Thursday, February 28, 2008

Christine Aguilera - Perfect C-Section

Christine Aguilera is a talented, beautiful young woman who is all over the magazines and internet with her beautiful new baby. It is a lovely sight to see and I am sure she influences young women around the world on the wonders of new motherhood. But my eyes and ears perked up when I read that she had a planned, elective (read "Doctor, I want that!") C-section at 37 weeks because "I'd heard horror stories about tearing. I really wanted a calm and peaceful environment. I didn't want any surprises."

Now I don't blame a 27 year old narcissistic diva for how she feels. I also understand the fears new prospective mothers have about their changing bodies, new responsibilities and major life changes a child brings. But where are the doctors in all of this? Is this the new trend? C-Sections, rather than nature's natural childbirth for anyone who asks?

Cesarean Section childbirth is major surgery. The abdominal wall and muscles are cut as well as the uterus.

There is a higher risk of blot clots following a C-section than a vaginal birth. Hysterectomy is more common after cesarean. The risk of maternal death is higher.

The risk of uterine infection is much higher after a C-section than it is after a vaginal birth. There is usually a longer hospital stay for the mother, and she is at a higher risk of being re-admitted to the hospital later for complications.

The severity and length of pain after a Cesarean is much greater than after a vaginal birth. You may feel more pain during a vaginal birth than you would during a Cesarean. But shortly after birth most of that pain will be gone (unless you receive intervention such as episiotomy). Pain from Cesarean surgery continues on into the early weeks and for some women, months.

C-Sections that are done in life threatening situations are necessary and preferable to any risk to the mother or baby. Elective, planned C-Sections because the mom is "afraid" or "vain" or just misinformed is really an indictment of the medical community.

I suspect we will have many young women wanting to follow in Mama Aguilera's footsteps. It will be interesting to follow the C-Section rates over the next few years.

Wednesday, February 27, 2008

Electronic Health Record - tick tock, tick tock

Go into most doctor's offices or clinics across the United States and you will see racks of messy files, patient charts, stacks of paper ready to be filed and lots of little messages and bits of paper that have no home. You could not differentiate if it is a chart room from 1943 or 2008, except that now there is 20 times the paper to be filed.

There is unanimous agreement from doctors, hospitals, patients, academics and Yes! our own government that Medicine is far behind other industries in automating with an electronic health record (EHR aka: electronic medical record). The push for the EHR has been around for 10+ years, continuing today from Pres. Bush and each of the presidential candidates in their "reform health care" platforms. Despite the unanimity around the benefits to society with a universal EHR, only 14% of doctors use a "minimally functional" that captures clinical notes, orders for prescriptions, lab and radiology tests and results.

Roughly half of all practicing physicians are in solo or small partnership practices. They don't have the resources, IT infrastructure, or development time to convert to the electronic health record. Large multi specialty groups (10 doctors or more) are the ones that are adopting this technology and generally they are very happy with the benefits to their practice lives and their patient care.

So when you hear the candidates talking about linking doctors, hospitals, all caregivers and patients electronically through an EHR and the wonderful savings that will be obtained by technology you should ask "Oh, yea, how do you think this is going to happen?" Despite billions of dollars invested in software development, we still do not have an interoperable EHR. The systems don't talk to each other and the vendors are competitors and are unwilling to interface with each other.

A personal health record that the patient keeps is one thing and is valuable for both self-responsibility and control. But that is very different from a real time, complete, instantly accessible electronic chart that can be used by each of your doctors, whether it be the ER or the dermatologist. The privacy issues will disappear if we truly think of what is needed for best patient care (not data mining so you can be sold something or denied coverage for a condition).

Over time (lots of time), I think we will get there. The solo practitioner is a dying practice model and Medicine is going the way of big business and larger groups. It will take this type of capital investment for the EHR to be implemented everywhere. Making sure our technology goals have the "patient first" will go a long way in speeding up the process.

Answer to Medical Quiz #7

The answer is #3, Leprosy. Leprosy, also known as Hansen's disease, is a chronic infectious bacteria that affects peripheral nerves, the respiratory tract lining and skin. Interestingly, only about 5% of people who are infected with the disease actually develop any symptoms. The mode of transmission is unknown, thought to be by respiratory droplets. Treatment with oral antibiotics is effective in treating Leprosy.

Tuesday, February 26, 2008

Medical Quiz #7 -How Smart Are You?

I'm back from Costa Rica with another New England Journal of Medicine challenge for you.

This patient is an immigrant from Pakistan. These lesions are not pruritic (itchy) or hypoesthetic (decreased sensation). What is the diagnosis? Click on the image for a better view. The answer will be posted tomorrow.
1. Granuloma annulare
2. Scrofula
3. Leprosy
4. Pityriasis rosea
5. Tinea Corporis (ringworm)

Thursday, February 14, 2008

A Little Time Off

The family and I will be taking a little trip so I'll not be posting EverythingHealth for about a week. Please click on some of the links to the right for a great potpourri of the medical blogs (and other favorites). Can you guess where we are going? (No it's not Hawaii)

Tuesday, February 12, 2008

Blue Cross-Outrageous Behavior

Blue Cross Insurance has now sunk to a new low. They have written letters to their "preferred providers" (I resigned from being 'preferred' years ago!) asking them to inform on patients who had preexisting conditions so they could rescind a patient's health care coverage.

The insurer is sending letters to doctors with the patient's insurance application, asking doctors to tell them immediately if the patient is seen for any condition they didn't disclose on the application. The letters say, “We ask your assistance to identify medical omissions because you, being the primary care provider, will have first-hand knowledge of services provided and/or requested.” This includes pregnancy and any other condition not disclosed.

The California Medical Association (CMA) has urged State Regulators to immediately order Blue Cross of California to stop. Asking doctors to share private health information with insurers is probably unlawful, unethical and disturbs the doctor patient relationship.

Wellpoint is the parent company of Blue Cross in many states, including California. Is it not enough that Wellpoint reported $61 billion in revenues for 2007? According to Business Week , Larry Glasscock, CEO of Wellpoint collected $46.2 million in total compensation in 2005. That's a nice hunk of change and it is now 2008. Their profits continue to rise. Are Doctors now expected to be informers for Blue Cross underwriting department?

Blue Cross states it is sending the letters to keep costs "at a minimum." Yes, those damn patients with medical costs certainly do eat into profits!

Sunday, February 10, 2008

Todays Chuckle - Cheap HMO

Thanks to MichaelClark for our joke of the day. How do you tell you have a Cheap HMO?

The Top 10 Signs You've Joined a Cheap HMO

10. Annual breast exam conducted at Hooters.
9. Directions to your doctor's office include, "take a left when you enter the trailer park."
8. Tongue depressors taste faintly of Fudgesicle.
7. Only proctologist in the plan is "Gus" from Roto-Rooter.
6. Only item listed under Preventive Care feature of coverage is "an apple a day."
5. Your "primary care physician" is wearing the pants you gave to Goodwill last month.
4. "Patient responsible for 200% of out-of-network charges" is not a typo.
3. The only expense covered 100% is embalming.
2. With your last HMO, your Viagra pills didn't come in different colors with little "M"'s on them.
--And the Number 1 Sign You've Joined a Cheap HMO...
1. You ask for Viagra. You get a popsicle stick and duct tape.

Saturday, February 9, 2008

One Year of Blogging

It was about a year ago that I became a blogoholic and started EverythingHealth. I've learned there are three different types of blogs. Anonymous bloggers that can say just about anything and rant and rave in an interesting fashion, companies or commercial blogs and blogs like mine that are transparent (you know who I am) and just want to express a point of view. Because I do a medical blog, I am particularly careful that the facts and information I give are accurate and have the best science behind it. I try to stay non-political (gosh that has been hard!!!) and kind.

I've learned that I get the most visits when another blog links to one of my posts (Thanks Kevinmd, Grand Rounds). I've learned that most people get to my blog via a search engine (Thanks Google and Yahoo). My wish, of course, is that people will be regular visitors and check every day or so and read everything! You can sign up for new posts via alerts. It's easy and safe with no spam.

I have had visitors from as far away as Bangladesh and Dubai. It is so exciting to see overnight visits from Spain, Ireland, Phillipines, Africa, India, England, Australia and China. I imagine someone far away reading an old post on "subdural hematoma" or "Cigarette Additives" or "Masaii Medicine". Still, the most visited post is "Do Doctors Make Too Much Money" and it is fascinating to me that people from all over the world read that one.

Please take a minute to look at the right side. I love my little widgets (see the new one that lets you look at walking routes in your own neighborhood...very cool). Also check out my links to my favorite blogs. Some are medical and some are funny or interesting.

I am grateful for all of the new blogger friends I have made and for the help and tips that experienced bloggers have given to me. It is the best kind of web village you can imagine.

Thank you for visiting and letting me have a reason to indulge in my addiction. Writing this blog makes me smarter and I feel like I have done my tiny part to promote health, knowledge and friendship around the World.

Thursday, February 7, 2008

Sweet Soft Drinks, Fructose Linked to Gout

The British Journal of Medicine reported on a 12 year study that showed sugar-sweetened soft drinks and fructose increased the incidence of gout.

Gout is the most common arthritis in men and its prevalence has doubled in the United States within the past few decades. Coincidentally, that is the same period in which fructose sweetened soft drinks represent the largest single source of calories in the U.S. diet. The researchers found that men (study age 40-75 years) who drank more sweetened drinks had more gout proportional to the number of drinks a week. It included sweetened fruit juices and soft drinks but not diet drinks.

What is interesting about this study is that we were never taught in Med School that soft drinks are a trigger for gout. If you research gout, you will find advice to avoid meats, gravy, tofu and purine rich foods such as seafood, oatmeal, peas, lentils, spinach, asparagus and cauliflower. The idea of limiting or eliminating fructose is rarely (or never) mentioned. Could we be giving the wrong advise? Sure we could and we probably are!

A gout attack will definitely give you a bad day! This study is another reason to never drink artificially sweetened drinks. Fructose is no-ones friend.

Answer-Medical Quiz #6

The answer is (drumroll....) #2 Pearly Penile papules. These are multiple tiny smooth, skin colored bumps that surround the coronal sulcus of the glans penis. They are completely benign and of no concern. Lots of smart people out there!!!

Wednesday, February 6, 2008

Medical Quiz #6

Here is our latest medical challenge and it is very common. What is the diagnosis? Click on the image for a better view and check back tomorrow for the answer:
1. Molluscum contagiosum
2. Pearly penile papules
3. Secondary syphilis
4. Obstruction of smegma-producing gland
5. Condyloma accuminatum

Sunday, February 3, 2008

Lack of Primary Care Will Derail Reform

Health care reform is dead in the water unless we fix what is going on with primary care medicine in this country.

Let's just play this out. We have about 47 million uninsured folks in the U.S. There aren't too many people who disagree with the need for universal coverage for all Americans. (How we pay for it is another topic... but expanding coverage is just good policy). At the same time as we are expanding coverage, the numbers of physicians in training who are choosing primary care medicine has fallen to 15%. That means 85% are deciding that specialty medicine is the way to go.

Most patients will not have a comprehensive primary care doctor who knows them, knows all of their health issues, makes sure they get preventive care and coordinates care. There just won't be enough primary care doctors to go around and the ones that have experience and good bedside manner will limit the number of patients in their practice by charging retainer fees (AKA: concierge medicine).

Here is what happens when a patient doesn't have a primary to call:

A patient with knee pain and joint stiffness may see an ortho doctor who will do X-rays and maybe an office MRI ($275 for comprehensive office visit, $400 for X-ray, $550 for office MRI). He prescribes pain medicine and informs her that there is no surgical diagnosis. Still in pain, the patient decides to see a Rheumatologist. At the Rheumatology office the X-ray might be repeated ( $250 comprehensive exam, $400 X-ray) and a collagen vascular blood panel will be run to rule out lupus, rheumatoid arthritis, infection and PMR, ($375). The patient is given a medication for pain but it interacts with the other pain med so now the patient ends up with abdominal pain.

The patient calls the Rheumatologist who says "Go to the ER" and tests are done there to look for an ulcer or GI bleed. ($4500 for 10 hours in ER). No active bleed is seen so the patient is referred for follow up to the Gastroenterologist ($275 comprehensive exam, $150 blood tests, $2200 upper endoscopy, $2200 colonoscopy)

By the way, the knee pain persists and the patient never does get anyone to coordinate physical therapy, which is what she needed in the first place.

This is not an indictment of specialty medicine. A specialist has a narrow scope of vision and that is what makes them valuable when we want to zone in on a problem. But what we are really lacking is a comprehensive physician who can diagnose, follow and coordinate the complex health needs of a patient.

The AMA has failed primary care and in some ways actively sabotaged it. Medicare (CMS) and Congress have driven the nail in the primary care coffin by underfunding and underpaying primary care for years. The federal government has abdicated responsibility for redesigning Medicare payment policies and these payment practices are carried into the private insurance market, further worsening the problem.

Unless immediate and comprehensive reforms are implemented, primary care, the backbone of the U.S. health care system, will collapse. Residents have already abandoned primary care as a career choice but I have no doubt we can get them back if we improve reimbursement and stature of the profession.

Saturday, February 2, 2008

Seven Medical Myths

I love the British Medical Journal because it is filled with wit and just good interesting stuff. Those Brits know how to keep it real! The December issue addressed medical myths that we've all heard for so long that everyone believes they are true. They chose seven to research and found no evidence to support them:

1. People should drink 8 glasses of water a day. They found that most people get water in their food and usual beverages and there was no evidence to force drinking 8 glasses.

2. We only use 10% of our brains. I found myself repeating this to my son just the other day. Metabolic studies that track differential rates of cellular metabolism within the brain show no dormant areas.

3. Hair and fingernails continue to grow after death. I think "CSI" on TV already dispelled this myth. It is dehydration and shrinking of the skin that makes it appear to grow.

4. Shaving hair makes it grow back faster, darker, coarser. It sure seems that way to me but, in fact, it is only the cutting of the fine tapered ends of hair that makes it seem coarser. Guess that stubble is just normal growth.

5. Reading in dim light ruins your eyesight. Hundreds of expert opinions conclude that reading in low light does no permanent damage. In the past they read exclusively by candle light and there was no increase myopia.

6. Eating turkey causes drowsiness. Although turkey does contain tryptophan, other proteins such as pork or cheese contain more tryptophan than turkey. It is probably the wine and other large side dishes of holiday meals that contribute to post meal drowsiness.

7. Mobile phones create electromagnetic interference in hospitals. Despite warnings by the press and even the Wall Street Journal in 1993, the British researchers could find no evidence for this myth. In 2005 the Mayo Clinic and various European researchers tested mobile phones and found no interference.

So there you have it. I think we had it right in the '60's...."Question authority"

Answer - Medical Quiz #5

The answer to the tongue lesion image below is #1- herpetic glositis. A severe herpes virus infection can inflame the entire oral cavity and cause multiple lesions on the tongue, lips and oral mucosa.

Friday, February 1, 2008

Medical Quiz 2008 - #5

Here we go again with another medical challenge. What is the diagnosis for this condition?
Click on the image for a better view. The answer will be posted tomorrow.
1. Herpetic glossitis
2. Apthous ulceration
3. Pemphigoid
4. Scurvy
5. Oral candidiasis

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...