Out of Town

I will be at my sister-in-law's wedding for the Labor Day Weekend, so check out my Favorite Links on the right side of this blog for some great reading and fun. Come back next week for more EverythingHealth.

Aren't Abby and Jay cute?

Katrina revisited

This time two years ago I was flying with my medical kit to New Orleans to help during the Katrina Disaster. I cannot get the gulf coast out of my mind and it is a tragedy that continues for millions of people. I offer these photos and I hope we will never forget that we are all in this crazy life, at this point in time.... together.

Need Botox? Come on in.

The New York Times cites a study in Dermatology that shows you can get an appointment quickly if you need Botox, but you will wait for weeks if you want to have a mole checked for cancer.

In medicine, we talk a lot about the problem of "access". Well, it looks like access is not a problem for cosmetic procedures. Dr. Kimball, a Harvard dermatology professor summed it up, "This study shows the Botox needs of the United States are being met". That is reassuring, isn't it? I was so worried about the millions of people who have fine wrinkles.

The lead author, Dr. David M. Pariser, president-elect of the American Academy of Dermatology said "We need to look further to find out what is leading to the shorter wait times for cosmetic patients".

Save your research grant, Dr. Pariser. Here is the answer: Just follow the money.

Botox is a quick procedure that requires little skill. The patient pays $400-600 cash. In and out with a smile of gratitude. Contrast that with an office visit for a skin exam. Insurance or Medicare will pay about $75 and the doctor may wait several months for payment after the bill with all the proper codes and documentation is sent.

Maybe an enterprising dermatologist will throw in a free skin exam with the next Botox treatment.

Breaking News - more uninsurred

According to the U.S. Census Bureau, the number of Americans without health insurance rose to 47 million in 2006 (up from 44.8 million). This means 15.8% of Americans have no health insurance to cover their medical needs.

Ever wonder why hospital costs are so high? Ever wonder why people use the ER for primary care? Ever wonder why we rank so low in the world on health outcomes? Ever wonder why people are so anxious about their future health? Do ya think our system might be broken?

Are Too Many People Being Diagnosed with Depression?

You can't open a medical journal or medical news without reading another article about how to screen patients for depression and prescribe antidepressants. The British Medical Journal has explored this in a "Head to Head" article where over diagnosis and under diagnosis of depression were debated.

On the Yes side is Dr. Gordon Parker who argues that feeling depressed is normal and that 95% of teachers studied, experienced feeling low mood and they met the "diagnostic" criteria for major, minor or sub depression. He believes the descriptive criteria for depression in the DSM-III (the bible of psychiatric diagnosis) is set too low and it medicalizes "normal human distress as mandating treatment." "Depression will remain a nonspecific catch-all diagnosis until common sense prevails," Dr. Parker says.

On the No side is Dr. Ian Hickie who counters that depression is not being overdiagnosed because increased treatment has led to demonstrable benefits and is cost effective. He believes the promotion of safer antidepressant drugs during the 1990s awakened broader interest in depression and the increased rate of diagnosis led to improved physical health, and abandonment of "demeaning labels of stress, nervous breakdown and adolescent angst."

I believe depression is over diagnosed. Stress, anxiety and sadness are normal human emotions and in our fast paced world we don't tolerate these feelings very well. People want and expect a quick fix when they feel bad. The antidepressants Paxil and Lexapro are the top two prescribed drugs in the US. Four antidepressants are in the top 15 prescribed drugs. (Paxil, Zoloft, Lexapro and Effexor). That is a lot of depressed people! There is a huge push by the pharmaceutical industry, the government (yes, the government) and the insurance companies for primary care physicians to quickly diagnose AND TREAT depression.

Depression is a serious disease and we are blessed to have good treatments but that many people do not need drugs.

Premie Baby born in airplane

Here is a heartwarming story for the weekend. A 25 weeks pregnant mom was traveling to Crete with her husband when she went into early labor. Her water broke and somewhere above Düsseldorf, Germany, she delivered a 1 lb. baby with the help of a flight supervisor. This air hostess hero, Carol Miller, took control of the situation and suctioned the little blue baby with a drinking straw. Because he wasn't breathing, she then gave mouth to mouth resuscitation and heart massage until they could do an emergency landing and rush the baby to a hospital in London. Think of how tiny one pound is. Like a barbie doll!

After 5 months in a neonatal ICU, little baby Alfie is now weighing in at over 5 lbs and has gone home with his first time parents and is expected to grow into a normal little kid.

What a stroke of luck to have a clear thinking flight attendant, who just happened to have nurse training, on that flight! She handled premie childbirth with the same grace as serving coffee and she was able to think "out of the box" when it was needed. Carol Miller of First Choice Airways is my first choice for hero of the weekend.

Doctor Online Ratings

Doctors used to get referrals from word of mouth. The internet has taken that to new highs with online physician rating websites like ratemds.com. Boasting 334,669 ratings and climbing, with 580 new ratings added yesterday, this trend of saying whatever you want anonymously and publicly should bring a chill to every practicing physician. With use of a smiley or frowney face, not to mention scathing comments, a patient now has the weapon to get even for that long wait or rude receptionist.

There is no stopping this trend. Medical Justice is a company that provides a contract for physicians to have patients sign that requires the physician to give "ratings permission". Does anyone think this will be effective? Some frustrated patients have created entire websites to criticize specific doctors that have annoyed them.

We will not be going back to the days of gossip across the back fence. Doctors will not be immune from the free speech of the world wide web and they better get used it. These online patient reviews give people a sense of control and it reflects the lack of credible information available when people are searching for a doctor. In a world where you have to pick your physician from an insurance list, reading the review is seen as a plus. Never mind that it may be one person's opinion.

We now have the ability to say anything about anyone and post it for millions of people to see. I think it would be more helpful if sites required people to use their real names rather than hide behind anon. As my mother used to say: "If you don't have something nice to say, don't say anything at all." In the world of web 2.0, that saying is about as obsolete as a horse and buggy.

Post Secret-a window into the mind

I found a new website that is a fascinating view into human nature. Post Secret was started by Frank Warren and he invites strangers to send him postcards that tell a secret. He now receives 100-200 cards a day from people who want to express their inner thoughts and secrets. Each week he chooses the 20 best cards to publish on his blog. Also, his is the most visited advertisement free blog on the internet. Check it out for a psychologic treat.

Medicare won't pay for preventable conditions

Medicare, the largest health insurer in the U.S., has announced that it will not pay for 8 hospital conditions that could be preventable. Starting in October, 2008, if a patient enters a hospital and acquires these conditions, the hospital will not get reimbursed for the costs. The conditions that we doctors call "never-events" because they should never happen, are:

• Urinary tract infection from a catheter
• Blood infections from IVs or catheters
• Pressure ulcers (bed-sores)
• Retained objects after surgery ( a sponge or instrument left inside)
• Air embolism
• Blood incompatibility (from transfusions)
• Mediastinitis (infections of the sternum that happen after heart surgery)
• Falls (very common and hard to prevent)

The hospital industry has already started protocols and procedures to prevent these conditions but it will take an all out effort by doctors, nurses, administrators and even families to make sure no patient has a "never-event".

I think this is good that Medicare is putting money on the problem. It will certainly get everyone's attention and drive safety and quality improvement to the next level.

Body Mutilation-Chinese Foot Binding

I love medical history and the idea that what we do today will seem barbaric to cultures in the future. One such ancient practice is Chinese foot binding. This practice, which went on for over 1000 years took foot fetish to a national high. At age 3 a little girls toes were broken and bent underneath the foot and wrapped in tight cloth. The goal was "three inch golden lotus" feet and it was the only way a woman could marry and the family receive a proper dowry.

Clearly the practice was incredibly painful and restricted movement. Girls and women couldn't walk or run and this made women dependent upon men. It was such a part of the culture, that the horror of mutilating women's feet seems to have been lost on the entire society. The practice was banned by the government in 1912 but foot binding continued in secret for many years after.

Female genital mutilation on the African subcontinent is yet another cultural practice that continues today and needs to be eradicated. Sometimes it is hard to believe we are in the 21st Century when such practices occur to millions of women.

Medical Procedures-show me the money

Several times a week I get mailers or ads offering courses in medical procedures. This one reads: "Why learn procedures? You are working harder and making less. (They got that one right). Procedures will help you increase revenue and profits without a large investment or extensive training. You do most of the work, others get paid more than you" (Bingo, right again). "Stop turning revenue away by sending your patients to specialists".

So what are these easy, fun and inexpensive procedures that will "put you on the path to a better practice"? The list is extensive: peels, microdermabrasion, hair removal, botox. If that is not appealing, I could learn "anti-aging medicine, advanced colonoscopy or carotid ultrasound". Lots of patients have varicose veins. For $750.00 and two days out of my life I can learn sclerotherapy.
My favorite is the "No-scalpel vasectomy".

The sad thing about these mailers is that the statements about increasing revenue by doing very little is real. Insurance and Medicare payments are disproportionately high for the amount of time and skill involved for most procedures. Or perhaps a better way of saying it is that physicians who spend time with patients, listening, diagnosing, interpreting tests and communicating are financially penalized. A scope or a scalpel will be far higher valued, even though the time spent (and brainpower) is far less.

Patients will pay large fees out of pocket for cosmetic procedures or anti-aging vitamins. In our capitalistic society, it is clear what is valued.

As long as primary care and "cognitive" specialists are reimbursed so poorly, these ads will have great appeal to many physicians. With the decline in medical students choosing primary care, pretty soon there will be no-one to market to.

Maggot Medicine

Warning, this is really gross but for you brave souls, now you can see first hand how maggots are used to help heal chronic wounds. Don't view if you can't stand the "ick" factor but be aware that most everything in Medicine involves "ick" and we docs find it pretty darn interesting.

Otitis Media- Treat or Watch?

Most parents are heartbroken when they hear their toddler cry with an earache. It is one of the most common reasons for a visit to the pediatrician and most parents expect antibiotic treatment. The American Academy of Pediatricians and the American Academy of Family Practice issued guidelines in 2004 for most cases of acute otitis media (ear infection) and those recommendations call for observation, not treatment.

A new study in Pediatrics reported that over 80% of physicians agree with the guidelines that observation is a reasonable option for acute otitis media. But only 15% of physicians really did it...85% prescribed antibiotics at the visit.

This shows how academic guidelines often don't reflect the real world of patient care. Physicians say that parental reluctance and the cost and difficulty of follow-up for children were the main reasons they prescribed antibiotics.

The same thing goes on in adult medicine all the time. Each patient can present slightly differently and a patient is not a textbook or a study population. The young woman with symptoms of a "cold" who is getting married in 4 days is going to get a prescription from me. The man who is flying to New York for a critical business meeting is going to get a prescription. It may not fit the guidelines, but real patients have complex lives that don't fit into a study. That's why they call it the "art" of medicine.

"Red Yeast Rice"- FDA warning

The Federal Drug Administration (FDA) has issued a warning to consumers to steer clear of several "cholesterol-lowering" supplements that may contain a drug - Lovastatin.

Red Yeast Rice, Red Yeast Policosonal Complex and Cholestrix are over the counter supplements that were found to contain the prescription drug, Lovastatin. The products are manufactured by Nature's Value, Kabco Inc, Sunburst Biorganics and Swanson Healthcare Products and are sold over the internet.

Lovastatin is a prescription statin that lowers cholesterol. Millions of people safely take Lovastatin but it can be dangerous if it is not prescribed by a physician and it can interact with certain antibiotics, other statin agents and antidepressants. High doses of statin drugs can cause muscle pain and kidney damage.

Red Yeast Rice products are not a problem in itself, but it shows how difficult it can be to monitor unsafe dietary supplements once they are marketed. The FDA does not routinely monitor dietary supplements. See my very first blog.

Caffeine reduces cognitive decline

As I am sipping my morning latte I am thrilled to read the results of a new study just out in Neurology that suggests that caffeine may reduce cognitive decline in women without dementia. Another gulp of coffee and I am that much smarter!

French researchers report that women who drank more than 3 cups of coffee per day had less mental decline during 4 years of follow-up, compared with those who drank a cup or less. Surprisingly, no such effect was seen in men.

Women who drank more than 3 cups a day had less decline in verbal retrieval and visiospacial memory during 4 years. Since word finding (verbal retrieval) seems to be a problem at about age 50, this is good news. The participants underwent a battery of cognitive exams at baseline, 2 years and 4 years follow-up. The results were adjusted for sociodemographic and clinical variables such as age, sex, education level, use of tobacco and alcohol and symptoms of depression.

Previous studies have suggested that caffeine, which is known to have positive effects on vigilance, attention, mood and arousal, may be neuroprotective.

So you don't like coffee? Not to worry...tea had the same effect. Another "Cup a Joe" for me.

"Minute Clinics" be afraid, be very afraid

We have lots of problems with access to care in the good ole' USA. Forty five million (and growing) have no insurance. Eight in 10 are from working families and 28% of young adults have no insurance. Even with health insurance, we are paying more out of pocket for health care.

So with all of these issues, isn't it amazing that the delegates to the American Medical Association have singled out retail clinics (also known as "quick care" or "minute clinics") as an area of burning concern.

These retail "drop in" clinics are showing up in Walmarts, drug stores and strip malls across the country. Staffed by advanced practice nurses or physician assistants, they limit their care to acute simple problems. Sore throats, urinary tract infections, rashes, and ear aches, managed using clinical guidelines, are the fare of these clinics and prescriptions can be quickly filled by the pharmacy close by. The clinics charge a flat fee (average $40-65) and no appointments are needed.

Some of the opposition comes from doctors that say these easy "in and out" patients are what keeps their practice viable and the clinics are unwelcome competition. Other opposition is concerned with patient safety (read: competition) and conflict of interest between the clinics and retailers that own them.

In Northern California a patient without insurance may call dozens of doctors before they can get an appointment. I challenge you to call a doctor in your community and try to schedule an urgent new patient appointment. The first question will be "What kind of insurance do you have?" There is a serious problem with access to care for patients who wish to pay!

For a single mom with kids, a busy college student or a blue collar worker who can't afford to take a whole day off trying to find a doctor, the retail clinics serve a purpose. The same organization that prides itself on autonomy and free market should focus on other more pressing issues facing health care.

Tattoos and Work

It's nice when other bloggers visit and mention my writing on their blogs. Compensation Force (an HR site) linked me and so, of course, I checked it out. The HR world is quite a newsy place! I enjoyed reading about "How to respond to a racist joke" (Don't laugh, play dumb with a blank look and say "I don't get it". Make the joke teller feel embarrassed). "Tattoos and work: how body art plays a role in whether you are hired or not" was another interesting link.

Tattoos fascinate me and when I see someone with body art down both arms, I often wonder "Where does she work?" Thirty five percent of Americans between 18-29 have a tattoo. I would have thought the percentage was higher. It seems like every young adult I see has a tattoo, but maybe that's just because this is sunny California. But wait, I was in Idaho and Utah and I saw lots of decorative tattoos there too, on both gals and guys. Has anyone checked out David Beckham's body art lately? Whew!

So if you want to see how employers look at body art check it out. I can tell you the world of medicine is pretty conservative but who knows what goes on under clothes?

Racial Diversity and Medicine

If you are Black, Hispanic or Native American, I bet you have noticed something. There are no doctors of your race to treat you. Blacks, Hispanics, and Native Americans make up 26 percent of the U.S. population, but only 6 % of practicing physicians come from these minorities. Underrepresented minorities have worse health status in many dimensions compared with the white population.

My work takes me to large metropolitan areas as well as hospitals and communities in more rural areas, and I am always struck by the lack of physicians of color when I see patients of every color in hospitals and clinics.

The Council on Graduate Medical Education says that "the racial/ethnic composition of the physician population should reflect the overall population's diversity". Since 1980, the percentage of U.S. medical graduates who are Asian American has risen 5 fold, but the underrepresented minority has remained flat.

Admission to medical school is dependent upon getting students interested and ready while they are undergraduates or even in high school. I believe we need a focused effort to identify underserved students and nurture them with financial support and mentoring. We need to make minority enrollment in medicine a priority. The past 25 years have shown us it will not happen without reaching out.

No Period Birth Control Pill

The FDA has approved Lybrell, the first oral contraceptive pill that allows women to Cease having periods! This "no period" OCP works the same way as the usual pill. It uses the same low dose estrogen/progesterone combination but instead of 21 days on and 7 days off, this pill is taken continuously throughout the month.

Menstruation occurs in a normal monthly cycle when estrogen, in combination with progesterone plumps up the lining (endometrium) of the uterus in preparation for the fertilized egg to nest there. With no fertilized egg, the lining sluffs off and bleeding occurs.

The OCP (birth control pill) shuts off your normal production of hormones and supplies a small amount of estrogen/progesterone so you don't get pregnant. Instead of 7 days off the pill when withdrawl bleeding occurs, the "no period" pill continues throughout the month so there is no withdrawl bleed and no period. You are just eliminating that week of no hormone in the pill.

May women ask "Don't I need to have a period to flush out the uterus?" The answer is no you don't. The original pill was designed in the early 1960's to artificially cause a withdrawal bleed because the developers thought women and religious organizations would never accept the concept of not having "normal" periods. There is nothing new about the technology of the "no period" pill. The only thing that seems to have changed is a wider acceptance of not having periods. This pill won't be for everyone but I am always glad when women's reproductive health is studied. The Birth Control Pill is one of the greatest inventions of the 20th century.

So for women who are tired of the hassle of monthly periods, and are already taking OCPs, Lybrell may be just the ticket. Because there is no period, if a woman thinks she might be pregnant (oops!) she should use a home pregnancy test.

Check out my prior post for more info on the Birth Control Pill.

Smoking Cannabis will Make you Crazy

Who would have thought, with all of the problems in the world, that "Reefer Madness" would rear its head and the headlines would be screaming "The Use of Cannabis Causes Psychosis".
The Lancet has just published a review of longitudinal studies and found that daily or weekly use of cannabis (marijuana) could increase psychosis by 40%.

These findings puzzle me. In the UK and New Zealand, 1 in 5 young people admit to smoking a joint weekly or over 100 times. Can we expect a 20% increase in schizophrenia as time goes on? What about the Netherlands? Marijuana is legal there, yet their rates of psychosis are not increased. There has been a large increase in marijuana use over the past 40 years, but we are not seeing an increase worldwide in rates of psychosis. The incidence of schizophrenia is stable or even decreasing by some Nations reports.

I am not advocating use of marijuana and the effects of any drug or alcohol on young, developing minds is cause for grave concern. But, my "reefer madness" red flag gets raised when I see science that doesn't seem to pass the smell (or inhale) test.

Why Are Doctor Bills So High?

Who hasn't wondered why doctors need to charge so darn much for an office visit? If you have insurance and bother to look at what the insurance company pays, it is always much lower than the charge. Why does medical care cost so much? Is the doctor gouging? One of the best explanations I have seen is stolen from another blog. I would like to give credit but all I know is the name Dr. Adam. He shows this letter to his patients:

Why are doctors' bills so high?

Over the past few years several patients have asked this question. It is a very good question that needs to be answered in the context of our current health care system.
When I was growing up and went to my family doctor, my parents or I paid around $10 for a typical minor problem visit (in 1966). With inflation, that would be around $62 today (in 2006 dollars) (http://www.westegg.com/inflation). Today Medicare reimburses me approximately $33 to $45 for a similar patient visit. When I was a teenager the overhead costs of my physician’s medical practice were low. My family doctor did not make appointments and thus did not need a receptionist. When you were sick you simply went to his office and waited your turn to be seen. If it was a busy day with lots of patients, I sometimes waited several hours before I was seen. He did not employ nurses nor did he have a transcriptionist (typist) write his notes. He worked by himself, but did have a part-time bookkeeper. He called me back from the waiting room, evaluated me and usually jotted down a sentence or two and that was it. I paid cash at the conclusion of the visit. He did not deal with insurance companies so he had very few phone calls and paperwork to deal with. He did not have high malpractice costs and he worked from his home office.
Over the past few decades, things have changed radically. The overhead costs for a physician are astronomical compared to the good old days of my family doctor.
My overhead costs are many. I pay the equivalent of 5 full-time employees: 1 ¾ transcriptionists/receptionists, 1 office manager/receptionist and 2 ¼ registered nurses. I need a receptionist to make and change appointments, call and remind patients of their appointments, collect co-pays and to answer phone call questions. I need a transcriptionist to thoroughly document all that I do, as insurance companies periodically audit my work to see if my billing level is justified by the work I have performed. The transcriptionist also makes copies of patient records and types letters that I send to other doctors regarding their patients that I see. I need a manager to oversee the scheduling, billing, and other operational activities. My office manger spends much of her time tracking down payments owed to us from insurance companies and answering billing questions from patients. I need nurses to help with patient care. The nurses also answer phone questions, call patients with lab test results, deal with getting approval for medications from insurance companies, and engage in other patient care-related activities.
I have medical licensing fees and ever increasing medical malpractice fees, even though I have never been sued. Medical equipment and supply costs, and building, utility and additional insurance fees add to my overhead costs.
Dealing with insurance companies adds other costs, including payments to a billing service that electronically processes and mails my bills, that cost thousands of dollars a year. It is unfortunate that insurance companies do not pay my practice for the extra work and hassle factors they create for my patients and me. When dealing with insurance companies I am at the mercy of their fee schedule. I document what I do, and I accept what they pay. If I feel that they are cheating me, or my patient, I will write a letter of protest to contest any denial of payment. Some insurance companies pay better than others. Some insurance companies are sensitive to the high cost of providing medical care today and some are not. A given insurance company may pay well for some services but poorly for others. There is one health insurance that I no longer accept because it paid too little and caused too many aggravations.
All the costs of running my medical practice, including the services provided by the transcriptionists, receptionists, office manger and nurses are paid for from the fees I collect for the services that I provide. When a patient receives a bill from me, it is important that they understand that only a portion of the bill actually pays me for my time, the rest goes to cover my overhead expenses of practicing medicine in today’s complicated health care system.
Occasionally there is a patient who is uninsured, or underinsured, who does not have the financial means of making payment for the services I have provided. If you feel you are such a patient, please call us; explain your circumstances and we will work out a reduced payment plan that will help you.

Sincerely,

Doctors and Money

My prior post engendered hundreds of visits and some great comments on Kevinmd blog. Check out these comments about "Do Doctors Make Too Much Money?" I guess money, sex and politics are what really get conversation going!