Sunday, December 30, 2007

2008 Resolutions for Patients and Doctors

#1 Doctor: Resolve to let patient speak without interruption and describe their symptoms.
Patient: Resolve to focus on the problem I am seeing the doctor about and not come with a list of 10 complaints for a 15 minute visit.

#2 Doctor: Resolve to keep a pleasant tone of voice when answering night and weekend calls from the answering service or nurses.
Patient: Resolve to get my prescriptions filled during office hours, not forget my medications while traveling and to use nights and weekend phone calls for emergencies only.

#3 Doctor:
Resolve to exercise a minimum of 4 times a week for better health.
Patient: Ditto

#4 Doctor: Resolve to train my staff and model excellent customer service for patients.
Resolve to understand that getting an instant referral, prescription, note for jury duty, letter to my insurance from the doctor is not my god-given right and I will stop bitching.

#5 Doctor: Resolve to give at least one compliment a day to my office staff, child and spouse.
Patient: Ditto

#6 Doctor: Resolve to apologize when I am late seeing a patient who has been waiting.
Patient: Resolve to not complain when the doctor is late because I understand that another human being needed attention. It might me me in the future who needs extra time.

#7 Doctor: Resolve to do one new thing a month that is novel that I would put off ( a play? travel? special activity with a child or spouse? computer skill? music? see a friend?)
Patient: Ditto

#8 Doctor: Resolve to review all insurance payers and drop contracts that are not paying market rates for my skills and education. I will not go bankrupt.
Patient: Resolve to try and understand the medical economics that require my doctor to drop my insurance. If my doctor isn't worth paying a little more for the visit I will find a new doctor.

#9 Doctor: Resolve for each new prescription I write I will explain 5 things. The name of the medication. The reason for the medication. The side effects. How to take it. And how long to take it.
Patient: Once the doctor has prescribed a medication, I will take it as prescribed.

#10 Doctor: I will give thanks that I have a wonderful profession where I can help people in a special way.
Patient: I will not underestimate the many years of training and sacrifice my doctors have gone through and I will appreciate that they are trying their hardest to help me stay healthy.

Saturday, December 29, 2007

Patients Who Google

I read an article in Time Magazine from a Dr. Haig who couldn't tolerate a patient who "googled" him, her health conditions and treatments. It made me stop and think about patients who "google". They often send me articles they have discovered about their illness or bring information they have downloaded. Many times the information is not exactly evidence based nor well researched. There are a plethora of experts with "Doctor" in front of their name that tout research that was published in an obscure journal. Other times it is anecdotal or advertisements. The internet can be a wonderful thing but one needs the ability to sift through the junk. When it comes to health, that is my role.

Despite the fact that there is very little a patient can bring me that I don't already know...I don't disdain the effort. An involved patient is one I can work with. I try to show respect for whatever product or treatment they are asking about but I don't hesitate to give "the other side of the story" if there is evidence against it. Many times it wont hurt anything but their pocketbook and I tell them so.

Here is what I don't like, however. I don't like it when a patient wants me to research something obscure. If they have heard of a new medication or treatment that is not yet proven, I ask them to get the information and I'll review it. According to a recent study in Annals of Internal Medicine, primary care physicians already spend almost an entire DAY a week doing unreimbursed work between patient visits. I want the patient to do the "googling", not me. I'll do the interpreting, if asked, at the time of the next office visit.

Tuesday, December 25, 2007

Giving Thanks

The darkness has settled in on this Christmas Day and the dishes are almost done. Wrapping paper is in the recycle can, the dog and cat are sleeping and everything is peaceful. For this and many things, I give thanks:

  • That my family is relatively well and my son's strept throat (or could it be mononucleosis?) has turned the corner.
  • That I am a physician and can actually treat these illnesses on holidays without bothering another doctor.
  • That we are warm and have a nice home and a full refrigerator...something 3/4 of the world's population does not have.
  • That my mom is still alive and has a good man to spend her life with.
  • That I am a physician and can offer a healing touch to others.
  • That my husband is a great partner and loving person.
  • That I live in a place with trees, the ocean, mountains and beauty.
  • That I am blessed with fantastic and interesting friends.
  • That we have great garbage pickup. I can't imagine life without it.
  • That Steve Jobs invented the ipod.
  • That my patient got better and was discharged from the hospital so I didn't need to go in and make rounds.
  • That there is a free application called "stat counter" that lets me see where people come from that have visited my blog. Hello Iceland, South Africa, Ireland and Australia. Greetings Botswana, Isle of Man, Canada, Jordan and Brazil. It is a miracle that we can all communicate with each other.
  • That "This American Life" on NPR is a free podcast since I never get to hear it when it is on the radio. I love it.
What do you count as your blessings? It is cathartic to really think about it. Merry Christmas!

Sunday, December 23, 2007

Track Santa's Progress Across the World

It is almost Christmas Eve and that means Santa will be starting his 'round the world magic ride. How does he do it? We can't always explain the magic of Christmas but with modern technology we can track Santa via Norad space stations. So if you have children or are just a child at heart, don't forget to Track Santa.
You can begin on Christmas Eve!

Saturday, December 22, 2007

Bad Habits

With the New Year looming, I always start getting more introspective. There is something about starting a new year that makes me think "change" is possible and I can be fresh and new.

Marshall Goldsmith has written a book called "What Got You Here Won't Get You There" with some simple tips for successful people. His premise is that simple bad habits keep us all from achieving what we could in life and we are often unaware of what we do. It applies to home and family as well as the workplace. Here are a few that may sound familiar:
  • Passing Judgement
  • Making destructive comments
  • Starting sentences with "no", "but" or "however". These terms are progress stoppers.
  • Failing to give recognition
  • Clinging to the past
  • Failing to express gratitude
  • Not being able to say "I'm sorry"
  • Making excuses - not owing up to our own actions
  • Goal obsession - getting so caught up that we don't focus on what is important.
Goldsmith says you can't overestimate the results of just plain "being nice". Listen to others without interupting. Give credit to others and don't be a limelight hog. Apologize when you do something wrong or hurt someone. Be positive when someone else expresses an idea or plan.

It seems like common sense and just good manners, but it's amazing how many times these little bad habits can creep up. I'm going to try and be aware of all of them for 2008!

Friday, December 21, 2007

Answer-Quiz #5

The answer is #3 - Ehlers Danlos Syndrome. This rare genetic condition causes hypermobility and extreme extension of joints due to abnormalities in collagen synthesis and connective tissue. Like many medical conditions, it was named after two doctors from Denmark and France who discovered it at the turn of the century. Thanks for playing.

Wednesday, December 19, 2007

Medical Quiz-How Smart Are You #5

I saw Cirque du Soleil this week. It is a wonderful acrobatic extravaganza and one act had three beautiful girls who did amazing, flexible things with their bodies that looked absolutely unreal.
I am sure they had this condition. Can you name it? Click on the image for a closer look.
Answer will be posted tomorrow.

Hearing Aids and Insurers

I blogged a few days ago about the fact that hearing aids are not covered by Medicare or by private insurance. Dr. John Ford at California Medicine Man wrote a thoughtful analysis about that question. Check it out!

Tuesday, December 18, 2007

Grand Rounds This Week

To see the best of this weeks medical blogs go to Shiny, Happy Person and marvel at the haiku theme. EverythingHealth was mentioned too by this clever British Psychiatrist.

Monday, December 17, 2007

Superbugs and Farming


A recent issue of JAMA addressed the issue of antibiotic resistance and the effect of farm practices on creating resistant "superbugs". This topic has been reported on for decades but more and more scientific evidence is emerging that cannot be refuted. Now researchers have found, in two distinct studies of humans, that bacteria are developing resistance to antibiotics on poultry farms and that these resistant bacteria are colonizing humans. The studies showed that the mutated strains of bacteria were identical in the animals and the humans who ingested the food.

Farmers have been feeding antibiotics to pigs, chickens and cattle for the past 50 years. Seventy percent of antibiotics used in the U.S. are given to food animals because they grow up 5% faster and use less feed if they are given antibiotics. This is not done to treat disease.

Bacteria are very adept at evolving genes that allow them to live, despite our amazing array of antibiotics. Antibiotic resistance evolves over time through natural selection and mutation and when antibiotics are overused, resistant superbugs emerge.

One half of staph aureus are resistant to our common antibiotics...the result is MRSA ...methacillin resistant staph aureus.

What is the answer? First recognition that this is a health issue that affects everyone. Antibiotic use for farm animal growth should be banned worldwide. (Some countries have already done this). We should start with the U.S. and forbid imports from countries that use antibiotics for growth. Factory farming must be humane and animal healthy. Overcrowding, over breeding, filth and hormone/antibiotic laced grain is obscene and dangerous. It is clear if you watch the attached video that factory farming must change.

Sunday, December 16, 2007

Hearing Aids - Surprise! You're on your own.

I learned something yesterday from a patient (and friend) that was a surprise to me! I did not know that hearing aids are generally excluded from insurance coverage and Medicare (insurance for Americans over 65) also does not cover hearing aids. I argued "No, that can't be true" but, sure young friend who suffered sudden hearing loss was correct. She should know as she had experienced the need to price compare and get the best deal at Costco.

Do any readers find this shocking? Hearing aids cost hundreds of dollars up to $2500. One study found that 55% of senior citizens not using hearing aids found cost to be the barrier. What about children that are hearing impaired?

Hearing aids are not a luxury. I've never known anyone to "fake" deafness just so they could wear an aid. Even the many hypochondriacs that doctors treat don't use lack of hearing to go from doctor to doctor or get lots of expensive tests. If you have hearing loss, it is easily diagnosed and treated with hearing aids. It is a medical condition.

The NHS in England offers free hearing aids to everyone who needs one. There can be an 8-14 week wait for a hearing aid. Or the patient can buy one from a private dispenser with a 2 week wait.
I don't know why this is excluded from coverage in the USA. Probably has something to do with cost, profit, lack of will. I don't know.

Saturday, December 15, 2007

The Uninsured - Everyones Concern

It's election time (the longest election in history)! Today's post will be a primer in who are the Uninsured in America that we hear so much about.

  • 45 Million people under age 65 lacked health insurance. (Over age 65, Medicare kicks in and Medicare is government sponsored. If you are a billionaire, you get Medicare too)
  • Eight out of 10 (8/10) came from working families and 70% worked FULL TIME.
  • 59% have gone without health coverage for 2 years or more.
  • Minorities ( translate: "lower income") make up the uninsured. (1/3 Hispanic, 1/4 Native American, 21% African American, 18% Asian American, 13% white).
  • 79% of the uninsured are American Citizens.
  • Having insurance improves health overall and could reduce mortality for uninsured by 10-15%.
I'm sure most American readers of EverythingHealth have health insurance of some type and wonder why 45 million don't? Are they lazy? Are they irresponsible?

61% of Americans get their health insurance from their employers and that has been eroding steadily throughout this decade. Employer sponsored health insurance is sensitive to changes in health insurance premiums and we have had double digit healthcare inflation since 2001. Employer sponsored health insurance is voluntary and fewer employers are offering health insurance as a benefit. Low paying jobs (which has been the job boon of this decade) do not usually pay health insurance. Over 80% of the uninsured are in blue collar jobs where the wages are low.

If you don't get your insurance through your job you pay huge rates and if you have any chronic health condition, no one will insure you. Only 5% of Americans purchase their own insurance.

Those are the facts! Future posts will explore solutions and compare what the candidates are proposing for Health Care in America.

Answer to Quiz #4

The answer is #5 - Calcinosis. These lumpy bumps are soft tissue calcium and phosphate deposits due to chronic renal failure. The parathyroid glands help regulate calcium in the body and these bumps resolved after she had her parathyroids removed. (NEJM)

Thursday, December 13, 2007

Tuesday, December 11, 2007

Grand Rounds-Check it Out

Grand Rounds this week is at Odysseys of George.
It is really great with beautiful diving photos and great links to the medical blogosphere. EverythingHealth is one of the featured links. Check it out.

Monday, December 10, 2007

Kids Fail Physical Fitness Test

The California Department of Education reports that more than two in three California public school students failed to meet State physical fitness standards. They measured over a million fifth, seventh and ninth graders in six areas:
  • Cardiovascular endurance
  • Body fat percentage
  • Abdominal strength and endurance
  • Trunk strength and flexibility
  • Upper body strength and endurance
  • Overall flexibility
There is a little good news here...compared to 2006, the scores increased 2% for fifth graders (to 27.1%), 1% for seventh graders (30.9%) and 3% for ninth graders (30.1%)

These numbers are a bit of a shock when you see them in black and white. California has great weather, lots of open space and, I thought, a more health minded population. Could it be the video games and TV? Is it lack of physical education in schools? The report didn't discuss the reasons but the results speak for themselves. Get these kids outside doing activities or we are going to be faced with a very unhealthy adult population in a few years. Hey Arnold, where are you?

Sunday, December 9, 2007

Physicians Roles at Guantanamo Bay

Hundreds of prisoners at Guantanamo Bay, Cuba have gone on hunger strikes to protest their indefinite detention without legal process and inhumane treatment. When this happens, 6-point restraints have been and are still being used to immobilize prisoners and nasogastric tubes are inserted for force feedings.

Force feeding of competent prisoners who have refused food is a violation of the Geneva Conventions, International human rights law and medical ethics. The World Medical Association has recently updated the Declaration of Malta with guidelines on care of hunger strikers. They have stated that if the hunger striker is not being coerced, either by other prisoners, officials or outside influences, forcing treatment on competent people is wrong.

"Forced feeding contrary to an informed and voluntary refusal is unjustified...Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment."

The International Tribunal for the former Yugoslavia ruled in 2006 that force feeding of a prisoner in handcuffs with a rubber tube "constituted treatment of such a severe character warranting the characterization of torture".

A Physician's duty to the patient is always the highest priority. Because all ethical rules for treating hunger strikers require the cooperation of physicians, physicians should prevent the force-feeding of competent prisoners by refusing to approve or participate in these activities.

Friday, December 7, 2007

It's Flu Season - Why in Winter?

The New York Times ran a great article about a study that answers an age old question. Why does the flu (influenza) season always happen in the winter? We seldom see flu in Summer or even the Fall. In the tropics flu doesn't even exist.

There have been hypothesis that it was from overcrowding in schools and homes, or in the winter people are stuck inside and can pass the germs. But people are crowded in the Summer too and travel on vacations in planes and we don't see influenza.

A clever researcher, Dr. Palese from Mt. Sinai School of Medicine in New York conducted studies on guinea pigs and found that the flu virus thrives and is passed through the air at low temperatures. At 41˚the animals passed the virus more readily and longer than at 68˚. The virus was passed at low humidity but not at all at 80% humidity.

Since you really can't do anything about the weather, the best way to prevent flu is to get a flu shot or move to the tropics. Mom was almost right when she said "Put on that coat and gloves or you'll catch your death". It is amazing that it took this long to get some scientific evidence about a virus that is so common.

Thursday, December 6, 2007

Wonder Where the Money Goes in Healthcare?

Here is the answer:
Breaking News: UnitedHealth Group’s former chairman and chief executive officer, William McGuire, M.D., will forfeit more than $400 million under agreements reached with the company and the Securities and Exchange Commission over an options backdating scandal, on top of $200 million he has already relinquished.

Answer to Quiz #3

The answer is # 5 Dupuyten's contracture

The flexion contractures of Dupuytren's involves the flexor tendons of the hands and creates a contracture that is not painful. The cause is unknown and treatment is surgical release of the tendons.

Wednesday, December 5, 2007

Medical Quiz - How Smart Are you #3?

This middle aged man comes to the office wondering what is wrong with his hands. He has no pain. What is the diagnosis? (Click on image for a close up view)
Answer will be give tomorrow.

Tuesday, December 4, 2007

Grand Rounds This Week

For great links to great medical blogs check out this weeks Grand Rounds, hosted by Dr. Geek. Thanks for including EverythingHealth, Dr. Geek. The reading choices are eclectic!

Monday, December 3, 2007

New Changes in Dental Prophylaxis

The American Heart Association has published the new recommendations that will spare thousands of patients from loading up on antibiotics before a trip to the dentist. For decades certain patients have been taking antibiotics for protection before dental procedures but now the rules have changed.

Infective endocarditis is a rare but life threatening condition that was thought to be prevented by patients taking antibiotics before dental procedures. I never knew that there was no scientific evidence on which to base those recommendations, but there wasn't. Doctors were taught to prescribe five days of antibiotics to certain "at risk" patients and in 1997 it was changed to a single dose of antibiotics. Many doctors still gave several doses despite the lack of evidence.

The new guidelines are a huge change from current practice. The only people who are recommended to receive the SINGLE DOSE of antibiotic are:
  • Patients with prosthetic heart valves
  • People with prior infective endocarditis
  • People with unrepaired cyanotic congenital heart disease (rare, rare, rare)
  • People with completely repaired heart disease with a prosthesis or catheter insertion within the past 6 months
  • People with a repaired valve with residual defect on or near the repair
  • People who have heart transplant who have developed a valve abnormality
THAT'S IT! For people with heart murmers, mitral valve prolapse or other conditions that previously took are off the hook.

This is welcome news to us primary care doctors and probably to dentists all over the world. It means no more letters and faxes from the dentist asking us to rush a prescription for antibiotics or sign off on the letter. It means no more echocardiograms to prove the murmer is "benign".

It proves that medicine is constantly evolving and changing and this is a change that will save both time and money for patients, dentists and physicians.

Saturday, December 1, 2007

RBRVS-For Primary Care No Good Work Goes Unpunished

The results are in - Medical Residents are not choosing to enter the Generalist fields of medicine in the United States. With current trends, less than 10% of those training in Internal Medicine will work as general internists. Compare this with JAMAs report that all European countries have a broad Generalist foundation comprising 70-80% of practicing physicians. The consequences of our failing primary care infrastructure will be higher costs, greater inefficiencies, lower quality, more uninsured and inability to get care even if you have insurance. If you think we have problems with financing health care now, you don't even want to see what is coming in the future!

In the U.S., current reimbursement substantially favors procedures and technical interventions and offers financial advantages for expensive care. This applies to all medical services, both hospital and physician. Hospitals are quietly closing routine care services all across the country in favor of specialty ortho (joint replacement, exotic spine treatment) and cardiac interventions. Routine obstetrics, pneumonia, diabetes and emphysema care are financial losers for the hospitals. The ever expanding preventions, vaccines, need for evaluation, counseling, talking with patients and guiding their health are financial losers for doctors.

What is the origin of these gross payment inequities? The Centers for Medicaid and Medicare Services (CMS) determines the reimbursement for professional services using a resourced base relative value scale (RBRVS). This complicated system is then adopted by health insurance payers also so it drives all reimbursement.

The committee that decides the value that determines $$ is called the RUC. It is made up mainly of specialists from the specialty societies. Only 3/30 seats have term limits. Specialties that account for a very small portion of all professional Medicare billing such as neurosurgery, pathology, otolaryngology, urology and plastic surgery sit in the seats that determine reimbursement. The proceedings are proprietary and are not publicly available for review.

This committee is a powerful force in the US medical economy. They create more and more incentives for specialty care and fail to accurately assess the practice expenses of primary care.
The new Medicare Part D drug benefit has created more non-reimbursed time and expense for primary care as they endeavor to match formularies for their senior patients. The RUC doesn't have a clue what it takes to practice primary care in America.

Residents are walking with their feet and who can blame them? The system is designed to get the result is is getting. Goodbye Primary Care! Hello expensive procedures and medical spas on every block.

We talk about universal coverage and health care reform without understanding that there will not be a solid base of physicians to deliver care to the population. A large portion of the population will not be able to have continuous and personalized care provided by Generalist physicians who have excellent clinical skills and good bedside manner. Having an insurance card (government or not) is not the same as receiving care.

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...