Bad science in clinic

I was very disappointed by my recent preceptor, who's pretty good with practicing evidence-based medicine (even when it contradicts the current trends), at recommending an unproven treatment to a patient. We had a patient with reflux disease who was well-controlled with a proton-pump inhibitor (PPI). He suggested that acupuncture might be a good alternative. Then went on to describe this study, in which patients who failed standard therapy with a PPI were randomized into one group that received a double-dose of PPI and another group that received acupuncture in addition to the standard dose. Surprise, surprise, the acupuncture group got better. This is a terrible study that is doing nothing but comparing apples to oranges. First of all, if patients failed standard therapy, the chances of failing a double dose is pretty damn high. Second, where is the control for acupuncture? How do we not know that the acupuncture group is getting a placebo effect? They could have easily placed needles in the wrong places as a control. Third, this doesn't even apply to the patient we were talking to, she was responding to PPIs. Overall, terrible advice by an otherwise well-informed doctor. At least he described the methods to the patient. Luckily, the patient preferred sticking to her trusty PPI.

The one thing I learned from the paper: In the UK, GERD is called GORD (gastro-oesophageal reflux disease).

In the donut hole

Ms. X is a 80-something year-old woman with congestive heart failure, high blood pressure, diabetes, rheumatoid arthritis and asthma (among other things). She on about 15 medications that adds up to nearly $4000 a year. Unfortunately, this falls right in the middle of the famous donut hole of Medicare Part D (the prescription coverage part of medicare). I never really thought much about it until I saw how this affects Ms. X. Here’s Medicare Part D’s payment schedule from 2010:

If your drugs cost between $2830 and $6440 per year, you get no coverage, but if your drugs cost more than $6440, you get 95% of it covered by medicare. This makes absolutely no sense to me. I was wondering how the hell this came about and it turns out that it’s the consequence of two separate coverage plans (one clearly made completely independently of the other). There’s Medicare initial drug coverage that covers 75% of all drugs on the formulary from $310 to $2830 (there’s a $310 deductible). Above $2830 there is no additional coverage by Medicare’s initial drug coverage. However, if you have to spend (out of pocket) more than $4550 (that’s your prescription drug costs go over $6440) Medicare’s catastrophe coverage kicks in. At this point, Medicare pays 95% of anything that goes over. Medicare does have an “Extra Help” program that includes coverage of the donut hole, but you have to make less than $16245 a year to qualify (not really much). Ms. X is a widower who rents an apartment in town. She has an income of about $18000 a year. She makes too much to qualify for the extra help. She can’t really afford to pay an extra $60-$80 a month that the extra “gap coverage” insurances cost. Now, I don’t spend much money, but I know that you really can’t do much on $18000 a year, especially if you have numerous chronic medical problems. Ms. X has gotten to the point that she is not eating well, she’s not filling some of her prescriptions and has even resorted to taking her son’s albuterol (he has private insurance) for her asthma.

Luckily, the healthcare reform package that recently passed will start closing this donut hole, but it looks like it won’t be until 2020 before the gap is completely closed. I’m not sure why it should take 10 years to fix it. I’d bet that none of the people who set this system up or who decided that it's ok to wait 10 years before closing the gap have an 80 year-old grandmother who steals their albuterol.

4th year will be sweet

Just about done scheduling 4th year and it looks like it'll be nice. Right now I actually have 22 weeks off! Of course some it will be taken up by taking the boards and interviewing for residencies, as well as research (and maybe I'll add a few more rotations later on), but it sure will be less hectic than 3rd year has been. What I'm really excited about is the end of working for grades, good evaluations, exams, busy work, etc... I will finally (with few exceptions) be able to spend 100% of my time in the hospital on learning what I am interested in. I kind of wish all of med school was like that.

Religious companies

There are some companies, fairly well-known ones, that I never knew attempt to push their religious beliefs on others. I find it pretty frustrating when I'm trying to purchase something and I get a religious sermon. Or an ad for car batteries is talking about God's love. I find it worse than religious organizations and televangelists, because, with them, you at least know what you're getting yourself into. But, I was looking for plane tickets recently and a wandering google search taught me that Alaska Airlines regularly distributes Bible verses with their meals. When common everyday companies, like Alaska Airlines, pushes religion when providing the service that you pay them for, it's insidious and not only offends me, but leaves a bad taste in my mouth. I mean, if I were to give my business to Alaska Airlines or Interstate Batteries (which I have before), I have donated to a religious cause (something which I try to avoid at all costs). They are private corporations and can do whatever they want... I'd just like to know about it so I can avoid giving my money to them in the future. So here's my list that may be growing, of companies I will try to avoid because I'd rather not have my business with them fund proselytizing. A good starting point is from a list made last year here. Another good list is here, but I'm not considering companies that just have owners who are religious and have a spiritual way of making decisions. It's more when employees or customers are exposed to religious propaganda, nonreligious employees/customers are discriminated against or the profits from the company goes to religious organizations.

Alaska Airlines
Anthem coffee shop in Tacoma, WA
Chik-Fil-A (aah! Making employees pray and Christian-themed toys in their children's meals... that's pure evil!)
Chymorvah bed and breakfast in Marazion, Cornwall, England
Delta Airlines
Domino's Farms in Ann Arbor, MI
Eden Foods
Hobby Lobby
In-and-Out Burger
Interstate Batteries
Florists in Cranston, RI 
Forever 21 (owner likes to demonstrate his faith by putting a bible verse on bags)
Oklahoma Joe's Bar-b-cue in Broken Arrow, OK (breaking its agreement to donate to Camp Quest after taking profits from supports).
Prometric (testing center was playing Christian radio in the waiting room... not what I want to hear just before I start taking Step 2).
Korte & Luitjohan Contractors in Highland, IL
Sting Ray Cafe in New Bern, NC
Trijicon (Hidden Bible verses written on military weapons).
Tyson Foods (thousands of chaplains "serving" their employees)
United States Postal Service (somehow packages that say atheist on them tend to get lost)
US Plastics sends religious messages to their customers
Voss Lighting Company of Lincoln, NE
Weingartz Supply Co. in Ann Arbor, MI
Wyndgate Country Club in Rochester Hills, MI

This is a slowly growing list. If you have any additions, please let me know.

Burnt out

It's official, I'm totally burnt out with 3rd year of med school. The primary care rotation is pretty relaxed, but I just can't get myself to study much or do any of the mind-numbing busy work that we are assigned. I'm glad I don't have something more intense like internal medicine or surgery scheduled now. Luckily, it looks like I'll have a pretty chill 4th year (though I'm not looking forward to taking Step 2 of the boards) and I'm looking forward to the adventure of applying for residencies.

How to lose innovation in your state

University of Virginia and Virginia Commonwealth University are two other places I am looking into for residency. But, I'm hesitating now because there seems to be a witch-hunt against scientists. The attorney general of Virginia is a grade-A nut who is wasting taxpayer money to "investigate" (i.e. go on a fishing expedition) a climate scientist to see if there was "any breach of ethics" (i.e. can we find anything that makes scientists look bad so I could say my twisted version of reality is right). Besides being completely unethical on the attorney general's part (is he really working for Virginians?), this is a great way to lose scientists in your state. For example, if I go into fetal imaging - something that I really am interested in - I may find something that would not fit with the attorney general's ideas about when life begins, and as a result I risk getting "investigated." You lose scientists, you lose scientific discoveries. You lose scientific discoveries, you lose new and exciting companies. You lose that and you've lost jobs, greater tax income, and a better future for the citizens of your state. But who needs all that, it snowed 60 inches in Virginia last winter, so clearly global warming is a fraud.