demonizing doctors, insurance, medicare, Washington Post

Can’t win for losing

The Washington Post recently decided to demonize doctors, with a headline trumpeting, “An effective eye drug is available for $50, but many doctors choose a $2000 alternative.”  The article tells the story of a miracle drug treatment for wet macular degeneration, which is one of the leading causes of blindness.  Avastin was approved in 2004 for treatment of colon cancer.  It targets a protein called VGEF, thereby decreasing harmful blood vessel growth in cancer.  This same protein is linked to wet macular degeneration.  The company that makes Avastin, Genentech, has created a slightly different molecule and development process to make Lucentis, which is FDA approved to treat macular degeneration.  For all intents and purposes, the drugs are the same.  Both target VGEF.  Both are effective for macular degeneration, according to several independent trials.  However, Genentech has only sought FDA approval for Lucentis to treat MD.  It does not produce Avastin in the proper size to treat MD.

Despite this, many ophthalmologists still use Avastin to treat MD.  They have to have a compounding pharmacy separate it out into the proper dose, which does introduce a risk of contamination, though the risk is slight.  However, using Avastin this way is certainly considered off-label, meaning using a medication in a way that is not FDA approved.

The newspaper clearly implies that doctors should use Avastin, and that there is no good reason not to. It implies that doctors who chose not to take the risk of using an unapproved drug are greedy, stating that the medicare reimbursement of 6% of the cost of the drug (a whopping $120) is driving their decision.

And yet, just a few months ago, The Washington Post published this article.  It decries the lack of oversight of pharmaceutical drug use in the elderly, specifically targeting the off-label use of drugs in Alzheimer’s patients.

So, which is it, Washington Post?  Am I a saint or a sinner?  Is off-label use good or bad?  Or maybe, just maybe, doctors are using their clinical judgment in individual situations to guide their decisions.


h/t to

coding, humor, insurance, medical billing, medicare

ICD-10 Crazy Codes

Medical coding.  It’s an entirely separate language that distills all medical problems down to a “code.”  Currently, ICD-9 is in use.  Every time you receive medical care, your diagnosis is translated to a code which is then used for billing purposes, among other things.   Your hypertension and high cholesterol? 401.9 and 272.4.  Your hypothyroidism? 244.9.

And so on.

ICD-10 is going into effect next year.  It will increase the number of possible codes from 17,000 to 141,000.  No potential for confusion or complications there.

Now, has medical practice become so much more complicated over the past 30 years that there are now 124,000 new diagnoses?  Of course not.  ICD-10 is just more specific than ICD-9.  Much more specific.

For example, if you were to present to your doctor now after getting bit by, say, a squirrel, the code would be E906.3 (bite of an animal other than an arthropod).  But under ICD-10, your doctor can actually code that it was a W53.21XD (bitten by squirrel) to make sure that it is not confused with a W55.42XD (bitten by pig).

Or, after that ill-conceived ocean swim, your doctor can bill appropriately for W56.01XD (bitten by dolphin) vs W56.11XD (bitten by sea lion) vs. W56.21XD (bitten by orca).

Do you see the importance of these distinctions??

There are other codes that I’m sure are crucial.  V9733XD (sucked into jet engine, subsequent encounter).  Got that?  Subsequent encounter.  They made a code to cover someone who got sucked into a jet engine, not once, but twice.


For those of you that worry about worst-case scenarios, there are also codes for you.  For example- T71224A (asphyxiation from being trapped in a car trunk).  This is to be distinguished from T71234A (asphyxiation from being trapped in a discarded refrigerator).  There are also codes to clarify if the fridge asphyxiation was accidental, assault, attempted suicide, or “undetermined.”  If you’re really unlucky, you might have to use V9020xA (drowning or submersion due to falling or jumping from a burning merchant ship- initial encounter).

By the way, I apologize for any typos.  I have a big bandage on my index finger, having done a W920xxA this morning (contact with powered kitchen appliance).

Actually, there’s one ICD-10 code that probably covers this whole coding thing quite nicely- K62.89 (pain, anus).


If you give a patient a chest x-ray…

It’s probably the rare parent these days who hasn’t read If You Give A Mouse A Cookie, an adorable book by Laura Numeroff.  In it, a little boy gives a cute mouse in overalls a cookie.  This one little act sets off an exhausting chain of events that eventually comes full circle.

I was recently reviewing old records on a new patient.  I noticed that he had had an awful lot of tests over the previous couple of years, which struck me as odd, given that he was a pretty healthy person. Looking a little further, it seemed that a cascade of events had been set in motion that had started with one innocent little test- which was not even indicated.

This patient was a former smoker, having quit many years ago.  His previous doctor ordered a chest x-ray to screen for cancer.  This was unnecessary in  the absence of symptoms as it’s a category D recommendation by the USPSTF.  Nevertheless, the doctor ordered it and the patient had it done.

And, with apologies to Laura Numeroff:

If You Give a Patient A Chest X-Ray

If you give a patient a chest x-ray, the radiologist will see some tiny nodules.
The radiologist will call you and recommend a chest CT.
When he gets the chest CT, which is otherwise normal, the radiologist will note some calcifications in his aorta.  This will make you nervous, and you will refer him to a cardiologist.
Because this is a cardiologist, in addition to ordering an aortic ultrasound, he will also order a stress test, echocardiogram and carotid ultrasound.
All of those studies will be normal, but the ultrasound tech will notice a thyroid abnormality.  This will cause you to send the patient for an endocrinology consult.
The endocrinologist will redo the ultrasound.  Then he’ll order a thyroid uptake scan.  This will show an active adenoma, which is benign, but he’ll recommend follow up ultrasounds every six months after that.  He also notices that the patient is slightly hypothyroid, and starts him on levothyroxine.
The medication elevates the patient’s blood pressure, so you start him on an ACE inhibitor.
The patient comes back to you two months later with an ACE inhibitor-induced cough.
And if you see a patient with a cough…you’re probably going to want another chest x-ray.
disease mongering, menopause, pharmaceutical companies, primary care

Disease Mongering

Disease Mongering.  The act of turning a normal ailment into a serious illness.

This phenomenon is rampant today, and it drives me nuts.

It seems that the first step in disease mongering is to create a scary, official sounding acronym.  ED.   RLS.  GERD.  Sounds a hell of a lot more impressive and official than impotence,  restless legs, and heartburn.

I recently had the thrilling experience of seeing disease mongering at its finest.  The latest ailment to afflict Americans? VVA.  Vulvovaginal atrophy (said in a deep, important voice).  Otherwise known as vaginal dryness and thinning of the membranes due to menopause.  VVA (said again in a deep, important voice) sounds much more serious and impressive.

This is not a new entity.  Post-menopausal women have been experiencing vaginal dryness and pain with intercourse since…well, since the first woman ever went through menopause.  I don’t think it’s a deep, dark secret.  It’s even a question on the checkoff list that I give all my patients at their annual physical.

Shionogi Pharmaceuticals would have us think otherwise.  They have started a marketing blitz to convince Americans of the seriousness of this new condition, VVA.

They have a new drug on the market- Osphena.  It’s what’s called an selective estrogen receptor modulator.  This means that it binds to certain estrogen receptors (in the vaginal mucosa, in this case) and not to others (like in the breast).  It’s kind of similar to Evista, an osteoporosis medication that selectively binds to estrogen receptors in the bone.  As a matter of fact, Osphena was originally developed as an osteoporosis medication.  When it didn’t work to treat that, it became a drug in search of a disease.  And thus, VVA was born.

Shionogi is working really, really hard at marketing this.  One of their reps snuck a box of these into my waiting room.

Snazzy pink bracelets.   Just what everyone wants to see after a month of pinkwashing.  These say, “Break The Silence.”  What silence?  The shameful silence of VVA, of course.    I cleared that box out of the waiting room as soon as I found out about it.  My office manager braided the bracelets into a long, pretty pink chain.  We’re going to use it to decorate the office Christmas tree.
The medication comes in these discreet little totes.
Why?  I don’t know.  Why would someone need to carry the pills in this special little bag?
Here’s the brochure about the medication.

I love the off-the-shoulder sweater.  Post-menopausal women are still sexy, see!

Here’s the main thing that I dislike about this.  Atrophic vaginitis, otherwise known as VVA (in deep, important voice!) has always been around.  There are multiple excellent, safe medications to treat it.  Topical estrogen, in cream, tablet, or vaginal ring insert works great.  I’ve NEVER had it not work for a patient.  It has a long safety record.  Whereas Osphena in a new drug.  It carries a risk of endometrial proliferation, which can lead to endometrial cancer.  And it actually increases hot flashes.

No wonder they have to work so hard to market it.

The moral of the story is: disease mongering exists.  It’s marketing at its finest, as it preys on our fear of disease.  Be aware of it and be wary of it.  And just because a drug is advertised on TV doesn’t mean it’s the best choice.  Find a doctor whose expertise you trust, and take his or her’s advice rather than an advertising agency’s.

medical education, primary care

Three Years of Medical School?

I read an interesting article in the New York Times the other day.  Called, “Should Medical School Last Just Three Years?” it outlines a movement by some medical schools to compress the current four year schedule into three years.

To give some background for this, let me outline the typical current medical school curriculum.  The first two years are the “basic science” years.  The first year (at least when I went to school)  typically covers anatomy (including cadaver dissection), physiology, microbiology, biochemistry, histology, and statistics. The second year covers pharmacology, pathophysiology, neurobiology, and epidemiology.  Years 3 and 4 are the “clinical years.”  Third year students spend their time on six-week rotating clerkships through the core areas of medicine- internal medicine (this one was 12 weeks), pediatrics, OB/GYN, surgery, psychiatry, and family medicine.  Fourth year is an elective year, used to explore subspecialty areas such as dermatology, plastic surgery, and ophthalmology.  It also has the all-important “sub-internship.”  This is an opportunity for the fourth year student to take on the role of an intern on a team, usually in whatever specialty they plan to go into.  I obviously did my “sub-I” in internal medicine.  It was incredibly valuable- more on this later.  The fourth year also has a decent amount of time dedicated to applying to and interviewing at residency programs (time-consuming and expensive) and studying for the second step of the licensing boards.

Proponents of compressing medical school seem to have three main motivations.  Here are each of them, with my response.

1.  There is a projected physician shortage.  Compressing medical school will produce more physicians.

Shortening medical school will produce more physicians for exactly one year- the initial year of implementation.  As long as class size remains the same, after that first year the same number will graduate every year.  In addition, there are a set number of residency spots in the USA.  The number of spots is tightly controlled by Medicare, which funds the graduate medical education program.  Without more funding for residency programs, there is NO WAY to increase the amount of doctors.  There will just be more MDs without residency training who therefore can not be licensed.

As if this wasn’t enough- we need to train the right kind of physicians.  We need more primary care docs, not more specialists.  Very few would disagree with this.  Producing more doctors is worthless unless they are more primary care docs.

2.  Medical school is expensive.  Most students graduate more than $150,000 in debt.

So, something is too expensive, and the solution is to get rid of it?  How about…revising the cost of medical school?  Creating better loan programs?  Creating loan repayment incentives?  I can think of plenty of ways to reduce cost, short of discarding a year.  That’s throwing the baby out with the bathwater.

3.  The fourth year is useless, filled with low-key relaxing electives.  The lead author of the proposal even says:

“We can’t dissociate medical education from societal and student needs,” said Dr. Steven B. Abramson, lead author of the perspective piece in favor of three-year programs and vice dean for medical education, faculty and academic affairs at N.Y.U. “We can’t just sit back in an ivory tower and support a mandatory year of prolonged adolescence and finding oneself, when society needs doctors to get out into the community sooner.”

This line of reasoning annoys me even more than the others.  For me, the fourth year was incredibly valuable.  My medicine sub-I was amazing.  My team, the patients and the nurses treated me like a physician.  It was my first opportunity to truly take responsibility of my patients and my actions, but yet still have someone looking over my shoulder.  “Prolonged adolescence?”  I think not.  After my sub-I, I did rotations in ophthalmology, dermatology, urology, reproductive medicine, and physical medicine and rehabilitation.  All of those taught me things that I use to this day.  I did a study abroad rotation in Edinburgh.  It was great to experience health care in another country.  I honestly think I would have missed out on a lot had I not had a fourth year.

Let’s also not discount what life experience and age add to creating a physician.  When I did my rotation in Scotland, I worked with medical students there.  In Scotland, students do a six year undergrad/medical program rather than the 8 years that we do here.  On the whole, I noticed a difference in the maturity level between the med students there and the ones in my class back in Rochester.

Compressed programs have been tried in the past- six and seven year combined BS/MD programs and 3 year MD programs. Pretty much all have failed after a few years.  Students we exhausted by the pace.

Are we trying to produce robots or physicians that are also people?

Medical school should not be compressed.  At the rate that medical science is advancing, I think a more cogent argument could even be made for lengthening it.

It’s not the medical education system that needs fixing.

What needs fixing is the entire US healthcare system.

exercise, running, running injuries


Once again, sorry for the long blogging absence.  I’ve been a bit down.

It all started at the end of August.  I woke up in the middle of the night with intense back pain.  Terrible, terrible pain on the right side of my low back, heading down into my hip.  I tossed and turned for the rest of the night, gulping ibuprofen and arranging my pillows in creative arrays to allay the pain. No luck.  When the sun rose, I was still in pain.

Never one to do things the easy way, I went to work.  It was painful, but doable.  I told myself that things would be better the next day.  They weren’t.  Friday morning rolled around and the pain was even worse.  Nothing if not stubborn, I again went to work.  It was agony.  At this point, sanity started to prevail and I cancelled the rest of my patients.  (To everyone that had an appointment on August 30th, I apologize!!!)  I made an appointment for a massage.  It was painful, but after it I could at least stand up a bit straighter.  For about a minute.

By this time, I had pretty much figured out what was going on.  The iliopsoas is a huge muscle that runs from the lower thoracic spine to the inner hip.  It is one of the major hip flexor muscles.

It’s a deep muscle, and pretty hard to treat.  How I injured it is beyond me, but I suspect it has something to do with the nagging low back pain that I’ve been studiously ignoring and running through for the past 2 years.

At any rate, I spent Labor Day Weekend in a recliner.  I ate, rested, and slept in it, as it was the only place I was comfortable.  Come Tuesday, I was back at work, but still in pain.

It’s now 6 weeks later.  I’m doing better, in that I can walk without limping.  However, I still have pain.  And it’s really, really aggravating.  I’ll be starting physical therapy soon, so hopefully this will help.  I plan to start swimming again this weekend, and I hope to begin slowly running again soon.  I will try to take the advice that I give to patients after an injury- start slow and listen to your body.

We’ll see.

doctors are human too, primary care

It’s All Right to Cry

I’m a crier.  I always have been.

I well up during television commercials.  Many a book has been returned to the library somewhat waterlogged by my teardrops.

I cry when I’m sad, when I’m happy, and when I’m angry.  I cry when I laugh.

And I cry in front of patients.

I used to be embarrassed by this.  I’d hide my tears with a tissue and a muttered excuse of “allergies.”  Or I’d turn my back to wash my hands at the sink, furtively giving my eyes a swipe.

But sometime in the past few years, I stopped being ashamed of my tears.  My patients come to me and share both their happiest and their most terrible moments.  I’ve been honored to tell many patients that they’re pregnant.  Why shouldn’t I cry with happiness at the beginning of a new life?

I’ve also had to tell too many patients that they are dying.  I’ve sat with them and their families during their final hours.  And if they’ve allowed me into such a sacred time in their life, why should I hide my tears from them?

I care about my patients, deeply.  Some say that it’s wrong for doctors to show emotion, and that caring so much can lead to burnout.  I say that’s a load of bunk.

For me, the day I stop caring enough to cry with a patient is the day I hang up my white coat and find another profession.