tag:blogger.com,1999:blog-291333072024-03-19T07:41:12.071-04:00The Doc Saver Blog - Health, Humor, and WhateverBlogs - Impact of a vanity press, at a fraction of the cost!<br><br>
Rants, raves, "humor," and other spontaneous eruptions about medicine, health information technology, and anything else that pops into my head and I can't get a journal or newspaper to print. No, there is nothing here about how to save documents, sorry."Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.comBlogger16125tag:blogger.com,1999:blog-29133307.post-27429167297996026932014-08-10T16:38:00.001-04:002014-08-10T16:38:51.171-04:00Incoming Alert!!!<div dir="ltr" style="text-align: left;" trbidi="on">
Just a warning - I have been informed by the editors at <a href="http://pulsevoices.org/">Pulse</a> (an online medical humanities site/organization that puts out emails at the end of every week that I really enjoy) that they are going to "publish" my ""poem"" (yes, that needs 2 sets of quotes) in the next few weeks, probably on 8/15 or 9/5. So, if you don't want to see it, unsubscribe now if you already subscribe to Pulse. If you don't subscribe (it's free), I would heartily recommend doing so after 9/5, when it should be safe. You may want to warn your unsuspecting friends and colleagues, too.</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-9661143314129296952014-05-26T22:37:00.000-04:002014-05-26T23:01:46.623-04:00Bathing Beauties<div dir="ltr" style="text-align: left;" trbidi="on">
No, not what you're probably thinking. This is just a ***health care free*** posting of some pictures I've taken lately in the back yard of birds bathing in a tiny, unculverted run of an intermittent stream in our back yard (for some reason, about 15' are unculverted before running into the next culvert). Seeing the yellow-rumped warbler (see the previous post for its picture) there made me start coming back and I discovered, after being here over 7 years, that is is a great spot to see birds - and particularly in the act of bathing. Some of the pictures below really should be viewed side-by-side in sequence as diptychs or triptychs to really get a sense of the action and what is going on in the photo with motion and/or water blur. I think they're kind of cool, but that's just me. But since I don't know how to get blogger to put pictures side-by-side, they will just be sequential.<br />
<br />
In no particular order:<br />
<br />
1) in the catbird bath (albeit not the seat)<br />
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Tufted Titmouse bathing and then looking at me quizzically.<br />
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Chick-a-dese out! (sorry about that...)<br />
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Cleansing itself of a cardinal sin?<br />
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<br />
A bathing Carolina Wren. I really like the second picture where it is completely submerged, but you need the preceding one to have a clue what it is. And I like the high-speed tail-wagging with blurry lines, too.<br />
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I am really annoyed that these goldfinch pictures aren't better. The male's glorious colors are washed out (which I could probably fix with some editing), but when he hopped over and I saw the female bathing there, too, it was awesome. Except: 1) depth of field was too shallow, so the male is out of focus with the female in focus; and 2) there is some green leaf blurred in the foreground I didn't even notice when rapidly shooting but that really messes up the "couple" shots.<br />
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And a chipping sparrow. I didn't manage to get any action shots.<br />
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That's it - this one's just for the birds.</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-35383809401809431282014-05-13T23:23:00.000-04:002014-05-13T23:23:35.224-04:00Just Say Nohydro<div dir="ltr" style="text-align: left;" trbidi="on">
Alas, neither the Globe nor the T&G would take this, so on the blog it goes:<br />
<br />
<div class="MsoNormal">
“Sinaloa
cartel sues US government for ban on heroin” is not a newspaper story we are
likely to see. However, “Zohydro maker
sues to block Massachusetts ban” has recently appeared in news reports across
the country. Why does the former seem
ridiculous and the latter like a legitimate business seeking to defend its
legal product?</div>
<div class="MsoNormal">
Governor
Patrick’s banning of Zohydro is one action to address the public health
emergency he declared over opioid addiction.
Vermont Governor Peter Shumlin devoted his entire State of the State
address this year to Vermont’s opioid addiction problem. Nationally, over 80% of abused opioids are
estimated to be prescription opioids, not heroin. So if we want to address the addiction crisis, we have no choice
but to address prescription opioids.
But why single out Zohydro?</div>
<div class="MsoNormal">
A little
history is helpful to understand why Zohydro, a slow-release formulation of
hydrocodone, is particularly deserving of attention. Our current crisis in opioid addiction has its roots in Zohydro’s
older sibling, Oxycontin, a slow release form of oxycodone. The manufacturer of Oxycontin, Purdue
Pharma, initially marketed it in a form that had no measures to prevent
grinding it up for an immediate high instead of the slow release it was
designed to have when swallowed. They
also poured millions of dollars into campaigns pushing the idea that we are
undertreating chronic pain and opioids were safe and effective for chronic pain
not caused by cancer or other terminal diseases. Prescriptions and abuse soared and it was dubbed “hillbilly
heroin” due to the massive addiction problem it created in Appalachia. After many years – somehow, just shortly
before the original patent expired – a new version of Oxycontin was introduced
that actually was more difficult to abuse and, not incidentally, extended the
manufacturer’s monopoly. Street prices
of Oxycontin dropped as, while it could keep someone out of withdrawal, it was
harder to use for a high.</div>
<div class="MsoNormal">
So, why
wouldn’t the makers of Zohydro bring out a tamper-resistant version like the
current Oxycontin, rather than one with no safeguards at all, like the original
Oxycontin? It is technically feasible –
in fact, Zogenix, the company marketing Zohydro, says it plans to do so in
about 3 years. Why not now? They offer no answer.</div>
<div class="MsoNormal">
Perhaps
they are addressing the urgent need for more options for treating chronic
pain. As a family doctor, I can
certainly testify that we need new and better pain treatments. But is there a pressing need for another
long-acting opioid? I don’t think
so. We have sustained release
oxycodone, sustained release morphine, methadone, fentanyl patches, and
buprenorphine. The FDA’s advisory panel
voted overwhelmingly <i>against</i> approving Zohydro, raising the as yet
unanswered question of why the FDA chose to overrule them and approve it at
all. However, marketed without any
protections against abuse, there will be immediate demand for Zohydro and it
will gain substantial market share and generate huge profits far exceeding what
a tamper-resistant version could bring in – the lessons of Oxycontin have
clearly not been lost on Zogenix and Alkermes, the actual manufacturer of the
drug.</div>
<div class="MsoNormal">
The courts
have ruled that the FDA approval of Zohydro trumps the state’s decision to ban
it. But Zohydro is a drug whose time
should never have come. It will do far
more harm than good. The massive
increase in US opioid consumption has not solved the chronic pain problem, but
it has killed thousands, harmed millions, and generated huge profits for the
pharmaceutical industry. The question
should not be whether a state like Massachusetts can ban Zohydro, but what went
on at the FDA that they approved this harmful, unnecessary pill. I have yet to find a single colleague in
primary care who thinks there is any need for Zohydro.</div>
<br />
<div class="MsoNormal">
As Nancy
Reagan might say, “Just Say Nohydro.”</div>
<div class="MsoNormal">
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And for those of you who only come here for the nature photos, we had a couple of migratory visitors.</div>
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A yellow-rumped warbler bathing in the back yard:</div>
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A black and white warbler:<br />
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And one of our common chipping sparrows doing some personal hygiene:<br />
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"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com1tag:blogger.com,1999:blog-29133307.post-38306363302241856202014-01-26T01:26:00.000-05:002014-01-26T01:26:17.166-05:00Addressing the Twin Problems of Chronic Pain and Opioid Addiction<div dir="ltr" style="text-align: left;" trbidi="on">
America is experiencing a remarkable resurgence in opioid addiction. New England, despite its reputation for Yankee toughness, currently seems to be the epicenter, and <a href="http://www.nytimes.com/2014/01/09/us/in-annual-speech-vermont-governor-shifts-focus-to-drug-abuse.html?_r=0">Vermont Governor Peter Shumlin devoted his recent State of the State message to Vermont's heroin problem</a>. How we got here is, alas, relatively simple, and starts with Purdue Pharma, the creators of OxyContin and the huge P.R. campaign claiming we are massively undertreating chronic, nonmalignant pain and that opioids are a safe and effective treatment for it. Perhaps my views are slightly skewed by practicing in a community health center, but I have become steadily less convinced that: a) chronic opioids are an appropriate treatment for many, if any, patients who are not suffering from painful, <i>terminal</i> conditions and b) the benefits to the few who are genuinely helped to be more functional and less miserable are far outweighed by the massive harm to society as a whole. At this point, personally, I have perhaps 3 patients whom I think may be genuinely benefiting and a few others who I think are unwilling to go through the discomfort of getting off opioids but probably aren't otherwise being harmed or harming anyone else. And I have probably terminated controlled substance contracts with over 90% of the patients I have had who have had them, many inherited from other providers but some started by me with the best of intentions or unintentionally as what I expected to be pain that should resolve in a month or two never did. I am now a buprenorphine provider (required of all faculty in my clinic to precept residents) and, while I think buprenorphine is really important as a way to make opioid addiction treatment available to far more patients than limited facilities and funding allow for methadone, I am particularly bothered that so many of our buprenorphine patients have been created by our own actions. And, while far safer than most other opioids, it is certainly contributing to supply of opioids on the street that are leading to ever more addiction.<div>
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<div>
What should we do? Well, below I am including one approach that I think should be considered. Alas, I am clearly in a minority as it is showing up here because I can't get any journal to take it. You can judge for yourself if it is just poorly-written, utterly stupid, or unpublishable for some other, obvious reason beyond being politically unpopular as it would require an acknowledgment of how bad current policies are and the devotion of new resources ("taxes") to carry out. Are there other possible solutions? Certainly. But is continuing on our current course, nibbling at the edges (Massachusetts has just enacted dose limitations, analogous to Washington State) going to make a dent in the problem, or do anything to help us figure out how we might actually do a better job helping all the people with chronic, nonmalignant pain for which we currently have no good answers?</div>
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<div>
<b><span style="font-size: large;">Addressing the Twin Problems of Chronic Pain and Opioid Addiction</span></b></div>
<div>
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The United
States health care system is simultaneously providing opioids to more and more
people for chronic, nonmalignant pain, experiencing a growing crisis in rising
rates of addiction to prescription opioids, and failing to make major advances
in pain treatment. A recent report from
the Institute of Medicine (IOM) highlights the high costs of chronic pain and
shortcomings in its assessment and treatment.
It cites estimates of at least 116 million Americans affected and annual
economic costs of $560-635 billion and contains a “Blueprint for Transforming
Pain Prevention, Care, Education, and Research.” The blueprint starts with a call for a comprehensive,
population-level strategy for chronic pain prevention, treatment, management,
and research, and supporting collaboration between primary care clinicians and
pain specialists.<sup>1</sup> </div>
<div class="MsoNormal">
The
difficulties in managing chronic, nonmalignant pain arise from several sources,
including problems with measurement, efficacy of treatments, and use of
opioids. Pain is an inherently
subjective phenomenon. Pain assessment
has become the Joint Commission-mandated “fifth vital sign,” but this
measurement has not led to advances in treatment of chronic pain. Furthermore, we have no magic bullets for
treating chronic pain. Many widely-used
interventions have been found to be little or no better than placebo.<sup>2-7</sup> Medications are typically mainstays of
treatment for pain, but the evidence base here is also lacking. A systematic review of medications used to
treat sciatica judged the evidence to be limited and of low quality.<sup>8</sup> Overuse of NSAIDs is discouraged due to
risks including GI bleeding, perforated ulcers, kidney damage, and now
cardiovascular events. We are cautioned
to limit use of acetaminophen, since it is the largest cause of acute liver
failure in the United States, with about half of cases resulting from
unintentional overuse.<sup>9</sup></div>
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In the last
two decades, there has been a large increase in the use opioids for the
treatment of chronic, nonmalignant pain, substantially due to new products and
heavy promotion from the pharmaceutical industry.<sup>10</sup> Treatment of chronic, nonmalignant pain has
become intimately linked with issues of opioid dependence, misuse and
addiction. The CDC has reported a
number of frightening and depressing statistics about opioid use in America – a
near-doubling of emergency department visits for misuse or abuse of
pharmaceuticals, mostly opioids, between 2004 and 2009, and a quadrupling of
both opioid sales between 1999 and 2010 and opioid overdose deaths between 1999
and 2008. Overdose deaths from
prescription opioids now outnumber deaths from heroin and cocaine combined.<sup>11</sup> The incidence and costs of neonatal
abstinence syndrome have also jumped dramatically.<sup>12</sup></div>
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One might
hope this national adventure in prescription opioid use was based on strong
evidence for their efficacy in the management of chronic, nonmalignant pain, as
opposed to pharmaceutical industry marketing.
However, the proliferation of short- and long-acting opioid formulations
has failed to yield a commensurate reduction in chronic pain. The extant, limited evidence suggests modest
benefits, at best, with some side-effects and unclear effects on quality of
life, employment status, and other outcomes.<sup>13</sup> It has been suggested that successful
long-term opioid treatment may not even be treating pain, <i>per se</i>.<sup>14</sup> Withdrawal symptoms make it difficult to
wean patients off these medications and to know whether discomfort with
reducing or stopping really reflects efficacy for pain or physiologic
dependence. The proportion of patients
treated with opioids who become addicted may be substantially higher than
generally believed.<sup>15</sup> The
CDC report makes clear the societal consequences of the massive increase in the
supply of prescription opioids. Even if
trends were to reverse now, the consequences our current practices will linger
for many years, as highlighted by a recent RCT of treatment for prescription
opioid abuse that found extremely high relapse rates after the cessation of
buprenorphine-naloxone therapy.<sup>16</sup></div>
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A number of
efforts have been implemented or proposed to reduce misuse and diversion of
opioids. Many states have prescription
drug monitoring programs (PDMPs) but access may be cumbersome and not all even
allow provider access. In
Massachusetts, we are not allowed to delegate access to a nurse or other clinic
personnel, yet the state legislature has passed a law requiring checking the
registry prior to seeing <i>every</i> new patient. PDMPs may reduce abuse but have not so far been shown to reduce
mortality.<sup>17</sup> The state-based
nature of PDMPs leads to issues that decrease any potential benefits, as
demonstrated by this email I received from a colleague:</div>
<div class="MsoBodyTextIndent" style="margin-left: .25in;">
Does anyone have access to
the Connecticut prescription monitoring program? I need to look up a patient.
I contacted them and they said that I should have a CT license in order
to get access.</div>
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Washington
State has instituted a guideline limiting maximum opioid dosing for non-cancer
pain<sup>18</sup> and New York City has issued guidelines to limit
prescriptions of opioids by emergency departments.<sup>19</sup> Mandatory continuing medical education
requirements in pain management, including both state-based programs and the
proposed opioid risk evaluation and mitigation strategies (REMS) from the FDA,
are hypothesized to help, without much supporting evidence. Becker and Fiellin discussed shortcomings of
the current REMS proposal and made some suggestions for improvement, while
discussing that these were still likely insufficient.<sup>20</sup> </div>
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Opioid
prescription registries and mandatory provider education will not solve the
interconnected issues of chronic pain and opioids, nor will guidelines. I can see three possible options for the
future:</div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<!--[if !supportLists]-->1)<span style="font-size: 7pt;">
</span><!--[endif]-->continue as we have been doing, nibbling at the edges without
addressing the central issues;</div>
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<!--[if !supportLists]-->2)<span style="font-size: 7pt;">
</span><!--[endif]-->ban most or all prescribing of opioids outside of the settings
of postoperative, trauma, and terminal disease care; or</div>
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<!--[if !supportLists]-->3)<span style="font-size: 7pt;">
</span><!--[endif]-->try a new, more controlled approach that might actually help
patients with chronic, nonmalignant pain access safer, more effective treatment
and provide better evidence about the benefits and harms of long-term opioid
and other therapies.</div>
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Option 1 is
self-explanatory. I had thought option
2 was both self-explanatory and unlikely, but Blue Cross Blue Shield of
Massachusetts (BCBSMA) instituted a new policy for opioid prescriptions on July
1, 2012, demonstrating that insurers can and will create policies moving in
that direction without any state or federal action. It allows prescribing an initial 15 day supply of short-acting
opioids and one additional 15 day supply within 60 days of the initial supply;
any other short-acting prescriptions will require prior authorization. Prior authorization is required for all new
long-acting opioid prescriptions and for all buprenorphine prescriptions.<sup>21</sup> This will almost certainly decrease opioids
prescribed to BCBSMA patients, increase administrative burdens on providers,
decrease BCBSMA costs for opioids, and shift some costs of opioids onto
patients. However, it is unlikely to
lead to increased knowledge about the treatment of chronic, nonmalignant pain
and the role of opioids therein.</div>
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For option
3, I propose an approach with three key components: 1) development of regional,
regulated, multidisciplinary pain treatment centers, whose providers could
access a wide range of therapies and prescribe long-term opioids for chronic
pain if deemed appropriate; 2) development of training programs and
certification for primary care specialties in both chronic pain management and
addiction medicine; and 3) strict annual limitations in how long an outpatient
could be prescribed opioid medications by other providers outside of the
setting of terminal disease – perhaps 2 months cumulatively by all
providers. Due to the nature of opiate
addiction, there is a strong argument for time limitation. Dose limitation, such as that enacted by
Washington State, likely also has a role, particularly given the evidence
suggesting its efficacy in reducing overdose deaths.<sup>18</sup> Patients reaching their annual limits (with
exceptions for clearly-identifiable situations like undergoing multiple
surgical procedures) who felt they needed more opioids would be referred to one
of the pain treatment centers, where they would receive a thorough assessment,
state-of-the-art pain treatment (which might or might not include opioids), and
the opportunity to participate in clinical trials of new approaches to pain
management.</div>
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This would
accomplish several important goals simultaneously. We will not cure everyone’s pain, but we will not be
undertreating it. I believe the vast
majority of providers would gladly trade the right to prescribe unlimited
opioids to their patients for a system that would let them treat acute pain and
provide a resource for helping them manage patients whose chronic pain was not
adequately controlled, irrespective of whether opioids were an issue. Instead of saying to a patient, “No, I am
not giving you any more opioids for your pain,” they could convey the much more
positive message, “I cannot prescribe you any more opioids, but since your pain
is still causing you such distress, I am referring you to a center that can
provide you the best available care for your pain, which may or may not include
opioids.” These centers would be
ideally positioned to enroll patients in high quality studies and advance the
science of treatment for chronic pain, much as cancer centers of excellence do
today.</div>
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There are a
number of reputable pain clinics in existence, but nowhere near enough to meet
the demand, and most primarily focus on procedural interventions that are
well-remunerated. A key question is
whether there are sufficient providers qualified and willing to work in the
centers I am proposing. Three
specialties currently have subspecialty certification in Pain Medicine –
Anesthesiology, Physical Medicine and Rehabilitation, and Psychiatry and
Neurology. This needs to be expanded to
primary care specialties. Training
would need to include the range of options available for treating pain,
including pharmacologic, behavioral, interventional, and physical approaches
and a solid grounding in behavioral and addiction medicine. I recognize that this approach could not be
implemented nationwide with existing personnel, but there is no reason that one
state, region, or even an integrated delivery system could not undertake a
pilot program.</div>
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While these
centers would likely have close oversight of opioid prescribing, pain
specialists and other clinicians who prescribe opioids currently have no
protection from what might seem like capricious enforcement actions by the Drug
Enforcement Administration. Treatment
protocols and internal oversight in these centers should lead to both safer
prescribing and lower risk for enforcement actions. Although the barriers to creating effective health care teams
should not be underestimated,<sup>22</sup> the opportunity to work in
state-of-the-art, multidisciplinary pain centers at the forefront of clinical
research should attract more providers into the field and facilitate formation
of effective teams. Such a system could
increase fragmentation of care, so it would need to be carefully designed to
include patients’ primary care providers as key members of the team, as called
for by the IOM.<sup>1</sup></div>
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Who would
oversee such centers and how this would occur would require creative thinking
and novel collaborations, since different aspects would likely fall under the
purviews of the Drug Enforcement Administration, state medical licensing
boards, and the Substance Abuse and Mental Health Services Administration – but
the model of office-based buprenorphine treatment for opioid addiction suggests
this is not an insurmountable barrier.
At least initially, centers would likely need set-aside research funding
pools, but over time they almost certainly would become highly competitive for
more traditional grant funding. We will
need to accept a new social contract in which indefinite access to opioids for
pain is not viewed as a “right” and the centers will need Institutional Review
Boards willing to deal with the complex issues raised by the studies that will
be proposed. However, patients do not
have an inherent right to receive unproven therapies and long-term opioid
therapy for nonmalignant pain is clearly a risky, unproven therapy.</div>
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The
reorganization I am proposing would place us well on the way to addressing the
IOM’s charge to transform the treatment of chronic pain.<sup>1</sup> The failures and harms of our current
approach are obvious. Tinkering will
fix neither treatment of chronic pain nor the epidemic of prescription opioid
abuse. Given the high costs to society
of both, can we afford not to try a new model such as this?</div>
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</span></b>
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<b>References<o:p></o:p></b></div>
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1. Institute of
Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention,
Care, Education, and Research. Washington, DC: National Academies Press; 2011.</div>
<div class="MsoNormal">
2. Kirkley A,
Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery
for osteoarthritis of the knee. N Engl J Med 2008;359(11):1097-107.</div>
<div class="MsoNormal">
3. Laupattarakasem
W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for
knee osteoarthritis. Cochrane Database Syst Rev 2008(1):CD005118.</div>
<div class="MsoNormal">
4. Eccleston C,
Williams AC, Morley S. Psychological therapies for the management of chronic
pain (excluding headache) in adults. Cochrane Database Syst Rev
2009(2):CD007407.</div>
<div class="MsoNormal">
5. Rubinstein SM,
van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative
therapy for chronic low-back pain. Cochrane Database Syst Rev 2011(2):CD008112.</div>
<div class="MsoNormal">
6. Gross A,
Miller J, D'Sylva J, et al. Manipulation or mobilisation for neck pain.
Cochrane Database Syst Rev 2010(1):CD004249.</div>
<div class="MsoNormal">
7. Chou R, Atlas
SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back
pain: a review of the evidence for an American Pain Society clinical practice
guideline. Spine (Phila Pa 1976) 2009;34(10):1078-93.</div>
<div class="MsoNormal">
8. Pinto RZ,
Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with
sciatica: systematic review and meta-analysis. BMJ 2012;344:e497.</div>
<div class="MsoNormal">
9. Bower WA,
Johns M, Margolis HS, Williams IT, Bell BP. Population-based surveillance for
acute liver failure. Am J Gastroenterol 2007;102(11):2459-63.</div>
<div class="MsoNormal">
10. Ornstein C,
Weber T. Patient advocacy group funded by success of painkiller drugs, probe
finds. Washington Post 2011 December 23, 2011.</div>
<div class="MsoNormal">
11. Vital signs:
overdoses of prescription opioid pain relievers---United States, 1999--2008.
MMWR Morb Mortal Wkly Rep 2011;60:1487-92.</div>
<div class="MsoNormal">
12. Patrick SW,
Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal
abstinence syndrome and associated health care expenditures: United States,
2000-2009. JAMA 2012;307(18):1934-40.</div>
<div class="MsoNormal">
13. Noble M,
Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic
noncancer pain. Cochrane Database Syst Rev 2010(1):CD006605.</div>
<div class="MsoNormal">
14. Sullivan MD,
Ballantyne JC. What Are We Treating With Long-term Opioid Therapy? Arch Intern
Med 2012;172(5):433-4.</div>
<div class="MsoNormal">
15. Juurlink DN,
Dhalla IA. Dependence and addiction during chronic opioid therapy. J Med
Toxicol 2012;8(4):393-9.</div>
<div class="MsoNormal">
16. Weiss RD,
Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended
buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase
randomized controlled trial. Arch Gen Psychiatry 2011;68(12):1238-46.</div>
<div class="MsoNormal">
17. Gugelmann
HM, Perrone J. Can prescription drug monitoring programs help limit opioid
abuse? JAMA 2011;306(20):2258-9.</div>
<div class="MsoNormal">
18. Franklin GM,
Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D. Bending the
prescription opioid dosing and mortality curves: impact of the Washington State
opioid dosing guideline. Am J Ind Med 2012;55(4):325-31.</div>
<div class="MsoNormal">
19. Juurlink DN,
Dhalla IA, Nelson LS. Improving opioid prescribing: the New York City
recommendations. JAMA 2013;309(9):879-80.</div>
<div class="MsoNormal">
20. Becker WC,
Fiellin DA. Federal Plan for Prescriber Education on Opioids Misses
Opportunities. Ann Intern Med 2012.</div>
<div class="MsoNormal">
21. Blue Cross Blue
Shield of Massachusetts. New Quality and Safety Measures in Opioid Management,
Effective July 1, 2012. (Accessed March 30, 2012, at
http://www.bluecrossma.com/bluelinks-for-employers/whats-new/special-announcements/opioid-management.html)</div>
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22. Grumbach K,
Bodenheimer T. Can health care teams improve primary care practice? JAMA
2004;291(10):1246-51.</div>
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"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-47390304000135105182014-01-19T23:38:00.001-05:002014-01-19T23:38:38.511-05:00Hot and Cold under the Collar<div dir="ltr" style="text-align: left;" trbidi="on">
Warning - this post has nothing to do with medicine, EHRs, or anything I've written about before. It will mostly be of interest to my geeky friends who haven't already heard all this.<div>
<br /></div>
<div>
We've been getting letters from the gas company that our consumption is around the 75th %ile of our "peer" houses. I find it hard to believe they are comparing to true peers - we have 2 set-back thermostats that go down at 11 PM and I have made interior storm windows for all the windows that will accommodate them. But our gas bill certainly is unpleasant in the winter.</div>
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<br /></div>
<div>
I was also made aware that the gas company was offering a $100 rebate on the purchase of a wifi-enabled thermostat. So, I figured, let's give it a try, though I wouldn't expect much savings when we already have programmed, set-back thermostats. Our house just has 2 wires going to each thermostat and, according to their websites, all the wifi thermostats except the Nest require more wires than that. So, I swallowed hard and bought a Nest, even though we are an Apple-free family(TM).</div>
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<br /></div>
<div>
The Nest installed easily. Despite my starting it off with some settings, the house was noticeably, unpleasantly cold at first. That has improved. Its "away mode" kicked in a few times when we were home, yet when we went to Hawaii, it took about 3 days for it to decide we were away. Luckily, I could turn it down remotely, anyway.</div>
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<br /></div>
<div>
However, the boiler is right off my office and I started noticing an annoying buzz coming and going at night and eventually realized it was from the controller box. One of the relays was buzzing so I ordered a replacement. I later thought to swap with the relay for the other zone and... it wasn't the relay, it was the circuit. The one with the Nest. Googling quickly revealed that, in a 2-wire system like ours without a "common wire" for power, the Nest frequently pulls a small amount of current to keep its battery charged. Some furnaces are listed on the Nest website, if you know to go hunt, as incompatible because this is enough to make them turn on. Ours doesn't, but the relay buzzes. I could quiet it a bit by suppressing harmonic vibration of the box, but it's still there. I emailed Nest support, who eventually responded that I could return the Nest to the place of purchase. Thanks, guys. I'm still trying to decide about that. Google having just announced that they are purchasing Nest is pushing me more toward removal...</div>
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<div>
One thing the "smart thermostat" hasn't helped at all is the fact that our bedroom is the coldest room in the house - a corner room, and I think a smaller amount of radiator for its square footage than the other rooms. That got me thinking - with small computing devices like the Arduino and sensors so cheap, should't I be able to put temperature sensors in each room and turn the hot water supply to the radiator on or off depending on whether the room was above or below a temperature I set? Then, even though the whole upstairs in just 1 zone, each room could be its own mini-zone, with a demand for heat in any room kicking on the boiler. I think an über-geek friend has sensors for climate control in individual rooms in his house. (I am a bit worried that his Arduino network has started addressing him as "Dave.") He was sure I was reinventing an existing valve and, while I'm not sure it's quite the valve he was thinking of, it turns out folks in the UK have had thermostatic radiator valves (TRVs) for years and now can get electronic/programmable/remote controllable ones. But, remember, they have a long tradition of gas meters you have to keep feeding to stay warm and the like, so I suspect even current construction likely has shut-off valves on radiators. Here in the US, we believe that, if we are cold, we should heat up the entire planet. If I wanted to install such things in my house, I'd have to cut into all the radiator piping and sweat in new joints for the TRVs. Not worth it to me.</div>
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<br /></div>
<div>
This strikes me as a good case for the heavy hand of jackbooted government thugs. If building code for hot water heat had required shut-offs for each radiator, I could easily put in a system to keep the bedroom more comfortable at night without heating the rest of the house, keep the boys' rooms cooler when they were away, etc. It would probably increase the cost of a new house by, say, $100, but could save hundreds of dollars a year on energy bills. But there's no incentive for any builder to do it unless they are pushing the house as a "green house" and consumers are aware of the potential value of this. It should be easier and cheaper to do a retrofit on forced air heating systems, where you just need to open or close dampers in ducts (which might be a nice niche business for one of my legions of readers to look into starting).</div>
<div>
<br /></div>
<div>
Sorry, this is just another case (like health care) where a regulated market could deliver greater efficiency than the free market. Remember, the theoretical free market requires complete information on the part of buyers and sellers.</div>
<div>
<br /></div>
<div>
Speaking of which, today's <a href="http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html?src=me&ref=general">latest NY Times article on the cost of health care, focusing on Dermatology</a>, is well worth reading. Damn - almost made it through without any reference to health care.</div>
</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-10446231901078330572014-01-18T18:04:00.000-05:002014-01-18T18:04:03.905-05:00The Ins and Outs of Primary Care<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Arial, Helvetica, sans-serif;">I realized I might as well post this piece here that came out this week my Department's "Thursday Morning Memo," a weekly email containing brief, reflective writings about our roles and experiences in primary care. It's just a reflection from a couple of recent experiences on some of the things we are losing as primary care moves more and more toward complete separation of outpatient and inpatient care.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">As this was written for folks in my Department, there are some local references that might not make sense to someone outside the Department reading it.</span><br />
<br />
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"> Like many
primary care physicians, I have mixed feelings about the evolution of my role
in inpatient care. I like taking care
of acutely ill patients and (usually) seeing them get better. I like (well, liked) being there for my
patients, bringing my knowledge of them developed over time as an outpatient to
their inpatient care and, hopefully, avoiding mistakes and duplicated effort
that new providers might make. Of
course, like most of us, I don’t like the extra time demands of going to see
hospitalized patients – and it seems particularly painful if I have no official
role in their inpatient care. Clinical
systems don’t like those time demands, either, if they come out of scheduled
clinic time; more and more, inpatient care is firmly walled off from outpatient
care, connected at best by a discharge summary sent to the PCP and very rarely
with any attempt to communicate when a patient is admitted.</span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"> In
different practice locations, I have participated in various inpatient call
schemes, including every 3<sup>rd</sup> night coverage for the practice, taking
a week at a time, and no inpatient call – but not being on call for all my
patients (nearly) all the time, so I cannot claim to occupy the moral high
ground on continuity. Mark Doescher and I published an
editorial in the early days of the hospitalist movement, pointing out that
there was no good evidence for better outcomes and there were potential
significant downsides from loss of continuity.
But forces other than maximizing patient outcomes have driven the
movement toward hospitalist care as the default in more and more settings,
while the evidence for quality benefits continues to be rather modest.</span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"> Recently, I
had 2 seriously ill patients hospitalized at University Hospital. I was not, of course, contacted when they
were hospitalized, though I did receive notification when one was transferred
to the ICU because of a relatively new policy in the ICU to contact PCPs when
their patients are admitted. Since I
have an office in the Benedict Building in addition to seeing patients at the
FHCW, it is relatively easy for me to visit my patients at University Hospital,
unlike Memorial, which requires making a trip just for the purpose.</span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"> Both
patients primarily spoke languages other than English, which can present a
barrier. The floor admission note when
one patient was transferred out of the ICU noted that she spoke broken English
and her native language and a limited interview was conducted in English as “no
interpreter was available.” To my
relief, when I went to see her, the speakerphone on a pole (product of a past
project in our Department) was right next to her bed, so clearly someone knew
about using that, even if not the admitting resident. Other times I visited her, it took up to 5 minutes to find the
speakerphone so I could contact a telephonic interpreter. I spent my time just asking what questions
she and her family had and doing my best to answer them, in the absence of any
communication from the inpatient team beyond what I could glean from their
notes and her labs. A couple of times,
I hunted up her nurse to see if they could ask to covering inpatient provider
to write some orders to make her more comfortable. My patient asked if I could, please, come see her every day. I said I would come frequently, but probably
it wouldn’t be every day. It certainly
seemed that nobody else was taking the time just to sit and answer questions
with an interpreter.</span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"> My second
patient sustained a stroke and initially had complete expressive and dense receptive
aphasia. Her recently-immigrated family
spoke little or no English but, luckily, I speak one of their languages
reasonably well and I had met several of them previously so they knew who I
was. They had many questions – many of
them unanswerable, like why this had happened and what was going to happen to
her. They asked when I could come back
and see her again. The day she was
being transferred to a rehabilitation facility, I came by and found she had
made remarkable progress from my previous visit a few days earlier, with good
comprehension and the ability to express brief sentences with only moderate
dysfluency. The family members
clustered around her immediately asked me to talk with her about her discharge
plans, as she was saying she wanted to go home and did not understand why she
should go somewhere else. After I
reviewed the rationale and potential benefits of intensive rehabilitation prior
to going home, she agreed to the plans for a discharge to rehab.</span></div>
<br />
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"> In these
cases, my visits were purely social.
They were not billable (or at least not billed) and came out of my “free
time.” I am no saint – I did not see
these patients every day, nor do I do this very often for patients hospitalized
at Memorial given the added barrier of needing to make a special trip
there. But having two hospitalized
patients at the same time and seeing how much my visits apparently meant to
them and their families has made me reflect on the perhaps Faustian bargain we
have made to separate outpatient and inpatient care in the name of greater
efficiency (our Department and clinics love the increased clinic sessions and
scheduling predictability, and evidence suggests modest decreases in inpatient
costs and length of stay with hospitalist care). It certainly doesn’t feel patient-centered. Perhaps, as we move to Accountable Care
Organizations, we could reconsider this path, since payment should not depend
simply on visit volume, but I suspect no metrics, even patient satisfaction,
would capture the benefits of maintaining this human connection in a way that
could change the calculus of this choice.
Absent a metric and a push to improve it, are we and our patients losing
an important component of the patient-provider relationship?</span></div>
</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-35801562327107767422013-12-31T21:23:00.000-05:002013-12-31T21:30:54.755-05:00Happy New Year 2014<div dir="ltr" style="text-align: left;" trbidi="on">
Pushed by popular demand (translation - I think the one person who asked me is popular), I have drawn yet another in my series of poorly-drawn cartoons, in honor of the new year. You can tell it's a new year-themed cartoon because it says, "HAPPY NEW YEAR!" right at the bottom. It could have been a Halloween cartoon, I suppose, but I didn't draw it till now. It is completely apolitical, unrelated to medical care, and has no social commentary at all. Well, at least it really doesn't refer to electronic "health" records in any way. Perhaps because, now that Mark is being employed by Epic, I have a conflict of interest. Nah, just didn't happen.<br />
<br />
I will try to blog more regularly. There are lots of things I've been meaning to write about, so maybe I'll get off my rear at some point soon.<br />
<br />
Anyway, to completely obviate the need for a brag letter that ain't coming, Mark is now working for Epic, proving that Zoology is a viable major, as long as you have a Computer Science minor, Keith is now a junior and it seems switching from Econ to Comp Sci (so he can get a Zoology job after graduation, I'm sure), and Rose had both knees replaced in July and is still not exactly a happy camper.<br />
<br />
Best wishes to you (whoever you are, reading this) and yours for the new year!<br />
<br />
And now, the alleged cartoon:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrH_hYJQGyCS8rOZT2prT6xCdSpxo6WhFP8h3_A1IAXtWVptiGZj6BId1FCcQjWGUBFSl8qq7a4953BKgGKlzj4uEf9suOu5Kib5EfM5VWwamll-0t3bEHkjsYD2rFrSq2IAc5kg/s1600/Abdominal+snowman+2013.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="512" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrH_hYJQGyCS8rOZT2prT6xCdSpxo6WhFP8h3_A1IAXtWVptiGZj6BId1FCcQjWGUBFSl8qq7a4953BKgGKlzj4uEf9suOu5Kib5EfM5VWwamll-0t3bEHkjsYD2rFrSq2IAc5kg/s640/Abdominal+snowman+2013.jpg" width="640" /></a></div>
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"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-62710054934352173562013-12-29T18:01:00.000-05:002013-12-29T20:02:20.752-05:00Yes, Virginia, there is a Santa Claus<div dir="ltr" style="text-align: left;" trbidi="on">
I am a really crappy blogger - nobody will come looking if I go 6+ months with no posts. On the other hand, that could be considered an act of charity. And, in the spirit of the season, a guest entry on charity from Ted Cruz:<br />
<br />
<h1 align="center" style="text-align: center;">
<span style="font-size: 12pt;">Yes, Virginia, there
is a Santa Claus</span></h1>
<div class="MsoNormal">
<span style="background-color: white; background-position: initial initial; background-repeat: initial initial;">VIRGINIA, your little friends are wrong. They have been
affected by the skepticism of a skeptical age. They do not believe even what<span class="apple-converted-space"> </span>they see. They think that nothing can
be which is not comprehensible by their little minds. All minds, Virginia,
whether they be men's or children's, are little. In this great universe of ours
man is a mere insect, an ant, in his intellect, as compared with the boundless
world about him, as measured by the intelligence capable of grasping the whole
of truth and knowledge.<br />
<br />
Yes, VIRGINIA, there is a Santa Claus. He exists as certainly as love and
generosity and devotion exist – okay, even more certainly, since my actions and
those of many of my colleagues and supporters raise reasonable doubt about the
existence of love and generosity. Alas! how dreary would be the world if there
were no Santa Claus. It would be as dreary as if there were no VIRGINIAS. There
would be no childlike faith then, no poetry, no pretense that, despite its long
history of failures to make tolerable this existence, the "free market" would solve
all problems, including lack of access to health care by the uninsured indigent
amongst us. We should have no enjoyment, except in the further accumulation of
wealth by the 1%.<br />
<br />
Not believe in Santa Claus! You might as well not believe in fairness! You
might get your papa to hire men to watch in all the chimneys on Christmas Eve
to catch Santa Claus, but even if they did not see Santa Claus coming down,
what would that prove? Nobody sees Santa Claus, just as nobody has ever seen a
free market in health care, but that is no sign that there is no Santa Claus.
The most real things in the world are those that neither children nor men can
see. Did you ever see fairness dancing on the lawn? Of course not, but that's
no proof that it is not there – it could be, since it’s sure not in Congress.
Nobody can conceive or imagine all the wonders there are unseen and unseeable
in the world.<br />
<br />
You may tear apart the baby's rattle and see what makes the noise inside, but
there is a veil covering the unseen world which not the strongest man, nor even
the united strength of all the strongest men that ever lived, could tear apart.
Only faith, fancy, poetry, love, romance, can push aside that curtain and view
and picture the supernal beauty and glory beyond. Is it all real? Ah, VIRGINIA,
in all this world there is nothing else real and abiding.<span class="apple-converted-space"> </span><br />
<br />
No Santa Claus! Thank God! he lives, and he lives forever. Otherwise, I should
have to admit that the opposition of my colleagues, my backers, and myself to
allowing all Americans access to some form of health insurance, however
imperfect, was selfish, small-minded, wicked, and cruel, a phantasm produced by
snorting the white pow(d)er of Koch – worse even than what Scrooge would abide.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="background-color: white; background-position: initial initial; background-repeat: initial initial;">Yes, VIRGINIA, there is a Santa Claus. And he wants you to get off your lazy butt
and get a high-paying job with good benefits, if you want more than a lump of
coal this year. Being 8 years old is no
excuse for sloth. To help you in this
endeavor, we are also cutting off unemployment insurance payments to your
parents, who would have gotten new jobs by now if they had not been narcotized
by the government dole.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="background-color: white; background-position: initial initial; background-repeat: initial initial;">Yours truly,<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="background-color: white; background-position: initial initial; background-repeat: initial initial;">The “Honorable” Ted Cruz<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
<span style="background-color: white; background-position: initial initial; background-repeat: initial initial;">P.S. Feel free to
come by my office in Washington, DC any time for a cup of tea – but please
bring your own tea bag. Don’t be a
moocher!</span></div>
</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-71465662914586727102013-06-03T23:12:00.002-04:002013-06-03T23:12:27.172-04:00EHRs - evidence-free medicine?<div dir="ltr" style="text-align: left;" trbidi="on">
I wasn't going to write another EHR-related post. Not yet, time for a change. But <a href="http://annals.org/article.aspx?articleid=1692572">this article</a> just came out online first in the Annals of Internal Medicine, funded by the Robert Wood Johnson Foundation and the Commonwealth Fund. The conclusion of the abstract really says about as much as we all need to know, since we already all know it, except for ONCHIT, it seems:<br />
<br />
<span style="background-color: white; border: 0px; color: #333333; font-family: Helvetica, sans-serif; font-size: 13px; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;">Few physicians could meet meaningful use criteria in early 2012 and using computerized systems for the panel management tasks was difficult. Results support the growing evidence that using the basic data input capabilities of an EHR does not translate into the greater opportunity that these technologies promise.</span><br />
<span style="background-color: white; border: 0px; color: #333333; font-family: Helvetica, sans-serif; font-size: 13px; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;"><br /></span>
<span style="color: #333333;"><span style="line-height: 19px;">And many large sites, like academic medical centers, have not just one, but several EHRs, along with perhaps a data repository or two, plus all the systems they have to interact with. I guess the HITECH Act is good for the economy, guaranteeing that a bunch of people will have IT-support jobs that pay reasonably well into the indefinite future, and low risk of offshoring.</span></span><br />
<span style="background-color: white; border: 0px; color: #333333; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: inherit;"><br /></span></span>
<span style="background-color: white; border: 0px; color: #333333; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: inherit;">Or, to paraphrase the famous line from <a href="http://www.imdb.com/title/tt0040897/" style="font-style: italic;">Treasure of the Sierra Madre</a> (which I'd give more than 8.4/10 stars), "Clothes? We don't have to show you no stinkin' clothes!"</span></span><br />
<span style="background-color: white; border: 0px; color: #333333; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: inherit;"><br /></span></span>
<span style="background-color: white; border: 0px; color: #333333; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: inherit;">I'll try for more variety in my next post.</span></span><br />
<span style="background-color: white; border: 0px; color: #333333; line-height: 19px; margin: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: inherit;"><br /></span></span>
<br /></div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-86122958024771534472013-05-30T00:33:00.003-04:002013-05-30T00:34:15.102-04:00A strong vote of confidence in our EHRs from current users<div dir="ltr" style="text-align: left;" trbidi="on">
I just ran across a blurb today pointing to <a href="http://profitable-practice.softwareadvice.com/four-years-later-the-impact-of-the-hitech-act-0513/">this article</a> on the web discussing changes in EHR purchasing between 2010 and 2013. I acknowledge that I have not done full due diligence to examine their methodology and biases, but I see no reason to believe that the figures they present are grossly distorted for any obvious reason.<br />
<br />
Briefly, what caught my attention is that the proportion of those looking to buy an EHR in 2013 vs. 2010 who are replacing an existing EHR jumped from 21% to 31% (but <a href="http://www.healthcareitnews.com/news/ehr-users-dissatisfied-consider-switch">this article</a> suggests it could be as "low" as 17% in 2013). My first thought was that maybe these were people changing from discontinued/unsupported systems; this is why a couple of community health centers I know of here in Massachusetts made that move, because they had MISYS and AllScripts bought and shot it. However, a bit farther down, data are shown that by far the largest reason for switching was dissatisfaction with the old system and this was more common in 2013 than 2010, with >60% citing this as their reason for switching in 2013. Given the issue of EHR lock - the systems are very expensive and vendors make it as hard as possible to get your data out to move to another EHR (generally not even providing users a data dictionary to understand how their own patient data are stored) - jumping ship to another EHR because of dissatisfaction means you really hate the one you have. Then think about all the costs of retraining clinical and support staff for the new EHR, the lost productivity as they go through another learning curve - the costs are likely not much lower than buying an initial system, though I've never seen any articles with data about the costs of switching. You truly have to hate your EHR to switch because you don't like it rather than because it is no longer supported or doesn't qualify for Meaningless Use incentives. (And let's not even think about the poor schmoes who bought an "EHRMagic" EHR and learned that the magic was that their MU certification would <a href="http://www.hhs.gov/news/press/2013pres/04/20130425a.html">disappear</a>.)<br />
<br />
Strong incentives to buy black box products with penalties coming soon for not using them (e.g., not using e-prescribing), when there are huge exit barriers, bears no resemblance to the assumptions of a "free market." I really wish that the "anti-big government" forces in Congress would go after this one. Unfortunately, as we all know, they are quite happy with a forced subsidy to big business, even at the price of more expensive, lower quality health care and worse health for Americans. But nobody gets elected, or voted out of office, on the basis of their positions and votes related to EHRs, do they?<br />
<br />
And I can think of no better way to end this rant than with a turkey photo or two.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIUB2zUZd36JRmNuftbhoxBdYuEx3vuihOHieyaaeZUh6yvgqL7nqQzGM_gkudwBQys8XB5UG3VIaucCxv_ymMDZv873ftVkHDozpSilSceQIg7wEyNxSH6lCcngNrUuuPCa_ayA/s1600/IMGP0273.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="424" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIUB2zUZd36JRmNuftbhoxBdYuEx3vuihOHieyaaeZUh6yvgqL7nqQzGM_gkudwBQys8XB5UG3VIaucCxv_ymMDZv873ftVkHDozpSilSceQIg7wEyNxSH6lCcngNrUuuPCa_ayA/s640/IMGP0273.JPG" width="640" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzsuutjFAVzKjmrHzgR2kDdJtu7VYQD3bLvfhwFofo52oPKPWCuZih7OtRbLGMyKIBTKIK20hCvJYEx2MLxB05YmkB8f5RqWUCSpWBFvaOEa4dZzwCWvvX8aoTTTB56akLchkEhA/s1600/IMGP0289.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="424" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzsuutjFAVzKjmrHzgR2kDdJtu7VYQD3bLvfhwFofo52oPKPWCuZih7OtRbLGMyKIBTKIK20hCvJYEx2MLxB05YmkB8f5RqWUCSpWBFvaOEa4dZzwCWvvX8aoTTTB56akLchkEhA/s640/IMGP0289.JPG" width="640" /></a></div>
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"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com1tag:blogger.com,1999:blog-29133307.post-17575847778769724412013-05-26T00:34:00.002-04:002013-05-27T12:08:14.018-04:00More EHR crankiness - parallel evolution or just unacknowledged copying?<div dir="ltr" style="text-align: left;" trbidi="on">
I just bumped into <a href="http://www.antheliohealth.com/downloads/Council-EHR-commentary.pdf">this letter</a> submitted as commentary to Congress from the "Healthcare Innovation Council" of Antheliohealth. The members are certainly more prominent than I, and while Antheliohealth is clearly in the business and hence potentially biased, they make very similar comments to those I made in the Health Affairs Blog post I linked to in my previous posting here. It is interesting that they used virtually the same title as I did (though I could not believe I somehow sent mine in as "The EHR Has No Clothes" and not "The EMR Has No Clothes"), without any attribution and, more importantly, without sending me a large check. But it could just be parallel evolution.<br />
<br />
They went all the way to suggesting an end to the "Meaningful Use" program (I believe that is referred to in the trade as an act of MUtiny). I had wanted to do that in my HA Blog piece but figured that would make it truly unpublishable - and it was already an incredible thrash to finally get it published anywhere. And there is the issue of fairness - those adopting EHRs now are counting on the MU payments to help them cover the frequently obscene costs. Even I think that abruptly ending the program would be unfair and unwise. But there are, er, fair and balanced options that could be chosen. E.g., the MU Stage 2 rollout could be put on hold while the specifications could be revised to focus on truly meaningful use - helping providers deliver higher quality, more patient-centered care. One could even put a freeze on eligibility for MU incentives - e.g., no contracts for an EHR by an organization not already using a certified EHR signed after a specified date would be eligible for MU payments until the freeze was lifted when the new MU Stage 2 requirements were issued.<br />
<br />
And I still don't understand the incredible resistance to adopting VistA. Sure, it needs installation and support, but all EHRs do, and the software licensing cost is $0, which leaves a lot of money on the table for installation and support. (I've offered to cover the entire software acquisition cost for my clinic if we dump NoxGen for VistA.) It actually has evidence for improving care and, for an enterprise-level EHR, is relatively well-liked.<br />
<br />
But, I know, I know, it has no glitzy GUI and is written in that truly archaic language, MUMPS. As is Epic...<br />
<br />
Ok, for you non-geeks who accidentally clicked on this, here's a picture of a white-breasted nuthatch in our backyard for your troubles (those are maple flowers in the tree):<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlHrOqeRlA1PkuFzNKoO6OrD4K-S7bGZDMaBq0XA1y4bCaMzO6YM3hgv-wXmDMs4LmGu8QgVqXdlWHE5t8yZiZC-645k-lGIgNoN9AxD0oUlLxHmunCwdIHwAaAczYohru9RCgVg/s1600/White-breasted+nuthatch+in+flowering+maple-2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="423" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlHrOqeRlA1PkuFzNKoO6OrD4K-S7bGZDMaBq0XA1y4bCaMzO6YM3hgv-wXmDMs4LmGu8QgVqXdlWHE5t8yZiZC-645k-lGIgNoN9AxD0oUlLxHmunCwdIHwAaAczYohru9RCgVg/s640/White-breasted+nuthatch+in+flowering+maple-2.JPG" width="640" /></a></div>
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"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-72054639899531103012013-05-17T23:27:00.001-04:002013-05-17T23:27:16.360-04:00Your HIT parade - Problem lists!<div dir="ltr" style="text-align: left;" trbidi="on">
As some know, <a href="http://healthaffairs.org/blog/2012/06/20/the-ehr-has-no-clothes/">I think our national electronic health record (EHR) policy is woefully misguided</a> - providers/organizations are being pushed hard to buy an EHR, any EHR (I think the official title of this strategy is, "Let 1,000 EHRs fester"), with the costs of acquisition and barriers to exit so high that most purchasers get locked into whatever they buy, even after discovering it is a POS and most of what they were promised was vaporware. These complex systems are devoted to charge capture/justification, not patient care, and are <a href="https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf">chief suspects in increases in Medicare coding intensity/costs</a> unrelated to any actual changes in care. (Here's the <a href="http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?pagewanted=all&_r=0">NY Times article</a>.) Well, duh! They are NOT, in general, focused on helping clinicians actually provide better care (except for the few that were actually developed by clinicians to help them practice). However, I can think of few ways to make this clearer than the email I received today:<br />
<br />
<br />
<div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="background-color: yellow; font-family: 'Times New Roman', serif; font-size: 12pt; line-height: 115%;">Health
Resources and Services Administration</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="background-color: yellow; font-family: 'Times New Roman', serif; font-size: 12pt; line-height: 115%;">Health
Information Technology and Quality Improvement Webinar</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="background-color: yellow; font-family: 'Times New Roman', serif; font-size: 12pt; line-height: 115%;">Friday,
May 17, 2:00 PM ET</span></b></div>
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<br /></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b><i><span style="background-color: yellow; font-family: 'Times New Roman', serif; font-size: 16pt; line-height: 115%;">“Using
an Electronic Health Record to Create Patient Problem Lists”</span></i></b></div>
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<br /></div>
<div class="MsoNormal">
<span style="background-color: yellow; font-family: 'Times New Roman', serif;">This
webinar will focus on how safety net primary care providers can meaningfully use
electronic health records (EHR) to create and maintain patient problem lists.
Created by EHRs, patient problem lists are a core requirement of Meaningful Use.
This function serves as a powerful tool for maintaining a patient’s medical
history while also helping to engage patients to better track and manage their
health care. </span></div>
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<span style="background-color: yellow; font-family: 'Times New Roman', serif;"><br /></span></div>
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</div>
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<span style="background-color: yellow; font-family: 'Times New Roman', serif;">Presenters will demonstrate how
patient problem lists are created and maintained by EHRs, and share their
strategies on how providers can use them for quality improvement and patient
engagement. Lastly, staff from the U.S. Department of Health and Human Services
will discuss the importance of patient problem lists in achieving Stage 1 and 2
of Meaningful Use.</span></div>
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<span style="background-color: yellow;"><span style="font-family: 'Times New Roman','serif';">Register
here: </span><a href="https://mail.umassmed.edu/owa/redir.aspx?C=XxbR3alJxUKxsrfgSbP5m-X81Iz_JtAIfQGKy2eSsTMKKdCgcA10Wm8oTtYbh8HSA6_S6cmE3KY.&URL=https%3a%2f%2fcc.readytalk.com%2fcc%2fs%2fregistrations%2fnew%3fcid%3d3g2cm558x3gp" target="_blank"><span style="font-family: 'Times New Roman','serif';">https://cc.readytalk.com/cc/s/registrations/new?cid=3g2cm558x3gp</span></a><span class="MsoHyperlink"><span style="font-family: 'Times New Roman','serif';">.</span></span><span style="color: blue; font-family: 'Times New Roman','serif';"></span></span></div>
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<span style="background-color: yellow;"><span style="font-family: 'Times New Roman','serif';">Previous
HRSA Health IT and Quality Webinars can be accessed at the HRSA Health IT and
Quality Webinar website: </span><a href="https://mail.umassmed.edu/owa/redir.aspx?C=XxbR3alJxUKxsrfgSbP5m-X81Iz_JtAIfQGKy2eSsTMKKdCgcA10Wm8oTtYbh8HSA6_S6cmE3KY.&URL=http%3a%2f%2fwww.hrsa.gov%2fhealthit%2ftoolbox%2fwebinars%2f" target="_blank"><span style="font-family: 'Times New Roman','serif';">http://www.hrsa.gov/healthit/toolbox/webinars/</span></a><span class="MsoHyperlink"><span style="font-family: 'Times New Roman','serif';">.</span></span><span style="font-family: 'Times New Roman','serif';"></span></span></div>
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<span style="background-color: yellow;"><span style="font-family: 'Times New Roman','serif';">Questions for presenters are
welcome prior to the event and may be emailed to<span style="color: blue;">
</span></span><a href="https://mail.umassmed.edu/owa/redir.aspx?C=XxbR3alJxUKxsrfgSbP5m-X81Iz_JtAIfQGKy2eSsTMKKdCgcA10Wm8oTtYbh8HSA6_S6cmE3KY.&URL=mailto%3ahealthit%40hrsa.gov" target="_blank"><span style="font-family: 'Times New Roman','serif';">healthit@hrsa.gov</span></a><span class="MsoHyperlink"><span style="font-family: 'Times New Roman','serif';">.</span></span><span style="font-family: 'Times New Roman','serif';"></span></span></div>
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<span class="MsoHyperlink"><span style="font-family: 'Times New Roman','serif';"><br /></span></span></div>
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<span style="font-family: Times New Roman, serif;">If a webinar is needed to help people learn about creating problem lists in their EHRs and discuss how they can be useful in patient care, we are in seriously deep trouble. After being sure you are looking at the right chart, the problem list is typically the first thing you look at. How can it be possible that we are pushing people to buy and use such useless crap where conducting such a webinar does not seem utterly nonsensical? And that people are paying many thousands, and often millions, of dollars for these pieces of crap.</span></div>
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<span style="font-family: Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times New Roman, serif;">Don't get me wrong - as a geek, I think the EHR has huge potential for increasing the efficiency and effectiveness of health care. I just think we are squandering nearly all of that potential with our current, misguided policies and driving costs up substantially with little or no payoff. Except to the EHR companies, who are making billions. "Free market" Republicans should be up in arms over this forced subsidy - except, of course, they really care about helping businesses make money, not free markets, competition, efficiency, or saving taxpayer money.</span></div>
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<span style="font-family: Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times New Roman, serif;">Stay tuned - I hear that next year, HRSA and ONCHIT are planning on cosponsoring an advanced-level webinar, "Creating a Progress Note Using an Electronic Health Record." </span></div>
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<span class="MsoHyperlink"><span style="font-family: 'Times New Roman','serif';"><br /></span></span></div>
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</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com1tag:blogger.com,1999:blog-29133307.post-54985970933831665532013-05-16T15:20:00.000-04:002013-05-16T15:20:43.941-04:00The Guns of Never One (with apologies to Alistair MacLean)<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
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This will probably be my last posting on guns for a while. I hope...</div>
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<br /></div>
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I love hearing gun nuts (and specifically the NRA) argue
that the problem with gun violence is not related to high prevalence, unsafe
storage, lack of background checks for gun show and internet sales, etc., but
an issue of keeping “mentally ill” people from obtaining guns. While fighting vigorously against any
national registry of gun ownership, <a href="http://www.washingtonpost.com/politics/remarks-from-the-nra-press-conference-on-sandy-hook-school-shooting-delivered-on-dec-21-2012-transcript/2012/12/21/bd1841fe-4b88-11e2-a6a6-aabac85e8036_print.html">he advocates for creation of “an active national database of the mentally ill”</a>. For some reason, alas, he has neglected to
publish the criteria that would constitute the admission ticket to this elect
group, nor does he seem to contemplate several other issues:</div>
<div class="MsoNormal">
</div>
<ol style="text-align: left;">
<li>Isn’t creating a
national registry of the “mentally ill” a far greater intrusion on liberty and
the right to privacy than a registry of gun owners? The latter is a voluntary choice.</li>
<li>Since mental
illnesses are defined and redefined essentially by consensus, inclusion on such
a list has a substantial degree of arbitrariness, both in condition definition
and assessment. Furthermore, since symptoms wax and wane, many people cross back and forth across the magic lines
we draw for diagnosis on a regular basis.</li>
<li>We have very poor
predictive ability for homicide and suicide among persons with serious medical
disorders (see, for example, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21250894">this article</a>).</li>
<li>Many people who
commit violence with guns would not meet criteria for any list of diagnoses
that the NRA and its allies would agree to.</li>
<li>In contrast, felons have already been convicted of criminal behavior.</li>
</ol>
<br />
<div class="MsoNormal">
In my practice in community health centers and public
hospitals, I have had patients who have been victims of gun violence and
patients whose families have been affected by gun violence. A couple of years ago, I was told that one
of my patients had died. He certainly
had mental illness, and was seeing a counselor and taking medications. He had grown up as a victim of violence and
had a violent youth. He was struggling
to keep his life together and, especially, to keep his teenage son from
following in his footsteps. But, as it
turns out, he had an estranged ex-girlfriend I had never heard about who had a
no-contact order on him. One day, he
found her in a store, shot and killed her, went back to his room, and committed
suicide. Would I have wanted him to
have a gun? No. Would I have expected him to use a gun on
someone? No.</div>
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<br /></div>
<div class="MsoNormal">
If the NRA trusts the nation’s medical providers to make the
determination of who can safely be allowed to own a firearm, practitioners of
evidence-based medicine can help:</div>
<div class="MsoNormal">
</div>
<ol style="text-align: left;">
<li>As above, we have
no good way of predicting who will commit a gun-related crime or suicide.</li>
<li>However, owning a
firearm, or having one in the house, substantially increases the risk of gun-related suicide,
homicide, and injury.</li>
</ol>
<br />
<div class="MsoNormal">
The answer seems pretty obvious. In fact, I am willing to take on the burden of being “The
Decider” for the entire nation. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Q: Should _____
(fill in name) be allowed to own a gun?</div>
<div class="MsoNormal">
A: No.</div>
<div class="MsoNormal">
Repeat as necessary.</div>
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<br /></div>
<span style="font-size: 12pt;">(P.S. In fact,
I am perfectly happy to allow responsible ownership, storage, and use of
hunting rifles; in Alaska, for example, many people really are subsistence
hunters, and we have to do something to control deer populations with their
natural predators eliminated. But do we
need more 5 year olds being given "first shotguns" and then killing 2 year olds???)</span></div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-87015349270418929392013-05-15T18:31:00.000-04:002013-05-15T19:06:12.891-04:00What, Exactly, Is It that We Don’t Understand about the Right to Bear Arms?<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
Americans continue to face a civil rights crisis. Following the recent, tragic events in
Boston, Wayne SelPierre, Executive Vice President of the National Bomb
Association, stated, “The only thing that stops a bad guy with a bomb is a good
guy with a bomb. As long as bombs are
illegal, only criminals will have bombs.
And we have seen that outlawing bombs has not kept them out of the hands
of criminals, while law-abiding Americans have been deprived of their Second
Amendment rights by monumental, unconstitutional overreach by the federal
government. The NBA believes it is time
that Americans have their constitutional rights to bear any and all arms
restored and we will be filing suit against the federal government challenging
the unconstitutional infringement of our right to bear bombs.”</div>
<div class="MsoNormal">
Pundits in
the lamestream media have claimed that the NBA is a bunch of extremist nut
cases, but if the Founding Fathers had only intended for Americans to have the
right to bear firearms, they would have said so. “Arms” is a synonym for armaments and a quick check in any
dictionary makes it clear this is not limited to pistols, rifles and assault
weapons.</div>
<div class="MsoNormal">
Some might
argue that bombs have no uses other than to kill and maim, but these
unenlightened persons have obviously never engaged in the sport of dynamite
fishing, nor used a small explosive charge to open the lid on a too-tightly
closed jar of pickles. Bear bombing
is a far more challenging sport than bear hunting with a rifle. It
requires both getting much closer to a bear than needed with a barely-sporting
hunting rifle with telescopic sight and anticipating speed and direction
changes a bear will make while lobbing your grenade. A child who has learned to throw the grenade not where the bear
is, but where the bear will be, is a child who has learned an invaluable life
lesson. She will be a leg up on her
non-bear bombing peers, assuming no hunting accidents. Cleaning and cooking a detonated bear
similarly requires far more skill and effort than slicing up and roasting an
intact carcass.</div>
<div class="MsoNormal">
Some might
argue that the Founding Fathers could never have anticipated modern
developments in personal explosives like dynamite, plastic explosives, and
IEDs, but that’s the same, lame argument that the Senate rightfully discarded
when courageously refusing to buckle to the will of the majority of the
American people and ban assault weapons or magazines holding large numbers of
bullets. In fact, the inability of the
Founding Fathers to anticipate those advances in personal firearm technology is
what makes regaining the right to personal explosives so crucially
important. While Wayne LaPierre of the
NRA claimed that the only thing that can stop a bad guy with a gun is a good
guy with a gun, the NBA has pointed out that, against a gunman armed with
multiple assault weapons with high capacity magazines and wearing body armor,
an individual with a concealed pistol has virtually no chance – but a patriotic
American lobbing a concealed grenade at the gunman or gunwoman? Game over.</div>
<div class="MsoNormal">
When even a
Canadian peacenik like Bruce Cockburn wistfully sings, “If I Had a Rocket
Launcher,” it is clear that this un-American, unconstitutional restriction on
our right to bear arms must go. I hope
that our courageous Congress sees fit to act without waiting for the NBA case
to proceed glacially through the court system so that, eventually, the Roberts
court can restore our constitutional rights.</div>
It is important not to lose sight of principle and just grab an easy,
incomplete victory. The Second
Amendment gives Americans the right to bear arms. Period. Next week, I’ll
discuss handy, home uses of sarin wrap.</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com3tag:blogger.com,1999:blog-29133307.post-89128882595777337892013-05-15T18:24:00.000-04:002013-05-15T18:24:20.165-04:00Owner-Donor: Two Words to Make Guns Life-Saving<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
Let’s get
real – people with guns and ammunition kill people. There is overwhelming evidence that restrictions on access to
semiautomatic weapons, high-capacity magazines, and just plain guns reduce
gun-related deaths – not just murders but suicides and accidental deaths. Despite that, it seems unlikely Congress is
going to do anything that could actually make Americans safer and reduce the
carnage. But does this mean we should
throw in the towel? Absolutely not – a
towel thrown in the air could easily be mistaken for a skeet, with very
unpleasant consequences. Yelling
“Duck!” when throwing the towel would only increase the risk.</div>
<div class="MsoNormal">
Instead, we
need accept that our elected representatives lack the guts to stand up to the
gun lobby and move on to more constructive ways of dealing with the mayhem we
know will continue coming. First, there
is an obvious way to make guns save at least as many lives as they take. No, I don’t mean requiring every man, woman,
and child to pack heat. More guns =
more death, remember? Rather, without
restricting access to guns at all, we simply pass a law that requires anyone
owning a gun to agree to be an organ donor – the Owner-Donor law. Sure, you say, but what about those cases
where the gun owner has not committed suicide or been shot with his or her own
gun, hopefully sparing the heart, lungs, kidneys, liver, and other
transplantable organs? No problem –
living organ donation is already accepted and widespread. If you shoot someone with your gun and it is
not found to have been self-defense against a legitimate mortal threat, you
have just agreed to donate a kidney and/or a lobe of your liver. You can keep your other kidney – unless you
do it again. If your gun is not
securely stored and is used by another person to harm someone, you have also
just agreed to become a donor – thank you.
Use of a gun in committing a crime, similarly, should constitute an
automatic donation consent, so if your stolen gun is used to commit a crime,
thank you twice! </div>
<div class="MsoNormal">
Imagine the
headlines this policy could create.
“RISE IN GUN DEATHS OVERWHELMS HOSPITALS WITH ORGAN TRANSPLANTS – ORGAN
WAITING LISTS ELIMINATED!”</div>
<div class="MsoNormal">
Of course,
some might criticize this as a facile oversimplification that ignores the real
complexities involved. Adult-sized
organs are not suitable for transplantation into children, so how could this
proposal address the needs of children awaiting organ transplants? But I am not the only person to offer facile
oversimplifications in the debate about gun violence. Wayne LaPierre of the National Rifle Association made the absurd
statement after Newtown that the only thing that can stop a bad guy with a gun
is a good guy with a gun. But that
strategy did not stop Columbine.
Besides, what if the good guy has a bad day? Do we need two armed good guys, keeping eyes on each other all
the time? And then how will they see
the armed bad guy approaching?</div>
<div class="MsoNormal">
Instead, we
need to mandate that all schoolchildren pack heat in school. Given the importance of guns in American
society, it is criminal that we are not devoting at least 25% of time in school
to guns. If recess were changed to
target practice and physical education (or science – gun advocates don’t seem
to have much use for that) to firearm education, we could finally lead the
world in one area of education and guarantee that any bad guy thinking of going
into a school for target practice would think at least twice. Which would be at least two times more than
many gun advocates seem to be thinking.</div>
<div class="MsoNormal">
But, you
say, kids tend to have poor impulse control and not think through the long-term
consequences of their behaviors. If
Sally dumps Harry’s lunch tray, isn’t there a risk that Harry will draw and
somebody, or some bodies, get shot?
Sure, but it’s a small price to pay for liberty. Besides, did you forget about all the kids
on the organ transplant waiting list?
With Owner-Donor, when Harry shot Sally could yield 2 kidneys from the
late Sally, 1 from Harry, another from Harry’s mom or dad who was the
registered owner, plus Sally’s other useful organs.</div>
<div class="MsoNormal">
As the
famous American philosopher Benjamin Parker once said to his nephew, “With
great power, comes great responsibility.”
It is time for American gun owners to step up to the plate – and the
operating room gurney.</div>
</div>
"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com0tag:blogger.com,1999:blog-29133307.post-33827727233798405392013-05-15T18:21:00.000-04:002013-05-15T20:38:54.553-04:00A blog? What's up with that???<div dir="ltr" style="text-align: left;" trbidi="on">
I have gotten frustrated that many pieces I write, whether "humor" or policy-related, keep not getting published. There's not much point in writing just for yourself. Several friends have suggested starting a blog (soooo last decade, I know, but I remain firmly committed to antisocial networking - no Twits, Tweets, Facebook, etc.). I suspect they are just hoping not to keep getting crap in their inboxes that they need to delete immediately but occasionally start reading before realizing their mistake. Far easier to ignore a blog or an email saying "Read my latest blog posting. Please???"<br />
<div>
<br /></div>
<div>
I will start off with a couple of satiric pieces I wrote on the topic of gun control and have not been able to find a venue willing to accept. After that, all bets are off. You may see health policy musings, rants about our stupidity in health information technology policy, poorly-drawn cartoons, pictures of animals or plants I've taken (but NO cute kitty pictures, I promise! I reserve the right to put up cute puppy pictures, should we ever get a dog. I.e., don't worry about that, either), or just about anything else.</div>
<div>
<br /></div>
<div>
Feel free to pass the site on to friends you want to lose, strangers on the street, eccentric billionaires or publishing magnates you know, or anyone else. After all, Google will tell me if nobody is ever reading this, which could push me back to email inundation for dissemination.<br />
<br />
Just to prove that entropy always wins, below are a few recent, random photos. The first is just a demonstration of what kind of pinko I am.<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVMwWp6uuz76MjjrWWmtOe4Pkivz9uAtTEj0jv6h7AQ-D53OJBHLNcBcT-s1SJ4vAwRniBDnY7bilqTF8pwDqtSRt3ERNOO-dYw2j4yn3Y11HNXcz8sZfi2PZEbuBYDQkzr_DwXA/s1600/Emerging+bleeding+hearts.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVMwWp6uuz76MjjrWWmtOe4Pkivz9uAtTEj0jv6h7AQ-D53OJBHLNcBcT-s1SJ4vAwRniBDnY7bilqTF8pwDqtSRt3ERNOO-dYw2j4yn3Y11HNXcz8sZfi2PZEbuBYDQkzr_DwXA/s1600/Emerging+bleeding+hearts.JPG" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small; text-align: left;">Yes, those are emerging fronds of a bleeding heart.</span></td></tr>
</tbody></table>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuWS3BM50E-pemoy503yckNZChBhoZwyqghgq1lZFnbe6MVbe56yHWfT014pyTllc7wbYG7o4C8E3UNrvqXz07tP5rjCBxqd9OSjfhVRcKfpfcNSI3jHaZQAtUifOI2H5Z43Pmiw/s1600/Emerging+fern+fronds.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuWS3BM50E-pemoy503yckNZChBhoZwyqghgq1lZFnbe6MVbe56yHWfT014pyTllc7wbYG7o4C8E3UNrvqXz07tP5rjCBxqd9OSjfhVRcKfpfcNSI3jHaZQAtUifOI2H5Z43Pmiw/s1600/Emerging+fern+fronds.JPG" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small; text-align: left;">An emerging fern frond. I just think they look very cool. And, after New England winters, I cannot be happy enough when spring gets here.</span></td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYDdvelvc8og7HRT_-P2fNKKuWRAzBBX66HrvzH9rcCIgIfRRrBHrx5BFlLMCS8s91UbxP8ZV_jDKuVrlrVVo2fGxoDw3kt1x81RcAmgOIP9lt09494t5Io00WbMQN-_SyvNWCvw/s1600/Colorful+developing+maple+seeds.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="425" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYDdvelvc8og7HRT_-P2fNKKuWRAzBBX66HrvzH9rcCIgIfRRrBHrx5BFlLMCS8s91UbxP8ZV_jDKuVrlrVVo2fGxoDw3kt1x81RcAmgOIP9lt09494t5Io00WbMQN-_SyvNWCvw/s640/Colorful+developing+maple+seeds.JPG" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small; text-align: left;">Developing maple seeds - I am amazed at how colorful they are.</span></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNfyhKaFAGvcQWVd6RjSMIggLZXahi5Uhw_WYcad7IuLn0LJ5uspQFzIJReo-ft3LhJ1JWqbs3K_Or-RWxYLN5qiqTVloKS1LRKCqSDauhxjxMyMke9SrWq89TRAiHX2fb0TXWAw/s1600/White-throated+sparrow.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNfyhKaFAGvcQWVd6RjSMIggLZXahi5Uhw_WYcad7IuLn0LJ5uspQFzIJReo-ft3LhJ1JWqbs3K_Or-RWxYLN5qiqTVloKS1LRKCqSDauhxjxMyMke9SrWq89TRAiHX2fb0TXWAw/s1600/White-throated+sparrow.JPG" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small; text-align: left;">A white-throated sparrow in a blooming forsythia bush in the yard.</span></td></tr>
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</div>"Doc Saver"http://www.blogger.com/profile/03647449329837966980noreply@blogger.com3