This won't be easy . . .

[drbandage]

I just finished breezing through one of the interesting articles that appears at the top of this page in the Streaming CPAP and Sleep Apnea News.

If you check out the link posted below, you'll see I felt compelled to comment. While the doctor (who may or may not be a physician) obviously was trying to say something helpful, the information he posted was not entirely accurate, potentially dangerous, and shows how much work is still to be done in getting reliable information out to the medical community and the general public.

http://www.medindia.net/news_comment/up ... nt.asp?ss=

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): news, CPAP

[pedroski]

Well said Scott.

The good doctor doesn't have a handle on it at all, and if the MD's don't what hope have the rest of us?

Peter

[rested gal]

Thanks for the link, Scott. Your comment was excellent! You're certainly doing your part and more to get the word out whenever/wherever possible. Would that more doctors understood OSA the way you do. Thank you, thank you!

[NightHawkeye]

The good doctor doesn't have a handle on it at all, and if the MD's don't what hope have the rest of us?

And that's why it's important to take charge of your therapy personally rather than depending on a physician, few of whom seem to suffer from apnea themselves.

There is nothing at all difficult or expensive about testing or treating apnea, yet the medical community makes it both difficult and expensive to diagnose and treat. It is rather galling to me that physicians elevate the cost of an inexpensive test to thousands of dollars and then DME's similarly elevate the cost of CPAP equipment.

When companies in my industry don't add value to their products, they soon find themselves out of business. Why does that not happen in the medical community where examples of inefficiency, laziness and corruption abound?

There's no one quite so interested in your own health as you are. It seems to me that one point largely missing from the entire discussion about getting the word out regarding sleep apnea is the need for an attitude shift on the part of physicians and patients so that patients shoulder a much greater burden of responsibility for their own treatment.

After all, shouldering this added burden and assuming personal responsibility for one's apnea treatment is exactly what makes cpaptalk such a valuable treatment resource for apnea sufferers. When people come here they not only get up-to-date apnea diagnosis and treatment information, they get much needed training in how to actively take charge of their own health care.

Just my $0.02.

Regards,
Bill

[drbandage]

It's's important to take charge of your therapy personally rather than depending on a physician, few of whom seem to suffer from apnea themselves.

I hope you're kidding about that, Bill. Physicians are just as likely as anyone else to be afflicted by this.

There is nothing at all difficult or expensive about testing or treating apnea,

Huh?
Bill, compared to the cost of an EKG, or a chest x-ray, or a pap smear, or a diabetes screen, and most other screening tests, I would have to say I very much disagree. Appropriate testing for apnea is far more expensive and difficult. And as far as treating, it is far less difficult and expensive to treat high blood pressure, diabetes, high cholesterol and many others ailments. A proper diet and medications, along with lifestyle changes are not only cheaper but easier than lifelong CPAP and the proper support that is required to ensure adequate compliance.

yet the medical community makes it both difficult and expensive to diagnose and treat

see above

It is rather galling to me that physicians elevate the cost of an inexpensive test to thousands of dollars

again, see above

And I'm not sure why you believe physicians elevate the cost. There may be an medical economist who can explain this to you better than I, but other than private sleep labs (who do have to compete with others, ultimately) , I can assure you that as a practicing physician, I and most other docs have absolutely no say in what this test or any others cost. It's not like I or any doc I know can "negotiate" the cost of a certain test. Insurance companies are ruthless negotiators on how much they will reimburse for any test, or even approve a test for that matter.

Certainly, there is a cost of doing business that is fueled by many very complex issues (including malpractice insurance and the need to practice "defensive medicine", as well as all the little insurance piggies feeding at the trough and the enormous infrastructure accompanying it).

When companies in my industry don't add value to their products, they soon find themselves out of business. Why does that not happen in the medical community where examples of inefficiency, laziness and corruption abound?

Dunno what your industry is, but if you were to scrutinize the medical community even a little bit, your research would conclude that there is enormous competition to "add value", and a number of very obvious examples come to mind. And there are many, many well publicized examples of providers, and clinics, and health plans that have gone belly up because of their inability to be competitive.

And as far as inefficiency, laziness (?) and corruption, I do think you're using a very broad brush to tar an entire community. Certainly, the practice and delivery of medicine is far more complex and challenging than virtually any other industry with which you may be familiar. I don't think that inefficiency, laziness and corruption are more prominent in the medical community, although I do see why any repercussions from any of these issues are more painful. There is a higher standard of care that is required than almost any industry you can think of, because the stakes are that much higher. Tall Trees Take the Most Wind. The complexity of medical economics is mindboggling difficult to fathom, and with all due respect I don't think your comments reflect any serious understanding of it.

There's no one quite so interested in your own health as you are. It seems to me that one point largely missing from the entire discussion about getting the word out regarding sleep apnea is the need for an attitude shift on the part of physicians and patients so that patients shoulder a much greater burden of responsibility for their own treatment.

Bill -
You might want to refer to the following post. There are several others in which I have mentioned repeatedly the need to get the word out to the people that need to be educated: the medical community and John and Jane Q. Public. Hence, the campaign for bumper stickers, business cards, letter to the editor, and all manner of others. Please note Mile High Sleeper's recent post and open up the Collective Wisdom post under Sleep Apnea awareness. You find this to be an area of emphasis, rather than something that is "largely missing from the entire discussion".

scherebh wrote:


1) - Why couldn't you just look at those results and tell me over the phone what the diagnosis is and how it can be corrected? Does an office visit generate that much revenue?

2 - Why do I have to wait to get this thing? It ammounts to making me suffer (that's really not overstating it).


My only question is how long does it typically take to get the prescribed unit delivered to the house?
_________________
Hi Schereb -
I know that you said that you only have one question, but since there were two asked . .
I will take a quick stab at the first question.

Actually, docs can schedule phone appointments, and yes they do get paid for these. In fact, I do this on a regular basis. It is often times more efficient for all parties. Having you come in for an office visit certainly doesn't mean that the doc was trying to "feather his nest". On the contrary, an office visit can be much more expensive for the doc and pay less than a phone appoinment would.

Taking a non-cynical view of this, in a complex, difficult to treat disorder such as sleep apnea, I would definitely ask my patients to come in for an office visit. I would want to discuss face to face their new diagnosis, and go over the prognosis, treatment options, potential complications and side effects, and a number of other issues, including appropriate follow up care, compliance, and support groups, as well as answering any questions they might have. I don't think many docs would want to manage such a meaningful interaction over the phone. Not to say it couldn't be done or isn't being done, but I know many patients that would be insulted if you tried to do all this over the phone.

My phone appointments are usually to convey lab or imaging results, or offer a suggestion about changing a medication.

Granted, your doc may not have given you nearly as much information as I mentioned above. But whether he did or didn't, it is definitely a good idea to be a self advocate in medicine and elsewhere in life. I would encourage any patient to know that their responsibility is to ask questions about the new diagnosis, the prognosis, their treatment options, and the other issues I mentioned.

Certainly, docs have an obligation to offer important information to the patient, no doubt. But the patient, IMHO make a big blunder when they abdicate their responsiblity to be an informed consumer. I think it is not a good idea to just say (or act) as if "doc, you're the boss". It's a partnership, and the patients who do best are those that recognize that ultimately they must be the number one advocate for their own health. The questions would always be warranted: diagnosis, prognosis, treatment options, and possible complications. Sort of like when you are trying to get your car repaired.

That is my position as a physician, but also as a patient.
I hope this perspective is useful to you.

drB

Just my $0.02.

Regards,
Bill

And here's your change! ':D'

[NightHawkeye]

DrB,

First, let me say that I'm a big fan of your advocacy efforts. Words like great, overdue, and thank you come to mind. So, please don't take my comments personally. They were intended to be objective. (To the extent that they weren't, I apologize.)

However, issues associated with the cost of traditional apnea diagnosis and treatment, to me at least, are at the top of the list of obstacles facing patients. In fact, for those among us without insurance, or those who have limited benefits, mere diagnosis may seem to be out-of-reach, simply due to cost.

It needn't be that way. I would suggest to you that most apnea patients can be fully diagnosed with nothing more than an overnight oximetry screening, which paradoxically seems to be readily available at no charge from many DME's (who presumably know that they're likely to get increased business by offering this service).

I've heard the arguments that oximetery screening doesn't evaluate the long list of potential maladies which can occur while one sleeps. That argument is fallacious at best, and disingenuous at worst. A sleep lab PSG, as has been well documented on this board, doesn't work all that well itself, either as an apnea diagnosis vehicle or for titration. Perhaps my viewpoint is a bit jaded though. I failed two PSG's a dozen years apart and was told very authoritatively that I did not have apnea. Fortunately, I took charge myself by procuring an oximeter which then indicated apnea. (The diagnosis was subsequently confirmed in Encore Pro data.)

. . . compared to the cost of an EKG, or a chest x-ray, or a pap smear, or a diabetes screen, and most other screening tests, I would have to say I very much disagree. Appropriate testing for apnea is far more expensive and difficult. And as far as treating, it is far less difficult and expensive to treat high blood pressure, diabetes, high cholesterol and many others ailments.

I respectfully suggest that you might consider reassessment. A 24-hour Holter monitor is only about 20% the cost of an overnight PSG, and the newer cardiac screening tools are much less costly than the Holter monitor. I simply don't believe that the sleep lab PSG is justified as the first line diagnosis and screening tool for apnea. It's cost far outweighs the potential benefits. Plus, as was true in my case, the PSG is given far more credence than is justified. A PSG has serious shortcomings. It has been well documented that the sleep many folks get during an overnight PSG is not representative of their usual night's rest. An overnight oximetry screening would allow far more folks to be screened for apnea and treated than is ever going to occur so long as the extremely expensive PSG remains the standard.

A proper diet and medications, along with lifestyle changes are not only cheaper but easier than lifelong CPAP and the proper support that is required to ensure adequate compliance.

I agree wholeheartedly!

And I'm not sure why you believe physicians elevate the cost. There may be an medical economist who can explain this to you better than I, but other than private sleep labs (who do have to compete with others, ultimately) , I can assure you that as a practicing physician, I and most other docs have absolutely no say in what this test or any others cost. It's not like I or any doc I know can "negotiate" the cost of a certain test. Insurance companies are ruthless negotiators on how much they will reimburse for any test, or even approve a test for that matter.

Perhaps placing the blame totally on physicians was unfair. I'll change my wording to the "healthcare industry elevates the cost".

And as far as inefficiency, laziness (?) and corruption, I do think you're using a very broad brush to tar an entire community.

Indeed, but I also read the Wall Street Journal regularly, and so I am aware of some of the shenanigans occurring within the health care community which rank right up there with the recent Enron debacle. I'll mention, for example, the two top officers of United Healthcare who walked away with over a billion dollars. Of course, legal proceedings have now declared that they must repay over six-hundred million dollars of that. But that's still in court, I believe, so who knows how it will eventually play out.

Certainly, the practice and delivery of medicine is far more complex and challenging than virtually any other industry with which you may be familiar.

I don't think so. I am quite familiar with some very complex industries. I'm sorry, but I don't buy the argument for one second that the practice of medicine is so complex and challenging. In fact, it is quite apparent to me, and to many others on this discussion board, that some physicians are simply quite ignorant on subjects involving their core competencies. You do yourself a great disservice by trying to defend them.

At any rate, the diagnosis and treatment of sleep apnea is neither overly complex, nor overly challenging. Diagnosis can, and should be, simple. As we regularly see on this board, treatment is not too complex for the folks who gather here. Folks here are, I believe, not greatly different from the general population.

Please take my comments objectively. That is how they are intended. Like you, I would like to see a much larger number of folks correctly diagnosed and treated. I believe, however, that will only come about if the cost of diagnosis and treatment is reduced.

Regards,
Bill

[drbandage]

First, let me say that I'm a big fan of your advocacy efforts. Words like great, overdue, and thank you come to mind. So, please don't take my comments personally. They were intended to be objective. (To the extent that they weren't, I apologize.)

Apologies accepted. Your comments were directed at a very diverse medical community of which I am a proud member. When you disparage physicians with silly accusations that we are insensitive because "few of us seem to suffer from apnea ourselves", and that we are slothful, inefficent and corrupt by comparison with your industry, you do not come across as objective.


I think it would be easy to understand why your comments are personally offensive, since they stereotype a community that is, while far from perfect, full of wonderfully caring, hardworking, principled individuals. Just as an aside, I was “late to the party” in medicine. I was the oldest medical student in the United States when I matriculated, and had broad exposure to a number of industries, including executive positions, so I feel that my observations about the medical community are not formed in a vacuum.

I would certainly agree that issues associated with the cost of traditional apnea diagnosis and treatment are important obstacles facing patients. I would not agree, however, that they are at the top of the list.

The medical community in general throws cost out the window in many instances when it comes to diagnosis and treatment, and I don’t mean that as a compliment. But, when you look at how much a single MRI costs, much less one with contrast, in confirming the diagnosis in a patient with low back pain and simple sciatica, you can see that the cost of diagnosing apnea is not such an obstacle. There are many other examples of cost of diagnosis not being the reason for a missed diagnosis.

When you look at how much money is spent on such things as hemodialysis, chemotherapy, radiation, or surgery for example, you can also readily see that many hundreds of thousands are spent on the treatment of all manner of medical issues. So, I really think that fingering "cost of traditional apnea diagnosis and treatment as the most important obstacle facing patients" is missing the point.

As I have said in several other posts, the biggest problem we face is lack of appreciation of the prevalence and severity of the problem. As far as prevalence, the numbers are shocking, with most recent studies showing that one in four adults in the United States is “at high risk” for OSA. Yet, to much of the public and regrettably many well-intentioned physicians, sleep apnea is often thought of as an affliction of middle-aged, overweight men. The disorder afflicts untold millions of otherwise young and fit women and men. Ignorance to these facts stand in the way of an appreciation for the importance of the pursuit of the diagnosis.

38,000 cardiovascular deaths a year in the United States are directly attributable to sleep apnea, not to mention a large number of serious, co-morbid medical and psychological conditions, such as hypertension, abnormal heart rhythm, sleep deprivation, stroke, heart disease, diabetes, depression, memory loss, poor judgment, and change in personality. As a result, undiagnosed sleep apnea victims are significant consumers of healthcare services. But the diagnosis is elusive because the level of suspicion is not high enough, not because the cost of diagnosis is so forbidding. (See sciatica example above.)

Now in regards to diagnosis, you assert that most apnea patients can be “fully diagnosed” with nothing more than an overnight oximetry screening. You state that "A sleep lab PSG, as has been well documented on this board, doesn't work all that well itself, either as an apnea diagnosis vehicle or for titration." Even if one were to grant you that sweeping statement, you're still left with the fact that a sleep lab PSG is certainly superior to an overnight oximetry screening by itself, if for no other reason than the fact is that a PSG by definition includes an oximetry screening.

Obviously, the other issues that are neglected by using only an oximetry screen are not trivial. Sleep architecture is a key component of sleep hygiene. All manner of sleep problems may present as a false negative when using oximetery to “fully diagnose” sleep apnea. Certainly, my diagnosis of severe Periodic Limb Movement Disorder would have been missed entirely with an oximetery screen. I, for one would not stand for it if informed that my loved one’s sleep apnea issue had been "fully diagnosed" without a PSG, and the overwhelming body of evidence affirms that point of view, your failed PSG’s not withstanding.

A 24-hour Holter monitor is only about 20% the cost of an overnight PSG, and the newer cardiac screening tools are much less costly than the Holter monitor.

I don’t understand your point here. Neither Holter monitors, nor other cardiac sceening tools are suggested for helping to diagnosis sleep apnea, much less a full diagnosis and all that it implies.


When you state that the PSG is given far more credence than is justified, I wonder to whom you may be referring as far as the credence. The lay public? Certainly, those physicians who administer PSG ‘s recognize that there are potentially serious shortcomings, as you may readily observe by examining any of the postion papers in the American Academy of Sleep Medicine website. And obviously, it is common knowledge that an overnight PSG may not be representative of a usual night's rest.


Where I find the most common ground with you, Bill, is when you assert that an overnight oximetry screening would allow far more folks to be screened for apnea. There are many cases where a screening exam may rule in, but not rule out a suspected diagnosis. In this case, failing the oximetery screen would be signficant information, but not sufficient. And passing the oximetery screen would not rule out the other serious sleep problems that may coexist without evident desaturations.

Perhaps placing the blame totally on physicians was unfair.

You would be correct if you removed “perhaps”.

Indeed, but I also read the Wall Street Journal regularly

Since you do, I am sure you find that corporate shenigans that you illustrate are certainly not limited to, nor representative of the the "health care community". A quick scan of the the WSJ will obviously focus on the corporate financial issues. The remark I found to be off target was the assertion that the medical community itself is replete with boundless examples of inefficiency, laziness and corruption, and your example of a couple of corporate crooks in an insurance company do little to bolster your argument.

I couldn’t say for sure, but I would reckon that the two top corporate officers of a health insurance mega-company conglomerate that you mention likely have very little in common with me or the other docs and nurses who you labeled unfairly. Titans of Industry in the Corporate Insurance world don’t qualify as members of any medical community with which the vast majority of caregivers are affiliated.

I'm sorry, but I don't buy the argument for one second that the practice of medicine is so complex and challenging.

Bill, now you're scaring me.
You are kidding, right? Bill? Bill?

"Real knowledge is to know the extent of one's ignorance." Confucious.

In fact, it is quite apparent to me, and to many others on this discussion board, that some physicians are simply quite ignorant on subjects involving their core competencies.

Now, there is a fact that is indisputable. Big surprise that there are some players that are not getting the job done. How this simple observation could translate into your assessment of the practice of medicine as being neither complex nor challenging is unfathomable.

You do yourself a great disservice by trying to defend them.

Bill, please keep in mind who I am defending. I am not rising to the defense of physicians who are ignorant. I am calling your broad labeling of an entire community baseless and uncalled for. The greater disservice is saying nothing in the face of such a reckless accusation.

At any rate, the diagnosis and treatment of sleep apnea is neither overly complex, nor overly challenging.

Oh, really? That would explain a lot. As –SWS and many other intellectually curious folks have noted, sleep medicine is really in it’s infancy. Take a breeze through the volumes of conflicting literature and theories on the etiology of sleep apnea and the complexities of the Black Box algorithms and then let me know if you still believe that.

As we regularly see on this board, treatment is not too complex for the folks who gather here. Folks here are, I believe, not greatly different from the general population.

I would dare that the demographics of the regulars on this message board are vastly different from the millions of people, poor and elderly, for whom trolling the internet and putting the pieces together on this board would be far beyond their means, much less managing a very challenging treatment where compliance is indisputably a huge obstacle for even the most determined.

Please take my comments objectively. That is how they are intended.

I think you’re going to need to keep working on that, Bill. I think it is apparent that objectivity is not your strong suit.

[NightHawkeye]

Dr Standage,

Disregarding your unprofessional personal attacks, you have missed my point entirely. For you to claim that cost is an insignificant issue in seeing that the largest the number of patients are diagnosed for a disorder is woefully ignorant. To claim the medical community is providing a great service to society by ignoring costs is mere justification for the absurd.

. . . the practice and delivery of medicine is far more complex and challenging than virtually any other industry . . .

I don't for one second believe this, but it is one great rationalization. It excuses "sleep docs", for instance, from needing to learn much about the CPAP machines they prescribe. Would you have us quote this mantra to excuse the fact that less than 50% of diagnosed apnea sufferers in the U.S. actually stick with their therapy. Should we believe this very low compliance simply results from the "complex and challenging" nature of the disorder. European references have indicated that compliance is in the 80% range there. Clearly, the data supports that much greater compliance rates are possible in this country. I suspect that compliance of those who find their way to this board is higher still, likely in the high 90% range.

If money (which, by extension, is time) were of no consequence then physicians here would take the time to learn why the xPAP compliance rate in this country is abysmal, and they would adjust their practices accordingly. Just taking a few hours once a year to learn a little about the machines they prescribe would likely help compliance rates a great deal. It's clear from postings on this forum that most "sleep docs" know little or nothing about the specific machines which are available; nor do they know how to adjust the machines they prescribe. I speak from personal experience on this. My "sleep doc" displayed no knowledge of specific machines, and indicated amazement at the Encore Pro and oximeter data which I brought in to show him. Many here have shared similar experiences. While I liked my "sleep doc" and am grateful that he was willing to work with me, that doesn't change the fact that his standard practices missed the apnea diagnosis, and it doesn't change the fact that he knows little about xPAP machines.

Again, I would suggest to you, that you do yourself a great disservice by attempting to defend the absurd practices common in your industry. Defending the indefensible insults the intelligence of your readers. Just about everyone on this board is well aware of the out-of-control costs of medical care.

It is my belief (and this has been my main point) is that a simple inexpensive home oximeter screening would allow far more apnea patients to be diagnosed than the current PSG does. To pretend that the cost of diagnosis is inconsequential in determining how many people are diagnosed is unrealistic. Assuming that 1/4 of the U.S. population suffers from sleep apnea, this is about 75 million people. To diagnose nearly all of them will probably require screening about 150 million. The cost of doing so with PSG's costing $3000 each would run about $450,000,000,000, or about 20% of the national budget.

I realize that a number this big is "complex and challenging". Simply trust me when I say that screening this many potential apnea sufferers with PSG's is not gonna happen. Nor should it. There are many other worthy health-care uses for which that money could be spent.

Again, I repeat my assertion that far more apnea sufferers could be diagnosed with a simple inexpensive oximeter screening than will ever be reached with a PSG. Like with a simple blood test, just about the entire population of the country could easily be screened with oximeters within the next year, and most apnea sufferers diagnosed and treated. Pretending that this many folks could be reached with PSG's is not realistic. Screening even 10% of the population with PSG's would likely bankrupt the entire medical insurance industry.

Regards,
Bill

[drbandage]

Bill –
There is one striking and undeniable difference between your posts and mine. Have you noticed?

My response to the wild assertions and overly broad statements that you make is to actually quote you, verbatim, and then respond. I did this on ten occasions in my last post. You, on the other hand, are given to merely providing a biased synthesis of what you think you may have heard. Your synthesis is not an accurate depiction of what was said. An ill chosen word, deliberate or not, can dramatically change what the message is. After reading your feeble diatribe, I am left with the inescapable conclusion that you are just terribly unskilled at paraphrasing (and I am being generous to a fault), or that you deliberately distort what I have said to suit your own diabolical whims. Neither one is a pretty thought. Distortion of the message is not desirable. To wit:

Mr. Bill sez:

For you to claim that cost is an insignificant issue in seeing that the largest the number of patients are diagnosed for a disorder is woefully ignorant.

Bill, please document where I “claim” what you have stated. What I actually said was:

When you look at how much money is spent on such things as hemodialysis, chemotherapy, radiation, or surgery for example, you can also readily see that many hundreds of thousands are spent on the treatment of all manner of medical issues. So, I really think that fingering "cost of traditional apnea diagnosis and treatment as the most important obstacle facing patients" is missing the point.

Mr. Bill sez:

To claim the medical community is providing a great service to society by ignoring costs is mere justification for the absurd.

Bill, please document where I “claim” what you have stated. What I actually said was:

The medical community in general throws cost out the window in many instances when it comes to diagnosis and treatment, and I don’t mean that as a compliment

Mr. Bill sez:

To pretend that the cost of diagnosis is inconsequential

Bill, please document where I "pretend" what you have stated. What I actually said was:

The medical community in general throws cost out the window in many instances when it comes to diagnosis and treatment, and I don’t mean that as a compliment.

Please look for the nuances that will allow for intelligent discourse, and abandon your bomastic rhetoric. You sound like a third grader trying to use words that you don't even understand, and ideas that are not firmly grasped. More than that, you sound like you are deliberately misconstruing what I have said.

What is your intention in that? Do you want to be able to say you beat up a doctor? One of those monsters in your past that missed your diagnoses? Look elsewhere, or you'd better come loaded for bear. I have a very low tolerance for people who are deliberately manipulative and deceptive. Even if you were well intentioned, you can't be be so cavalier with your statements that you ruin your credibility. And you have.

Please don't ignore this, Bill:
Please respond with any, and I mean any quotes that substantiate your spurious accusations that I point out above. I double dog dare you, Bill. Failing that, I will have no choice but to conclude they are merely your fabrications. (And then I will apologize to the readers on your behalf for insulting their intelligence.)

Time to put up, or shut up, Bill. What's behind that swagger? Is your name Billy, or is it Silly? Shouldn't be hard to answer those three questions if you've got the facts. And if you don't, then just apologize and move on.

If you seek honest dialogue, then please try hard to grasp the nuances in conversation. It is a critical skill when attempting meaningful discourse, if that is indeed your intent.

On the other hand, you did actually include ONE (!) quote, and thank you for doing so, because I think our interchange here is starkly revealing . .

. . .the practice and delivery of medicine is far more complex and challenging than virtually any other industry . .

Mr. Bill sez:

I don't for one second believe this, but it is one great rationalization.

It seems unlikely, but perhaps you are familiar with the expression: Doubt is the Beginning of Wisdom. Perhaps if you were to consider it thoughtfully for at least "one second", the veil of ignorance would begin to lift. Bill, just because you don’t believe it, does not make it wrong, or transform it into a rationalization. I don't know what your esteemed "industry" is (other than it is one that is superior to mine in regards to the level of sloth, inefficiency, and corruption), but I would find it hard to envision having the chutzpah to posture as an expert in your industry, much less level an accusation that you have resorted to "rationalization". Medicine is what it is, and apparently you lack the sophistication to discern what is virutally universally acknowledged: ". . . the practice and delivery of medicine is far more complex and challenging than virtually any other industry".

From the naivete of your comments, it seems that you have little if any meaningful insight into a field to which I have devoted more than 16 years, in addition to being a patient myself for many decades even prior to medical school. I don't think you would find many people with critical thinking skills who would embrace your opinion.
Maybe a poll is in order . . .

Mr. Bill sez:

If money (which, by extension, is time) were of no consequence

Please provide a quote (or anything even close) where I state that "money is of no consequence".

Mr. Bill sez:

nor do they know how to adjust the machines they prescribe.

Bill, I hate to break it to you, but doctors are very, very busy usually, and it is quite the norm to have trained technicians "adjust the machines they prescribe." Examples: TENS units, hemodialysis macines, Holter monitors, infusion pumps, etc. etc. Techs are a key part of providing care, and doctors cannot reasonably be expected to know how to personally adjust all the machines that they prescribe. I certainly don't, and I think my doc's time is better spent assessing the data and coming up with the appropriate care plan than "learning how to adjust the machine".

Mr. Bill sez:

most "sleep docs" know little or nothing about the specific machines which are available

Here, your source for this broad statement is your personal observation and assessment of the selective postings of a subpopulation represented on this board. That won’t get it when the burden of proof that is required in making such a damning and inclusive statement falls to you. Using sweeping indictments unsupported by data, such as 'most "sleep docs" know little or nothing' to support your accusation is reckless and insupportable.

Mr. Bill sez:

I speak from personal experience on this.

Well, that certainly qualifies you to offer informed opinions about the state of the nation's health care system.

Perhaps my viewpoint is a bit jaded though. I failed two PSG's a dozen years apart and was told very authoritatively that I did not have apnea.I liked my "sleep doc" and am grateful that he was willing to work with me, that doesn't change the fact that his standard practices missed the apnea diagnosis, and it doesn't change the fact that he knows little about xPAP machines.

Dang, you had me going there for a minute. A glimmer of insight possibly? But, no.
Perhaps your perspectives would broaden if you were to consider the value of your own anecdotal evidence in reaching broadbased conclusions to be apocryphal at best, as most scientists would.

you do yourself a great disservice by attempting to defend the absurd practices common in your industry. Defending the indefensible insults the intelligence of your readers.

Bill, first of all, thank you for your selfless efforts in not only protecting me from doing myself a great disservice, but also from insulting the intelligence of our readers. Please let me know when it is my turn to have an opinion.
Impressive rhetoric from you, if only it were true. Again, please provide quotes (in context) anything that would support your accusations that I am in support of "absurd practices”. You would be well served to note that my defense was of a diverse group of men and women, who are by and large, highly educated and extraordinarily dedicated to a calling that requires an enormous commitment to the care of people in need.
BTW, readers, I am sorry for insulting your intelligence.
In just three short posts, you have made an impressive number of lamentable accusations and laughably myopic observations. What follows is a brief sampling:

You have missed my point entirely.
It is my belief (and this has been my main point) that a simple inexpensive home oximeter screening would allow far more apnea patients to be diagnosed than the current PSG does.

OK, Bill, fine, point well made. I can see why you would choose to subtly slander so many when nobody listens to you. Despite your keen powers of observation, I guess the following responses from me didn't resonate with you:

Where I find the most common ground with you, Bill, is when you assert that an overnight oximetry screening would allow far more folks to be screened for apnea. I would certainly agree that issues associated with the cost of traditional apnea diagnosis and treatment are important obstacles facing patient.

“we could easily screen just about the entire population of the country with oximeters within the next year”

Bill, have you been sniffing glue, or what?! This is a perfect example of a overly broad (and inaccurate) statement demonstrating either magical thinking, or at least a profound ignorance of reality. Not to say it would not be a noble goal, but let’s be realistic at least.
Doing the math: "Screen just about the entire poplulation of the country" = 293 million people. (US Census: 2004).
52 weeks in a year times 5 days per week = 260 days.
Working M-F, that would funnel in more than one million patients per day. Seems doable. "Easily". RFLOL!

other fine Mr. Bill-isms:

in the medical community where examples of inefficiency, laziness and corruption abound

It is rather galling to me that physicians elevate the cost of an inexpensive test to thousands of dollar

It's's important to take charge of your therapy personally rather than depending on a physician, few of whom seem to suffer from apnea themselves

There is nothing at all difficult or expensive about testing or treating apnea

most apnea patients can be fully diagnosed with nothing more than an overnight oximetry screening

At any rate, the diagnosis and treatment of sleep apnea is neither overly complex, nor overly challenging.

As we regularly see on this board, treatment is not too complex for the folks who gather here. Folks here are, I believe, not greatly different from the general population.

Oh, yeah. Sure.

the medical community makes it both difficult and expensive to diagnose and treat

Just taking a few hours once a year to learn a little

as simple as that, and we didn't even know it? Wow.

And yes, it was no typo, you said it twice, so I know you meant it.

I don't buy the argument for one second that the practice of medicine is so complex and challenging.

And my own personal favorite:

Simply trust me when I say

As John McEnroe would say: You've GOT to be kidding me!


Bill, please holster your gun before you shoot your foot clean off!

Anyway, as another wise person once said:
"Never argue with someone for whose opinion you have no respect", so I'm going to stop now.
Actually, I should have wised up after your first lame brain response, my Bad. But, I was trying to give you the benefit of the doubt.

So, with apologies to Linus Pauling (see below), and other great thinkers, but not to you, Bill, or others who would needlessly slander the medical community, and pompously parade their overblown egos around as if they actually had an insightful view of their own ignorance.

Science is the search for truth - it is not a game in which one tries to beat his opponent - Linus Pauling (forgive me, Linus)

I've started to enjoy pummeling you unmercifully, Bill, because you are so arrogant, and I know if it were a fight, the referee would have stopped it by now. Delivering a comeuppance to a pompous, ill-informed jackass such as yourself is a guilty pleasure that I seldom indulge, but what do you expect from someone who comes from a community that is lazy and corrupt?

Next time, don't bring a knife to a gunfight.

You might as well save your fingers for better things, Bill, as I will not be responding to, nor reading any more of your silly posts. I feel guilty enough for having wasted my precious time responding to your nonsensical postulations.
The End.

[oldgearhead]

And as far as treating, it is far less difficult and expensive to treat high blood pressure, diabetes, high cholesterol and many others ailments.

2006 total xPAP costs (No insurance or DME involved) = $930.00

Projected 2008 drug cost (with only Medicare) = $6200.00.

Better look at those drug prices again, Doc...and I don't have diabetes,
or high blood pressure. I have RA, CHF, and A-Fib. All three are under
control, but the cost will be impossible when I retire. So I guess I won't retire.

[NightHawkeye]

"Never argue with someone for whose opinion you have no respect", so I'm going to stop now.
Actually, I should have wised up after your first lame brain response, my Bad. . .

You responded because the truth in what I said made you mad.

Because of that you resorted to condescension and personal attacks instead of addressing the single issue I presented in my last post - a clear case of not seeing the forest for the trees.

You don't like my writing style or my opinions - that's fine.

“we could easily screen just about the entire population of the country with oximeters within the next year”

Bill, have you been sniffing glue, or what?! This is a perfect example of a overly broad (and inaccurate) statement demonstrating either magical thinking, or at least a profound ignorance of reality. Not to say it would not be a noble goal, but let’s be realistic at least. Doing the math: Working M-F, that would funnel in approximately one million patients per day. Seems doable. RFLOL!

I have done the math. I'll even provide another example explicitly illustrating the point. In my community there are 52 family practice physicians serving an area of 200,000 people. Assuming that 25% - 50% of folks meet some general criteria for potential apnea, that would add 5 to 10 patients to each physicians workload per day.

Unrealistic? Laughable? Doable? Hmm . . ., Certainly it's more realistic than requiring PSG's for an apnea diagnosis. In my community we have maybe ten beds for PSG's and months long waiting lists. It would take over thirty years to accomplish the same screening with PSG's.

One final point needs to be made. You said, and I quote you precisely here.

Distortion of the message is not desirable.

However, you rewrote my words and then attributed them to me in a quote! This is not only bad form. It would get you a failing grade in most college courses I'm familiar with. Here's the attribution you made:

“we could easily screen just about the entire population of the country with oximeters within the next year”

Here's what I actually said:

. . . just about the entire population of the country could easily be screened with oximeters within the next year, and most apnea sufferers diagnosed and treated.

To make sure I went back and searched the entire cpaptalk database, and the quote you provided shows up only one place - where you constructed it.

You've distorted my words and meaning, both figuratively and literally, drbandage. You may be free to do that, but don't be surprised when you get called on it.

Regards,
Bill

[drbandage]

I don't have diabetes, or high blood pressure.

OGH -
Since you don't have any of the ailments that I listed, I don't think the post applies to your particular situation.

I have RA, CHF, and A-Fib.

You are correct, of course, in noting that some diseases are more expensive to treat than others. Certainly, it's no day at the beach to have heart failure, and atrial fibrillation, both of which typically require multiple often expensive meds to keep under control. I wonder if they came before or after your OSA? (The chicken and the egg thing.) And of course Rheumatoid Arthritis can be a very nasty thing requiring multiple (and expensive!) meds, typically using a combination of several drug$$.

There are basically four main categories of arthritis drugs: analgesics; nonsteroidal anti-inflammatory drugs (NSAIDs), which include the cyclooxygenase-2 (COX-2) inhibitors; glucocorticoids, which are more commonly called steroids, and disease-modifying antirheumatic drugs (DMARDs).

So, in summary, you are correct, your multiple diseases requiring polypharmacy are not as cheap as simply treating hypertension and diabetes. Sounds like you'd better keep your day job, OGH, at least until you win the lottery.
Best of luck with your challenges.
drB

[drbandage]

Earlier tonight, I received a PM requesting that I clarify my calculations about a post claiming we could screen the "entire population" of our country in one year.
As I said previously, I have no intention of engaging in further dialogue with the Poster Who Shall Remain Nameless. Nor am I interested in his replies, for the reason that I stated.

I have tried hard to honor that commitment, but for the purpose of full disclosure, I want to acknowledge that I have inserted the requested data into my original post as noted above with a one time edit. I tried to resist including anything further, to avoid clouding the issue, but I couldn't resist a couple more pokes, and for this I am mildly remorseful.
I will get over it in time.

[NightHawkeye]

drbandage, on the one hand (with your new edits) you taunt me:

Bill, please document where I "pretend" what you have stated.
. . .
Please don't ignore this, Bill:
Please respond with any, and I mean any quotes that substantiate your spurious accusations that I point out above. I double dog dare you, Bill.
. . .
Time to put up, or shut up, Bill. What's behind that swagger?
. . .
If you seek honest dialogue
. . .

On the other hand you repeatedly state that you want no further dialogue with me.

And yet in the same breathe you impugn my intent, while throwing even more questions and challenges in my direction.

What is your intention in that? Do you want to be able to say you beat up a doctor?

Do you want readers here to feel sorry for you because you rode in here on your white steed of a unicorn, bound on a mission of mercy, but got beat up by some dumb schmuck (third grader I believe you said) who mangles his words, can't grasp subtleties, and is incapable of understanding the complex and challenging aspects of the profession to which you are dedicating your life?

I only posed one simple challenge for you, doc.

You say you have provided an estimate on how long it will take to screen the country for apnea, yet when I read your newly edited post I see no estimate on how long it will take to screen the country for apnea.

Doing the math: "Screen just about the entire poplulation of the country" = 293 million people. (US Census: 2004).
52 weeks in a year times 5 days per week = 260 days.
Working M-F, that would funnel in more than one million patients per day. Seems doable. "Easily". RFLOL!

I would suggest that a new post containing your estimate is in order.

I'm still here, doc. On this forum, status doesn't mean too much. I'm not sure infantile temper tantrums go far in swaying opinions either. Truth counts for a lot here though. Because I believe that my challenge to you on the need to reduce the cost of apnea diagnosis and treatment is important, I will endure further "pummelling" (your word, not mine), if need be, in hopes that eventually my point gets across. I believe that you are sincere in your desire to help, only you haven't yet grasped the significance of cost in achieving that goal.

Regards,
Bill