Compression-only CPR (video)

A research group from The University of Arizona's Sarver Heart Center developed and tested compression-only CPR. A new commentary by this group appears in the May 2011 issue of The American Journal of Medicine. To learn how to perform compression-only CPR check out this video.

AJM Editor-in-Chief previews the May issue (video)

New articles in press posted on AJM's website

Three new articles in press were posted on The American Journal of Medicine's website this week. All three are currently available for free.

Painless Horner's Syndrome Through Occupational Exposure, June 2011 issue

Dysgeusia: An Atypical and Neglected Psychiatric Symptom Induced by Fibrillary Astrocytoma, June 2011 issue

Elephantiasic Thyroid Dermopathy, September 2011 issue

Ryan's Medicare overhaul: Would it increase the rate of medical bankruptcy?

Blog Commentary

With no Democratic support, the US House of Representatives passed Rep. Paul Ryan's much-ballyhoo'd 2012 budget proposal on Friday, April 15.

Rather than go into great detail regarding Ryan's Path to Prosperity, I'm going to focus on one piece that could be financially devastating for many Americans-- his plan to remake Medicare into a voucher system for anyone currently under 55 years of age. This is a financially dangerous idea.

A group of Harvard researchers has released multiple studies showing that medical costs contribute to more bankruptcies in the US than any other factor. Reporting in The American Journal of Medicine in 2009...

Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.[Emphasis added.]

In other words, patients were almost 2.5 times more likely to go bankrupt because of medical bills in 2007 than in 2001 (when this group conducted its first landmark medical bankruptcy study). And 75% of these bankruptcies were among people who had health insurance.

Fast forward to 2011, the same Harvard research group revealed new data regarding medical bankruptcies in the State of Massachusetts. (You'll remember that Massachusetts passed healthcare reform several years ago under then Governor Mitt Romney. The Massachusetts plan requires people to buy health insurance; this plan was the blueprint for the much-maligned Affordable Care Act [AKA Obamacare].) What they found was that even though healthcare reform provided widespread coverage in Massachusetts, it didn't significantly reduce the number of people going bankrupt due to medical bills. From The American Journal of Medicine blog...

Despite broad insurance coverage in Massachusetts after reform, bankruptcy filings due to medical costs did not decrease significantly between 2007 and 2009. There is a web of causality behind this finding. Although only 11% of Massachusetts debtors remained uninsured, there was widespread underinsurance, leaving people with high out-of-pocket costs in deductibles, co-pays, and uncovered services. In addition, many debtors lost their jobs due to illness or experienced reduced income due to illness. In cascading events, loss of income led to loss of housing in many cases. [Emphasis added.]

So, what's this got to do with Ryan's voucher system? A lot! For everyone who is currently under 55, Ryan proposes to change Medicare to a voucher system. Everyone would receive an annual allowance-- $15,000/year is what Rachel Maddow reported but real numbers are hard to obtain. This allowance would be a set amount and would not increase at the rate of inflation. During the year, any medical costs over that annual allowance amount would be paid out of pocket by the individual.

The Congressional Budget Office estimates that Ryan's plan may help save the government money, but seniors could end up paying an additional $12,510 each per year. This figure assumes no major changes in health status; anyone who has the misfortune to contract a serious illness, has a major accident, or needs an expensive surgery would, of course, pay much more than that.

The bottomline is people are going bankrupt at an increasing rate due to medical bills, and even with healthcare reform in Massachusetts, people are still going bankrupt because many people are buying inadequate insurance (AKA what they can afford). Given these realities, if the government forces people to pay all medical costs after a certain dollar figure has been reached, there could be an astronomical increase in bankruptcies in the US-- especially if the feds choose a ridiculously low allowance figure.

-- Pamela J. Powers, MPH, AJM Managing Editor

The Perils of Video Games

Disc Jockey Tenosynovitis

A healthy 25-year-old, left-hand dominant woman presented to clinic experiencing progressively worsening pain for 2 weeks in her right thumb. The pain was intense on waking and increased when grasping objects or shaking hands. She denied trauma and said she had not previously experienced thumb pain while working as a beautician for the past 3 years. The patient reported that 1 month earlier she began playing the video game “DJ Hero” during most nights of the week for several hours at a time...

In the video game “DJ Hero,” players use a simulated turntable to repetitively and quickly move their right wrist back and forth (radial and ulnar deviation) while pushing 3 colored buttons with the right hand to match the beat of the music identified by colored icons on the screen. The motion is designed to simulate the “scratching” of a vinyl record on a turntable that some disc jockeys have performed over the past few decades.

To read this article in its entirety, please visit our website.

-- Allan L. Suttle, MD, Erik A. Wallace, MD

This article originally appeared in the April 2011 issue of The American Journal of Medicine.

Tort Reform: Liability Protection Removed from Connecticut's New Healthcare Plan

Blog Commentary

A recent editorial in The American Journal of Medicine-- The 800-Pound Gorilla in the Healthcare Living Room-- resulted in a minor tidal wave of physician comments about the cost of defensive medicine in the US and the addition of tort reform to the Affordable Care Act when it is revised. Here are just a few of the many comments AJM received.

As practicing physicians, we're are never afforded the luxury of making any mistakes...period. A mistake, or percieved mistake, is magnified tremendously in the hair salons and country clubs and can do great harm to a physician's credibility, particularly in smaller towns. So, until the public learns to accept clinical judgement and the inherent occasional misdiagnosis, there will be very little change in the way we physiscians practice.

I recently cared for a patient during rounds as a hospitalist who had been admitted with numerous vague complains in the past year, this time headache. Review of her chart showed over 30 CT scans of various parts in the preceding year, including 2 of her brain in the past week, all negative. It is time we stop worrying about losing our careers to a frivolous lawsuit and spend more time caring for the health of our patients. Not only it is costly to society and to the patient, but unnecessary tests can also be harmful.

From the beginning of med school, we hear about lawsuits. Fear is rampant. Every Dr I know practices defensive medicine. The costs are astronomical. I have seen thousands of examples.

I wish to divert attention to another commentary in the same journal, "On the Critical List: The U.S. Institution of Medicine". Another organization setting the "rules of the game" as deliniated in this article can be the legal profession.

Ironically, as physicians debated defensive medicine on AJM's blog, trial lawyers in Connecticut successfully removed liability protection from that state's new healthcare plan for the indigent. From the Hartford Courant...

...a key provision of the plan was that doctors, in return for following the new procedures and ordering fewer tests, would be protected from malpractice suits if the outcome of a case was not favorable for the patient. However, with backing from the Connecticut Trial Lawyers Association, that provision was removed from the SustiNet bill two weeks ago.

According to the newspaper, cardiologists are fighting back against the lack of malpractice protection in Connecticut's plan.

Cardiologists are considered a particularly important group for the new best-use procedures because they tend to order a battery of expensive tests when patients show signs of heart trouble. If specialists like them failed to participate in the SustiNet program, cutting medical costs could be more difficult.

On Tuesday, the Connecticut chapter of the American College of Cardiology withdrew its support for the bill and said that it would circulate an open letter to House Speaker Christopher G. Donovan and Gov. Dannel P. Malloy saying that it could not support the bill without the malpractice protection.

At Better Health, a community of blogging doctors, one physician predicts doctors will begin to "play hardball" over malpractice reform.

As screws continue to get tightened on doctors’ ability to order tests thanks to third-party oversight bodies, look for more physicians to play hardball about liability limits at both the state AND national levels.

Doctors are being forced to do do their part to control health care costs as a result of our increasingly government-controlled health care initiatives. It’s high time for the trial lawyers’ to do the same. And there’s already precedent to doing so: just look to the legal protections military doctors enjoy when caring for their members. While legal recourse still exists in the military, the challenge of suing the government on behalf of their employees thwarts frivolous claims.

What is playing out now in Connecticut foreshadows what will happen if and when tort reform is addressed at the national level.

-- Pamela J. Powers, MPH, AJM Managing Editor

Role Modeling: A Personal Anecdote

The term “role model” refers to someone who is a colleague, often an older and more experienced individual, commonly imitated by younger colleagues. This interaction usually occurs in a professional setting. A role model can also be a mentor, a topic on which I have written in another editorial.1 In thinking about this topic recently, I was struck by how much of my own professional behavior was and still is modeled after traits that I found admirable in various individuals from my early educational and professional life.

You also may find it interesting that this term first appeared in Robert K. Merton's socialization research of medical students.2 Merton suggested that students compare themselves with individuals or reference groups of people who occupied the social role to which they themselves aspired. As for me, I am convinced that role modeling begins in early childhood. For instance, our 2.5-year-old granddaughter says, “I do it” about something and then attempts to imitate how my daughter, my wife, or I have performed some activity. My wife and I are convinced that we ourselves imitate the hard-working and serious demeanor of our parents, who lived through the great economic depression of the 1930s. My university and medical school teachers or career mentors served as role models for professional behaviors I still practice. Let me give you some specific examples. During my undergraduate years at Yale University, I consciously wished to imitate the style and substance of 3 individuals. The characteristics I admired have become part of my own daily work personality.

The first of these role models was Charles Garside, an assistant professor of European history who lectured to a vast class in the first semester of a European history survey course. Professor Garside was one of the most charismatic and inspiring speakers that I had ever seen up to that time in my life. As a result of his highly effective teaching skills, my roommate and I made great efforts to assimilate the huge amount of material that this course covered. His lectures were so exciting that we literally felt like we were “walking on air” when we left the classroom...

To read this article in its entirety, please visit our website.

-- Joseph S. Alpert, MD, editor-in-chief, American Journal of Medicine

This article originally appeared in the April 2011 issue of The American Journal of Medicine.

The Consequences of Requesting “Dispense as Written”

Almost 5% of all prescriptions are designated as "dispense as written" and request a brand name drug, rather than a generic drug. Dispense as written requests for chronic prescriptions have been associated with a 50% - 60% greater odds that patients will not fill the prescription.

Abstract

Background
All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.

Methods
We identified beneficiaries of a large pharmacy benefits manager who submitted a prescription claim from any pharmacy in January 2009. We categorized claims as a physician-assigned dispense as written, patient-assigned dispense as written, or no dispense as written. We described rates of these requests and used generalized estimating equations to evaluate physician, patient, treatment, and pharmacy characteristics associated with dispense as written requests. We also used generalized estimating equations to assess the relationship between dispense as written designation and rates prescriptions are not filled by patients.

Results
Our sample included 5.6 million prescriptions for more than 2 million patients. More than 2.7% were designated as dispense as written by physicians, and 2.0% were designated as dispense as written by patients. Substantial variation in dispense as written requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). When chronic prescriptions were initiated, physician dispense as written (odds ratio 1.50, P<;.001) and patient dispense as written (odds ratio 1.60, P<;.001) were associated with greater odds that patients did not fill the prescription. Conclusion
Dispense as written requests were common and associated with decreased rates of prescription filling. Options to reduce rates of dispense as written requests may reduce costs and improve medication adherence.

To read this article in its entirety, please visit our website.

-- William H. Shrank, MD, MSHS, Joshua N. Liberman, PhD, Michael A. Fischer, MD, MPH, Jerry Avorn, MD, Elaine Kilabuk, BA, Andrew Chang, MPH, Aaron S. Kesselheim, MD, JD, Troyen A. Brennan, MD, JD, Niteesh K. Choudhry, MD, PhD

This article originally appeared in the April 2011 issue of The American Journal of Medicine.