Originally Posted by pbrower2a

In a competitive industry, almost anything that reduces costs reduces prices. Physicians who have practices more likely to be sued (let us say obstetrics or neurosurgery) pay higher premiums for malpractice insurance than do those less likely to be sued.

The above is an excellent example of a "cost driver". I've seen little debate/working to solving the problem of some medical procedures/drugs , which have inherent risks. I think the discussion should revolve around "how do we fix the cost/benefits of inherently risky medical situations". Perhaps, decoupling accidental harm from outright negligence would be a good start.

But even at that, physicians have another good cause to avoid lawsuits: should they lose, physicians don't look so great to potential patients. I have noticed a book in the local library with such a title as "Bad Physicians", naming names of physicians who have had disciplinary measures taken against them not only for incompetent to substandard medical behaviors, but also sexual harassment and dishonest dealings with payers (including insurance).

The above is a valid alternative to malpractice. I'll be the first to admit that any profession has its bad apples. I've read "Good Pills, Bad Pills". There are some medications which are ineffective, waste of money, cons outweigh the pros, etc. My guess is that some medical procedures, say lobotomies are, just bad procedures.

You wouldn't want to deal with a physician who cheats insurance companies, would you?

Nope.

There are also lists of people with a proclivity to sue physicians for malpractice. Some people are looking for easy money, as in getting a settlement for a bad diagnosis. Such a bad diagnosis could be a patient's fault -- such as for failing to disclose an existing condition while tempting a physician to commit malpractice. If you are a physician you want no such person as a patient. It is up to patients to disclose all pre-existing conditions to a physician. Good physicians of course insist on the transfer of records from previous physicians.

Agreed. (Though hiding pre-existing conditions from insurance companies has all of the positive incentives there are. )

But before you go on a spiel about the necessity to constrain the costs of frivolous lawsuits for malpractice (and they happen, and they cost physicians dearly), then that would be a valid reason for a single-payer system that would maintain lower costs in part by taking malpractice lawsuits as a potential gravy train for some "winner" of the medical lottery.

I don't understand the above, please clarify.

Originally Posted by Ragnarök_62

Perhaps, decoupling accidental harm from outright negligence would be a good start.

That's already in law. The harm has to have been caused by a physician's or drug's incompetence and/or bad judgment before it is actionable.

The above is a valid alternative to malpractice.

It's a complement, not an alternative. Revealing bad physicians helps protect other people from being hurt by them but does nothing to compensate those who already have been. (And vice-versa for malpractice.)

My guess is that some medical procedures, say lobotomies are, just bad procedures.

True, but as long as the medical profession considers them good ones, individual physicians aren't liable for using them even if harm results.

I don't understand the above, please clarify.

If I understood correctly, he was talking about socializing compensation for iatrogenic harm rather than making individual physicians liable. However, I might be wrong; best let him answer.

Originally Posted by The Rani

Most benzodiazepines.

Care to elaborate? What about pre-op anti-anxiety? What about agitated mentally ill people? What about palliative in hospice?

James50

to constrain the costs of frivolous lawsuits for malpractice (and they happen, and they cost physicians dearly), then that would be a valid reason for a single-payer system that would maintain lower costs in part by taking malpractice lawsuits as a potential gravy train for some "winner" of the medical lottery.

The only recourse for a patient when something goes wrong would be to get medical rectification. A single-payer system would necessarily do that. In view of the consequences of medical malpractice to the patient, it would be best that the malpractice "lottery" disappear altogether.

Originally Posted by The Rani

Who's playing games, me or people who claim to know all about tort reform but can't answer simple questions about it? At least pb gave it a shot.

You asked this question: How does lowering liability insurance rates decrease the practice of defensive medicine?

To answer this question I needed information. Presumably, some physicians practice defensive medicine. You are a physician. So I asked this:

Why would a physician practice defensive medicine?

You answered with another question: Why do you think doctors don't want to get sued?

This is a bizarre response. I never said anything about whether I think doctors want to be sued. The question I asked was that why would a physician practice defensive medicine. Were you implying that doctors practice defensive medicine because they don’t want to be sued? If so, it seems to me that’s a pretty stupid way to proceed if you don’t want to be sued. So I asked a clarification question:

Why do you think defensive medicine has anything to do with getting sued?

To which you answered with still another question: Does that mean you don't know the answer?

If course I don’t know the answer. What the hell would I be asking it? So I concluded you were playing games.

Originally Posted by Mikebert

You asked this question: How does lowering liability insurance rates decrease the practice of defensive medicine?

To answer this question I needed information. Presumably, some physicians practice defensive medicine. You are a physician. So I asked this:

Why would a physician practice defensive medicine?

You answered with another question: Why do you think doctors don't want to get sued?

This is a bizarre response. I never said anything about whether I think doctors want to be sued. The question I asked was that why would a physician practice defensive medicine. Were you implying that doctors practice defensive medicine because they don’t want to be sued? If so, it seems to me that’s a pretty stupid way to proceed if you don’t want to be sued. So I asked a clarification question:

Why do you think defensive medicine has anything to do with getting sued?

To which you answered with still another question: Does that mean you don't know the answer?

If course I don’t know the answer. What the hell would I be asking it? So I concluded you were playing games.

Or she's emulating a dead philosopher and trying to get you to realize it for yourself by continually asking you questions. It seems Rani doesn't want to be a deus ex machina and tell you straight out, but wants you to follow a path which will lead you to realizing it on your own.

Am I assuming correctly The Rani, or just wildly off the mark?

~Chas'88

Originally Posted by The Rani

Yes, no, yes, no.

Yikes! Glad you are not my doctor or the doctor of any terminally ill people. Maybe thumbscrews is more your style.

James50

Originally Posted by The Rani

How'd a kid like you get so much smarter than all these grown-ups?

Chas88 is smart, but the overuse of rhetorical questions is not effective as argument. Besides that, it is annoying to people who want to have a real discussion (like me). You can take each one of your questions and turn it into a statement. Of course, then you would have to support your statements, and that is more work. Multiple questions is just a sophisticated form of hiding and is also lazy.

I never liked the Socratic method either.

James50

Originally Posted by The Rani

I've always thought people were better off learning things on their own than being spoon-fed.
By the way, you even screwed up my answer, when I did actually give one. Look again.

Yea, just saw that. I have corrected. One thing I will say about you - there is no wasted effort.

James50

Originally Posted by The Rani

I've always thought people were better off learning things on their own than being spoon-fed.

Why do you think that? What makes Socrates so great? Why does our legal system use argument to get at the truth? So you would just let kids learn to read on their own? Every teacher should just stand at the head of the room and ask questions?

James50

Originally Posted by The Rani

You learn a lot more about the world when you find it out for yourself.

No, in most disciplines there is a body of human knowledge that must be conveyed before you can get to the frontiers. This body of knowledge gets larger all the time and the time it takes to become fully educated is getting longer and longer. For knowledge to progress, there must be a period of indoctrination. Then you are ready to start asking the questions.

Perhaps philosophy is different, but not much. As to what we are doing here on this forum, I view it as jousting. Questions make it into jujitsu. For me, that is not as much fun. YMMV.

James50

Originally Posted by The Rani

Thumbscrews for the terminally ill? Well, whatever works.

Yea, never mind. I do think you are being unnecessarily hard hearted.

I watched my father in the last 10 days of dying. I was grateful for the anti-anxiety medications he got.

I have had surgery and was grateful for the pre-op anti-anxiety.

I have a mentally ill daughter. The calming effects of these meds has saved her life at times.

James50

Originally Posted by The Rani

You learn a lot more about the world when you find it out for yourself.

True, but most of us are not in a position to find out most things for ourselves. So the respose to a non-answer will generally be to find someone else who will answer it.

I'm curious as to why you think benzodiazepines should not be used to treat pre-op anxiety or in hospice care. But you probably won't answer that, either. (I do have a guess in the latter case, but it's something I'm a little surprised you'd care about.)

Originally Posted by The Rani

Ohhhh ... I strongly disagree.
Good luck with that, choose your master wisely.

I do not believe in masters. I look for teachers and try to learn what they know.

James50

Originally Posted by The Rani

Indoctrination is a strong word.

Okay, how about we need instruction?

I always felt like a class that was all questions was a waste of my time and usually indicated the teacher was too lazy to prepare a lesson.

Originally Posted by The Rani

As for benzos, yes people love them. They aren't so good for you. Such are many things in life.

Benzos are cheap and effective. They can be abused.

Have you had some personal experience that has turned you against them?

Please instruct me.

James50

I guess the health care debate is coming down to whether America will grapple with the new 4T or remain mired in the culture wars of the 3T.

Rep. Stupak is trying to kill the bill because it does not absolutely prohibit abortion by health care providers, even despite the restraints of the Senate bill.

More specific details here:
http://www.nytimes.com/2010/03/21/he.../21health.html

Originally Posted by The Rani

How'd a kid like you get so much smarter than all these grown-ups?

I like reading about old dead Greeks & other abandoned philosophies which stress that the individual must find enlightenment him/herself. Sure people can lead/push them in the right direction, but enlightenment can not be given, it must be fought for.

Usually it means something to the person when they discover enlightenment themselves than when someone else just hands it to them, because they fought for that, they worked for it, and they earned it.

That essentially sums up most of Western Philosophy & Mysticism. My personal favorite Mysticism to read up on is Spiritual Alchemy, which is another "the seeker must purify themselves" kind of philosophy.

Thanks for the compliment. I know coming from you that it definitely means something.

~Chas'88

Originally Posted by The Rani

I'm a psychiatrist. What would you like to know, and about which ones?

Cool.

You condemned them as a class. Yet, they have lots of uses in various circumstances. Anxiety is debilitating. Why let people suffer? Particularly people in hospice or people overcome by agitation so that they are a danger to themselves as well as others. Are you against medication in general or just benzos?

BTW, your name gives me little comfort. You are a kind person I hope.

James50

Yikes. Firedoglake has 217 oppose or lean oppose. Is this thing really going down? http://bit.ly/4uSzsO

James50

Great article on BBC with graphs showing that the US has been lacking and falling in terms of healthcare.

http://news.bbc.co.uk/2/hi/americas/8578001.stm

Originally Posted by James50

Cool.

You condemned them as a class. Yet, they have lots of uses in various circumstances. Anxiety is debilitating. Why let people suffer? Particularly people in hospice or people overcome by agitation so that they are a danger to themselves as well as others. Are you against medication in general or just benzos?

BTW, your name gives me little comfort. You are a kind person I hope.

James50

As a class, benzos are based on a chemical structure that's considered too toxic to put in your gas tank.

There are much safer - and equally effective - ways to deal with anxiety, pain, or even just get high

Originally Posted by Eric the Green

I guess the health care debate is coming down to whether America will grapple with the new 4T or remain mired in the culture wars of the 3T.

Rep. Stupak is trying to kill the bill because it does not absolutely prohibit abortion by health care providers, even despite the restraints of the Senate bill.

More specific details here:
http://www.nytimes.com/2010/03/21/he.../21health.html

But I thought "we were all in this together."

In your view, I guess that doesn't include infertile couples who have to get a newborn smuggled in from Moldova, otherwise they get on a waiting list that is longer than the one for New York Giants season tickets.

Oh, I forgot: Only the economic - and behavioral - Overclass has to sacrifice anything.

Is there any danger to these drugs in short-term use? They're potentially addicting but that shouldn't matter either for pre-op anti-anxiety use or in hospice.

Originally Posted by The Rani

They affect respiratory and cognitive functioning.

I did a Google search for their side effects and I found this article: http://www.aafp.org/afp/20000401/2121.html

On respiratory effects, the article states:

"With the introduction of chlordiazepoxide (Librium) in 1960, and because of the relative safety of benzodiazepines, these agents rapidly replaced barbiturates as sedative-hypnotics. They cause significantly less respiratory depression than barbiturates and, consequently, are rarely lethal in an overdose."

"Significantly less" does imply that they do cause some. If administered under medical supervision for a short time, is it your opinion that's a serious problem? You did say you would approve of using them for psychiatric patients, my take on that is that you sometimes prescribe them yourself.

On cognitive effects:

"Benzodiazepines induce anterograde amnesia, which accounts for the beneficial effects of benzodiazepines such as midazolam (Versed) for presurgical medication. These specific amnestic effects appear to be separate from sedation.11 Episodic memory (the remembering of recent events and the circumstances in which they occurred and their time sequences) is particularly impaired and more markedly so in heavy alcohol drinkers who also use benzodiazepines. Specific deficits in visuospatial ability and sustained attention have also been described in patients who have taken therapeutic doses of benzodiazepines regularly for longer than one year."

So yes, there's some cognitive impairment especially in the area of memory, but it looks like under normal supervised use these effects are temporary (and in some cases part of the desired effect rather than a side-effect).

The rest of the article was about problems in combination with other drugs, especially alcohol, addiction/tolerance/withdrawal, dangers when taken in pregnancy, increased risk for elderly patients. The article concluded that:

"Although benzodiazepines are effective in a wide range of medical and psychiatric conditions, caution must be exercised with their use, particularly when these agents are prescribed to patients with an active or remote history of substance abuse or addiction. Their greatest asset is also their greatest liability: drugs that work immediately tend to be addictive. Compared with benzodiazepines, antidepressants have a longer onset of action but are the best agents for long-term treatment of anxiety disorders. Anticonvulsants, antipsychotics, antihypertensives and buspirone also are effective but have an intermediate onset of action.

"Clinical judgment is based on an assessment of the risks versus the benefits of therapy. Such an approach might take into account whether substance abuse is active or remote, whether other family members or other health care professionals are actively involved in the patient's care, and how well the physician knows the patient. Physicians should also freely seek consultation from specialists such as psychiatrists and addiction medicine specialists. Education, consultation and documentation not only improve the level of clinical care but also provide necessary risk management and medicolegal liability protection."

So obviously there are significant risks associated with these drugs. It looks to me though that they might be safe enough in short-term use with proper supervision. Do you disagree? If so, why?

(Do I get a gold star for doing some research on my own, Dr. R? )

Originally Posted by The Rani

I guess you can listen to google, or someone who has actually prescribed the stuff.

That's only true if someone who has actually prescribed the stuff is willing to talk, which apparently:

And actually, no, I'm not interested in giving a benzo lesson on the forum.

Is not the case.