Posts Tagged ‘health care’

The Corona Virus Timeline.

Wednesday, April 1st, 2020

It is now becoming a theme on the left that Trump was not quick enough to recognize the coming epidemic.

For that reason, I think it valuable to keep a record of the time line.

Here is the January 12, 2020 WHO report on the virus epidemic in China.

The evidence is highly suggestive that the outbreak is associated with exposures in one seafood market in Wuhan. The market was closed on 1 January 2020. At this stage, there is no infection among healthcare workers, and no clear evidence of human to human transmission. The Chinese authorities continue their work of intensive surveillance and follow up measures, as well as further epidemiological investigations.

Here is the January 30, 2020 report by WHO on the epidemic in China.

The Committee believes that it is still possible to interrupt virus spread, provided that countries put in place strong measures to detect disease early, isolate and treat cases, trace contacts, and promote social distancing measures commensurate with the risk. It is important to note that as the situation continues to evolve, so will the strategic goals and measures to prevent and reduce spread of the infection. The Committee agreed that the outbreak now meets the criteria for a Public Health Emergency of International Concern and proposed the following advice to be issued as Temporary Recommendations.

The Committee emphasized that the declaration of a PHEIC should be seen in the spirit of support and appreciation for China, its people, and the actions China has taken on the frontlines of this outbreak, with transparency, and, it is to be hoped, with success.

Trump stopped incoming flights from China on January 31, 2020.

At this point, sharply curtailing air travel to and from China is more of an emotional or political reaction, said Dr. Michael T. Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

“The cow’s already out of the barn,” he said, ”and we’re now talking about shutting the barn door.”

A Minnesota epidemiologist’s opinion.

Nancy Pelosi tours Chinatown on February 24, 2020.

House Speaker Nancy Pelosi made a point of taking a walk through San Francisco’s Chinatown on Monday to show that it is safe, after some merchants have seen a 50% drop in business as some fear they could be exposed to the coronavirus.

As her visit began, a large portion of Chinatown had lost power. That didn’t deter the Speaker from walking along Ross Alley and Grant Avenue.

“I’m here,” she said. “We feel safe and sound with so many of us coming here. It’s not only to say it’s safe but to say thank you for being Chinatown.”

On March 16, 2020, Mayor de Blasio was still enouraging people to attend crowded events.

For most of last week, as Mayor Bill de Blasio continued to urge New Yorkers to mostly go about their daily lives — sending their children to school, frequenting the city’s businesses — some of his top aides were furiously trying to change the mayor’s approach to the coronavirus outbreak.

There had been arguments and shouting matches between the mayor and some of his advisers; some top health officials had even threatened to resign if he refused to accept the need to close schools and businesses, according to several people familiar with the internal discussions.

So much for the urgency in dealing with the epidemic.

Some thoughts on what reform in healthcare would look like.

Monday, April 1st, 2019

I have previously posted some articles on the French healthcare system, which is the best in Europe.

Here is an article on the French system.

The French citizen or resident joins Caisse Nationale d’Assurance Maladie deTravailleurs Salariés (CNAMTS)—health insurance organisation for salaried workers. That covers about 80% of the population now and it pays 80% (often more like 70%) of a fee schedule for the doctor visit although specialists are allowed to charge more. French doctors are divided for payment and fee schedule purposes into three “sectors” after 1980. Sector 1 doctors agreed to abide by the fee schedule established in 1960, modified for inflaton and technological changes. They are mostly primary care doctors although some had waivers from the fee schedule prior to 1971 because they were more experienced or had great reputations. Few are still practicing. Sector 2 doctors could set their own fees but reimbursement was still determined by the fee schedule. These two categories correspond roughly to Medicare assignment in the US. If you accept assignment, you agree to accept Medicare payment as the full payment (or 80% of it plus the Medi-Gap payment).

The French have private insurance companies that provide what we call “Medi-Gap policies for Medicare. Theirs cover everyone.

It seems unlikely to me that Democrats would accept a health plan that allowed balance billing, which is the only way to control costs, short of pure rationing. The French basically provide a fee schedule that is the same for everyone but which allows doctors to charge more if the patient is willing to pay. For example, I called the office of a new internist last week to schedule an appointment. The clerk required that I submit all my insurance information, not my health status, and the doctor would decide if he would see me. If he is that busy, perhaps he could justify charging more.

Here is another article from that series explaining the French system.

French primary care physicians are paid less than American but medical school in France does not require a college degree and is free. I suspect that system might be more attractive in the US than many realize.

Unfortunately, such a radical reform is unlikely. There are other options under consideration.

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Where is health care going ?

Saturday, August 25th, 2018

UPDATE: A new analysis of Obamacare’s role in the conversion of American Medicine to an industry with corporate ethics.

The health system is now like a cocaine junkie hooked on federal payments.

This addiction explains why the insurance companies are lobbying furiously for these funds alongside their new found friends at left-wing interest groups like Center for American Progress. The irony of this alliance is that the left-wing allies the insurers have united with hate insurance companies and want to abolish them. The insurance lobby is selling rope to their hangman.

Hospital groups, the American Medical Association, the AARP and groups like them are on board too. They are joined by the Catholic Bishops and groups like the American Heart Association and the American Lung Association. (If you are donating money to any of these groups you might want to think again.) This multi-billion dollar health industrial complex has only one solution to every Obamacare crack-up: more regulation and more tax dollars.I practiced during what is more and more seen as a golden age of medical care. Certainly the poor had problems with access. Still, most got adequate care, either through Medicaid after 1965, or from public hospitals, many of which were wrecked by Medicaid rules and by the flood of illegal aliens the past 40 years.

Obamacare destroyed, probably on purpose, the healthcare system we had. It had been referred to by Teddy Kennedy, the saint of the Democrats Party as “a cottage industry.” As far as primary care was concerned, he was correct. What we have now is industrial type medicine for primary care and many primary care doctors are quitting.

So why is there waning interest in being a physician? A recent report from the Association of American Medical Colleges projected a shortage of 42,600 to 121,300 physicians by 2030, up from its 2017 projected shortage of 40,800 to 104,900 doctors.

There appear to be two main factors driving this anticipated doctor drought: First, young people are becoming less interested in pursuing medical careers with the rise of STEM jobs, a shift that Craig Fowler, regional VP of The Medicus Firm, a national physician search and consulting agency based in Dallas, has noticed.

“There are definitely fewer people going to [med school] and more going into careers like engineering,” Fowler told NBC News.

There are several reasons, I think. I have talked to younger physicians and have yet to find one that enjoys his or her practice if they are in primary care. That applies to both men and women. Women are now 60% of medical students. This has contributed to the doctor shortage as they tend to work fewer hours than male physicians.

A long analysis of physician incomes shows that 22% of females report part time work vs 12% of males.

Physicians are the most highly regulated profession on earth. The Electronic Health Record has been made mandatory for those treating Medicare patients and it has contributed a lot to the dissatisfaction of physicians.

THE MOUNTING BUREAUCRACY
This “bottleneck effect” doesn’t usually sour grads on staying the course, Fowler finds, but he does see plenty of doctors in the later stages of their careers hang up their stethoscopes earlier than expected. Some cite electronic health records (EHRs) as part of the reason — especially old school doctors who don’t pride themselves on their computer skills. New research by Stanford Medicine, conducted by The Harris Poll, found that 59 percent think EHRs “need a complete overhaul;” while 40 percent see “more challenges with EHRs than benefits.”

If I remember my arithmetic, that adds up to 99% unhappy with the EHR.

Most primary care physicians I know are on salary, employed by a hospital or a corporate firm. They are require to crank out the office visits and are held to a tight schedule that does not allow much personal relationships with patients. The job satisfaction that was once a big part of a medical career is gone.

Does Hillary Clinton have Parkinson’s Disease?

Sunday, September 18th, 2016

The Hillary collpase last Sunday has prompted a lot of speculation on her condition. Early on I was inclined to blame her neurological condition on her history of concussion and cerebral vein thrombosis.

That seemed logical, given her history. However, it does not explain her quick recovery. It also has nothing to do with pneumonia.

This video has now convinced me that she has Parkinson’s Disease, and it is fairly advanced. In the video, the physician mentions Apomorphine, which is not morphine but an alpha adrenergic drug used in Parkinson’s Disease.

Currently, apomorphine is used in the treatment of Parkinson’s disease.

What use does it have in Parkinson’s? It is used for “Non-motor symptoms.”

What does that mean ? Parkinson’s Disease is characterized by a serious of motor disabilities.

The cardinal symptoms of Parkinson’s disease are resting tremor, slowness of movement (bradykinesia) and rigidity. Many people also experience balance problems (postural instability). These symptoms, which often appear gradually and with increasing severity over time, are usually what first bring patients to a neurologist for help. Typically, symptoms begin on one side of the body and migrate over time to the other side.

These symptoms are typically controlled with Dopamine like drugs, such as L-Dopa. There are other symptoms less easily controlled.

For example, in advanced cases, difficulty swallowing can cause Parkinson’s patients to aspirate food into the lungs, leading to pneumonia or other pulmonary conditions. Loss of balance can cause falls that result in serious injuries or death. The seriousness of these incidents depends greatly on the patient’s age, overall health and disease stage.

Hmmmm.

There are also side effects of L Dopa.

L-DOPA therapy is further complicated by the development of movement disorders called dyskinesias after 5 – 10 years of use in most cases.

Dyskinesias are movement disorders in which neurological discoordination results in uncontrollable, involuntary movements. This discoordination can also affect the autonomic nervous system, resulting in, for example, respiratory irregularities (Rice 2002). Dyskinesia is the result of L-DOPA-induced synaptic dysfunction and inappropriate signaling between areas of the brain that normally coordinate movement, namely the motor cortex and the striatum (Jenner 2008).

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Interesting comment on Hillary’s career.

Friday, July 29th, 2016

This was posted on facebook as a comment to a WSJ piece on her campaign strategy.

Dick Morris, former political adviser to President Bill Clinton: If you happen to see the Bill Clinton five-minute TV ad for Hillary in which he introduces the commercial by saying he wants to share some things we may not know about Hillary’s background, beware as I was there for most of their presidency and know them better than just about anyone. I offer a few corrections:
Bill says: “In law school Hillary worked on legal services for the poor.”
Facts are: Hillary’s main extra-curricular activity in ‘Law School’ was helping the Black Panthers, on trial in Connecticut for torturing and killing a ‘Federal Agent.’ She went to Court every day as part of a Law student monitoring committee trying to spot civil rights violations and develop grounds for appeal.

Was this true ? Snopes has a sort of rebuttal.

Hillary Rodham (as she was known then) wasn’t a lawyer then, either: She was a Yale law student, and like many of her politically-minded fellow law students who saw the latest “trial of the century” taking place just outside the main gate of their school, she took advantage of an opportunity to be involved in the case in a minor, peripheral way by organizing other students to help the American Civil Liberties Union monitor the trials for civil rights violations. Her tangential participation in the trial in no way helped “free” Black Panthers tried for the murder of Alex Rackley

So the description credited to Morris is correct.

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Another update on the NHS, Bernie’s favorite health plan.

Friday, February 12th, 2016

NHS

I have mentioned problems with the NHS here before.

That was about emergency care.

Last fall there was a concern about junior doctors emigrating to other countries.

Britain is already suffering from a serious, and unprecedented, shortage of GPs, on a scale that doctors’ leaders say is fast becoming a crisis.

According to figures released last week, a staggering 10.2 per cent of full-time GP positions across the UK are currently vacant, a figure that has quadrupled in the past three years.

Two-thirds of practices are now finding it ‘difficult’ or ‘very difficult’ to find locums — freelance medics — to cover the shortfall.
As our population gets steadily older, and sicker, frontline surgeries are becoming increasingly swamped.
‘We are in dire straits if we do not act to address the GP recruitment crisis immediately,’ the Royal College of GPs warned last week.

In standard government medicine fashion, the British Health Minister imposed a new employment contract that ignored doctors complaints.

The result ?

Junior doctors are threatening a mass exodus to Australia after Jeremy Hunt forced through his controversial new contract yesterday.
There has been a huge surge in the numbers seeking certificates to practise abroad and some have already lined up jobs.
Almost 760 doctors were issued with documents by the General Medical Council in the first four weeks of this year – nearly 200 a week and almost double the usual number. Although they include some older GPs and consultants, the vast majority were disillusioned younger doctors.

Becoming a doctor is a classic middle class occupational choice. Few doctors become rich and almost none do so from actual practice. There was a phase in the 1960s when doctors suddenly became much more prosperous as Medicare was introduced, providing payment for care that had been done for no charge mostly. With time, the US government has reduced compensation and imposed rules designed to reduce costs. With the imposition of Obamacare, many older doctors who do not have heavy student loan balances and whose own children are educated, are choosing to drop all insurance, including Medicare, and practice for cash.

Obamacare has resulted in many hospitals consolidating and buying up medical practices to develop a vertically integrated system of health care delivery that resembles old industrial models. The result for physicians is a trend to salary jobs and dissatisfaction with their careers.

I met a woman geriatrician, the only fellowship trained geriatric specialist in central Iowa. She had quit Medicare. That sounds a bit suicidal if all your patients are Medicare age. What had happened was she was being harassed by Medicare because she was seeing patients too often. Many of them were frail elderly living at home. She dropped out and began charging her patients cash for services. She was making a decent living after a year and was happy with her decision. I don’t know how many realize that geriatrics, as a specialty, is a university subsidized field. There is no private geriatric practice because the doctor can’t survive on what Medicare pays. She tried and had to quit. She is doing it on her own now.

That was about Medicare. The same is happening with Obamacare and the medical conglomerates that have been assembled in anticipation of the “Industrial Model” of medical care. How is that working out in Britain ?

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The Muslim war on immunization.

Saturday, January 16th, 2016

If anyone wonders about the level of civilization in Muslim countries and especially those in “radical” or “takfiri” subsets, the war on polio immunization should be a clue.

Recently, a suicide bomber attacked a polio immunization center in Pakistan.

The World Health Organization’s anti-polio vaccination program inside Pakistan has been a prime target of the Taliban. Mullah Fazlullah, the emir of the Movement of the Taliban in Pakistan, was one of the first leaders to have opposed polio vaccinations. On his radio program, Falzullah, who is also known as Mullah Radio, denounced polio vaccinations as Western attempts to sterilize Muslim boys.

Other Taliban commanders, including Mullah Bahadar and Mullah Nazir, who was killed in a US drone strike, as well as Pakistani clerics and leaders in the tribal areas, suspended polio vaccinations in areas under their control until the US ceased drone strikes against Taliban, al Qaeda, and other jihadist commanders.

Taliban commanders have also accused vaccination programs as serving as cover for CIA and western operations to target jihadist leaders inside Pakistan.

The largely Muslim state of Uttar Pradesh in India has been the last outpost of remaining polio cases in the world.

India was declared free of the wild polio virus in January 2011 however cases of flaccid paralysis continue to be reported in thousands from across the country. “In spite of the WHO declaring India polio-free, there has been an increase in the cases of non-polio paralysis. It is a huge cause of concern,” said Dr SD Gupta, president, IIHMR University.
In 2004, 12,000 cases of non-polio paralysis were reported which increased to 53,563 cases by 2012. According to the data published by the union health ministry in July, 2015, the total number of non-polio acute flaccid paralysis (NPAFP) cases across the country were 18,141, of which 5918 were reported from UP, 668 from Rajasthan, 102 from Telangana, 385 from Karnataka and 865 from Maharashtra, among others.

What is going on ? It seems that new enteroviruses may be involved. India has been largely successful in eliminating wild Polio virus.

India’s success in eliminating wild polioviruses (WPVs) has been acclaimed globally. Since the last case on January 13, 2011 success has been sustained for two years. By early 2014 India could be certified free of WPV transmission, if no indigenous transmission occurs, the chances of which is considered zero.

Great efforts were made.

The VE against types 1 and 3 was the lowest in Uttar Pradesh and Bihar, where the force of transmission of WPVs was maximum on account of the highest infant-population density. Transmission was finally interrupted with sustained and extraordinary efforts. During the years since 2004 annual pulse polio vaccination campaigns were conducted 10 times each year,

Muslims are determined to stop this effort. More evidence that they are not ready for civilization.

2015 is gone, thank God.

Friday, January 1st, 2016

2015-a-maes-Marty_thumb

I am content to see the year 2015 gone. I can remember as a college student thinking that 1960 would never come. That was a good year. I didn’t graduate from USC as planned but I did get married and I did get accepted to medical school.

Some of the story is here in my short biography. More of it is here in my “stream of consciousness.” The next installment is here as I describe Basic Training.

When I got back from Basic Training in December 1959, I had my first date with Irene Lynch. A year later to the day, we were married and a week later, I got a letter from SC Medical School telling I had been accepted to the class beginning in September 1961. So, 1960 was a pretty good year.

In 2015 I spent what I think will be my last year teaching medical students at what is now named “Keck School of Medicine of USC” and is where I attended from 1962 to 1966. I went back to teaching there in 1998 in a program called Introduction to Clinical Medicine, which seems to be disappearing into the “Family Medicine” Department which is a shame.

I now have a book of memoirs called “War Stories: 50 years in Medicine” and which is a Kindle book only so far. Much of my medical school experience is included along with stories from my years as a surgeon. It started to be “40 years a surgeon” but I decided to include the rest and changed to 50. In June 2016, it will 50 years since I graduated from Medical School and that seemed a appropriate.

I enjoyed my time with students and I am quitting only because of frustrations with the Electronic Medical Record, about which I used to be enthusiastic, and with changes in the County Hospital which used to be a wonderful teaching institution. The Electronic Medical Record, now more often called The Electronic Health Record, probably because much of it is not about medicine, is a big problem.

The EHR, as it is called, has acquired a bad reputation.

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An update for fans of the NHS

Friday, November 27th, 2015

NHS

I have posted a number of essays on what I think health reform should look like. None of it looks like the NHS. Now, we have new information about how the NHS is functioning.

Figures collected by the Royal College of Emergency Medicine (RCEM) over the last seven weeks showed 88 per cent of A&E patients were treated or admitted within four hours – seven per cent below the 95 per cent target.
The report said that hospitals are also experiencing major problems discharging patients who are medically fit to go home.
Hospitals in England are failing to meet the 95 per cent target of seeing patients within four hours

The problem is being exacerbated by ‘bed blocking’ – where a patients cannot leave because there is not the right support in place in the community – with about a fifth of hospital beds being occupied in some parts of the UK.
Experts say the increasing problems in social care are having a major impact on the NHS.

This is an old problem with free care. We used to have patients in County hospital who would heat thermometers with hot coffee to avoid being sent home. Some of them were mentally disturbed and I have one such story in my book, “War Stories; 50 years in Medicine.

The NHS is having troubles all over.

The data shows performance getting worse since hospitals began submitting the data at the start of October.
Then, just over 92 per cent of patients were seen in four hours, falling to 88 per cent in the middle of November.
More than 6,300 planned operations have been cancelled over the seven-week period.
As an overall average, each site cancelled 21 operations per week, ranging from no cancellations to 137 in a single week.
The Department of Health and NHS England used to publish weekly data for England on how A&E departments were performing but have now stopped doing so.
Instead, data is published monthly but only covers figures from more than a month ago.

Hiding bad news is an old tactic of bureaucracies.

The Medical History of the American Civil War IV

Friday, September 4th, 2015

More of the series on my lecture on the Civil War.

Slide30

The Ambulance Corps were organized and the photo shows one group during the war.

Slide31

The next Army Surgeon General was Letterman who changed Tripler’s organization and built larger hospitals and worked on sanitation projects that had been ignored by the early medical services. Disease was a greater risk to soldiers than wounds and had been since Classical Greece. When large numbers often were accumulated without proper sanitation, disease was rampant. Florence Nightingale was one of the first to realize the importance of cleanliness.

Slide32

One of the greatest medical pioneers of the Civil War was John Shaw Billings who designed hospitals, including The Johns Hopkins Medical Center. He was never Surgeon General but he did organize what became the Public Health Service.

Slide33

One of Letterman’s new hospitals was this one which was constructed in time for the battle of Gettysburg.

Slide34

One of the brilliant surgeons who joined up and contributed was this man, John H. Brinton. Typically, he was dismissed by the politicians around Lincoln because McClellan had appointed him.

Slide35

The most common medical problem was chronic diarrhea.

27,558 Union soldiers died of chronic diarrhea. Without bacteriology, still unknown in 1865, it is impossible to trace the causes.

Typhoid fever killed another 27,056 soldiers.

In the Boer War, in 1899 to 1902, typhoid fever killed thousands of British troops.

of the British Force of 556 653 men who served in the Anglo-Boer War, 57 684 contracted typhoid, 8 225 of whom died, while 7 582 were killed in action.(11) As had been the experience in America, the disease was found to be one which occurred in static camps.

This occurred years after infectious diseases had been identified and the cause of illnesses had been described.

The First Word War was the first war in which more men died of wounds than of disease.

Slide36

This slide, from the “Medical and Surgical History of the War of the Rebellion, shows the seasonal nature of the disease. The nutritional aspects are seen in the incidence during the siege of Atlanta.

Slide37

One example of another page of the History. There were over a million cases of acute diarrhea during the war. “Colored Troops” only appeared after 1863.

Slide38

Diseases were classified according to the medical knowledge of the time. “Miasma” were those which we now know to be infectious. Malaria, for example, mean “Bad Air” in Latin.

Slide39

Tuberculosis was a severe chronic disease which would not be curable until Streptomycin came along in 1946. There were two forms, “consumption” which was the pulmonary form, was not known to be contagious. “Scrofula” is the cervical lymph node form and is associated with milk from infected cows. This was the form studied by Louis Pasteur who recognized that it was transmissible and that heating milk prevented it.

Slide40

Treatment of disease was as primitive as one might expect although quinine was known and used by the Union Army. The blockade of the South prevented its use there. Vaccination was widely practiced and opium was used for pain. There was anesthesia since 1846 and chloroform was more common than ether.

Slide41

Malaria was widespread in the US at the time. Mosquitoes were vaguely known to be associated. Mosquito nets were used although the mechanism was not well understood.