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Showing posts from June, 2011

Doctors Adapting and Trying to Survive

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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 coup…

Tennis at San Quentin

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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 ca…

Rob a Bank to Get Health Care

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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 committe…

Pterygium

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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)

Stop Unnecessary Medicare Tests

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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 absolute…

No Advantage for Screening Ovarian Cancer

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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 screeni…

Sunburned Feet

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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.

Sunburn

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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.  Choo…

Vitamin D Improves COPD

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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 (smal…

Octomom's Doctor is Placed on Probation

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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 throug…

The Placebo Effect is Strong Medicine

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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!

Should Doctors Wear White Coats?

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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…

Heart Disease and Heart Attacks

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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.

Why You Need a Colonoscopy

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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 colon…

Facial Cellulitis

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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)