died in the WTC to be a tradgedy, but the scope of the tradgedy in Iraq is greater.   From a public health standpoint, these aretragic times that we live in.  W's myopic focus on Iraq has had devastating effects on our economy, our international credibility, and the lives of 100,000 Iraqi's ... "Most individuals reportedly killed by coalition forces were women and children. "   So Sad.  So Frustrating.

Posted by Jacob Reider, MD at 12:41 PM | Permalink | Comments (2)

 .. and Bush overall ... according to this poll

.....

But Tennesseans not all that issue savvy

Despite the impression the above findings might give, a close look at five domestic agenda items suggests that Tennesseans as a group hardly qualify as well-informed, ideologically consistent policy wonks. For example, only about half of Tennessee adults can accurately name Kerry as the candidate who supports rescinding the recent federal income tax cuts for people earning over $200,000 a year. About a quarter (23%) incorrectly attributed the proposal to Bush, and 27% admit they don't know which candidate supports the measure. Similarly, only about half (50%) rightly name Bush as the candidate who favors giving parents tax-funded vouchers to help pay private or religious school tuition. Thirteen percent attribute the plan to Kerry, who actually opposes it. Over a third (37%) admit they don't know.

Knowledge levels are even lower on the other three issues. Well under half (42%) are aware that Bush wants to let younger workers put some of their Social Security withholdings into their own personal retirement accounts. Nineteen percent incorrectly think Kerry supports the measure, and 40% say they don't know one way or the other. Just over a quarter (28%) rightly name Bush as the candidate who supports giving needy people tax breaks that would help buy health insurance from private companies. Thirty percent inaccurately name Kerry as the measure's proponent, and 41% admit not knowing. Finally, just 39% know that Kerry advocates requiring plants and factories to add new pollution control equipment when they make upgrades. Fifteen percent wrongly attribute the policy to Bush, and 45% don't know.

So goes another non-medical post.  My second in as many weeks.   ... now back to your regular programming .. already in progress...

Posted by Jacob Reider, MD at 01:49 PM | Permalink | Comments (1)

Published tomorrow: For-Profit Hospitals are Costlier Than Non-Profits. This is from the "duh" department. But while we would intuit that this is the case, this article provides clear evidence that profit clouds healthcare decisionmaking.

Posted by Jacob Reider, MD at 10:07 PM | Permalink

A Chance to Cut is a Chance to Cure mentions a Medical Economics article about jobs in primary care, and how Internists are (in some markets) in greater demand than family physicians. Hospital systems greater interest in Internists"... is partly a byproduct of employers' current focus on recruiting specialists" according to one of the recruiters quoted in the MedEc article.

Well .. we family physicians can be a bit .. uh .. thin-skinned about this sort of stuff, so please forgive me if I seem a bit negative about the post for a few reasons:

I am disheartened that rather few internists are attracted to primary care. 

I am disheartened that some recruiters and "hospital systems" are drawn to Internists rather than family physicians due to a perception that Internists drive more specialty referrals. Business is business, I suppose. So if the goal of a hospital system is to drive referrals .. and increase utilization of highly reimbursed services (such as surgery), then I suppose these concepts are right on target and we all should nod our heads in agreement.

Yet I wonder if this all misses the point. Why are we providing healthcare? Is the primary goal is to earn money .. and healthcare is the market? (Just like selling cars or baseball hats or computers) .. I sure hope not. As a profession, we do what we do because we want to deliver a valuable service to the world.

Yes - we want/need to be reimbursed - or we couldn't sustain the service. But reimbursement isn't the primary goal.  And if we consider the goals (implied, perhaps) of family physicians - I would suggest that they coincide with the healthcare needs of a community better than most other physicians.

Yet employers of physicians are sadly more interested in the financial picture than the healthcare needs of a community.

• They need to build demand for their service by hiring an Internist rather than a Family Physician. Wow.

Let's change a few words and see how similar that is to:

• "General Motors needed to build demand for their cars by killing off public transportation.

Yeh .. I'm streching the analogy a bit .. but .. you get the point .. is healthcare about "increasing market segment" or about "meeting a community's healthcare needs?" I argue that the two are inherently at odds. Physician supply and recruiting remarkably DOES change healthcare. Yet these "market force" decisions will hurt us far more than they will help us in the long run. We need a system where the skills of physicians trained and recruited will meet the healthcare needs of a community - not the fiscal needs of a hospital or healthcare entitiy.

Posted by Jacob Reider, MD at 12:39 AM | Permalink

Stupid and Dangerous is a new weblog written by my neighbor here in the suburbs ... He poses a great idea that Condi Rice was leading up to in her recent appearance on Fox News Sunday:

Dr. Rice was quoted as saying, "I think we also have to take seriously that they might try during the cycle leading up to the election to do something. In some ways, it seems like it would be too good to pass up for them, and so we are actively looking at that possibility, actively trying to make certain that we are responding appropriately."

"Canceling the election would have the additional benefit of allowing us to declare, “Mission Accomplished” in our reconstitution of Iraq’s civil authority. We promised the Iraqi people a democracy. If we cancel the 2004 election, we can announce in all sincerity that what they now have is an American-style democracy."

Posted by Jacob Reider, MD at 08:43 PM | Permalink

Matthew's The Health Care Blog has some great insight into the discord between GWB's agenda and the scientific community.  I think I'm gonna give Kerry $50 today.  

Posted by Jacob Reider, MD at 01:56 PM | Permalink

From the Adam Smith Institute Weblog - Private health: bigger than NHS!

This week, BBC Radio 4 asked me to do an interview on the origins and growth of the non-state healthcare market. Boning up for it, I was reminded just how significant the independent sector is. It provides 85 percent of the UK's residential care beds, for example, and 20% of all acute elective surgery - that's the stuff like hip replacements that isn't exactly life-threatening, but which you want to get done fast anyway. Indeed, the independent sector has more beds than the NHS and local-authority care homes put together! It employs almost as many people - roughly 750,000 of them - and it accounts for a quarter of UK health and social care spending. In addition to the 15,000 nursing and residential care homes that the sector provides, private agencies care for more than 200,000 people in their own homes.

Of course, the other (unanswered) question is whether this is good.  If the NHS needs so much supplementation for those who can afford it, what happens to those who can't afford it?  This makes for a very compelling case that a two-tier healtchare system doesn't ration healthcare resources.

huh?  yes .. I said ration.  With limited resources, and infinite need, we need to RATIONALLY deliver the limited resource.  This is rationing, and despite the negative connotation usually assocated with it .. this is not a four-letter word.

Bottom line is well summarized in The Onion this week.

Posted by Jacob Reider, MD at 09:24 AM | Permalink

New York Times: A Conversation With | Steffie Woolhandler: Heal Health Care System? Start Anew

Steffie is one of my heroes.  It's now been 14 years since The original paper appeared in the New England Journal of Medicine.  Yikes.  I was applying for medical school at the time, and a friend of mine sent me a copy of a draft version of the article. 

In medical school, I helped start an Albany chapter for the Physicians for A National Health Program .. and when this new thing called the Internet came along, I built the organization a website and hosted it on a server I managed in 1995.

These days I don't have enough time to work on PNHP stuff very much, but this doesn't mean I'm not still passionate about it.  Tha huge administrative overhead that the US insurance industry adds to the cost of healtcare in this country is terrible.  Read the Woolhandler article -- it's very compelling.

Posted by Jacob Reider, MD at 12:40 AM | Permalink | Comments (1)

Posted by Jacob Reider, MD at 01:22 AM | Permalink

Posted by Jacob Reider, MD at 06:38 AM | Permalink | Comments (2)

While I squawk about medical weblogs providing trancparency into the practice of medicine, most people at last week's conference agreed that there is such a thing as too much transparency.    Where is the line between too much transparency and just enough?  I'm not sure.  Today's entry may tread the line .... hmmm ..

 The New York's department of Professional Misconduct and Physician Discipline is New York's attempt to insure that physicians practicing in this state are well trained and well behaved.  Sometimes I help review the cases of physicians who are - for some reason - being scrutinized by this department.  While I sometime know why the physician is being reviewed, I usually make an effort to be blind to this - I think that it makes my review more objective.

It's always awkward.  I feel uncomfortable challenging another physician's judgement, decksionmaking skill, or personality.  The process usually involves reviewing a videotape of the physician interacting with one of the "standardized patients" we have in the medical school.  (A "standardized patient" is an actor - someone employed and trained by our faculty to act out a particular problem.  We use these "patients" in the training of our students, and it gives us insight into the students' ability to interact with patients, and their physical exam skills.)

After I review the videotape, I usually review a few real charts from the physician's practice, and then there is an interview during which I ask questions about the progress notes and the videotape.  This often the most awkward part, but of course reveals the most about their thought processes.  Here's the sad news:  some physicians simply should not be practicing medicine.  They're humans too - so physicians are sometimes in a position that makes them unable to properly do their jobs.  The trouble is that their livelihood depends on their practice - and most physicians have enormous debt that remains from medical school and residency - even as many as ten or fifteen years later.

LIke the bus driver who can't see very well - it's a sad situation, but it's clearly unsafe.  The tricky ones are where it's not so obvious as the vision impaired bus driver. 

Hence the need for reviews such as that described above.  In the end - I make no decision, thankfully.  Rather - I provide feedback to the State, and they are empowere to take corrective action based on my assessment and several others. 

I find the process to be remarkably appropriate.  The situations are alwayds delicate, but I think that the process is thorough enough to identify problems if they exist - yet with enough "due process" to provide respect and some presumption of "innocence."

Want to see if a physician in New York has been disciplined in any way?  New York has made that easy too ... just go to the New York State Physician Finder and look up the physician.  Once you've found the physician, click on "Legal Actions" and you can see any current or previous actions against that physician.  Now there's transparency, eh?

Posted by Jacob Reider, MD at 10:44 AM | Permalink | Comments (1)