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Elective Major Orthopedic Surgery in Octogenarians

Elective Major Orthopedic Surgery in Octogenarians

By 2030, patients aged 85 and older are projected to account for 2.3% of the United States population, but this figure is expected to nearly double by 2050. There has also been an increasing trend in surgery being performed in the very elderly, but these patients have multiple risk factors that may increase their risk for adverse outcomes after surgery. As a result, there has been some controversy around performing elective surgeries to enhance quality of life (QOL) in this patient population. Typically, major orthopedic procedures like spinal fusion, total hip arthroplasty (THA), and total knee arthroplasty (TKA) are performed electively to alleviate pain and improve QOL. In a study published in the Journal of Bone & Joint Surgery, Hiroyuki Yoshihara, MD, PhD, and colleagues examined the trends and in-hospital outcomes of elective major orthopedic surgeries in patients who were at least 80 years old from 2000 to 2009 using data from the National Inpatient Sample on patients who underwent spinal fusion, THA, and TKA. The analysis included more than 70,000 spinal fusion cases, 233,000 THAs, and 417,000 TKAs. Complication and mortality rates were also compared for patients aged 80 and older with those aged 65 to 79. Incidence, Complications, & Mortality According to the study, there was an increasing trend in the age-adjusted incidence of spinal fusion, THA, and TKA in patients at least 80 years of age from 2000 to 2009. The age-adjusted incidence of spinal fusion increased from 40 to 101 per 100,000 people per year. For THA, the incidence increased from 181 to 257 per 100,000 people. For TKA, the incidence rose from 300 to...

Should You Wear a Hazmat Suit When Operating an Elevator?

In their quest to culture every object on planet Earth, researchers have found that hospital elevator buttons are more contaminated with bacteria than restroom surfaces. Of 120 randomly cultured elevator buttons, 73 (61%) grew bacteria. Washroom surfaces were cultured 96 times with 41 (43%) showing microbial growth. As is customary with papers like this, the media sensationalized the findings with headlines like, “Why you should never ever touch that hospital elevator button.” Most stories eventually mentioned the fact that the authors said the majority of bacteria found “had low pathogenicity,” but some, including Vox.com, mrsaidblog.com, newsok.com, and mynews13.com, did not. In fact, the MRSAID blog also confused the benign streptococcus found in this paper with the pathogen that causes strep throat. I’ve written several posts about the culturing of various inanimate objects and pointed out that disease transmission has not been documented for almost all surfaces on which bacteria are found. Like most papers in this genre, this one has some flaws. You can read the full text here. It was published in an open-access journal called Open Medicine. It is not among the top 40 internal medicine journals listed by impact factor. In fact, it has no discernible impact factor at all and is not listed PubMed. The title of the paper, “Elevator buttons as unrecognized sources of bacterial colonization in hospitals” overstates the case a bit. Table 1 of the paper shows the types of bacteria found on both the elevator buttons and surfaces in the restrooms. Pathogens were few. Multiple organisms were found in several instances accounting for some of the numerical discrepancies. I could not...
Hello Darkness My Old Friend

Hello Darkness My Old Friend

My friend Nick, the ER doctor, called me the other day to tell me that one of my patients had died under his care. He didn’t have to do that, but he knew I had followed this woman for several years and knew her family well. She had nearly died under my own care a few years ago, but through outstanding work by the ICU and other nurses, had survived and gone home to her grandchildren and had seen the birth of her first great-grandchild. She had thanked me for saving her life, when in truth, I had been largely responsible for her getting in trouble in the first place. I hung up after the call and was suddenly overwhelmed by a rush of shame, despair and a feeling of loss so powerful that I had to stop the car and cry. Images of dead and dying patients flooded my head for reasons that I still don’t understand. I felt as if I had wasted most of my life pursuing an illusion and that the cost to my family and myself had been too high for too small a gain. I have been shedding a lot of tears lately. Those who have read these posts or who have read my novels know that I am at heart a hopeless romantic. Even my cynical, curmudgeonly rants are based in a vision of how things should be rather than the pragmatist’s view of how things actually are. I have always been sentimental, but as I have aged, I have found my control slipping. I tear up at trivial things. I’m liable...
Doctors Make Mistakes – Video

Doctors Make Mistakes – Video

Every doctor makes mistakes. But, says physician Brian Goldman, medicine’s culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Source:...
My War with the Anti-Vaxxers

My War with the Anti-Vaxxers

In the 19th and first half of the 20th century, infectious diseases killed many. In fact, in the 1918 influenza pandemic, 2 million people around the world succumbed to this virus. The discovery of Penicillin yielded a great weapon in our fight against the early demise of peoples from these infections. However, they failed to address the problem of deadly viruses. The next great weapon in our infectious disease arsenal appeared with the discovery and development of vaccines. By 1977, smallpox was eradicated around the world. In a like vein, polio was wiped out of the Western Hemisphere by the year 2000. Measles and Pertussis were considered nearly eradicated in the Western Hemisphere as well up until the last few years.  Science and history clearly give rise to evidence that the eradication of these diseases was the direct result of these vaccination campaigns. Why are we seeing a resurgence of nearly eradicated infections? A big reason is that parents are taking advantage of vaccine exemptions and choosing not to vaccinate their children. Not only do they put their own children at risk, but others, especially immune-compromised children. In fact, many doctors no longer accept unvaccinated children as patients for this very reason. We do not want our more susceptible patients to fall victim to these diseases while sitting in our waiting rooms. According to a survey of doctors on SERMO, the largest social network exclusive to physicians, 79% of doctors feel that unvaccinated kids should not be allowed to attend public schools. “…79% of doctors feel that unvaccinated kids should not be allowed to attend public schools.”   Many...

Distracting Electronic Devices Don’t Affect Learning. Really?

After listening to a lecture, third-year dental students at Harvard were surveyed about distractions by electronic devices and given a 12-question quiz. Although 65% of the students admitted to having been distracted by emails, Facebook, and/or texting during the lecture, distracted students had an average score of 9.85 correct ,compared to 10.444 for students who said they weren’t distracted. The difference was not significant, p = 0.652. The authors concluded, “Those who were distracted during the lecture performed similarly in the post-lecture test to the non-distracted group.” The full text of the paper is available online. As an exercise, you may want to take a look at it and critique it yourself before reading my review. It will only take you a few minutes. As you consider any research paper, you should ask yourself a number of questions such as are the journal and authors credible, were the methods appropriate, were there enough subjects, were the conclusions supported by the data, and do I believe the study? Of course, many more questions could be included. Google “how to critique an article,” and you will find numerous lengthy treatises on the subject. “The authors are from Harvard, so they must be credible.”   The paper appears in PeerJ, a fairly new open access journal with a different format. Authors have to pay to have papers published, but they can opt for a reasonably priced plan for lifetime memberships with variable numbers of papers included. It’s too new to have an impact factor, but stats on the website state that the paper has had over 3,100 views and been downloaded 218...
Controlling HIV Without Medication

Controlling HIV Without Medication

Research indicates that about 1% of patients with HIV are able to keep the infection under control without the need for antiretroviral therapy (ART). Dubbed “controllers,” these patients have been thought to hold clues on how to develop a vaccine against HIV because of their unique immune responses. “The body’s defenses in these patients allow them to fight the virus more effectively than others with the infection but don’t prevent them from being infected,” says Richard T. D’Aquila, MD. “Understanding the underlying processes could help researchers determine which immune responses should be boosted in non-controllers so that their stronger defenses could hold the line against HIV without ART in the same way these processes happen in controllers.” Understanding Controllers Controllers have plasma viral loads that are consistently less than 5,000 copies/mL as well as stable, high CD4 cell counts for many years without ART, according to Dr. D’Aquila, senior author of a study of controllers published in PLoS ONE. For their study, the research team investigated a newly discovered immune defense called the APOBEC3 system. APOBEC3 proteins work within immune system cells to block replication of HIV. In most patients with HIV, a gene produced by HIV works to remove APOBEC3 from cells so that HIV can replicate. “We hypothesized that controllers may have a stronger APOBEC3 defense than most patients with HIV,” Dr. D’Aquila notes. Upon studying the cells of controllers, the investigators found that controllers do indeed have larger supplies of APOBEC3, long after acquiring HIV, in specific white blood cells. It is within these cells (resting memory T cells) where HIV lies inactive until ART is...
Organ Donation in the ED

Organ Donation in the ED

Emergency physicians (EPs) are at the forefront of efforts to save patients or preserve options for organ donation for those who cannot be saved. On average, 18 Americans die every day while waiting for transplantable organs. Studies suggest that identifying potential organs for donation early from the ED may help increase organ procurement. However, there is little data that takes into account ethical viewpoints when it comes to organ procurement in the ED, according to Arvind Venkat, MD. Current organ donor protocols mandate that patients be referred to the local organ procurement organization (OPO) even when the resuscitative process is just beginning, and the prognosis may still be in doubt. “If death is likely, EPs are expected to continue existing measures or implement new measures to preserve the option of organ donation until OPO representatives arrive,” explains Dr. Venkat. “Under current referral policies, EPs may feel precluded from communicating directly with patients’ families about the rationale for aggressive treatments to preserve the option of organ donation when the opportunity for curing the patient has passed.” This can be especially burdensome at times of high ED and ICU volume and when delays occur.   Seeking Practical Solutions “EPs should be allowed to have honest and forthright communication with families about the status of patients who are viewed as potential organ donors and when OPO referrals have taken place,” Dr. Venkat says. Regardless of whether or not OPO representatives are present, open communication should include: ♦  An explanation of the resuscitative efforts. ♦  The patient’s likely prognosis. ♦  An honest description of options in the dying process. With open communication, family...
A Look at Pregnancy-Related Attrition in General Surgery

A Look at Pregnancy-Related Attrition in General Surgery

Studies show that attrition from general surgery programs is high, even with the introduction of work-hour limitations and new restrictions on hours for general surgery residents. Research has also shown that many factors play a role in residency attrition, most notably lifestyle considerations. Several studies have linked female sex to an increased risk of attrition, but not all research has corroborated this relationship. “Women still represent the minority among surgical residents throughout the United States,” says Erin G. Brown, MD. “There are many stereotypes regarding attrition among female residents, including pregnancy during residency being a risk factor for attrition.” Exploring the Issue A significant number of residents report being perceived negatively if they become pregnant during training, according to some investigations. “Since more women are entering medicine, it’s important to examine the potential links between sex, pregnancy, and attrition,” says Dr. Brown. To address this research gap, Dr. Brown and colleagues conducted a study to determine whether child rearing during training increased the risk of attrition from general surgery residency. The study, published in JAMA Surgery, was a retrospective review of general surgery residents at the University of California, Davis over a 10-year period. The study team analyzed voluntary and involuntary attrition rates as well as the incidence of child rearing among residents. “Our study found that neither sex nor child rearing was a risk factor for attrition in general surgery residencies,” Dr. Brown says. Overall, the attrition rate for women was not significantly different from the proportion of men who left the general surgery residency program. The attrition rate, which was 18.8%, was comparable with rates published in...
SCCM 2015

SCCM 2015

New research was presented at SCCM 2015, the Annual Congress of the Society of Critical Care Medicine, from January 17 to 23 in Phoenix. The features below highlight some of the studies emerging from the conference that are relevant to emergency physicians. Advanced Directives & Intubated ED Non-Survivors The Particulars: Studies have shown that patients who are intubated in the ED have a high in-hospital mortality rate. However, little is known about the impact of advance directives on mortality. Data Breakdown: Patients intubated in the ED who died before hospital discharge were reviewed in a study to calculate the proportion of those who received at least one code, had a do not resuscitate (DNR) order, and/or had care withdrawn. Within 48 hours of admission, 72% of patients had died, 40% had received at least one code, and 59% ultimately had care withdrawn. A DNR order was placed during the hospital course for 17% of patients. Take Home Pearl: The majority of patients intubated in the ED who do not survive appear to die within 48 hours, and many ultimately have care withdrawn. A Look at ED Visits Attributed to Rape The Particulars: In the United States, data are lacking on the impact of rape on medical care and outcomes. Nationally representative epidemiologic estimates of ED visits attributed to rape may shed some light on this research gap. Data Breakdown: For a study, researchers analyzed all ED visits with an external cause of injury code for rape using the Nationwide Emergency Department Sample. Between 2008 and 2010, nearly 50,000 ED visits were attributed to rape. Approximately 65% of rape victims...
CROI 2015

CROI 2015

New research was presented at CROI 2015, the annual Conference  on Retroviruses and Opportunistic Infections, from February  23 to 26 in Seattle. The features below highlight some  of the studies that emerged from the conference. Deferring HCV Treatment in Patients With HIV The Particulars: Studies have shown that successful treatment of hepatitis C virus (HCV) reduces the risk of liver-related complications. However, treatment is often deferred in patients with limited liver fibrosis due to cost considerations and the promise of better treatment options in the future. Little is known about the impact of deferring HCV treatment on liver progression among patients with HIV. Data Breakdown: For a study, researchers compared liver-related events and duration of infectiousness between patients with HIV who were treated for HCV 1 month after an HCV diagnosis, 1 year after a diagnosis, or as they reached fibrosis grades F2, F3, or F4. When compared with treating patients 1 month after diagnosis, delaying treatment until 1 year after diagnosis or until F2, F3, or F4 led to 14, 43, 142, and 418 additional cases of liver-related death per 1,000 HCV infections, respectively. The average length of time that patients were infectious increased from 5 years with treatment started 1 month after diagnosis to 21 years with treatment started at grade F4 fibrosis. Take Home Pearl: Timely treatment of HCV infection among patients with HIV appears to help prevent liver-related death and decrease the length of time that patients are infectious. Incentivizing Linkage to Care & Viral Suppression The Particulars: Data are lacking on the effect of financial incentives for linkage to care and viral suppression (VS)...
Cardiovascular Care for Hispanic Americans

Cardiovascular Care for Hispanic Americans

According to current estimates, more than 53 million Hispanics live in the United States, constituting about 17% of the total U.S. population. Hispanic Americans are the fastest-growing racial or ethnic population in the country and are expected to make up about 30% of the total population by 2050. “Hispanics are a diverse ethnic population, varying in race, origin, immigration status, and other socioeconomic factors,” says Carlos J. Rodriguez, MD, MPH. “The diversity among U.S. Hispanics presents many challenges.” Dr. Rodriguez says that Hispanics are a segment of the population that has been somewhat ignored in clinical research relating to cardiovascular disease (CVD). “We’re lacking comprehensive research data on the prevalence of risk factors for CVD among Hispanics,” he says. Only recently have national surveys started including more in-depth information pertaining to Hispanic Americans. Greater efforts have been made to specifically address CVD risk among U.S. Hispanics of late. This research has indicated that there is a sizeable burden of CVD risk factors among these individuals. More studies are still needed because Hispanics are the largest ethnic minority in the U.S. and are likely to significantly impact future healthcare costs. A Comprehensive Review There currently is no comprehensive resource about the cultural values and behavioral aspects that influence the promotion, prevention, and acceptance of heart health and treatment recommendations for Hispanics. To address some of the gaps in knowledge about the burden of CVD among Hispanics, the American Heart Association (AHA) released a scientific advisory on the status of CVD and stroke in Hispanic and Latino Americans. Published in Circulation, the document provides for the first time a comprehensive overview...
Hip Fracture in Older Adults

Hip Fracture in Older Adults

As life expectancy continues to increase in the United States, the number of elderly people and those with chronic health conditions like osteo­porosis is also rising. The number of people older than 65 is expected to increase from 37.1 million to 77.2 million by the year 2040. With this aging trend, the incidence of hip fractures is also expected to increase. “The care of patients with hip fracture is improving, but it’s still a significant healthcare challenge that dramatically affects patients and their caregivers,” says W. Timothy Brox, MD. “These individuals are at greater risk of death after their hip fracture. They also experience other problems, including being unable to return to prior living circumstances, the need for increased super­vision, and decreased quality of life and mobility. Furthermore, hip fracture patients are at increased risk for secondary fractures.” Welcome Guidelines In 2014, the American Academy of Orthopaedic Surgeons (AAOS) released a clinical practice guideline (CPG) on managing hip fractures in the elderly. The guideline included many evidence-based recommen­dations throughout the continuum of care, ranging from preoperative treatments to post-discharge management. Some of the recommendations in the guidelines are aimed at reducing delirium in hip fracture patients, according to Dr. Brox, who chaired the AAOS CPG writing group. “Delirium is common among hip fracture patients,” he says. “Patients with postoperative delirium are less likely to return to their pre-injury levels of function. They’re also at higher risk for postoperative complications and are more frequently placed in nursing homes. The lower the incidence of post-fracture delirium, the more completely and effectively patients will recover.” Beyond delirium, the AAOS writing group gave...
Analyzing Statin Use

Analyzing Statin Use

Recently, the American College of Cardiology (ACC) and the American Heart Association (AHA) updated their cho­lesterol guidelines, which shifted away from a focus on treating to target LDL cholesterol levels and toward minimizing global cardiovascular risk. The updated ACC/AHA guidelines substantially broadened the number of people for whom statins are recommended, primarily by enlarging the eligible population to those with lower levels of cardiovascular risk. Examining Patterns Whereas previous studies have shown that statin use is increasing in the United States, others have shown that use of these medications is suboptimal, even among high-risk individuals. “We have few data that have looked at how cardiovascular risk and specific risk factors contribute to the actual prescribing of statins,” says Michael E. Johansen, MD, MS. In an effort to address this research gap, he and his colleagues conducted a study—published in Annals of Family Medicine—that looked at the relationships between statin use and cardiovascular risk as well as diagnosed hyperlipidemia and other specific risk factors using a nationally representative sample. The study by Dr. Johansen and colleagues analyzed data from the 2010 Medical Expenditure Panel Survey and involved more than 16,000 patients aged 30 to 79. Those who reported filling at least two statin prescriptions were classified as statin users. “Overall, only about 50% to 60% of people at high cardiovascular risk were prescribed statins,” says Dr. Johansen. The study revealed that slightly more than 58% of individuals with coronary artery disease (CAD) and 52% of those with diabetes older than 40 were statin users. After adjusting for cardio­vascular risk and sociodemographic factors, the probability of being on a statin was...
Keeping Cancer Survivors Healthy

Keeping Cancer Survivors Healthy

For more than 15 years, the “Eight Ways to Stay Healthy and Prevent Cancer” message campaign has provided an evidence-based, user-friendly approach to cancer prevention. Graham A. Colditz, MD, DrPH, and colleagues developed a parallel set of recommendations to help care for cancer survivors. The new recommendations, “Cancer Survivors’ Eight Ways to Stay Healthy After Cancer,” were published in Cancer Causes & Control. Eight Key Strategies Dr. Colditz recommends that providers remind cancer survivors that it is important, particularly toward the end of treatment, to revisit how they can pursue healthier lifestyle behaviors to improve their survival. The following actions are recommended: 1. Do not smoke: Patients with smoking-related cancer who quit the habit survive longer than those who keep smoking. For patients with cancers that are not smoking-related, the benefit from quitting smoking will translate through lower risk of heart disease, stroke, or even a second cancer. 2. Avoid secondhand smoke: Beyond its general health risk, “some patients may be particularly susceptible to the effects of secondhand smoke due to their treatment,” says Dr. Colditz. 3. Exercise regularly: There is concrete evidence for some specific cancers that the higher the level of physical activity after a cancer diagnosis, the better the cancer-specific survival. It also cuts the risk for heart disease and other chronic conditions. 4. Maintain a healthy weight: Gaining weight after cancer increases the risk of cancer recurrence and other chronic diseases, says Dr. Colditz. 5. Eat a healthy diet: Healthy eating for cancer survivors should be the same as for the general population. The focus should be on fruits, vegetables, whole grains, and healthy fats....
Diabetic Kidney Disease: Coming to a Consensus

Diabetic Kidney Disease: Coming to a Consensus

As the incidence and prevalence of type 2 diabetes have grown, there has also been an increase in the number of people developing diabetic kidney disease (DKD) and end-stage renal disease (ESRD). “Diabetes is the leading cause of ESRD, accounting for almost 50% of cases,” says Mark E. Molitch, MD. Incidence rates for ESRD have stabilized over the past few years, but differences remain among high-risk subgroups, including middle-aged African Americans, Native Americans, and Hispanics. The healthcare disparities may be partially due to increasing rates of obesity and diabetes among younger people from these populations. Research has shown that the overall costs of care for people with DKD are extraordinarily high, due in large part to the strong relationship of DKD with cardiovascular disease (CVD) and the development of ESRD. In 2011, overall Medicare expenditures for diabetes and chronic kidney disease (CKD) in people aged 65 and older were approximately $25 billion. As patients transition to ESRD, studies have shown that the per-person per-year costs are $20,000 for those covered by Medicare and $40,000 for patients younger than 65. Importantly, much of the excess CVD resulting from diabetes is accounted for by people with DKD. Addressing Vital Issues In 2014, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation because of the high human and societal costs associated with DKD. “The consensus report addresses vital issues regarding patient care,” says Dr. Molitch, who co-chaired the consensus group. It highlights current practices, gaps in knowledge, and new directions for improving...
CIPN: A Guide for Prevention & Management

CIPN: A Guide for Prevention & Management

Chemotherapy-induced peripheral neuropathy (CIPN) is a common treatment-related adverse effect that can significantly affect long-term quality of life and interfere with cancer treatments. The pain can lead to reductions in chemotherapy doses and early discontinuation of the therapy. Studies estimate that about 38% of patients who are treated with multiple agents will develop CIPN, but this rate varies depending on the types of chemotherapy regimens used, duration of exposure to these agents, and how patients are assessed. “CIPN is an important issue, especially within the context of the most commonly used chemotherapy regimens,” says Dawn L. Hershman, MD, MS. “Many of the drugs that have been evaluated for treating and preventing CIPN are agents that have documented efficacy for other common neuropathies. CIPN, however, is more difficult to manage than other neuropathies because there is greater variability in its pathophysiology and associated symptoms.” A New Guideline In 2014, the American Society of Clinical Oncology (ASCO) released a systematic review and evidence-based guideline on the management of CIPN in adult cancer survivors. The ASCO writing panel that developed the guideline systematically reviewed randomized controlled trials (RCTs) from the literature on managing CIPN, compared outcomes among trials, and provided guidance on the effectiveness of prevention and treatment options for CIPN in adults with a history of cancer. Primary outcomes included incidence and severity of neuropathy as measured by neurophysiologic changes, patient-reported outcomes, and quality of life. For the analysis, 48 RCTs met the eligibility criteria and comprised the evidentiary basis for the recommendations. “We studied many agents that have been used for CIPN, but few actually worked,” explains Dr. Hershman, who...
Managing the High Costs of Diabetes Care

Managing the High Costs of Diabetes Care

The adoption of the Affordable Care Act (ACA) and rules imposed by insurers for scheduling and receiving care can be especially disconcerting for patients with diabetes. “With the ACA, patients are often left wondering about their access to care and to medications with higher price tags,” explains Jason C. Baker, MD. “The ACA has not matured to the point where it addresses coverage of newer diabetes drugs. This means some patients may be relegated to sticking with older medications that may be less effective or have more side effects rather than using newer treatments that are potentially more effective.” Dr. Baker says that diabetes treatment should be personalized based on the unique needs of patients. “Older and less expensive medications may work well for one patient but result in side effects for another,” he says. “It’s important to consider all options when selecting diabetes medications, including newer and more expensive drugs. This allows for personalization of care and can increase our chances for success.” How Can Doctors Help? Dr. Baker says that doctors should strive to be proactive in the ever-changing healthcare environment. “One way to do that is to document how patients respond to new diabetes medications,” he says. “By logging this information routinely, we can organize our arguments for getting specific drugs covered by ACA and other insurance carriers. As we document the efficacy of newer drugs, we’re providing the foundation to informing insurance providers of the benefits of therapies, which in turn may increase accessibility to these drugs in the future.” Clinicians should also serve as patient advocates when costs become an issue. “It’s important for...
Contracts

Contracts

The hospital where I do much of my elective surgery recently terminated the contract it had with a large Hospitalist group and announced plans to hire Hospitalists directly as hospital employees. A less publicized part of that move is an attempt through the Credentials and Bylaws committees of the medical staff to terminate the credentials of physicians who are associated with that group under an ‘exclusive contract’ provision in the hospital bylaws. In essence that provision states that certain areas are recognized as being best served by an exclusive contract and that physicians credentials to admit and treat patients under those arrangements are contingent on the continued contract. This has been traditionally applied to services such as Radiology, laboratory services, and Pathology. More recently (20 years) it was applied to Emergency Medicine. At my hospital is has not been applied to Anesthesia, Cardiology, or Hospitalist services. The administration would like to change that. Standing in the way is specific language in the current bylaws that addresses this eventuality for those areas where exclusive contracts have not previously existed. The proposed change in the bylaws language was put forth by several employed physicians and almost got through committee until a sharp-eyed private practice physician on the committee noticed it and had it removed. (No, it wasn’t I who did that, but I applaud his vigilance) Why should I care? After all, this is about Hospitalists. I rarely, if ever, use them for my own patients and the group involved does not consult me with any regularity. It would seem that I don’t have a dog in this hunt. But I...
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