Tuesday, October 30, 2007

The End of Polio

A medical student today will go through their entire career without ever seeing a case of polio. The polio virus was feared throughout the early 20th century, leaving millions paralyzed or dead. During Summer and Autumn, polio epidemics spread human to human with this highly contagious disease. In the 1940's and 50's, negative pressure ventilators called the "iron lung" were used to support patients with paralyzed respiratory muscles. In 1952 the worst polio epidemic struck the United States, with 58,000 cases and 3,145 deaths. Over 21 thousand victims were left paralyzed.

By 1964, the oral polio vaccine, developed by Albert Sabin, had become the recommended vaccine. It was easy to administer and large populations could be vaccinated.

The effort to eradicate polio was launched in 1988 and involved the World Health Organization, Rotary International, the CDC and UNICEF. Through everyone pulling together, more than 210 polio endemic countries were targeted for childhood vaccination. Today only 4 countries - Afghanistan, India, Nigeria and Pakistan have polio. Fewer than 2000 children were paralyzed by the disease in 2006.

If the Global Polio Eradication Initiative is able to stick to its strategic plan, polio will be completely eradicated from the human population. This shows that political will and governments and industry working together can achieve wonderful things for mankind. This initiative had corporate support, pharmaceutical support, non governmental organizations (NGOs), the Gates Foundation and many small countries involved with donating funds to stop polio. Ireland, Bangladesh, Russia, Norway Canada, Germany, the U.K. ,India and the United States were all heavy contributors.

This success story shows that political will, oversight and responsibility are the ingredients for saving our planet. Let the End of Polio show us that we can work together successfully for a common good.

Sunday, October 28, 2007

It's Post Secret Day

Every Sunday the new Post Secrets are online. They only last a week. Don't miss out at this sad, amusing, wonderful look at mankind.

MRSA- it's tiny microbes

With all of the continued interest in MRSA (methacillin resistant staph aureus), it is a good time to remember just how bacteria work. According to author Bill Bryson..."if you are in good health and averagely diligent about hygiene, you will have a herd of about one trillion bacteria grazing on your fleshy plains-about a hundred thousand of them on every square centimeter of skin. You are for them the ultimate food court, with the convenience of warmth and constant mobility thrown in. By the way of thanks, they give you B.O."

Trillions of Staph Aureus microbes live on your skin and in your nasal passages. These bacteria are not harmful, and in fact, we depend upon them, living in harmony with other bacteria to keep our bodies and our planet in check. We think because we have invented antibiotics and disinfectants, that we can wipe out bacteria. What we have done, however, is just allowed them to evolve into another type that is resistant to our drugs and become penicillin (methacillin) resistant.

Your body's natural defense system will try to keep bacteria from hurting you. Millions of white blood cells are designed to identify and destroy a particular sort of invader. When the bacteria (or virus) obtains entry through catheter or a break in the skin they can invade another part of your body where they shouldn't be. Your white cell scouts call for reinforcements and the white cells, like little soldiers, come marching in to deactivate the bacteria.

Getting "sick" is a sensible response to infection. Sick people go to bed and are less likely to spread infection to others. When you rest, your body's cells can focus on the infection.

The phone call I hate the most is a patient who says, "I feel like I'm getting sick and I need antibiotics because I just can't be sick because I am getting on an airplane and I have to go to New York because I have a very important meeting and I just can't be sick."

Come on! You have to give your body a fighting chance because the microbes do become resistant to antibiotics (witness MRSA) and a stressed, tired body just can't mount the defence against infection. We would have been much more successful with bacteria if we saved our best weapon against them - antibiotics- for serious infections.

Our best defense against MRSA is good handwashing and alcohol wipes on surfaces. In a hospital, where patient's immune systems are down, it is critical for caregivers to wash hands between patients and to replace catheters using established infection control protocols.

Again, to quote Bill Bryson in the must read book, "A Short History of Nearly Everything", "It is worth remembering that most microorganisms are neutral or even beneficial to human well-being." We need to help our own natural defenses by resting when we are ill, and save antibiotics for the serious infections.

Thursday, October 25, 2007

Rate Your Doctor

I think the internet will have a huge impact on patient satisfaction of how they are treated by doctors. The idea of internet sites that rate doctors and hospitals has been around for about 5 years. In the past the sites have been difficult to view, some cost money and they were not user friendly. But like anything new...it may now have reached a tipping point.

I logged onto Ratemd.com and was surprised to see how easy the site was to navigate. It was free and you could look up doctors by name or city. I looked for my name...not there. But I found ratings on many of my doctor colleagues and 12 ratings on one of my "larger than life" medical school pals who now practices in Southern California. Wow he better make some improvements. It sounds like he is running a factory and the patients are none too happy. With a 5 point scale (5 being excellent) patients could rate doctors on punctual, helpful and knowledgeable and leave comments.

I found only a few surprises. In any medical community, we know who is outstanding and who was probably in the bottom third of their class. We know who is weird but brilliant and who has mediocre skills and a bad personality. The ratings of the doctors I know seemed to fit what I would imagine their patient interaction skills were.

The criticism of these sites is that only the very happy and the very unhappy patient will take the time to post a comment. That is probably valid...but it is still useful information for the person looking to find a doctor. Patients often have nothing to go on except a list of names. Another criticism is that it is not a good way to judge quality. I agree with that, but we don't seem to be providing any alternative. Until we can define, measure and report on quality, we are stuck with patient satisfaction. The quality experience is what a patient wants and these sites give a glimpse into that experience.

Tuesday, October 23, 2007

Patient Safety- Run the OR Like a Jet Plane

We all know about the poor patient who goes in for a right kidney operation and ends up having the "good" left one removed instead. Or the patient with the allergy who is given the wrong anesthesia and has a reaction. Or the patient who is given the wrong blood type. These things happen despite the fact that doctors and nurses are doing their very best to heal under really tough circumstances.

I saw a film at a conference that really impressed me about how we need to fundamentally change how we address patient safety and live up to Galen's dictum of "primum non nocere" ("first do no harm.")

The film showed an operating suite, with the scrub nurses, anesthesiologist, surgeon, medical student, radiology tech all gathered around the patient lying on the operating table. Instead of just starting the operation, they stopped for a required "time out". The protocol was rigid.

The circulating nurse identified the patient by name, birthdate, age and what the operation was for. She identified that the preop exam was on the chart and mentioned the allergies. Next the Surgeon formally gave the patient's brief history, other health risks and what his intent was for the operation. The scrub nurse identified herself and pointed out that she had the equipment ready and the specific tools the surgeon would require. The anesthesiologist went next with his name (they are all behind masks, you know) and mentioned the anesthesia was on board. He introduced the medical student and then said the operation could begin.

The formal time out was over and the operation began. It was very proscripted and weird to see, but it was immediately obvious to me that this is how it should be done. A pilot does the same thing before she takes the responsibility for the passengers lives in her hands. All systems are checked and verified formally with the control tower and the co-pilot. Even though the plane has been flown hundreds of times on the same route, a protocol is followed before takeoff.

If I or my family or my patients are scheduled for surgery, I want a team that does a formal "time out" and treats it as seriously as flying a jet plane.

Saturday, October 20, 2007

Transparent Pricing for Patients

There is a big push toward having patients be smarter consumers of health care as a way to control costs. Employers are pushing for medical savings accounts (where the patient has a pot of money they spend on health care or just save) and more and more insurance products have high deductibles and more cost sharing by the patient. The simple way of explaining it is that if someone else is paying the bill (insurance, medicare, the government) people will just use lots of care and testing and medications and procedures and have no regard to cost.

In a normal market, lower cost, high quality products would prevail. The medical market should operate that way but it doesn't because the incentives aren't aligned. The person receiving the benefit ( the patient) is often far removed from the true cost.

The only way a true market could work is if the consumer (patient) KNOWS WHAT SOMETHING COSTS! Here is the rub. It is near impossible for a patient to find out ahead what the cost of a test or operation or even a doctors visit will be. The system is so complicated, answering that easy question is not so easy.

Hospitals don't have one pricing method. They have contracts with each insurance company (there are hundreds) and each is written in a different way with different discounts for each service. A colonoscopy can cost $800.00 at one place and $6500 someplace else. Can you believe that range? The price is often not what the provider gets paid anyway. That price may or may not include the medications given or the gastroenterologist portion of the bill. In a hospital setting the price may differ if you are covered by one of hundreds of insurance plans or by Medicare. There are laws that say a provider can't charge less than it's lowest price contract and they don't want to charge less than what they could be paid by the highest price contract. There are also trade secrets so they aren't disadvantaged the next time they contract with an insurer. Are you dizzy yet?

There is no other industry where the consumer receives a service and doesn't know the cost. But there is no other industry that is so over regulated with such complicated payment methods either. There is no other industry where a product (service) is given and the government payment doesn't cover the cost of that product.
(How long would Blackwater contract with the government if they didn't get paid their cost? Why are other industries so eager to tap into the taxpayer's bank? Ah, but that is another blog)

Our industry- American Health Care- needs to get a grip and solve this problem. It isn't easy and I'm not blaming hospitals or doctors. Heck I am part of the problem too. Doctors also have to inflate their charges to cover the government payments that don't cover the cost of care. But it is insane to expect patients to be frugal purchasers of health care when they aren't told what something will cost.

Wednesday, October 17, 2007

Surgical Model

In my medical training, oh so many years ago, we learned from cadavers. While this was a good way to learn basic anatomy, the physiology of how the body worked was a slower process. Thanks to Unbounded Medicine for this look at the way students can learn now. This reproduction of a patient was crafted with animal organs that really give the student a much better idea of how the body functions.

Tuesday, October 16, 2007

MRSA - It's preventable

Everywhere I turned today, I was engaged in discussions about methicillin resistant staph aureus (MRSA) and tonight I read a new article in JAMA that says it is twice as prevalent as we thought.

MRSA is a common skin bacteria-Staphylococcus aureus-that has become a "bug on steroids" and is resistant to penicillin, methicillin and other drugs that used to kill it flat. It has developed over time and 85% of infections are associated with hospitals and long term care centers. When it enters the skin barrier through incisions or IV lines, it can cause serious internal infections and is a leading cause of death.

Staph aureus is found in the nose and respiratory tract and healthy people can be carriers. It can live on clothing and curtains and (I've heard but not verified) that in England they are prohibiting physicians from wearing ties because of possible contamination.

MRSA infections are preventable and the bacteria is killed by topical alcohol.We've known that hand washing saves lives since Philip Ignaz Simmelweis discovered clean hands save lives in Vienna in 1847. He was fired, by the way, for such an outlandish idea that physicians should wash before they deliver babies or do surgery!

Topical alcohol based hand rubs, hand washing between patients, using infection control protocols for IV and line placement and screening for and isolating carriers of MRSA are all ways to drop this infection rate to zero. Paul Levy, the blogging CEO at Beth Israel Boston has been openly revealing his hospitals efforts to reduce MSRA and all hospital acquired infections. This is something that we should openly discuss, tackle as health providers and each of us help our colleagues remember to wash so we can drop these infection rates pronto.

Monday, October 15, 2007

Healing Environments

While the housing market has bombed, new hospital buildings are the rage in California due to a law that says they need to be seismically (earthquake) safe. As hospitals are planning the hospital of the future, many are using architectural design to reduce stress and promote safety and healing.

What type of building promotes safety and healing? We know what doesn't work. I've practiced in hospitals where the beds are so close together I could examine two patients at once without moving my feet. One wall mounted TV services two patients, so if you don't want to watch another episode of "Cops" while you are recovering from surgery, you're out of luck. And what about those bed trays on wheels that hold your food, your medication, your cards from relatives and your personal grooming supplies all together... clutter does not promote healing or good sanitation.

Most hospitals are hip to the fact that "noise" is a problem for patients and they try to keep the nursing station area quiet. It usually doesn't work. Phones are ringing, trays are clacking, nurses and doctors are talking and the best a patient can do is treat it like "white noise".

Here is what I would like to see in a healing environment:
  • Windows looking out into nature with black out curtains. (The best sleep I ever get is in a hotel. Where do they get those curtains?)
  • Bathrooms that are designed to prevent falls. Bars on walls, plenty of room to maneuver an IV pole or walker. Toilets that are higher than usual for ease of sitting.
  • Standardized room designs so nurses can be efficient and have all of their supplies and medications handy and in identical locations. Wall computers in every room for nurse and physician charting. Cabinets to hide supplies and a closet for patients belongings.
  • Window bed for family to spend the night.
  • Priority on patient privacy. Private rooms, private conference rooms for family.
  • Warm and very clean play area for children and their parents to hang out. Updated magazines, coffee and tea, water and computer in the family area.
  • Garden/Atrium for patients, family and staff to be with nature quietly.
  • Nutritional, organic food for patients and staff.
  • Non-smoking inside and out.
  • Absolutely no eating or food at the nursing station. Cold pizza and stale Sees candy...ugh!
  • Nursing stations designed with input of nurses and their workflow to capitalize on efficiency, safety and patient centered care.
I don't think any hospital administrators should design a hospital without getting patient, nurse and physician input. I mean real input. Ask patients and their families what they would change. Query them while they are in the hospital and make them part of the design team. Nurses should work with the architect from the beginning. They are the backbone of the hospital and to design without their input is folly.

Friday, October 12, 2007

Plastics and Chemicals That Can Harm

The chemical, bisphenol-A (BPA), is used to produce polycarbonate plastic and epoxy resins and is found (get this!) in water bottles, baby bottles, food containers, compact discs and dental sealants. The chemical can leach into foods, be inhaled or enter by other routes and the US Centers for Disease Control and Prevention found this chemical in the urine of 95% of people they sampled. BPA is an estrogen mimic and may interact with estrogen receptors.

Numerous animal studies have been conducted for years that link BPA with diseases and they have identified a mechanism where BPA exposure in pregnant rats causes genetic changes that persist through the life of the offspring. They also found neurological effects of BPA exposure that caused the mother rat to groom the pup less. The findings were species specific, but they involve areas of the brain that play a role in hormonal regulation and sex-related behaviors across species.

The complex factors, both environmental and genetic, that affect health are difficult to sort out. It is hard to extrapolate from animal studies to humans and the complexity of hormones makes cause-effect relationships almost impossible to prove.

But, we are facing a worldwide increase in obesity, diabetes, prostate and breast cancers, autism and attention deficit hyperactivity disorder.

As I look around the changes in society... plastic bottled water everywhere, clear plastic containers for food, plastic bags, plastic toys, plastic backpacks...I certainly support the toxicologists and environmental scientists in this work and if there is an inkling that BPAs are harmful to humans...they should be banned everywhere.

Congratulations to Al Gore who just won the Nobel Peace Prize.
A man of courage and integrity, Al Gore has opened the world's eyes to just how small planet Earth is. In the entire universe, it is the only place where life exists. Lets get it right.

Thursday, October 11, 2007

Withdrawl of Kid's Cough Medicines

McNeil Pharmaceutical has stepped up to the plate and done the right thing by voluntarily withdrawing a number of cough and cold preparations that may be harmful to kids under the age of 2. Recent findings show these medications can be overused by parents and there are no safe guidelines for tiny tikes and these preparations. McNeil has begun by informing physicians of the following:

We have decided to voluntarily withdraw the following over-the-counter (OTC) infant cough and cold medicines from the market:

Concentrated Tylenol® Infants' Drops Plus Cold
Concentrated Tylenol® Infants' Drops Plus Cold & Cough
PediaCare® Infant Dropper Decongestant
PediaCare® Infant Dropper Long-Acting Cough
PediaCare® Infant Drops Decongestant (containing pseudoephedrine)
PediaCare® Infant Dropper Decongestant & Cough
PediaCare® Infant Drops Decongestant & Cough (containing pseudoephedrine)

We believe the decision to voluntarily withdraw these products may help to reduce these instances of misuse among children under 2 years of age.

This voluntary withdrawal does not include:
Children’s Tylenol® cough and cold medicines for children over age two
PediaCare® Children’s cough and cold medicines for children over age two
Infants’ and Children’s Tylenol® pain relievers and fever reducers
Infants’ and Children’s Motrin® pain relievers and fever reducers

This is an example of a large company putting patient safety before profit. Kudos to them!

Tuesday, October 9, 2007

Sport Concussions

One of my most "googled" blogs was "A bump on the head". Falls and head injuries are common and an estimated 300,000 sports-related concussions (also known as mild traumatic brain injury) occur annually in the United States. Researchers estimate that 63,000 of those occur in high schoolers playing football.

The tough thing about concussions is that there is no marker or test to know if a person has one. With new technology like functional MRIs (fMRI), doctors can see changes in brain function and link those changes to the recovery time needed for injured athletes. With a concussion, fMRI identifies abnormal hyperactivation in specific brain regions that control cognitive process, such as memory. They can provide the first understanding of how a concussion affects the brain.

fMRI machines are scarce and found only at academic medical centers and the cost for a scan can run up to $1200. Until the technology becomes more common, we are left with arbitrary guidelines that are shifting toward a more conservative treatment of young athletes. Coaches, trainers and parents are thinking twice about sending a kid back into play too soon. Any insult to the head that results in a temporary or transient change of mental state (even if there is not loss of consciousness) needs to be labeled a concussion.

The problem remains that there are no symptoms or signs that can predict when it's safe to return to play. We don't have any evidence to guide us but if early studies with fMRI are an indication, recovery may take longer than we originally thought.

Sunday, October 7, 2007

Medicare Drug Plan - Profitable to Insurers

The New York Times has an article that is no surprise to physicians and pharmacists who care for patients. Guess what? The wonderful Medicare Drug Plan for seniors has turned into a cash cow for insurance companies that administer it. Duh! Since when do Insurers ever do anything with the government that doesn't fatten their pockets?

Audits, conducted by the Department of Health and Human Services found serious compliance problems in deceptive marketing practices, denial of claims and handling of appeals. Sales agents sold products that were not really available, formularies did not cover needed drugs and there was no way for a patient or doctor to appeal or even get someone to answer the phone. Claims were denied and people were told they were not enrolled even though they produced cancelled checks. Wellpoint, one of the nations largest insurers, has a backlog of 354,000 claims. Gee, they are in the insurance business and can't handle claims? Isn't that their only reason for existing?

These same insurance conglomerates, Wellpoint, United Healthcare, and Humana to name a few, also sell Medicare Advantage plans which offer a full range of coverage including hospital and doctor care. The investigators found the same abuses in these plans as well as the drug plans.

As long as we allow large corporations to make obscene profits on our Medicare tax dollars, we will have a health care system that fails in the United States. I have said it before...I want my tax dollar to be used for improving and sustaining health of people...all people. Stop this corporate privatization of Medicare. Stop allowing big Pharma and big Insurers to rape the coffers. We deserve better.

Friday, October 5, 2007

Doctors and Email

I tried to phone a patient last night with the results of her bone density test. She wasn't home and the thought of playing phone tag for the next few days was not appealing. I asked her husband for her email address and emailed her the results with my recommendations. Mission accomplished!

Everyone emails. My son chats online with all of his friends together every night. You can order shoes online (Zappos is great), do banking online, make reservations online, even hire gardeners online...but you can't communicate with your physician online. There is a web revolution and medicine is still in the last century.

A 2002 Harris poll found 70% of patients wanted online access to their doctors and 40% would pay for it. Although it is now 2007, not much has changed. Medicine is astonishingly behind the rest of the world. From the physician view, here's why:

Doctors want to reduce their cost of business and their staff time. They see email as a new service that will not be reimbursed. They worry about opening a floodgate of trivial emails with the expectation of a physician response. They worry that serious health issues will be presented in email that should be seen in person. They know they are already performing hours of unreimbursed work a day and don't want to voluntarily make it worse. For physicians time is money and this is just more time without money. They worry about security issues and lawsuits.

The physicians that are practicing "concierge medicine" (also known as retainer practices) have it figured out by charging a joining fee that covers email and phone calls. The rest of us just adopt email one by one. For me it is a time saver. Nothing is worse than ending my day with a stack of charts, labs and phone messages that need to be returned. Last night I did that for 2 hours and my mood was bad. Email saves me time and is quicker than the phone call. Both are unreimbursed but email is a patient pleaser and a bad mood never comes through electronically.

Thursday, October 4, 2007

Thunderstorms and iPods

Letters have been circulating in the New England Journal of Medicine about the potential dangers of iPods (and MP3 players) and their ear wires attracting lightning to strike during a thunderstorm. An initial report of a jogger wearing his iPod and being struck by lightning came from Vancouver, BC. The patient did not lose consciousness, but he had amnesia, perforated eardrums and a fractured mandible (jawbone) after the lightning current struck him. Was the iPod to blame?

There is no evidence that a metal or electronic apparatus carried or worn on the body makes a person more attractive to lightning. Rocking along to an iPod may prevent the user from hearing thunder. That is a danger because there is no place outside that is safe when thunderstorms are in the area. Under a tree is the worst place to be and when you hear thunder you should not be outside at all.

It is possible that the iPod wires actually conducted electricity away from the patient's ears and away from his heart where the lightning could have killed him. Skin offers no impedance to electricity and will conduct it readily. The patient had external burns where the ear wires laid against his cheek and neck but no burns inside the ear canal, another clue that the iPod might have conducted the energy away.

In summary, the experts believe the MP3 player may have actually saved this guy. If common sense were as common as the iPod, there would be fewer joggers in thunderstorms.

Tuesday, October 2, 2007

Give an Hour - mental health for vets

Just when I feel so discouraged about the direction our country is headed, I get a lift by learning about a new organization that is developing a national network of mental health professionals that will provide free care for returning Iraq and Afghanistan vets and their families.

"Give an Hour" is a non-profit of volunteer mental health professionals across the United States that will donate an hour a week of continuing care, support and treatment...free to the vet or his family. They provide easy access to skilled professionals for people affected by war.

Our combat vets are coming home with depression, anxiety, post traumatic stress disorder and feelings of disassociation. It can be a surreal experience to re-enter American life and carry the horrors of war inside when everyone else is going about life as usual. Many of these men and women fail to seek or receive appropriate care and their families are also struggling with the changes war has brought.

According to Medical News Today about 1.8 million veterans are uninsured and lack access to VA hospitals. Give an Hour is helping to bridge that gap.

If you are, or know of , a psychiatrist, psychologist or psych social worker, please pass this link on to her.

Monday, October 1, 2007

How to Interpret Medical Studies

We are bombarded with news of medical breakthroughs every day. How can you know what studies are valid and important, and which ones are just fluff? Here are some ways to tell the difference:
  • How many people were in the study? The more the better
  • Who were the subjects, researchers and sponsors? The funding source of the study is important and might change the motives. Do the researchers have credentials? Are the subjects like you? A study of Tibet Nuns might not be as meaningful.
  • What was studied? The best studies look at outcomes...such as rates of heart attack or stroke. Other studies focus on test results. Outcome studies are the hardest to do, but the results are the most meaningful.
  • Meta-analysis: The researchers pool many study results to analyze information from hundreds or thousands of patients.
  • Case controlled study: Compares cases (people with disease) to controls (people without disease) to see why the disease occurs.
  • Single randomized controlled trial: patients are divided into two groups. The experimental group receives a new treatment while the control group gets an inactive treatment. The larger the difference in results, the stronger the evidence.
  • Expert opinion: Only as good as the evidence it is based on. Often it is from BOGSAT - A bunch of guys/gals sitting around talking.
  • Single Cases or Testimonials: "I lost 30 lbs in my sleep". "Loose weight while eating."
Most studies published in peer reviewed Medical journals are well done. But remember that the dramatic results on the front page of the news, may be refuted by another study a few weeks later. It is always wise to wait and see if the researchers work can be duplicated.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...