Tuesday, June 28, 2011

Doctors Adapting and Trying to Survive

Close your eyes and think of a doctor.  Do you see a Marcus Welby type? A middle aged, smiling and friendly gentleman who makes house calls?   Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you?  If that is what you envision, either you haven't been to the doctor lately or you are in a concierge practice where you pay a large upfront fee for this type of practice.  Whether you live in a big city or a rural community, small practices are dissolving as fast as Alka Selzer.  Hospitals and health systems are recruiting the physicians, buying their assets (unfortunately not worth much) and running the offices.

Doctors are leaving small practices and going into the protection of larger groups and corporations because of economic changes that have made it harder and harder for small practices  to survive.  The need for computer systems,  increasing regulations, insurance consolidation, skyrocketing overhead and salaries coupled with low reimbursement has signaled the extinction of the Marcus Welby practice.  Some older doctors are finishing out their years and will shutter their offices when they retire.  Young to middle age physicians are selling out to large groups and new physicians would never even consider this type of practice.  They are looking for an employed model from the outset.

Every doctor (I know) who is currently in private practice  is weighing his/her options for survival.  Doctors are learning and performing new services for which patients will pay out of pocket.  Botox, anti-aging therapy, weight loss, retainer services, home visits, cosmetic services, acupuncture, prolotherapy and medical directorships are all outside of the Medicare/Insurance payment world.   Physicians are surviving with these creative revenue producers and doing the best that they can.

The world of medicine has changed. Health Care Reform is rewarding integrated care and this will be good for patients and quality.  Doctors need the capital that large systems can provide to put in the electronic health record (ehr) and support its use.  They need the protection of health systems to pay their overhead and ensure that employees are trained.   It is unlikely that large organizations can run lean offices but they can provide standards that improve care and patient experience.  I am in favor of practice standards and a continuum of care between primary care, specialists and the hospital.

Marcus Welby practiced in a silo.  He could remove your appendix, deliver your baby, deal with your wayward teenager and help grandma die peacefully.  The truth of the matter was he had no technology except hand-holding and about 10 medications to offer.  

This is 2011 and things have changed.

Saturday, June 25, 2011

Tennis at San Quentin

Many people can't understand why a law abiding citizen like me would go to San Quentin Prison and play tennis with the inmates.  I've written on this before and it is a fascinating look at life we don't usually get to witness.  Today was another San Quentin tennis day where I got to play some good, friendly tennis as well as hear some stories of redemption.

I spent a good deal of time talking with an inmate named Sam (not his real name).  He was doing 15 to life for a stabbing death of another young man.  Sam was on a date and two other guys started harassing them. It was an unanticipated fight with a stranger that got out of control.  One day you're a student and the next day you are going to prison for life.

Sam came into San Quentin at age 18 and has spent 24 years there.  He is in the college program, the tennis team ("inside tennis") and has a job making furniture for which he is paid .25/hour.  They have a commissary at San Quentin and the prisoners can buy food and (authorized) magazines there.  They can order items like tennis shoes too.  They are not allowed any electronic equipment - No ipods, cell phones, computers.  On the yard I see some guys with old fashioned sony walkmans so some music is permitted.

Because of California prison overcrowding, the guys are often transferred to other facilities with no warning.  Sam was transferred to another California Prison and  he told me he spent 8 horrific months there.  There were no cells, just dorm living with no privacy, constant noise, guys playing loud dominoes (slamming the tiles down and shouting) from early AM to late night.  He said he had to be on guard from the moment he arrived and had not one person he could trust.  Most of the prisoners were on psychiatric medication and one was defecating all over the dorm.  The guards would not provide clean up material so Sam took it upon himself to clean daily.

"I spent every waking minute avoiding altercations, scanning the environment, staying alone on my bunk, trying to avoid a fight"  Sam said.  "I had to be altert to everything to avoid being pulled into a fight or worse.  I'm coming up for parole.  I can't risk  anything that would affect that and being at _____prison really put me at risk."

When one guy got in his face and threatened him over something as silly as a magazine, Sam used some very impressive skills to defuse the situation.  He pulled the guy aside, away from the others ("saving face technique") and talked in a low voice to engender trust and "respect".  Respect is very important in prison.  I learned the worst thing you can call someone is a "b___ch".  Those are fighting words.

Just when Sam felt his lowest, he got transferred back to San Quentin.  San Quentin is unlike other prisons, and many of the men have experienced them all.   They actually have rehabilitation and programs and the lifers are a pretty mellow bunch.  They are long past their gang-bang youth years and many do yoga, tennis, meditation and have come to personal terms with their past.

Sam will be coming up for parole in a few months and hopes to get out.  All the guys talk about getting out but in the 3 years I have been going to San Quentin, I know of only one who was paroled.  The sad thing is that Sam has no family on the outside.  A cousin ("she's not really a relative") has written him over the years.  That's it.

Frankly I don't know how anyone survives in this world without family.  It is a tough life if you don't have a safety net and too many of the men in prison have never had a functional family that supported them or believed in them or gave them any kind of launching pad for life.

Playing tennis with the civilians gives these men an opportunity to feel "normal" for a little while.  They can practice social skills with "civies".   They are on their best, courteous behavior and I've never heard an angry word, a swear word or even a bad line call. 

Tuesday, June 21, 2011

Rob a Bank to Get Health Care

Just when you think things can't get any nuttier with American health care, here comes the strange and sad case of James Richard Verone.  Mr. Verone, age 59, was laid off from his job of 17 years as a Coca Cola deliveryman.  He went through his savings and  took a part-time position as a convenience store clerk but he had no health insurance.   He had a back ache from lifting and bending and pain in his foot that caused him to limp.  He also suffered from carpal tunnel syndrome and arthritis.  When he noticed a protrusion on his chest he knew he needed medical attention.  What is a impoverished, uninsured guy to do?

He woke up, showered, put on a freshly ironed  shirt and walked into a bank and handed the cashier a note demanding $1 and medical attention and then he waited for police to show up and arrest him.  Before his caper he send a letter to the Gazette, listing the return address as the Gaston County Jail. 

"When you receive this a bank robbery will have been committed by me", he wrote. "This robbery is being committed by me for one dollar.  I am of sound mind but not so much sound body."

Verone, who has never before been in trouble with the law,  has already seen some nurses and has a jail doctor appointment on Friday.  He wants the protrusion on his chest treated and he hopes to get back and foot surgery.  (Mr. Verone needs to know that surgery is a last option and there are many treatments and steps before such aggressive action is contemplated)

James Verone believes that if the United States had a health-care system which offered people more government support, he wouldn't have to make the choice he did.

Before you write this guy off as a kook consider this...

With back pain, carpal tunnel and a chest protrusion, he cannot go on the open market and buy insurance, even if he could pay the premium which would probably exceed $1500/ month and have a $5000 deductible and exclude certain conditions.   He is essentially uninsurable.  Since he is working, he may not qualify for Medicaid.  There are millions of James Verones all across the United States.  They pay for care out of their pockets when they can, use the emergency room when they can't stand it anymore and suffer pain and disability far more than they seek help.   As James Verone says "If you don't have your health you don't have anything."

The Affordable Care Act is supposed to help Americans like James Verone get affordable health insurance.  Most of the provisions do not go into effect until 2014 which gives the opponents lots of time to overturn it and keep things just as they are.

I doubt that James Richard Verone's scheme will work.  You can't be kept in jail for simple larceny and get free health care.  He will probably be fined and turned out on the street to limp back to work and struggle with his chest protrusion on his own.

(hat tip to SJ for the story)

Monday, June 20, 2011



This 45 year old man came to his doctor about a triangular shape growth in the inside corner of both eyes.  It had been present for a long time but seemed to be increasing.  There was no pain, no discharge and no visual problem.  The internal eye exam was normal.  What is the diagnosis?

These common conjunctival growths are called a pterygium (pronounced "teryjium").  We don't know what causes them but there are theories that UV light exposure is associated and working outside.   They are more common in men and people living closer to the equator.   Dust and wind may also play a role along with predisposing genetic  factors also.  

Sunglasses and hats may protect from pterygium. The growths do not affect vision unless they extend close to the pupil.  They can be surgically removed if they extend into the visual field but usually they are just a cosmetic nuisance. 

(Photo compliments of Consultantlive)

Sunday, June 19, 2011

Stop Unnecessary Medicare Tests

We are in a time when  Medicare is bankrupt and the GOP wants to privatize it and make seniors go to the open market to get insurance. Even the idea that we would dismantle this important social benefit is shocking yet everyone knows we have to bring costs under control.  So now we find that hundreds of hospitals (and radiologists)  in the United States are performing unnecessary CT scans on both Medicare and privately insured patients.

Not only is there an exposure to radiation when a patient undergoes a CT scan, the New York Times reports some hospitals were performing double scans over 80% of the time on patients.  It is rare that there should ever be 2 scans performed in succession.  Not only is the patient receiving twice the radiation, but Medicare is paying twice for an expensive test. (payment goes twice to both the hospital and to the radiologist separately).  Double CT scans are equal to about 700 standard chest X-rays.  That is truly excessive radiation unless it is absolutely necessary for diagnosis and treatment.

Before doctors start shouting that these double scans are necessary to make a diagnosis one must look at the extreme variation.  Some academic hospitals never do double scans while a community hospital in West Michigan gave two scans to 89% of its patients.  That variation in practice cannot be justified.

It is time to get serious about why such abuses in cost and quality are occurring.  We have created a system where there is a huge incentive to over treat and over prescribe.  From too frequent colonoscopys to MRIs to prostate biopsies, back surgery and thousands of other procedures - we reinforce overuse by paying more for doing more.  There is zero incentive for doctors or hospitals to stop doing more and in fact, those hospitals and radiologists who justify double CT scans on patients are  handsomely rewarded.  When you add in the fear of a lawsuit in case a rarity is "missed", it is surprising there are not more double scans being done. 

It is going to take us a while to climb out of this mess we have created called "American Health Care".  There are too many stakeholders that like the status quo and will go down fighting when change is proposed. 

The American Medical Association (AMA)  is still having debates about the mandate in health reform that  says Americans purchase an insurance plan.  Those opposed to a mandate believe a federal mandate "will undermine the innovations and improvements in  health care financing that can evolve in a free market."

Yes...a free market that pays handsomely for double CT scans.

Thursday, June 16, 2011

No Advantage for Screening Ovarian Cancer

There were 21,880 new cases of ovarian cancer diagnosed in the United States in 2010 and it is the 5th leading cause of cancer death among women.   Women are understandably afraid of ovarian cancer because there are usually no early warning symptoms and when discovered,  the disease is often advanced, difficult to treat and highly lethal. A large and well run study, reported at the American Society of clinical Oncology 2011 Annual Meeting showed no advantage for screening for ovarian cancer in women.

We are so used to having screening tests to detect early cancer (prostate, breast, cervical, colorectal) that women expect screening for ovarian cancer also.  This trial has shown that screening by vaginal ultrasound and CA 125 blood test were ineffective for finding early tumors of the ovary.  Women screened annually and followed up for 13 years died in similar numbers from ovarian cancer as women who were not screened.  Additionally, the diagnostic follow up of false-positive screening results was dangerous and fraught with complications.

These discouraging findings point to the rapid progression of ovarian tumors.  Ovarian cancer screening did not reduce deaths among average-risk women.

The symptoms of ovarian cancer can be vague but women and their physicians should be aware of them:
  • pelvic pain
  • abdominal bloating and pressure
  • urinary urgency
  • fatigue
  • back pain
New and persistent symptoms should not be ignored.  Women with a family history of ovarian and breast cancer need to be especially vigilant and genetic testing can be performed to assess the risk and give important information to women about their risk.

A few other tidbits for women to know.  Oral contraceptives do not increase the risk of ovarian cancer and in fact,  the use of birth control pills may confer a 40-50% reduction advantage for women.  Low fat diets and exercise may also help prevent ovarian cancer by keeping body mass index (BMI) under 25.

Women who have children before age 30 and breast feed also have less ovarian cancer.

Ovarian cysts are common in menstruating women and they are not associated with ovarian cancer.

Over 50% of all ovarian cancers occur in women older than age 65.

For past EverythingHealth post on ovarian cancer and fertility drugs go here

Wednesday, June 15, 2011

Sunburned Feet

As a follow up to my last blog, check out these sunburned feet from a friend vacationing in Southern California.  Ouch.  Feet are especially sensitive because men wear socks all the time and they never get sun exposure.  Another worrisome area is the head, especially with a bald spot.  Don't let a sunburn ruin your vacation.  Prevention is the key.


Summer is here and this is the time for sunburn because people are so happy to be on vacation or out in the sun, they underestimate how much sun their sensitive skin can tolerate.  Sunburn is caused by UV radiation actually burning and damaging the cells of the skin.  While fair skin is more likely to burn, even people with darker skin can be easily sunburned if they are getting sun during the hottest part of the day from 10AM to 3PM.  The best way to treat a sunburn is to prevent it from even happening.

Prevention:  Wear large hats and loose long sleeve clothing.   Apply sunscreen with UVA and UVB protection.  The FDA has just announced regulations that will require protective sunscreen to say "broad spectrum" on the label to show it protects against both types of rays.  Also look for the words "water resistant" and a statement about the amount of minutes the product is resistant.  The old labels that claimed waterproof or sweat proof just didn't hold up.  Choose a sun protection factor  (SPF)  of 25 or more but understand that anything over 50 has not been proven to be of higher value.   Finally, even high SPF sunscreens will not protect you from dangerous burns.  The amount of time you can spend in the sun is incremental and sunscreen must be reapplied frequently.

Babies and toddlers cannot tolerate sun. (think of their soft, soft skin)  It kills me to see kids in strollers with sun beating down on them.  Little ones need shade and protection.

Treatment:   Severe cases of sunburn are really sun poisoning.  If you have chills and large water blistering you have serious skin damage.  Even mild sunburn results in skin redness and irritation.  Peak effects of sunburn are noted at about 12-24 hours after exposure.  Severe pain, blistering, nausea, vomiting or fainting require medical attention.

For mild sunburn, cool compresses will help on the area. Blisters are a sign of a 2nd degree sunburn and raw dermis is underneath the blister.  Avoid popping blisters or rubbing the skin. Aloe based lotions can cool the skin and help healing.  Aspirin or anti-inflammatory medications and drinking lots of fluid will help with pain. 

 A sunburn  will heal in about a week but the damage to the epidermis lasts a lifetime.   This slideshow shows the damage to the skin from sun exposure.

Monday, June 13, 2011

Vitamin D Improves COPD

I am frequently extolling the health benefits of Vitamin D because almost weekly there is a new study that correlates high vitamin D levels with reducing some disease.  The latest is from the American Journal of Respiratory and Critical Care Medicine and research shows that high doses of vitamin D supplementation improved respiratory muscle strength in patients with Chronic Obstructive Pulmonary Disease (COPD).  The patients that did not receive supplemental vitamin D had blood levels of 22.8 compared to 53.8 in the supplemented group.  The patients who were supplemented had improved respiratory function, strength and less shortness of breath.  It certainly didn't cure or reverse COPD but the improvement was an encouraging trend in this terrible chronic disease.

In reading about this it got me thinking about COPD and the fact that it is one of the most common reasons for hospitalization and disability in the United States. It is a progressive disease that affects the alveoli (small air sacs that exchange oxygen) and small bronchioles of the lungs.  These airways and air sacs lose their elastic quality and become thick and inflamed.  Mucus forms and patients become progressively short of breath and eventually need supplemental oxygen just to breathe.  COPD is the fourth leading cause of death in the United States.

Did you know that most COPD is caused by smoking?   It isn't contagious.   There is no cure and it ends in death.  People always think of lung cancer and smoking but COPD is often even a worse outcome and it is preventable.

If you smoke and have a cough in the morning when you wake up- you are already exhibiting signs of chronic bronchitis or early COPD.  I tell patients it is like having an immune deficiency of the lungs.  You get more colds and flu and pneumonia.  Smoking is the culprit and even second hand smoke can be damaging to the lungs.

All the Vitamin D in the world will not reverse the effects of cigarettes.

Wednesday, June 8, 2011

Octomom's Doctor is Placed on Probation

Remember the media blitz over Nadya Suleman, the Southern California mother who underwent IVF and gave birth to eight babies?   The unemployed, single mother of 6 was only the second ever to give birth to a full set of octuplets.   Now, two years after the sensational births, the California State Medical Board has revoked the license of Beverly Hills fertility doctor, Michael Kamrava.  However the board then stayed the revocation and placed him on probation for 5 years in California.   The Board's report stated he committed gross negligence by making "an excessive number of embryo transfers" into Nadya Suleman.

Along with Suleman, Dr. Kamrava was charged with gross negligence in the treatment of two other female patients; a 48-year-old who suffered complications after she became pregnant with quadruplets and a 42 year old with advanced ovarian cancer after receiving fertility treatments.

In his defense, Dr. Kamrava's attorney said that Suleman failed to follow through in terminating an excessive number of fetuses.  This argument was soundly rejected by the board.  The board also rejected the argument that publicity surrounding Suleman's case would serve as a deterrent to Dr. Kamrava in the future.  "The board is not persuaded that relying on the public or the media to fulfill or supplement the board's public protection role is sound policy." 

The Medical Board document is quite amazing.  Nadya Suleman underwent a total of 14 stimulation cycles that resulted in 4 single births, one set of twins and finally Octuplets when Dr. Kamrava implanted 12 embryos, utilizing a direct mechanical insertion procedure that he developed.  He did not consider referring her to a mental health professional, despite her odd pregnancy-seeking behavior that included a desire for 10 children, her request for twins, her stockpiling of 29 frozen embryos  and a request to use a surrogate.

So what does it mean to have the license revocation stayed and to be placed on probation?  First he has to enroll in an ethics course within one year.  He needs to have a licensed physician "practice monitor" who is not in a business relationship with him.  This monitor has access to all of his records and needs to submit a quarterly report to the Board indicating if Kamrava's practices are within the standards of safe medicine.  If the monitor resigns, a new replacement monitor must be found.

In lieu of a monitor, Dr. Kamrava may participate in a professional enhancement program that includes quarterly chart review, semi-annual practice assessment and semi-annual review of professional growth and education.  He cannot supervise physician assistants during the probation.  He can't practice medicine in his home (? does anyone do that anymore?).   If he stops practice, he needs to notify the Board within 30 days and if he practices in another state he needs to notify also.

Dr. Kamrava holds medical licenses in Ohio, California and Massachusetts.

In the meantime, Nadya Suleman soldiers on as a single mom with 14 kids.  I think the Board should have demanded babysitting time from Dr. Kamrava.

Tuesday, June 7, 2011

The Placebo Effect is Strong Medicine

Thanks to Kevin MD , (via Lukas Zinnagl, MD) for pointing me to this fascinating video on the Placebo Effect.  What is amazing is that placebos work even when the patient knows it is a placebo!  That is the power of the mind.  Check it out an be amazed!

Saturday, June 4, 2011

Should Doctors Wear White Coats?

The Doctor's white coat has been a symbol of the profession for decades.  In the 1800's and up through the early 20th Century, doctors wore street clothes while performing surgery...rolling up their sleeves and plunging dirty hands into patient's bodies.  They often were dressed in formal black, like the clergy to reflect the solemn nature of their role.  (And seeing a doctor was solemn indeed as it often led to death)

A 1989 photograph from the Mass General Hospital shows surgeons in short sleeved white coats over their street clothes and in the early 20th Century the concept of cleanliness and antisepsis was starting to take hold in American medicine.  Both doctors and nurses started donning white garb as a symbol of purity.  The white coat took on more and more symbolic meaning and the "White Coat Ceremony", where medical students are allowed to don the formal long white coat,  has even been a right of passage with graduation from Medical School.

For the past few years, the American Medical Association and other medical societies have debated if it is time for the white coat to be retired.  A study of New York City doctors in 2004 showed their ties were a source of infectious microorganisms.  The NIH in Britain barred ties, lab coats, jewelry on the hands and wrists and long fingernails because of infection.  Researchers from Virginia Commonwealth University showed bacteria from a white cotton lab coat can cause infection just minutes after touching skin.  Another study reported that the majority of medical personnel change their lab coats less than once a week.

At this time there are no recommendations for doctors regarding wearing lab coats.  I've not seen a good comparative study on the hazards (or benefits) of wearing the white coat.  Are street clothes any more sanitary?  Isn't the real issue hand washing and good hygiene from caregivers?

A number of surveys of patients show they "overwhelmingly" prefer their physicians to wear white coats.  Patients seem to have more trust in and comfort with physicians who wear the coat.  For many patients it is still a symbol of professionalism and good care and it helps them identify the physician.

I must admit I like my white coat.  It has pockets that are filled with my needed paraphernalia and tools.  It protects my clothes and when I don it, I take on a professional personae...I'm no longer a wife, mother, insecure female,  or worried about (fill in the blank)...I am a doctor.  It helps me shift into a professional role with focus and clarity.  I know it is psychologic,  but for me it works.

So what do you think?  Do you like your doctor in a white coat?  Would you prefer regular street clothes?  Physicians, do you still wear the white coat?

Heart Disease and Heart Attacks

This amazing site called Kahn Academy is just filled with information on every subject!  This video explains atherosclerosis, heart attack and heart failure.  Watch and learn.

Thursday, June 2, 2011

Why You Need a Colonoscopy

One of my pet peeves as a Physician is when people talk about screening tests "Preventing Cancer".  Mammograms, pap tests, prostate tests (PSA), X-rays, blood tests, ultrasounds do not prevent cancer.  The best they can do is detect an abnormality early and allow for treatment.  None of those tests prevent a malignancy.  There is one screening test, however, that CAN prevent cancer and that is a Colonoscopy.  This is because of the natural history of colon cancer.

Colon cancer starts with small benign growths called polyps that progress through several stages of cellular change and transform from normal tissue into adenocarcinoma.  This is usually a slow process that takes  years to occur.  Certain genetic factors are at play and not all polyps develop into cancer.  But identifying and removing polyps that are found at a screening colonoscopy prevents colon cancer.

Isn't that amazing?

If there is no family history of colon cancer, it is recommended that a screening colonoscopy begin at age 50.    If there are no polyps seen, the USMSTF guidelines recommend the next colonoscopy is 10 years later.

If a polyp is identified and removed, the follow-up colonoscopy depends upon the histologic type of polyp.  A small adenomatous polyp is re-screened in 5 years.  A  tubulovillous adenoma  should have a repeat procedure in 3 years. A hyperplastic polyp should be re-screened in 10 years because the risk of developing cancer is very low.  Despite these clear guidelines, many doctors recommend shorter intervals which results in significant expense and unnecessary discomfort and risk for the patient.

Colonoscopy is the only screening test I know of that can prevent cancer.  It is fairly simple, does not need to be done often and  if everyone over the age of 50 had screening,  it has been estimated that between 60-90% of deaths from colon cancer could be prevented (that’s potentially 30,000-45,000 lives saved) .  

If you are over 50 and have not had a colonoscopy...just do it!

(Hat tip to my blog buddy at Abnormal Facies for the great image and  information)

Wednesday, June 1, 2011

Facial Cellulitis

This 39 yer old woman had a small sore inside her nostril.  It worsened  and her nose started getting red so she was put on ciprofloxacin antibiotic.  The redness improved but 5 days into treatment two pustules developed and the erythema worsened.  A culture of one of the pustules grew out methicillin-resistant Staphylococcus aureus (MRSA).  She was treated with intravenous antibiotics and her infection cleared up.

Cellulitis means an infection of the dermis and subcutaneous tissue and it can be caused by a number of pathogens.  The usual culprits are Strep and Staph that enter through a break in the skin.   MRSA is a "superbug" Staph infection that is resistant to the usual antibiotics that work for Staph.  Infections on the face are of great concern because they can spread to other important structures and even the brain.

Here is another photo of severe cellulitis on a patient's leg.

(Case from ConsultantLive)

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...