Dr. Andy

Reflections on medicine and biology among other things

Wednesday, August 31, 2005


I don't have much to add. My prayers are with everyone affected, particularly the doctors working hard to care for the sick and injured in the face of so much adversity.

Add to that stuff like this
Children's Hospital under siege
Tuesday, 11:45 p.m.

Late Tuesday, Gov. Blanco spokeswoman Denise Bottcher described a disturbing scene unfolding in uptown New Orleans, where looters were trying to break into Children's Hospital.

Bottcher said the director of the hospital fears for the safety of the staff and the 100 kids inside the hospital. The director said the hospital is locked, but that the looters were trying to break in and had gathered outside the facility.
I'd encourage everyone to give what they can, as rebuilding as it sounds like New Orleans is basically destroyed

My personal pick is Catholic Charities but Instapundit and others have lists of other potential charities

Monday, August 29, 2005


One thing I find fascinating is how different physicians approach billing and how various incentives impact this. For so-called "non-procedural" specialties (those that rely on the brain not interventions) like allergy we have so called E&M codes which we have to assign to each patient. There are 5 levels, with 1 being minimal involvement and 5 an incredibly complex patient. New patients are worth more and for specialists billing a new patient as a "consult" (meaning someone, usually the primary care provider but sometimes another specialist specifically sent the patient to you) yields a higher payout.

Codes among specialties (E&M versus procedures for surgeons, etc) are each worth something called relative value units (RVUs).

The rules as to what you need to do (and document) for each level of billing make quantam mechanics seem easy, so there is a lot of subjectiveness in billing.

When I was a fellow we had 2 types of attendings: full time academics and volunteers in private practice who'd come in around 1/2 day per week and precept fellows. The full-time academics were signficantly more aggressive (i.e. billed at higher levels) in their billing than the attendings in private practice. Since each increase in RVU meant an increase in revenue, I'd have thought a priori that the private practice attending would bill higher since the money went right into their pocket, whereas the academics made a salary with some incentive income at the end of the year based on billing.

After a year as a full-time academic attending and having talked to a lot of attendings in both academics and private practice, I think I understand a bit better.
Physicians are very risk-averse and overbilling is a high risk strategy. It increases your current income (or incentive pay) but if you get audited, you can be in real trouble.

Imagine the private practice attending who gets audited. He gets a request for records of a set of patietns which is a pain to start. Then the insurance company concludes he has overcharged for a certain percent, extrapolates that to all his patients they've paid for and demands X dollars back. Then he has a dilemma. Do you just pay the money back (and this could be many months later, making it a big pain to come up with and an accounting/tax nightmare) or to fight. Every hour the attending personally spends is time not seeing patients and the outside is uncertain. He could hire help to fight, but that costs more money, again with uncertain return. So the low-risk strategy is to bill conservatively, make a bit less and not have to give money back when audited.

For someone in an academic instituion, the calculus is a bit different. First, since the money doesn't go right into your pocket it also won't come right out. I get paid a salary and I think there is some clause about fraud, but what might be considered a difference of opinion on billing isn't covered, so it would be very hard for the hospital to take money back from me. Second, the hospital is standing behind me ready to fight. Any academic institution has a small army of coding experts, lawyers and administators to comb records and contest "down-coding" done by insurance companies. The hospital incentive is to fight tooth and nail to discourage future audits not just of me but of every doctor and department. So from the perspective of someone on salary plus bonus you might as well bill aggressively and figure it won't be my problem if I eventually get down-coded on audit.

Of course, some institutions have relatively perverse incentives. In my case, I get a bonus based on hitting a signficant produc

Thursday, August 18, 2005


I've sent in my application and made my reservations for the Arkansas Traveller 100 mile race October 1st and 2nd (be cautious about any race that lasts more than 1 day).

It is hard not to feel some trepidation about such a long event, but I'll be more prepared for this race than any ultra I've done, having run 200+ miles in July and aiming for the same in August. My weight should also be good, but anyway you look at it 100 miles is a long way.

By the way committed is what I am to the race, not what should be done to me!

Ragweed is coming

If you are allergic (with symptoms such as nasal congestion, itching, mucous discharge and sneezing and red watery eyes in the fall) your life is about to get worse.

Some tips for avoiding the worst of it are here. I know it reads like an advertisement for allergists, but the AAAAI is our trade group.

Cost effective medicine

"Hospitalizations decreased 88 percent, and medical visits by almost 60 percent. Medical expenditures decreased by about 75 percent," said study co-author Dr. Abigail Shefer, a medical epidemiologist at the National Immunization Program run by the U.S. Centers for Disease Control and Prevention.
Original study is here (and it is impressive). Of course for some reason the study doesn't include medical care for all the kids rendered autistic by this vaccine (sarcasm, it is thimerisol free).

The one caveat is that it is unclear how long-lived protection from the vaccine virus will be. Since it is significantly attenuated (that is weakened) compared to wild-type, it is likely that protection will wane (unlike infection with the wild-type strain which provides life-long immunity). The good news is that zoster (reactivation of infection which lies dormant in nerve cells) seems to be significantly less severe in people who have been vaccinated. At worst, waning immunity will mean a booster shot every 10-20 years.

Bats and rabies

A sick bat found in a cabin at the Flathead Methodist Camp near Rollins led state health officials to tell the parents of 96 girls who stayed in that cabin this summer they should consider giving their children rabies shots.
Public health officials are so wishy-washy.

"Official" recommendations are that anyone who can't be absolutely sure they were not bitten get prophylaxis. From the CDC website:
because bats have small teeth which may leave marks that are not easily seen, there are situations in which you should seek medical advice even in the absence of an obvious bite wound. For example, if you awaken and find a bat in your room, see a bat in the room of an unattended child, or see a bat near a mentally impaired or intoxicated person, seek medical advice and have the bat tested.
Of course given that rabies is almost uniformly fatal (but see here) it seems prudent to be careful.

Tuesday, August 16, 2005

Light posting

Posting has been light recently due to a variety of factors including spending a lot of time running, my partner being out of town and not having too much interesting to say.

I'll have more soon. This is an interesting post (hat tip Instapundit, not that he needs any traffic from me) about science blogging. As bloggers scientists have a big advantage over physicians in that science tends to have a lot of down time built in where us clinicians are busy seeing patients which is less conducive to blogging. Having done both, I don't mean to disparage scientists in any way, I just had a lot more free moments when I was in lab.

Thursday, August 11, 2005

What we are up against


This is a good new cartoon for fit rationalists

Wednesday, August 10, 2005

Helmet laws and faulty reasoning

A National Highway Traffic Safety Administration study shows that motorcyclist deaths increased when mandatory helmet laws were repealed in Florida. So what is the response of groups who oppose such laws:

Charles Umbenhauer, a lobbyist for ABATE, or American Bikers Aiming Toward Education, which fought to make helmet-free riding legal here, said the Florida report doesn't add anything new to the debate. There are risks to motorcycle riding, so it's not surprising that people die while doing it, he said.

What is surprising, at least to Umbenhauer, is that physicians and hospital groups often trot out financial information to argue for laws that require helmet use. Citing a July report from the Pennsylvania Health Care Cost Containment Council, Umbenhauer noted that hospital-acquired infections are likely a much bigger source of costs, sickness and death.

What a stupid argument. I'm sure smoking causes more deaths than asthma, but does that mean we shouldn't treat asthma?

Race and medicine

I've posted before about BiDil, the first medicine approved for a specific racial group (heart failure in blacks). I basically concluded that it was better to save lives than be politically correct.

This article in Nature Medicine may make me reconsider. The concern is that, with the drug approved and doctor's using it off label (for non-blacks) the company has no more incentive to understand the biology of why it works in some patients and not others.

Race is just a marker for some difference in the underlying pathophysiology of heart failure and its use suboptimal because some blacks will get it but not benefit and some non-blacks would benefit but won't get it. But now that the drug is approved, the company doesn't have as much incentive to figure this all out. Of course statistically there are probably more non-blacks who would benefit than blacks who wouldn't (just because there are many more non-blacks) but that certainly isn't as powerful an incentive as getting the drug approved in the first place.

AIDS vaccine funding

I bet you won't read about this in the BMJ or Lancet.

From the August Nature Medicine, which points out that Europe makes a minimal contribution to efforts to find an HIV/AIDS vaccine

Worse, what money they do spend is probably not well spent: Europe continues to promote fragmented projects, researchers say, while elsewhere, the Global HIV/AIDS Vaccine Enterprise and the US National Institutes of Health (NIH)’s proposed Center for HIV/AIDS Vaccine Immunology are fostering collaborations.
Puts into perspective all those stories about how stingy the U.S. was with tsunami relief (I know those didn't include private contributions so were B.S. anyway)

Fraud, fraud, fraud

Both the BMJ and Lancet last week had multiple articles about suspected fraud. They involve a series of alleged trials run by by Dr. Ram Singh from India that are suspect on a number of levels: his research output was prolific, particularly from someone in an impoverished area with minimal facilities, no association with a university or major medical center and no outside funding. (article from India times with response by Dr. Singh here)

There is now overwhelming evidence that his papers are, at best, deeply flawed and probably made up. To list some of the problems identified many data are missing, there are statistical anomalies and many other Indian researchers have stated that the type of research reported (e.g. detailed diet diaries) are improbable in a poor, largely illiterate population.

Remarkably, the BMJ study was published in 1992 and despite years of concerns and ongoing investigations, the journal has just now come forward with its concerns. Unfortunately, the Lancet would almost certainly not of published its article in 2002 had it known of the concerns.

It seems to me there is a inexplicable reluctance to question suspect reasearch and to label it as fraudulent (or wrong in the case where fraud isn't clear). In every field I've been in there are reports in the literature that those "in the know" are aware are simply wrong. Sometimes it is fraud, others people just f*^&ed up experiments, but no one ever demands a retraction or investigation.

While this may not matter for an obscure basic science study, it can wreak havoc in clinical work, particularly with increasing reliance on meta-analysis.

Another problem is who investigates once concerns are raised. Journals say they don't have the resources or authority, but other potential investigators have their own problems: specifically, universities and institutes have conflicts of interest and limited resources and government bodies aren't usually equipped for such work. Given the incredible demands journals put on authors during review it would seem they could take a bit more responsibility for ensuring that studies withstand questions that arise and air any doubts more quickly.

I think this is a major issue for science and one that no one really wants to deal with. I know I don't have great confidence in what is published, partly because of fraud and partly because of sloppiness. But someone needs to take responsibility for determining the validity of published research once questions are raised.

UPDATE: more on fraud and a less than vigorous response to it here. To be fair, the acts described seem a bit short of meeting what I'd call criteria for fraud. Researchers seem to have padded their grant applications and violated an obscure NIH regulation, not fabricated data.

Tangled bank XXXIV

is here

I don't post a lot about evolution vs. creationism (labeled as such or disguised as intelligent design) for several reasons, including other people do a better job at defending evolution than I do, and I'm never convinced creationists are open to reason.

I do post from time to time on examples of evolution, especially in the immune system mostly because I have a strong interest and background in immunology, but also because what ultimately supports my own confidence in evolution is all the small examples I've seen of it's explanatory power.

Tuesday, August 09, 2005

Grand Rounds XXXXVI

is here

"Housing bubble" standards

Warning: I know less about economics than I know about politics, so use caution in trusting my posts on this subject

As a relatively new homeowner I am interested in all the buzz about whether or not we are in the midst of a housing bubble. As a scientist (or scientist want-to-be) I am concerned that the concept of "bubble" is not well defined. To some, any decrease in the rate of housing price inflation is taken as evidence of a bubble, which is clearly not what people have in mind.

As an example, noted economist Paul Krugman wrote on Monday:
Bubbles end when people stop believing that big capital gains are a sure thing. That's what happened in San Diego at the end of its last housing bubble: after a rapid rise, house prices peaked in 1990. Soon there was a glut of houses on the market, and prices began falling. By 1996, they had declined about 25 percent after adjusting for inflation.
Is that really a bubble? I'm not so sure. If you go to the BLS website and use the handy inflation calculator, you'll see that a cummulative inflation was 20% in the intervening 6 years (i.e. a dollar in 1990 was worth $1.20 in 1996). Looked at in those terms the "bubble" looks a lot less impressive. Nominal prices declined about 5% over 6 years; not the rate of return homeowners are looking for, but not exactly a crash either.

If I tell you that house prices nationally will decline about 5% in nominal turns over the next 6 years, I don't think that would panic anybody except speculators. Those of us living in our homes and paying our mortgages each month will keep on doing that. Mind you, I'm hoping for some appreciation but such a minimal decline (remember, mortgages are in nominal dollars) won't be a huge deal

Whenver someone warns me about the "housing bubble," I make them define what a bubble is. 20% decline in nominal values? 25%? Those kind of drops seem unlikely to me. If what you mean by bubble is flat to slowly increasing prices or even a modest decline (say <10%) then sure maybe we are in one, but to me that isn't a bubble.

Saturday, August 06, 2005

This is huge

Government scientists say they have successfully tested in people a vaccine that they believe can protect against the strain of avian influenza that is spreading in birds through Asia and Russia.

. . . although the vaccine that had undergone preliminary tests could be used on an emergency basis if a pandemic developed, it would still be several months before that vaccine was tested further and, if licensed, offered to the public
I've been skeptical about how bad this apparently unavoidable pandemic would be, for reasons like this.

Friday, August 05, 2005

Acupuncture works!

But not very well.

A randomized trial of acupuncture vs. sham acupuncture vs. nothing in treatment of osteoarthritis of the knee showed a significant improvement in pain and joint symptoms at 8 weeks for acupuncture itself.

That is the good news. The bad news is that the effect is lost after 8 weeks, calling its clinical importance into question. In addition, sham acupuncture (superficial needling of non-acupuncture points) was more effective than doing nothing, suggesting a strong effect of getting any treatment. As the accompanying commentary puts it:
The bottom line from Witt and colleagues’ large, long, and high-quality study of acupuncture for knee osteoarthritis is that doing something is better than doing nothing. The question is whether one sort of doing something is better than any other sort.
I've blogged previously on the need for rigourous trials of alternative and complementary approaches, and while acupuncture enthusiasts might see this trial as good news, the data suggest at most a more rapid improvement in the acupuncture group.

I also noted the negative trial of Echinacae on rhinovirus infection in the NEJM. Big surprise.

The accompanying editorial notes the resistance to logic among supporters of such supplements:
The Web page of a naturopathic organization that participated in a recent negative trial of echinacea2 paraphrased the authors as follows: "Weber and the other researchers conclude that other echinacea preparations and dosing regimens may be effective for the treatment of colds, even though the product they tested in children was not."
which nicely points out the problem of those who "believe" no matter how much negative data accumulates.

Thursday, August 04, 2005

Startling Statistic

We had a talk at Grand Rounds this morning on health care costs, and the speaker noted the following:

Starbucks pays most of the medical premiums for workers with >20 hours per week and now spends more on medical care than coffee.

Amazing, if true.

Wednesday, August 03, 2005

Foot care

I had the honor of meeting John Vonhof, probably the world's most eminent expert on foot care for athletes, when he worked at the same aid station I did at Western States. John started out helping athletes at ultramarathons and adventure races with foot problems, learned more and more about it until he wrote a book which became the bible of athletic foot care.

My friend Geoff bought the book before Western States this year, and to his amazement did not have a single blister after running 100 miles of often steep, rocky trail.

John has now started a blog devoted to, what else, foot care and I recommend it and his book whole-heartedly.

UPDATE: fixed link to blog; sorry about that