How Much Does it Cost? I Dunno.

I can't think of too many services or products that a person would purchase without knowing how much it would cost. It is amazing that no-one knows the cost of their own health care services in advance...and furthermore, even we doctors have little clue about the charges and payments that our patients pay.

This odd phenomena is largely due to the fact that 3rd parties (insurance, government) pay the bill (or a fraction of the bill) so patients don't need to know. In fact, when I tell patients that it would be a waste of money to do a certain test...often the reply is "Oh do it anyway, my insurance will cover it."

Now that patients are paying more and more of the health care cost through high deductibles or Medical Savings Accounts, there will be more interest in what is billed.

I had a patient who came to me with unusually heavy menstrual periods. The diagnostic work-up and treatment led to an out patient surgery for a fibroid removal and D&C. The operation took place in October but she is now getting bill after bill and is spending a lot of time trying to figure out what is charged and what her share of the payment is. Here is her latest accounting:

Procedure / Amount billed/ Amount patient paid

Dr. Brayer Initial Appointment/ $115/ $74
Ultrasound / $1,226 / $101
Radiologist / $281 / $0
Ultrasound / $1,022 / $335
Radiologist / $281 / $1
Ibuprofen for Surgery / $32 / $32
Darvocet for Surgery / $13 / $13
GYN Consultation / $336 / ?
Operating Room / $17,991 / $1,367
Anesthesia / $810 / $100

Tissue Exam(Pathologist?) / $400 / $13

GYN Surgery / $1,500 / $180
GYN (something else) / $15 / $3

TOTAL so far
Billed- $24,022 / Patient paid- $2,218

Although the accounting is a hassle, my patient is happy to have only paid about 10% of the charges. I think 24K for out patient surgery is pretty pricey. For someone without insurance it would be unaffordable. Wouldn't it be nice to be able to know ahead what it would cost?

Rabies

Does anyone remember the old old Disney movie "Old Yeller"? I was just a kid when I watched this tear jerker, but what I remember most about it was that Old Yeller got rabies and died. Rabies was one of the first serious diseases I ever learned about as a kid. My first medical word was "hydrophobia".

In the U.S. and Canada, rabies is really rare. In Canada, only 24 cases of human rabies have occurred since 1924 and since 1970 six of the seven cases have been attributed to bats. In the U.S. 40 cases have been reported since 1990. Of those, 37 were caused by bats.

If a person is exposed to rabies, post exposure prophylaxis (PEP) is given. It consists of rabies immune globulin and a 5 dose series of rabies vaccine. An exposure is a bite, scratch or exposure of non-intact skin or mucous surface to saliva, tears or brain tissue. If the PEP is not given before the onset of neurologic symptoms, it will not work. After exposure, the usual incubation period for rabies is 20-60 days.

There is only ONE unvaccinated rabid patient that has survived. She was a 14 year old girl in Milwaukee who was diagnosed in 2004. She was placed in a chemical coma to slow down metabolism in the brain and given massive anti-viral medications and high dose Vitamin C. She was tested daily for levels of virus neutralizing antibodies in serum and over weeks she survived. The same protocol has been tried on other rabies victims without success.

So the take home message is that any contact with bats carries a risk of rabies. If you are bitten, immediately wash the wound with soap and water and capture the animal if it can be done safely. Local animal control services can assist and test the bat. The Emergency Department will evaluate regarding the need for PEP. Rabies is fatal but preventable with early preventive treatment.

Additionally, clinicians need to recognize that a majority of patients with rabies transmitted by bats might have no recollection of a bat bite so any patient with an unexplained acute, rapidly progressive viral encephalitis needs to have rabies in the differential diagnosis.

BTW...I re watched "Old Yeller" and it doesn't stand the test of time. It wasn't nearly as sad or shocking or interesting 40 (or more) years later.

Outside Hospital

Some of the comments on this video say the
general public will never "get it". I think readers of EverythingHealth will. Check it out.
(Hat tip to Jamesloganmd.com)

Quit Rewarding Drug Impaired

I read this morning that a celebratory concert is bring prepared for Nelson Mandela's 90th birthday in London. He has had a glorious and influential career and is a master statesman known all over the world. How wonderful that he is being honored!

With so many talented performers to choose from, why is Amy Winehouse selected to sing at that concert? Her drug addiction and arrests are also known all over the world. Her husband is awaiting sentencing for attacking a pub owner and it is always a media event to guess if she can perform without falling off the stage.

I know addiction is a disease that progresses without treatment. I am sorry for the waste of talent and the problems Ms. Winehouse faces. She is now reported to have emphysema that will affect her ability to sing.

I'm just tired of seeing impaired "girls gone wild" held up as a shining example of success and to have her on the same stage with a hero like Mandela is just plain wrong.

Surgical Checklist for Patient Safety

When a pilot sits in the cockpit, she methodically goes through a checklist of all systems and equipment before the plane is fired up. Even if the pilot has flown that plane and route 1000 times, the items on the checklist are reviewed one by one and no-one would think of flying the plane without completing the checklist.

Now, the World Health Organization (WHO) has developed a checklist to be used in the surgical suite by every surgical team before the patient is put to sleep. Up to 16% of surgical procedures result in an unexpected complication. The death rate from surgery in developing nations is an astonishing 10%. A study in Lancet found basic safety measures were overlooked in hospitals around the world.

One of my favorite medical writers is Atul Gawande, a surgeon and Harvard University professor. He worked with WHO and more than 200 worldwide medical organizations to create the checklist.

"What we identified, was that the idea of a checklist to make sure the basic steps are taken, could make a big difference not only in the poorest part of the world but even in the rich ones."
"We borrowed an idea that pilots have for 75 years," Gawande said. "It's like an airline check, you make it short, simple and the team can do better."

Its primary aim is to target the three biggest cause of mortality in surgery - preventable infections, preventable complication from bleeding, and safety in anesthesia.
It includes six basic steps in care, including verifying that it is the correct patient, ensuring equipment is not left inside the patient, and administering an antibiotic before making an incision - which cuts the risk of infection by half.

A study published in the Lancet, found that before the checklist was used there was a 64% chance that at least one of the procedures was forgotten - with no difference between rich and developing countries. However after implementing the checklist system, failure rates for the first 1,000 patients dropped by half to 32 percent. In a couple of place they cut it to 100 percent. More definitive results will be known later in the year after 3,500 major surgical interventions have been studied.

In the meantime three countries -- Britain, Ireland and Jordan -- have already adopted the checklist procedures in the operating rooms of their hospitals. I hope the USA follows soon.

WHO officials hope the checklist will be adopted around the world.

California HMOs - Raking in the Dough

Health costs and insurance premiums are rising at a rate that is completely unaffordable to companies, the government and to patients who buy their own insurance. We've seen these escalating costs for years and everyone who is connected to health care, either as a provider or a buyer knows we are standing at the edge of a cliff with a steep drop off.

So how is it that in 2007, HMOs in California spent $6 billion on administrative costs, which included large CEO salaries? (and that is in addition to billions of dollars in profits) . Talk about waste. That is 6 billion dollars in high premiums. Six billion dollars that did not go toward vaccinations, or mammograms or surgery or nursing care.

UnitedHealth Group, the largest health insurer in the nation, paid it's CEO $124.8 million in 2004. After an outcry, his salary went down to a paltry $12 million in 2006. Anthem Blue Cross (previously Wellpoint) paid its CEO total compensation of $52.4 million in 2006. That's enough to provide about 29,000 California children with health insurance. He also gets the use of the company jet and travel for his wife.

HMO plans are only part of the story. For enrollees who buy coverage in Blue Cross PPO plans, only 51 cents of every premium dollar is spent on health care. Profits account for 27% and that is on top of "administration", which I presume is those juicy salaries and perks.

These HMOs are for-profit, meaning they answer to wall street shareholders who want a return on the dollar. Is that where we want health premiums to go?

The next time a test or doctors visit is denied or you realize your out of pocket deductible is the only amount that is being paid, think about these salaries. Don't think health care reform is going to come easily. With these amounts of dollars, the incentive for change is a long way off.

Fake Cancer Cures

It is sad when a patient is dealing with a diagnosis of cancer and believes there is a cure out there that the doctors don't know about or are keeping from them.

The internet provides more opportunities for a cruel form of greed where fake cancer cures can be dressed up as "scientific" and sold to desperate patients. Bogus cancer cures have been around for decades, but online searches can bring them right to the patient.

The FDA has published a list of "125 Fake Cancer Cures Consumers Should Avoid". Check it out here.

Firms that engage in cancer treatment fraud often use exaggerated claims that should be red flags to patients and families. Some of them are:

• "Treats all forms of cancer"
• "Skin cancers disappear"
• "Shrinks malignant tumors"
• "Non-toxic"
• "Doesn't make you sick"
• "Avoid painful surgery, radiotherapy, chemotherapy, or other conventional treatments"
• "Treat Non Melanoma Skin Cancers easily and safely"

There is a big difference between investigational drugs that are being tested for efficacy and fraudulent products that have never been clinically tested or reviewed.

Painful Truth - Tim Russert

The medical blogosphere writers have been prolific in their speculation about Tim Russert's untimely death from a myocardial infarction last week. Did he have the right tests? Could more have been done to evaluate and prevent? How could a wealthy, intelligent guy who was under doctor care die from a disease we know so much about?

The best overall summary can be found today in The New York Times. Check it out.

ALS and Formaldehyde Exposure

Interesting information came from the Annual Meeting of the American Academy of Neurology held in Chicago in April. One presentation reported a link between workplace formaldehyde exposure as a risk factor for amyotrophic lateral sclerosis (ALS).

ALS (remember Lou Gehrig) is a rare, progressive and fatal neurodegenerative disease that hits during midlife. Only 5-10% have a genetic link and the majority of cases occur randomly with no known risk factors.

The American Cancer Society's Cancer Prevention Study II followed more than 1 million individuals over time. (a very robust study) They found that individuals who reported formaldehyde exposure in the workplace had a 34% higher rate of ALS than the no-exposure group and it was dose related. The occupations that are related to formaldehyde exposure are beauticians, pharmacists, morticians, chemists, laboratory technicians, physicians, veterinarians, dentists, firefighters, photographers, printers and nurses.

This is the first study that links formaldehyde exposure to ALS. It is hard to know what to do with this information (especially for those of us who are in those occupations) and it will be just one more piece of the research puzzle for determining prevention and treatment for ALS.

Fun Friday Info

Shocking Stats

60% of doctors don't follow hand-washing guidelines.
Source: CDC Morbidity and Mortality Weekly Report

96% of doctors agree they should report impaired or incompetent colleagues or those who make serious mistakes, but ...

46% of them admit to having turned a blind eye at least once.
Source: Annals of Internal Medicine

94% of doctors have accepted some kind of freebie from a drug company.
Source: New England Journal of Medicine

44% of doctors admit they're overweight.
Source: Nutrition & Food Science; Minnesota Medicine

58% would give adolescents contraceptives without parental consent.
Source: New England Journal of Medicine

Anatomy of a Doctor's Bill

Just how much of the $100 your doctor charges for taking 30 minutes to investigate your stomach pain goes into his pocket? After paying the bills, he gets less than half. The breakdown, according to Robert Lowes, senior editor at Medical Economics:

$3.50 for malpractice insurance

$3.50 for equipment, repairs, and maintenance

$6 for supplies, including gowns, tongue depressors, and copy paper

$7 for rent and utilities

$11 for office expenses, such as telephones, accounting fees, advertising, medical journals, licenses, and taxes

$28 for secretary, office manager, and medical assistant salaries and benefits

$41 Amount that goes into the doctor's paycheck

Over the course of a year, that adds up to $155,000, the annual salary of the average family physician. That number rose just 3.3% between 2002 and 2006, while expenses increased nearly 25% over the same period.

From Reader's Digest - July 2008

Shedding Hair in Men - What is Normal?

There has been no widely accepted method for assessing the number of hairs that are normally lost each day. Fresh from the Archives of Dermatology, we now know what a "normal" rate of hair shedding is in white men.

They used a method called the "60-second hair count". They studied white men with straight hair age 20-40 and another group of healthy white men age 41-60. Both age groups did the "60-second count" by combing the tops of their head (not the sides) from back to front over a pillow for 60 seconds. They used identical combs and shampoo for 3 consecutive days and did the combing on the 4th day. After combing for 60 seconds, they counted the number of intact hairs on the pillow and the comb. The test was repeated on 2 separate occasions.

The result? In the younger age group (20-40), average hair loss was 10.2 hairs and the older group (41-60) was 10.6 hairs, essentially the same.

The authors noted that the results may not generalize to women, non-white ethnicities and curly hair.

I must say I get more inquiries about hair loss from women than from men and the most common type of hair loss in women is female pattern balding which is diffuse rather than over the temple or crown or back like a man. Although it is probably hormonally related, we don't have a clear understanding of the physiology and it can happen at any time.

Other causes for female hair loss are a temporary shedding called "telogen effluvium" that often follows childbirth, crash dieting or severe stress. Certain types of autoimmune disorders result in alopecia areata, where hair comes out in clumps or patches.

I don't know if the "60-second" test would generalize to women. I will try it and report back on this blog, but keep in mind curly hair might be different. You can easily try it at home (male or female) and see if you average about 10 hairs too.

We Need Young, Fresh Doctors

There is a lot to be said for the seasoned clinician. The gray haired physician with years of experience and wisdom and a noble demeanor. But I am here to say...I want to see some young doctors in my medical community who love practicing medicine.

Here is what young physicians bring to Medicine:

• Availability (I am tired of referring my favorite patients to the ortho, or rheumatologist or neurologist and being told there is a 6 week wait)

• Availability (I am tired of having to beg a consultant to see a patient)

• Follow up consult note (When I take the time to send my work up notes, call ahead and arrange the appointment...I would like a follow up note from the consultant)

• Curiosity and interest ( I am a comprehensive internist and I only send patients who are a medical challenge. I want a doctor who is curious and interested in figuring things out. After the tests are done, I would like the consultant to work with me and the patient and come up with a solution, not just tell the patient to phone me to interpret the tests that he ordered.)

• Eagerness (I want a consultant who is happy to see my patients. Not someone who is burned out!)

• Humbleness (this may not be age related but I've sure seen my share of egocentric specialists)

I understand the concept of being burned out. I know how brutal the practice of medicine can be in a regulated, managed care world. I just wish there were some fresh, eager, well trained Doctors in my community. The older ones are a bit jaded and overworked. I admire the new generation of Doctor who protects their time and values family. Maybe they will love Medicine throughout their entire careers.

Grand Rounds

Head on over to Marianas Eye for this week's Grand Rounds...Featured Posts from the Medical Blogosphere.

Medicare Fraud

A high school dropout named Rita Campos Ramirez was able to perpetrate the largest health care fraud against Medicare with the use of a laptop at her home. For four years she electronically submitted bogus claims for equipment and services to the tune of $105 million.

Finally busted, she is now helping the Inspector General bust other doctors and businesses that bilk us taxpayers out of an estimated $60 billion a year. Yes, that's $60 Billion (with a B).

It appears that Miami, Houston and Los Angeles are big fraud cities. HHS investigators discovered that nearly half of 1,581 medical equipment companies they visited in the Miami area weren't open during the day and didn't even have phone numbers.

OK, let's stop right there. Miami only has about 400,000 people (although the entire metro area is over 2.5 million). Doesn't 1,581 medical equipment companies sound excessive for that population size?

The South Florida region bills Medicare more than $2 billion each year for injectable HIV medications. (Most HIV medications are oral, not injectable). That figure is 22 times as high as the amount of similar claims in the rest of the country and is far out of line with a population of 2 million people.

Why is it so hard to shut these crooks down? Pay a high school graduate minimum wage to look at electronic claims for a week and they could use common sense and tell you there is something wrong when a clinic bills for 1000 times more patient care hours than there are in a day. Pick up the phone and call the number. If no one is there, it doesn't exist. Duh!

What is annoying about this is that doctors are terrified of the Office of Inspector General (OIG) coming to their offices to review their charts and make sure the proper code was used. We are told we are subject to fines and jail if we code a 99214 (complex visit)rather than a 99213 (intermediate visit). We are told that the OIG has increased their inspectors and are going after doctors who miscode. I guess we are the easy targets.

Many physicians are just saying no to Medicare patients because the coding requirements are too onerous for the reimbursement. In the meantime, it sickens me to see the health care need and know that tax dollars are going to crooks because it is easy money.

Happy Fathers Day

This is how your kids see you. Live up to the challenge.

Top Ten Ways to Identify a Doctor

1. He can tell you something really bad in a nice way.

2. She can't remember her own anniversary but she still remembers the blood results of all the patients.

3. He sees blood and guts and can still think about food.

4. She can sleep (on command) on any surface, at any hour of the day.

5. He can wiz through a 300 page book in a day.

6. She is unshockable and talks about body functions at the dinner table.

7. He keeps asking for things that will never get done.

8. She thinks she has every disease she ever studied.

9. He knows anatomy and what works and what doesn't.

And number 10...

She looks at a naked person on the beach and the first thing she notices is the scar on their abdomen.

(Hat tip to Dimitri for the ideas)

Telephone Medicine

Things are really getting bad in the realm of wacky patient expectations!!!

My medical assistant brought me a phone message and explained "This person says she is your patient (I've never seen her and my practice is closed with rare exception) and she has swollen glands and she thinks it is strept and she wants you to phone in Z-Pack". The pharmacy number was kindly provided.

My reply: "Are you kidding me? Call her back and tell her we will get her in today for an appointment". (Same day appointment for a new patient...quite an offer!)

Medical Assistant a few minutes later: "I spoke to her husband. He says she doesn't want to come in. They will find another doctor who will call in a prescription".

Me: "Hahaha. They will make tons of phone calls and won't even find a doctor who will take a new patient, let alone call in a prescription for someone they have never seen."

(What part of poor medical care, medical-legal risk, doctor slavery and abuse, doctor shortage, entitled Americans do they not understand?)

MY BLOG IS NOT SAFE

Imagine my surprise to see a new fancy red scrolling widget on the right side of my blog that said "Days since Barack Obama has visited Iraq". The hours and minutes were changing (much like the one I placed that highlights the price of addiction to foreign oil). When I clicked on the image it took me to "GOP.com"...a republican site with lots of republican agendas.

Although it is really hard for me, I try to keep EverythingHealth non-political. There is good and bad with both political parties in the United States and politics itself is a pretty dirty, unhealthy business. But I am upset that hackers were able to get into my blog and actually post something on the template. Wow. Is nothing sacred?

I was able to remove the red widget. Everything else on my site is approved and I always appreciate controversial comments. I have never removed a comment.

But no more GOP propaganda, PLEASE.

Answer-Medical Challenge

The answer to the necrotic finger is #1 Thromboangiitis obliterans.

This is a vaso-occlusive disease that involves small- and medium-sized vessels of the upper and lower extremities. It is strongly associated with tobacco use. An angiogram of this patient's right hand demonstrated multiple chronic occlusions of the digital branches of the small arteries that were unresponsive to IV vasodilators, supporting the diagnosis of thromboangiitis obliterans.

• Marantic Endocarditis is deposits of non-bacterial vegetations on the heart valves.
  

• Brachial Entrapment Syndrome is muscular enlargement or compression in the arm that presses on arteries and nerves.

• Kawasaki Disease affects children and is a vasculitis that affects many organs like the heart, lymph nodes, and causes skin rashes.

• Takayasu disease is a rare arteritis that affects mainly the aorta.

Thanks for taking the challenge! Don't you feel smarter now?

Medical Challenge - What's the Diagnosis?

Here we go with this weeks medical mystery from the New England Journal of Medicine. I got it right! The patient is a smoker and his fingers turn whitish every time he is exposed to cold. What is the diagnosis that caused this severe lesion?
(click on the image for a better view)

1. Thromboangitis obliterans
2. Marantic endocarditis
3. Kawasaki disease
4. Brachial entrapment syndrome
5. Takayasu's arteritis

Take your best guess. The answer will be posted tomorrow!

It's Getting Hot - Drink Water

Thanks to Mens Health for pointing me to the most unhealthy drinks in America. Don't be fooled by:

• Glacaeu VitaminWater (any flavor 20 oz)- Pure deception at 130 calories and 33 grams of sugar. You might as well drink a Coke. Hey, this drink is made by Coca Cola! Surprise.

• Jamba Juice Peanut Butter Moo'd Power Smoothie (30 oz) 169 grams of sugar and 30 grams of fat will pack those fat cells on you. The only "power" will be cellulite.

• Arizona Kiwi Strawberry (23.5 oz can) - These cans always look healthy and cool and cost under $1 but they pack on 360 calories and 84 grams of sugar.

• Pina Colada - (you know the size) is the worst summer cocktail . They taste so yummy because they contain 625 calories and 75 grams of sugar. If you are trying to gain weight and don't care about empty sugar calories, this drink is for you.

• Baskin Robbin's Large Heath Bar Shake (32 oz). This is the #1 most unhealthy drink in America. It contains 2,310 calories, 266 grams of sugar and 108 grams of fat. Don't say you haven't been warned.

So what is the best Summer Drink? Iced green tea with agave sweetener and mint or ice water with lemon. Stay cool and healthy!

(Hey fellow bloggers or techy readers. I would love to know how to strategically place multiple pictures on the blog. As you can see, I am challenged)

Medical Research - Follow the Money

The use of psychiatric drugs in children has exploded over the past ten years. Powerful new medications for the treatment of attention deficit disorder and bipolar disorder have emerged on the market and we are now learning that three prominent researchers from Harvard have been paid millions by the pharmaceutical industry to promote these drugs for use.

University researchers are supposed to self-disclose consulting and speaker monies they are paid by pharmaceutical companies. They are required to supply conflict of interest forms but it appears they can write anything they want on them and there is little oversight. It has now come out that these physicians under reported their earnings by...are you ready for this....
Dr. Joseph Biederman -$1.6 million, Dr. Timothy Wilens - $1.6 million, Dr. Thomas Spencer - over $1million.

No wonder they wanted to hide it. They had lots to be ashamed of! When prominent and influential physicians publish articles and speak around the world at medical meetings, they are supposed to be completely free of bias. When the National Institute of Health (NIH) hands out taxpayers money for medical research, it is a huge conflict of interest for those same researchers to be paid from the company whose product is being studied.

This type of consultant pay is all too common in the medical world and we owe thanks to Sen. Charles Grassley (R-Iowa) for pushing this into the limelight.

Harvard's Mass General Hospital administered these grants and won $287 million grants in 2005. They didn't push too hard for self disclosure and there is a lot of hand washing and spin control going on, now that the truth has been dragged into the light.

To quote from the New York Times, "In the last 25 years, drug and device makers have displaced the federal government as the primary source of research financing, and industry support is vital to many university research programs. But as corporate research executives recruit the brightest scientists, their brethren in marketing departments have discovered that some of these same scientists can be terrific pitchmen."

For the multi-billion dollar drug industry, those millions given to the "Doctor Pitchmen" was money well spent.

Blood Pressure - Whats the Goal?

Our ability to recognize and control high blood pressure has had a dramatic impact on people dying from heart attack over the last forty years. There are scores of different medications that can be used to safely lower blood pressure.

Patients are still confused about what the goal is for blood pressure. And we've learned that measuring blood pressure in the doctors office is not the best way to see if the goal is reached. Patient anxiety, lack of skill by the doctor or nurse and just poor hearing through the stethoscope can affect the results.

New guidelines have evolved and here they are:

Goal blood pressure for most patients younger than 80 years is lower than 140/90. The goal should be under 130/85 if the patient has diabetes, kidney disease or cardiovascular disease.

The patient should have their own automated blood pressure monitor that they use at home and if the majority of readings are not below 140/90, medication should be adjusted or added to reach the goal. Some patients require three different drugs to achieve normal blood pressure. The most important factor in preserving kidney function or reducing heart attack is bringing blood pressure down to goal.

There are over 80 different drugs and combination drugs available to treat hypertension. (That tells you it is a common and chronic condition.) They fall in following classes of drugs:

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARB)
• Beta blockers
• Calcium channel blockers
• Diuretic

I always tell my patients, with that many choices, we will be able to find one that works and causes no side effects. It may take a little adjustment, but the end result is worth it.

Circumcision and STD - the jury is out

The evidence and medical research to support or refute circumcision in boys has not changed in the last 40 years! If you google "circumcision and STD" you will get thousands of search results and no clear science.

In 2006 a major study out of New Zealand showed circumcised men had less incidence of contracting sexually transmitted diseases than non-cut men. Score one for circumcision! Now a new study from New Zealand has been published in The Journal of Pediatrics showing there is no difference in the incidence of catching a STD. (What's with New Zealand? Is this their contribution to the world's medical knowledge?).

Another study in the United States showed circumcised men had a slightly higher incidence of STD. And yet another study showed circumcised men masturbated more, at least once a month. That one defies common sense. Kinsey proved masturbation was universal in the 1950s. Speaking of masturbation, circumcision became widespread in the 1800's when physicians pushed it as a way to stop the sin of masturbation and oral sex. Guess they misjudged that one!

"To circumcise or not" is an decision faced by most new parents and it is important to know that there isn't good scientific evidence to guide them. It is a personal, religious, cultural, emotional, irrational decision...not a scientific one.

Medical Quiz - Answer

The answer to the image below is #4 - Bilateral peritonsillar abscesses
The picture (along with this one) shows swelling of the soft palate and the uvula (image below) is pushed forward by the enlarged tissue. These abscesses are a medical emergency because they can suddenly interfere with breathing and the patient can become septic. Emergency drainage of the abscess is needed, along with antibiotics to treat the infection.

Thanks for your guesses.

Medical Challenge- You make the diagnosis

You make the diagnosis:
The patient is a 25 year old man who has a severe sore throat, some drooling and difficulty swallowing for the past day. His temperature is 100 and he has no appetite. When you look in his mouth and ask him to say "ahhh"...this is what you see.

What is the diagnosis:
1. Ludwig's angina
2. Glossopharyngeal nerve palsy
3. Pharyngeal gonorrhea
4. Bilateral peritonsillar abscess
5. Infectious mononucleosis

The answer will be posted tomorrow. Click on the image for a better view.

History is Made

History is made as Barack Obama has secured the Democratic nomination for President of the United States. Amazing. This has been the longest primary and it was easy to forget how important this race really is. Let the battle begin!

Check out Grand Rounds

If you like Medical Blogs you'll have fun reading this weeks Grand Rounds hosted at Happy Hospitalist. Check it out!

Lets Learn from Massachusetts

Taking a bold step, Massachusetts decided to cover all its residents with universal healthcare in 2006. It is not a surprise to many of us (and certainly not to the medical bloggers out there) that they soon ran into a problem with primary care access. The community clinics have hundreds of newly insured patients on wait lists of two to four weeks to see a primary care physician.

Making matters worse, the clinics cannot recruit primary care physicians and have had openings for over two years. "What Universal Care has done is highlighted the crisis and the problem that we have with the primary-care workforce," said Dr. Bruce Auerbach, president of the Massachusetts Medical Society. According to a study conducted in 2006 by the society, 53 percent of patients who had an appointment with a primary-care physician were able to see a doctor within a week of initiating contact. Last year, only 42 percent were able to see a doctor within a week.

I believe we cannot even begin to talk about health care reform until we make sure all citizens have health coverage. That is called "Universal Coverage" and Massachusetts has proven it can be done. But we must also address workforce shortages that will make access a huge problem if we start covering uninsured patients. It is not either/or. These issues go hand-in-hand and we must begin now.

As I have said before, it takes about ten years to restore the training pipeline for doctors. Medicare has a totally wacky payment system that disadvantages primary care and the insurance companies follow the same rules and codes, compounding the problem. The workload is no longer tolerable and the reimbursement is failing to keep up with practice expenses. Established primary care doctors are retiring early or limiting their practice to patients who pay a retainer. New doctors are shunning this specialty and we can't even import enough foreign medical graduates to fill the gaps. This impacts everyone with insurance...before we even add in the 45 million uninsured.

This country really has its head in the sand when it comes to health care and planning. What I am suggesting is not radical, but it does take vision and effort in Washington. Let's hope the next President will get good advice and start tackling these basic issues before enacting reform.

Medicare - not lovable

Some of my fellow bloggers are so good, I just want to highlight their posts. I happily link you to
Dr. Rob and the 10 reasons he dislikes Medicare. I agree wholeheartedly with all ten.

Medical Journal Update

I scan the Journals so you can watch "reality shows" on TV. Here are some interesting findings in the world of Medicine and Health:

Genes and Anxiety: Anxiety disorders are complex and researchers have provided the first evidence that a gene (RGS2) that influences anxiety in mice is associated with phenotypes for human anxiety disorders including childhood temperament, adult personality and brain function.
They also found a genetic connection for introversion.
(Anyone who has several kids knows they come out with different personality traits...here is more confirmation for Nature as the core. I've always said some people in our family "just don't have the anxiety gene." It's nice to be proven right.)
Archives of General Psychiatry


MRSA after Face-lift Surgery: Methicillin-resistant staph aureus (MRSA) infection is an increasingly problematic issue with all surgery. This study looked at patients who underwent face-lift surgery and subsequently developed MRSA post-op infections of the skin. They found two of the infections were complicated and required hospitalization and wound drainage. These MRSA infected patients had been in contact with health providers or hospitals prior to their surgery and the authors recommend well-developed screening , prevention and treatment strategies.
Archives of Facial Plastic Surgery

Depression in Adolescent Mothers: Teen pregnancy is on the rise again! Researchers looked at teens that had 2 pregnancies within two years. They found young moms who became pregnant again had depressive symptoms before the 2nd pregnancy. Depression may be an independent risk factor for subsequent pregnancy in African American adolescent mothers and they recommend improved recognition and treatment to avoid the risk of rapid subsequent pregnancy.
(I thought of Brittany Spears after reading this and her decompensation after the second birth.)
Archives of Pediatrics and Adolescent Medicine

Treatment of Colon Cancer and Medicaid: It has been said that the best predictor of health is income level. Researches investigated the influence of Medicaid (think: poverty) enrollment and the likelihood of receiving chemotherapy for treatment of colon cancer. They compared Medicaid (poor) and Medicare (old) patients and found that Medicaid patients were less likely to get chemotherapy, which affected the long term survival of these patients.
Archives of Internal Medicine

EverythingHealth quote for the day:

"To feel compassion is to feel that we are in some sort and to some extent responsible for the pain that is being inflicted, that we ought to do something about it."
Aldous Huxley (1894-1963)