Grand Rounds

Welcome to Grand Rounds! A special post-Thanksgiving edition serving up Seinfeld as the lighter fare after the big holiday meal.



In "The Burning" Kramer and Mickey act out sick conditions for medical students.

Alison looks at her promiscuous history with insulin companies, questions whether she's become too comfortable in her current insulin relationship and whether she should get back on the insulin dating scene. "I think I might be an insulin tart" in Shoot Up or Put Up: Comatose and rotting toes – the lighter side of insulin dependency.

Diabetes Mine honors Dr. Frederick Banting for his work on the ultimate diabetes invention which was of course insulin, which keeps diabetics. Diabetes Mine also reports on the hope for a new non-invasive glucose measurement device.

In "The Boyfriend", Elaine breaks up with Hernandez because he smokes. Jerry tells her, "You're like going out with C. Everett Koop!" referring to the U.S. Surgeon General who crusaded against smoking in the 1980s.

The Happy Hospitalist advises to Quit smoking now or experience the rare but unsightly side effects of continued tobacco abuse.

In "The Fusilli Jerry", Kramer tells a story of how the surgeon once performed a procedure on a teenage boy from Guatemala with no nose and "turned him into Ricardo Montalbán!"

The Examining Room brings us an advanced look at a book about a compassionate pediatric surgeon's experiences taking care of gruesome injuries and heartbreaking problems in Iraq.

Bringing together the worst in popular culture with a serious look at facial lacerations, Inside Surgery frames it up around Tiger Woods' car crash.

Other Things Amanzi posts Decisions for surgery: "when in doubt, cut it out".

In "The Seven", Elaine strains her neck trying to get a bike down from the wall. In pain she promises the bike to whoever fixes her neck. Kramer saves the day and wants the bike.

How to Cope with Pain published this post as part of a series on medications used for chronic pain. Ketamine, an anesthetic, holds great potential to help patients with chronic pain. However, currently it is controversial and still considered experimental.

Timed perfectly to coincide with the Twilight: New Moon vampire file fervour sinking its teeth deep into the world's neck, Canada's National Advisory Committee on Immunizations has updated its recommendations for rabies shots after bat run-ins. The requirement: "They must suck your blood."

In "The Parking Space", after borrowing Jerry's car, Elaine comes up with a wild story involving a pack of teenagers with a gun, because the car is now making a strange clanking noise.

Primary care physicians can assess readiness for treatment in depressed teens and should be prepared to follow teens not ready for treatment more frequently.

In "The Cheever Letters", George is to meet Susan's parents and is not looking forward to telling her father that his cabin had been burned down (by Kramer with the Cuban cigars Susan's father had given to George as a gift). Jerry suggests that the Rosses are likely to see the irony of the situation.

Medicine for the Outdoors provides this comprehensive background report on Wilderness Emergency Medical Services

In "The Diplomat's Club", Pitt goes to the pharmacy and mistakes Jerry for a pharmacist, as he is re-stocking a display that Kramer had knocked over. Jerry then proceeds to give Mr. Pitt some medications.

Florence Dot Com in "Thanks for Speaking Up" thanks two patient safety leaders for speaking out about the case of an Ohio pharmacist who has been jailed for an on-the-job medication error. As the blogosphere lights up this week to commemorate the 10th anniversary of To Err is Human, it's worth pointing out or (as Wachter and Cohen have done) calling out stakeholder groups that are not yet on board.

Laika's MedLibLog challenges the legitimacy of homeopathic medicines and their place on pharmacy shelves.

In "The Note", Jerry, George, and Elaine get free physical therapy massage by getting a note from Jerry's dentist (Roy) to present to the insurance company.

Colorado Health Insurance Insider focuses on Addressing the Problem of Cost. " Obviously no single health insurance company can set out on its own to reduce reimbursement rates, since the result would likely be that doctors and hospitals would leave that network in favor of other carriers with higher reimbursement rates. A government-set fee schedule makes sense (and would go a long way towards standardizing our health care costs), but it would likely face tremendous opposition from medical lobbying groups."

InsureBlog takes on the former Chief of Staff of a large Michigan hospital regarding health care "reform."

In "The Jimmy", George says he shouldn't have exercised because, even though he took a shower, "it wouldn't take" — he's a "human heat pump" and will be sweating later at an important meeting.


Dr. Jolie Bookspan provided this humorous post on the Forward Air Head Syndrome - Doing Sets and Reps and Missing The Point of the Exercise. "The Department for Silly Syndromes has determined that Forward Air Head Syndrome is closely related to Cerebral Detachment Syndrome..."

Thanks to Wikipedia for the Seinfeld descriptions.

Grand Rounds

Welcome to this special edition of Grand Rounds, the Best of the Medical Blogosphere, focusing on Health Care Reform. The tapestry woven through these exceptional articles demonstrates the many dimensions of the health reform challenge.

Why Do We Need Reform? Patient and Consumer Perspective

Type 1 diabetic for over 22 years, blogger Kerri Sparling says it all in her post at Six Until Me:

"Why, Insurance Company, are you so against proactive care? Why do I need to pay more for a brace or a shot or an extra visit when you're more content paying for a several thousand dollar surgery instead? Not enough bang for your buck? Why do you fight me tooth and nail against coverage for a continuous glucose monitoring device? Is my life not worth the investment to keep my legs on instead of paying 100% to amputate them in a few decades? I know I'm expensive as a chronic disease patient, but I'm healthier than 85% of the people I know. I eat well, I exercise regularly, and I am on top of my disease. Yet you deny me life insurance, you won't let me purchase a private health insurance policy, and you would rather see me on an operating table than taking up a doctor's time in an office visit. (And it's not like I'm taking up more than 5 - 7 minutes of a doctor's time, because that's about all we get, on average. Pathetic.)"

Laurie Edwards at A Chronic Dose reviews "Are We Feeling Better Yet?" a collection of essays from prominent women writers that speak to challenges and contradictions in our current system. While she found that no, we aren't necessarily getting better yet, the stories show where we need to go. Edwards argues that the patient narrative deserves a place in the reform conversation.

Robin S at Survive the Journey details the challenges of access based on socioeconomic and racial factors. A Johns Hopkins study found that socioeconomic and racial factors are predictors to admission for pituitary adenoma patients to high-quality care centers. " The number of patients receiving care in the >$60,000/yr income-bracket was almost double the other income levels."

Jeffrey Seguritan at nuts for healthcare reports on quick hospital readmissions which constitute an estimated $17 billion in costs to Medicare, and may signal poor quality in terms of inpatient and outpatient follow-up care. The Obama administration is proposing to penalize hospitals for quick readmissions and bundle hospital reimbursements for inpatient and outpatient care - - they'll need to carefully consider both severity of illness and gaming of the system.

Providers, Prevention and Self-Management

Jane Sarasohn-Kahn at Health Populi lays out the costs of chronic disease and the key role of self-care.

Jolie Bookspan finds that a major overlooked part of health care reform is that many standard payments are for things that shouldn't need to be done in the first place. See her example - of how to Prevent Back Surgery.

Stacey Butterfield at ACP Internist finds that health care reform starts at home, as physicians at one conference practice what they preach when it comes to preventive medicine.

Nancy Brown at Teen Health 411 finds that primary care physicians could do more to screen for teen eating disorders to avoid hospitalizations.

Meaningful Use and Enabling Technology

John Halamka at Life as a Healthcare CIO describes the first meeting of the ARRA/HITECH mandated HIT Standards Committee which focused on the following key themes:
"a. We need a high level roadmap of milestones to ensure we meet our statuary deadlines for initial deliverables in time for the 12/31/09 interim rule.
b. We also need a roadmap which takes into account the other mandates/compliance requirements already imposed on healthcare stakeholders such as ICD-10 and X12 5010. We need to ensure our clinical work is in synch with administrative data exchange activities already in progress.
c. Although we should provide for the exchange of basic text, we should strive for semantic interoperability whenever possible, using controlled vocabularies which are foundational to decision support and quality reporting.
d. We should set the bar for interoperability higher than the status quo but also make it achievable, realizing that rural providers and small clinician offices have less capabilities than large academic health centers. We'll need to retrofit many existing systems - healthcare IT is not a greenfield and thus we need to be realistic about the capabilities of existing software, while also encouraging forward progress and innovation.
e. Meaningful use will change over time. Data exchange and the standards we select must evolve. To ensure successful adoption throughout the industry, our work must be continuous incremental progress with phased adoption of standards."

Barbara Olson at On Your Meds discusses what "meaningful use" may mean for medication safety. She advocates for making medication histories and profiles of patients accurate and readily accessible across the continuum of care are among the most important targets for “meaningful use” initiatives.

Mr. HIStalk reports on the ONC's plans to define “meaningful use”. "Translation: we haven’t figured out what we are doing yet and aren’t ready to commit to anything."

Wes Rishel at the Gartner found that the successful EHR implementations included health information exchange and used "implementation approaches that are more highly directive and more keyed to supporting the practices' complete workflow changes necessary to benefit from the EHR."

Health Business Blog's David Williams interviews EHR vendor Practice Fusion's CEO, Ryan Howard.

Laika Spoetnik's MedLibLog gives an example of a real successful application of web 2.0 in patient centered healthcare for Parkinson's disease. Health 2.0 represents "a new way of thinking in healthcare:

1. the patient becomes centric, care becomes collaborative: the patient is not passive, he is “equal” to the healthcare provider. It isn’t “he asks, we provide”, but the patient definitively has a voice (and choice) in his own healthcare.
2. coherent and transparent healthcare.
3. expertise (few experts, but with very specialized knowledge)."

Dollars and Sense

Consumers Union Blog reports that two thirds of Americans support a public health care plan. "Affording healthcare is still a major issue with nearly two-thirds expressing major or moderate concern about the ability to afford doctor visits in the future. Sixty percent of Americans said they were concerned about the possibility of bankruptcy because of a medical concern."

DrRich at the Covert Rationing Blog explains why the representatives of all the major healthcare interests threw in with President Obama's healthcare reform. DrRich believes that this time is different than the Clintons' attempt in '93. "The private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do... And so, the last obstruction to healthcare reform has been removed."

Bob Laszewski at Healthcare Policy and Marketplace Review sends out an open letter to the Congressional Budget Office. "So, six months later lawmakers are sending one of these "cost containment lite" proposals after another over to the the CBO and the CBO is sending them back stamped, "insufficient funds." And there's lots of whining about it now going on atop the Hill where people are desperate to find easy money for health care reform. It will take more than $1.2 trillion to pay for health care reform and the Obama budget cuts have only identified about $300 billion toward that goal. We will not reform the health care system unless we really reform the health care system. The only thing standing between BS reform and real reform are the men and women--real men and real women--over at the CBO."

Jacob Goldstein at the Health Blog highlights OMB chief Peter Orszag's comments on the four steps to better cheaper care.

Louise at Colorado Health Insurance Insider describes the House pledge to have a sweeping health care reform bill on the floor by the end of July, and the details starting to come out about the direction they want to take. Requiring everyone to have health insurance coverage is one of the cornerstones of the reform.

Bob Vineyard at Insure Blog argues against the hidden costs of health care reform.

What's Working Elsewhere?

Alison Finney at Shoot Up or Put Up (Comatose and rotting toes - the lighter side of insulin dependency), was diagnosed with Type One Diabetes in 1983 at the age of 4. She gets her healthcare from the UK's National Health Service. While the British NHS may have it's faults, as a patient with a chronic disease she's a real fan.

Passing the Baton

Next week's Grand Rounds will be hosted by See First. Check out Evan Falchuk's See First article on the language of health care reform. Does it reveal a "deepening divide between how people talk about health care and what it really means to be sick"?

Check in at Get Better Health for the Grand Rounds schedule. Thanks to Val Jones and Colin Son for organizing Grand Rounds.