Matt should win the next Nobel Peace Prize. Dance around the world
Tuesday, December 29, 2009
It has been proven than there is tremendous variation in the practice of medicine across the United States. The Dartmouth data (Wennberg et al) has documented the differences in how medical resources are used and how different physicians practice medicine, depending upon where they live. The Dartmouth studies are mainly focused on cost and outcomes and make the case that improved quality is often inversely related to the cost of care. More (expensive) care is not necessarily better care.
Now that I am recovering from a total joint replacement, I am amazed to see the differences in how physicians, doing the same surgery, treat the patient. Total knee replacement (TKA) is one of the most common orthopedic procedures done today. Despite this, the patient cannot expect the same post op care.
I am in contact with a patient in rural Minnesota who had the same surgery 8 days prior to me. Here are some differences in treatment for the same surgery (TKA):
San Francisco - Hospital Stay was 4 days. Anticoagulants were used to prevent blood clots.
Minnesota - Hospital Stay was 10 days. Anticoagulants were not used and patient suffered deep vein thrombosis and pulmonary embolus requiring 3 days in ICU and several months of blood thinners afterward.
San Francisco-Patient sent home with narcotic pain relief and encouraged to take them for comfort and good sleep.
Minnesota- Patient sent home with only enough pain pills to use at night and to stretch them out.
San Francisco-Patient given home visiting physical therapy
Minnesota- Patient given exercises to to on her own without PT.
San Francisco-Wound closed with steri-strips
Minnesota-Wound closed with staples that are present 3 weeks post op and driving patient crazy
Except for the Pulmonary embolus (potentially a fatal event!) and the increase hospital cost, these are all differences that probably do not affect the total outcome one year post op. But with such a common surgery, I can't help but wonder why these variations in care occur? The surgeon's own preferences seem to determine what happens to the patient and how much pain and disability go along with the surgery.
I am glad I am receiving my care in San Francisco.
Posted by Toni Brayer, MD at 11:22 AM
Monday, December 28, 2009
Now that the Senate and the House have each approved a health care bill, we can expect the debate to continue into 2010 as they try to merge the language and fight for their different language and approaches to providing coverage and paying for it. "The Republicans vow to make the process as difficult as possible in hopes of stopping the legislation", according to the Washington Post. Nothing will be more contentious than abortion.
The current Senate bill allows any state to bar the use of federal subsidies for insurance plans that cover abortion. Only dollars from private premiums would be used to pay for abortions. This requires the States to divide subsidy money into separate accounts.
Since there is already a 30 year-old-rule that prohibits the use of federal money for elective abortions, I do not see why new language is needed that will hold up the process. Abortion opponents want new health care legislation to prevent women from buying plans that cover abortion, no matter which dollars the insurer uses to pay for it. In effect, it would make abortion an uninsured cost to all women.
A poll done by the Pew Research Center showed only 3% of respondents who opposed health care overhaul cited abortion as a reason. So why is the abortion issue threatening to side tract the broader debate about health care?
Posted by Toni Brayer, MD at 8:14 AM
Sunday, December 27, 2009
When I took a hiatus from blogging I had no idea it would have lasted this long. My absence was a planned one...I got a new right knee. After years of watching my activity level decline because of severe osteoarthritis in my knees, I decided to join the millions of other baby boomers and get a total knee replacement. Extreme? Yes! But I believe it will be "life transforming" and there aren't too many times you can have those expectations with a medical decision so I went for it.
So here I am on Day 11 after the surgery. Experiencing life as a patient is a wonderful grounding experience and every day I learn new lessons. Here are a few:
- Everyone has a different pain threshold. Doctors should not question or try to imagine some one's pain level. It is what it is!
- Even when the nurse gives good, clear discharge instructions...the patient will probably not remember any of it. (I have no idea when I am supposed to see the doctor again!)
- Pain is much worse at night. Take the medication and don't get behind.
- Every day is completely different than the day before. Knowing that can be so reassuring.
- Having a loving caregiver is essential. Buy one if you don't have one.
- You can't have too many pillows
- Take your own soft blanket to the hospital with you. Leave all jewelry at home.
- Take the stool softener.
- Don't let your cat or dog jump on the area you had surgery.
- Pay all bills, correspondence, work before your surgery. Recovery is a 24 hour a day job and you will not be able to think or blog during the post-op period.
Monday, December 14, 2009
Saturday, December 12, 2009
Just when you thought it was safe...now there is another article in the NewYorkTimes about the pharmaceutical industry pushing hormones for post menopausal women. It is a long and somewhat "shocking" article about how women have been sold a bill of goods regarding estrogen and progesterone after menopause and Wyeth Pharmaceutical paying multimillion dollar claims for women who took hormones and developed breast cancer.
Let me say...don't believe everything you read. As readers of EverythingHealth know, I am not a shill for big Pharma and have written critiques of their corporate tactics many times. But when it comes to Estrogen replacement it isn't just doctors and Pharma pushing drugs on unsuspecting women.
The link between breast cancer and endometrial cancer and estrogen (ERT) has been open dialog for decades. The pharmaceutical companies have had it listed in their marketing literature and good physicians make it part of the risk/benefit discussion. I have never felt pushed to prescribe ERT when it was not indicated and good evidence remains about the benefits of female hormones for bone strength and symptom control. Patients should know that for every 10,000 women who take estrogen, 8 more cases of breast cancer are seen. Other factors influence breast cancer like smoking, radiation (excessive chest X-rays, cat scans or mammograms), alcohol etc etc etc.
Now let's talk about menopause. Many women breeze through it but many others really hit the pits at "change of life" time. The herbal remedies just don't work for most women. Double blind studies have shown little or no benefit from black cohosh, soy, evening primrose, progesterone cream, dong quoi, chickweed and numerous others. I say if it works for you...go ahead and take it but if we give you placebo, you won't know the difference.
What does work for hot flashes, sleep disturbance, crankiness, depression, arthralgias and foggy brain is replacing the hormone that has declined in the body...Estrogen.
The studies show that women can safely take estrogen replacement to get them through menopause. There is no evidence that "bio-identical" estrogen is any safer than estradiol or Premarin. Suzanne Sommers is not a scientist. I would rather women use pharmaceuticals where we know the absorption rate and the ingredients are standardized.
Telling symptomatic women to avoid spicy foods, hot drinks, hot weather and "intense exercise, specially lovemaking" as some websites do is really an injustice. Scaring women by emphasizing the risks without the benefits is also an injustice.
Whenever I see that $79 million was paid in a lawsuit, I am not necessarily compelled by the evidence but instead think "follow the money". We will surely see more settlements, whether they are warranted or not, and they do not always serve the common good of women.
Posted by Toni Brayer, MD at 1:40 PM
Tuesday, December 8, 2009
Most doctors have a closet in their office filled with various pharmaceutical samples. The pharmaceutical industry has had "drug reps" or account reps or pharmaceutical sales staff making the rounds on doctors offices in every city and town across the United States for decades. The industry spent $33.5 billion promoting drugs and sending reps to doctors offices with samples in 2004. That is a lot of samples!
Most of us thought we were doing the right thing for our patients when we accepted drug samples. I was able to give patients a month (or more) free to make sure it worked and that they tolerated it. Other patients had no insurance and I supplied them with all of their medication for free from my sample closet. I had a good relationship with the rep and they kept my office stocked with the medication my patients needed. It seemed like a win-win for everyone.
But new information is coming out that makes me take pause. A 2008 study published in Medical Care said that patients who got samples paid $66 more over six months than patients who did not get free samples. Are physicians influenced to prescribe high cost, brand name drugs rather than cheaper generics? With Americans spending $200 billion in prescription drugs in 2002, it serves the pharmaceutical giants well to give out samples and potentially influence those choices.
When physicians are interviewed, they all say the samples, free pens and sales pitch does not influence their prescribing habits. No one likes to think they are influenced when they accept samples and when queried, they say they are choosing the best drug for the patient.
The bans on accepting samples are coming from hospitals and academic institutions, not from physicians who are actually seeing patients day in and day out in their offices. The AMA and the American Academy of Family Physicians say it is OK for physicians to dispense free samples. But more and more academic institutions along with Kaiser Health Plans are banning sales reps completely.
Everybody likes something for free. We just need to make sure it isn't free today...more costly tomorrow.
Posted by Toni Brayer, MD at 8:44 PM
Monday, December 7, 2009
As of right now (9:21 PST) the EverythingHealth poll on concierge medicine shows:
59% of readers agree with the principle of concierge and would pay the retainer if they could. Twenty-one% think it is "elitist" and unfair and 18% don't have a clue what "concierge medicine" is. For that 18%....please scroll down and read yesterday's post. You can't vote a 2nd time but you can comment here, if you now have an opinion.
Posted by Toni Brayer, MD at 9:21 PM
Sunday, December 6, 2009
A significant percent of people do not know what "concierge medicine" is. Also known as "retainer" practice, concierge is a growing type of medical practice where the patient pays the physician an up front fee (retainer) for services. The fee can range from $100/month to $20,000/year, depending upon the practice and the services offered. The fee usually covers all visits to the doctor, phone calls, more prompt service and email access. Labs, tests, Xrays, referrals to specialists, and hospitalization are not included.
More and more primary care physicians are forgoing the hassle of dealing with insurance companies and Medicare and are becoming concierge doctors. Because of the retainer, physicians can have a smaller practice and be more accessible to patients. The doctors that charge $20,000 a year have only 100 patients and provide "spa" service. (you do the math!) One of my colleagues has a long waiting list!!!
Patients who go to concierge doctors still carry health insurance for other health care but they have easier access to the primary care doctor and both physicians and patients are generally happy with the arrangement. If the patient doesn't feel like it is worth it, they can always just drop out. Many physicians say if they hadn't switched to concierge practice, they would have just quit medicine all together.
Some of the criticism of concierge medicine is that with the shortage of physicians, it only exacerbates the access problem. It is called "elitist" and leaves out the people who can't afford the retainer. Other critics say patients are paying for service that many physicians already provide without a retainer.
Check out the poll on the upper right side and give us your opinion of concierge medicine.
Posted by Toni Brayer, MD at 9:47 PM
Saturday, December 5, 2009
Thanks to KM for alerting EverythingHealth to a great website called Voices of Survivors. The spoken word is a powerful medium and the internet gives us a chance to hear from people we would never encounter in all of our lives.
If you or a friend have a chronic disease or cancer or just need inspiration to face life problems, click away on this site and read how others cope with a raw deal.
Posted by Toni Brayer, MD at 8:39 AM
Friday, December 4, 2009
The answer to yesterdays Medical Challenge is
B: Staph impetigo. The patient spread the infection by shaving. He was treated with a topical antibiotic and an oral antibiotic to cover methicillin resistant Staphylococcus aureus. The rash resolved without a problem.
Thanks for your good guesses!
Posted by Toni Brayer, MD at 9:01 PM
Thursday, December 3, 2009
This 28 year old young man is generally healthy but has had this rash on his chin for the last week. What is the diagnosis? (answer will be posted tomorrow...make your best guess)
A. Streptococcal impetigo.
B. Staphylococcal impetigo.
C. Candida folliculitis.
F. Contact dermatitis.
A. Streptococcal impetigo.
B. Staphylococcal impetigo.
C. Candida folliculitis.
F. Contact dermatitis.
Posted by Toni Brayer, MD at 7:12 AM
Wednesday, December 2, 2009
When you think about occupational hazards, it seems that Santa might be at a big disadvantage during holiday season. He is in constant contact with kids and babies crawling on his lap, whispering close to his face and coughing and sneezing. Santa better have a rock solid immune system or make sure he got both seasonal and H1N1 flu vaccine this year!
I wonder what the rate of illness is for shopping mall Santa?
Posted by Toni Brayer, MD at 6:02 PM
Tuesday, December 1, 2009
It is always great to find out the New York Times has learned from EverythingHealth. Today's article by Tara Parker Pope on 29 Days of Giving follows my Thanksgiving post. Taking the 29 days of giving pledge does keep you in the conscious giving mode. Give it a try. It's good for your health and immune system.
Posted by Toni Brayer, MD at 6:36 AM