Wednesday, March 31, 2010
The cost of medical care is high because the body is complicated and doctors and patients hate ambiguity. The cost is high because a missed diagnosis can lead to death and a large lawsuit. The cost is high because we have many specialists that view the body in tiny pieces and want to feel 100% correct about their piece. Let me give you a real life example:
My patient, Rick is a brilliant attorney. He has insulin dependent diabetes and heart disease and he takes good care of his health. He pointed out that his lower leg (around his shin) was red and swelling and then forming a painless hard lump. The exam showed a little redness, a tiny puffiness and a small firm lump in his leg tissue. I ordered some blood tests to make sure his diabetes was under control and to look for infection. Because I couldn't put a name on it and I was unwilling to say "Let's watch it, I don't think it is anything serious", I told him to ask his dermatologist , who he was seeing anyway. The Dermatologist said it wasn't in the skin, it was deeper so he was referred to an orthopedic specialist. The Ortho doctor said he wasn't sure and did an Xray. Since the bone was fine he ordered an MRI. The MRI showed no tumor, no vascular problem.
After several months of doctor's visits and spending $2,626.40, we have no diagnosis and I realize I should have said "Lets watch it, I don't think it is anything serious."
Rick has high deductible health insurance. He pays $4,800 annually out of pocket before insurance kicks in. He usually hits his deductible because of the diabetes medication and tests.
None of his doctors own imaging centers or labs. We don't make any money on ordering tests. We all wanted to help the patient in the only way we were trained to do.
I asked him if he would have been satisfied with me saying "Let's watch it, I don't think it is anything serious" after that first visit. He said, "Yes, I trust you". But he still has a leg that is swelling and a lump that forms daily. The symptoms are mild but strange.
Now we will watch it and it will probably go away and we'll never know what it was. That happens more often than not. We can all rest better knowing it is not serious but achieving our collective "peace of mind" is one reason medical costs are so high.
Monday, March 29, 2010
I am a bit obsessed this week with Celebrity Chef Jaime Oliver and his mission to reform the way Americans eat. I watched his new ABC show where he tries to reform the school lunch program in North Carolina where 50% of the town is obese. It is really a great show and it's great to see this type of "reality" TV rather than the usual fare. In honor of eating healthy, I am re-posting a blog from last year. It is worth repeating and here it is:
It takes a lot to shock me, but the article in today's New York Times about E. coli in ground beef is truly eye opening. I want you to read the entire article but here are some scary highlights and facts that show our meat sources are not safe for consumption:
- A single portion of hamburger meat bought at most supermarkets is not from meat run through a grinder. It is an amalgam of various grades of meat from different parts of many cows and even from different slaughterhouses.
- There is no federal requirement for grinders to test their ingredients for E. coli pathogen.
- Hamburger meat might be labeled "Angus Beef" but it can be made up of low grade ingredients cut from areas of the cow that have contact with feces, which carries E. coli.
- Many big slaughterhouses will only sell to grinders who agree not to test their shipments for E. coli because they fear that discovery will set off a recall of ingredients they sold to others.
- Meat grinders buy trimmings of fatty edges sliced from better cuts of meat and mix them with other fatty meat products that have been centrifuged and treated with ammonia to kill E. coli. One company, Beef Products Inc, produces seven million pounds a week that is sold to grocers and fast-food restaurants and served in the federal school lunch programs.
- The Agriculture Department regulations allow hamburger meat labeled ground chuck or ground sirloin to contain trimmings from those parts of the cow.
- Bacterial testing of ground beef is not required because the industry says the cost would unfairly burden small producers.
- Costco tests trimmings for E. coli before grinding.
- E. coli gastroenteritis is usually a mild disease. Five to 10% can be serious and cause hemolytic uremic syndrome and kidney failure.
- There is no question that the U.S.D.A. does not protect consumers from contaminated meat.
- Hamburger meat is not safe unless you have a butcher grind up a full cut of beef.
Sunday, March 28, 2010
I watched a good documentary called "Food, Inc". It was nominated for an Academy Award . The promo says you'll never look at dinner the same way and they are right. Since I am a fan of Michael Pollan and have read "Fast Food Nation", I was already one of the healthy food fans, but seeing how agriculture and farming has changed over the last 40 years was still a shocker.
There is no doubt that high calorie, sugar laden processed foods is contributing to serious health issues in America. And 10 billion animals (chickens, cattle, hogs, ducks, turkeys and lambs) are raised on factory farms under inhumane conditions.
So when I went to the grocery store today, I made a conscious choice to ask if Safeway had any grass fed beef. I am making a healthy stir-fry for dinner. The answer was "No", so I journeyed over to Whole Foods. I bought one lb of sirloin. The cost was a whopping $16.43.
I have to ask myself why grass fed beef should be so much more expensive than corn fed beef. There is no way the average family could afford to eat the way we should and the impact on our environment and our health is suffering terribly because of these perverted economics.
President Obama likes to shake things up. He has named Dr. Donald Berwick to head the Medicare and Medicaid Agency known as Centers for Medicare and Medicaid Services (CMS). This is a huge government agency with a budget of over $800 BILLION a year. That is more than most countries in the world. Dr. Berwick would be a major force in implementing the new health laws and changing Medicare to be more efficient and cost effective.
The average person probably doesn't know who Don Berwick is, but he is a big name in the Health Care industry. A pediatrician by training, he is the president of the Institute for Healthcare Improvement (IHI) and is a national leader on quality and patient safety. By telling stories that people can relate to, he is a transformational leader for reducing hospital errors and reducing variability in care.
Here is a quote from Dr. Berwick at the 2004 IHI meeting;
"I'm losing my patience, not with the people in healthcare, but with the system itself. Healthcare professionals are doing so many things so well; they're putting actual transformation within reach. Now we need to grab it. The clock is a tyrant and if you spend too much time 'getting ready' you're going to lose."
He started the 100,000 lives campaign which aimed to save 100,000 lives by June 14, 2006..and it did.
Dr. Berwick is an inspired choice to run CMS. I worry that he will last only a short time with such a bureaucracy, but if he can bring some of his ideas to the forefront and to congress, this will be a big win for medicine and for all Americans.
For more of Dr. Berwicks views, read here.
Thursday, March 25, 2010
Denial of care for children will not be allowed when the new Health Reform laws go into effect. Until it begins, it is business as usual for Blue Cross and Blue Shield of Texas.
Wednesday, March 24, 2010
I did a blog on Dupuytren's contracture last year that got a lot of interest. There are a lot of men out there with this condition and, apparently, many of them are reading EverythingHealth. I mentioned a new biologic drug that was being developed as a non-surgical treatment for Dupuytrens. At that time, it was still in testing phase and not available for use.
The product, collengenase clostridium histolyticum (Xiaflex) has now been approved and will be marketed by Auxilium Pharmaceuticas, Inc. It is injected directly into the palpable Dupuytren's cord, followed by a finger extension procedure 24 hours later to help distrupt the contracture cord.
The company plans to market Xiaflex to physicians experienced in hand injection procedures. The most common adverse reactions were fluid buildup, swelling, bleeding and pain in the injected area. No serious allergic reactions have been reported.
Tuesday, March 23, 2010
Monday, March 22, 2010
Well, it is an historic day as health reform has finally passed. Yes, it is a watered down bill that leaves much to be desired but...it is a start. After months of stops, starts, rhetoric, fear mongering, empty promises and long, heated debate, many Americans are not sure of what just passed. It will have different effects on different people and many of the provisions are delayed until 2014. Here are a few features of the new bill:
- Insurers will be prohibited right away from excluding children with pre-existing health conditions. Adults will have to wait until 2014 to be assured of coverage.
- Health plans will have to provide immunizations and other preventive health services for children and adolescents.
- Insurers cannot charge higher insurance premiums for woman and maternity care is covered.
- Most US citizens and legal residents must purchase "minimal essential coverage" for themselves and their dependents, either through the employer or exchanges that will sell policies to individuals. By 2014 you will pay a tax penalty if you ignore this mandate.
- The government will subsidize the purchase of insurance at incomes of four times the poverty level. For one person that is $44,000/year. For a family of four it is $88,000/year. The federal subsidy would go straight to the insurer. Really poor people would enroll in a newly expanded Medicaid program.
- Insurance companies will be prohibited from placing lifetime caps on their policies.
- Employers with 50 or fewer workers would be exempt from coverage provisions. If a firm has more than 50 employees it is not required to offer health insurance but if an employee gets a subsidy from the feds to purchase insurance on his own, the employer will be taxed a fee for every full-time worker.
- Small businesses will be eligible for tax credits in exchange for providing health insurance.
- Parents can keep children on their plans until they reach age 26.
- People with incomes of $200K or more and families with incomes of $250K will be subject to a new 3.8% "Medicare Tax".
That all sounds pretty good to me.
Saturday, March 20, 2010
I can't get the stories of Haiti out of my mind.
A patient showed up at the Port au Prince hospital ward with a massive left sided paralysis, an obvious stroke. This 48 year old woman had collapsed the day before and was now accompanied by her three grown daughters, who were most attentive and worried. I examined her in the bed with other patients and families gathered around. (There is no sense of privacy and even an exam seems to be everyone's business in Haiti). One daughter spoke broken English but I had a good translator that helped me get the information I needed.
It was a sad story. They had been on the 5th floor when the Earthquake hit. They fell straight down and dad was killed. One of the children had a crush injury to his leg and the entire remaining family was now "on the street". Just surviving must have been such a strain. Then...mom has a massive stroke.
As I was examining the patient further, one daughter handed me a quickly scrawled note. It read. "I have a problem She have a AIDS" In this private way, the daughter wanted me to know her mom had AIDS.
In a country with such poverty, lack of health care and lack of education, it is not a surprise that HIV and AIDS remains a significant problem and Haiti is the Caribbean island most affected by AIDS. There also remains a stigma and HIV infection is a big secret. Once I asked my Haitian interpreter to ask an emaciated patient if he was HIV positive and the interpreter couldn't even ask the question. It is just not done. It was a real act of bravery for that daughter to pass me the secret note.
Needless to say, AIDS will be the least of this family's problem. I can't begin to imagine how a woman with a stroke, who will likely not receive any rehabilitation, can live on the street. By the time I left, she needed 2 people to assist her out of bed into a chair...where she could not sit straight.
This is the continued tragedy of the Earthquake and the aftermath of human misery it left.
Thursday, March 18, 2010
Yesterdays medical challenge answer was Herpes Zoster (aka: shingles). Shingles is caused by the varicella-zoster (chickenpox) virus which lives in the nerve roots and can become reactivated later in life. The blistering eruption can be painful and one distinctive finding is that it rarely crosses the midline of the body. Each nerve has it's own "dermatome" distribution and the infection follows that nerve pattern.
It is recommended that people over age 60 receive the Shingles Vaccine (Zostavax) to prevent the activation of Shingles.
Wednesday, March 17, 2010
Reviewing the images of our Medical Mission to Port au Prince, Haiti brings back haunting memories.
#1 - 2 Dramatic collapsed buildings..there are thousands like this
#3 This man was outside of the emergency tent, lying alone and unattended
#4 Families stayed with hospitalized patients, sleeping on cardboard on the floor. With no homes to go back to, we had no problem giving them shelter. They supplied food for the patient and emptied the bed pans outside in an open ditch. There was absolutely no privacy for anyone and they were only able to get a few hours sleep at night
Tuesday, March 16, 2010
(note family is caring for the patients)
It has been two months since the disastrous earthquake in Haiti and the medical need is still dire. I just returned from a week in Port au Prince with a 17 person team of doctors and nurses to work with Partners in Health. We worked at the University Hospital, the only State hospital in this city of 3.5 million. What did we see?
We delivered medical care in tents like MASH units. There is one standing concrete structure housing about 50 patients and other tents being used for ER, ICU and Pediatrics ICU. Another tent is Surgery and TB ward. Our group staffed the nights on the Med Ward (we called it the catacombs), ICU and Pedi ICU. We worked 14 hour shifts and saw the most unbelievable filth, diseases and resilience of the Haitian people. We had no running water and that means no toilets too. We had 100% surgical infection rates. We chased mice out of patient's beds and shared our food and water with people who had none. We brought medical supplies and wished we had more. We made diagnosis without labs or imaging and treated serious diseases as best as we could in a "Charles Dickens novel" environment. In short, we worked ourselves to exhaustion and felt we barely made a dent in the problem.
Doctors and nurses are trained to "hand-off" patients at the end of the work shift. We often had no one to hand off patients to. The Haitian medical force has been decimated by the quake (killed or fled) and the other aid groups have pulled out. This created stress for us. Partners in Health is committed to Haiti but does not have the resources (or the permission) to run the State Hospital. Relying on volunteers is no way to run a health system.
Here are some amazing things we witnessed:
- The entire family stays with a patient in the hospital; sleeping on the floor, feeding and cleaning the patient. There is often no hospital provided food.
- The Haitians help each other too. If you don't have family you are really screwed but we witnessed kindness from others.
- Everyone in the vicinity crowds around if you are examining or talking to a patient. There is no privacy at all and no HIPPA. This was so odd to us but so accepted by them.
- Even when death was obviously coming and we warned the family, the family was always surprised and tried to wake the dead person up. The mourning ritual is extreme, loud, prolonged for hours and made everyone (including us) cry.
- No one complained despite the most horrible conditions. The Haitians do not deserve such a life.
- I did not see one cigarette in Haiti. They are too poor to smoke.
- Young people have end stage heart and liver disease from infections, malnutrition and other conditions that we eradicated decades ago. Poverty leads to early death.
If you have an extra ten bucks...think about a donation to PIH. You will not regret it one second.
Wednesday, March 3, 2010
The January 12 Haiti earthquake killed over 200,000 people and The United Nations reports nearly 1.3 million people are now homeless. The devastated capital of Port-au-Prince is home to 762,708 of them, living in squalid tent camps without proper sanitation. Officials have worried about "donor fatigue", especially with the Chile earthquake. But the situation in Haiti is so much worse than Chile because of the lack of a functioning government.
On Friday morning I will be leading a team of doctors and nurses who will fly to Port-au-Prince to work with Partners in Health (PIH) and provide medical care to the victims of the earthquake. We don't know exactly what to expect or what the working conditions will be like.
The need has moved beyond the initial trauma and surgery to general medical care and pediatric care for the millions of survivors. Sutter Health deployed an initial team to work with PIH right after the quake and now they are asking for more help. It is great to work for an organization that steps up to the plate and sees global health care as part of their mission.
So I won't be blogging on EverythingHealth for awhile.
I am taking my malaria prophylaxis because the rainy season is starting and mosquitos are everywhere. I know the conditions will be rugged with intermittent electricity and sleeping in tents. I hope the supplies and medications our team is taking will be enough. Nothing is worse than knowing there is a treatment that would cure, but not having it close at hand. We are trying to anticipate what is needed but there is only so much that we can carry. The airlines are charging $50-100 for an extra or overweight bag so the logistics of this type of travel are a challenge.
I will try to blog regularly at the Sutter Health site, SutterHelpsHaiti. It will depend upon my ability to send photos and text through my blackberry.
Stay tuned for the outcome of this exciting, scary and very worthwhile journey to help the victims of Haiti.
Tuesday, March 2, 2010
Comfort food is usually home made and carries some emotional significance with it. During times of stress or illness people often turn to "comfort foods" to feel better. Most everyone has a favorite comfort food and comfort foods are not necessarily one's favorite food. Ask yourself...what is my favorite food? Then ask "At the end of a long day, when I'm tired and stressed or sick in bed, what food would I like a loved one (mom) to fix for me?
Comfort foods are often fattening or unhealthy...macaroni and cheese, chocolate cake, fried chicken, chocolate pudding. Foods that are high in carbohydrates and sugar are often connected to childhood and make you feel homey and good. And different cultures have different comfort foods. Rarely is yogurt or a handful of almonds a comfort food in any culture.
There is nothing wrong with a fattening comfort food. The key word here is "comfort". If it elicits a fond memory of good times, it is comforting. The thing to notice is how often you are turning to "comfort foods". If it a regular happening it may be an indication of a life out of balance and that is where the focus should be. Eating comfort food several times a week can be a problem if that food is unhealthy. Emotional eating is also different from the occasional comfort food.
My comfort food is toast. When I'm sick I want "Wah Won Ton Soup". What is your comfort food?