Saturday, December 31, 2011

Seven Tips for Healthy 2012 Planning

As we welcome a new year it is an opportunity to re-evaluate, consider the coming year and make intentions for improving our health and sense of well being.  EverythingHealth sifts through the latest medical literature and evidence to offer these proven recommendations for staying on top of your game.
  • If you are 50 or older and haven't had a colonoscopy, schedule one in 2012.  It's time! 
  • Go online and check your Body Mass Index (BMI).  If you are too high, plan and execute on that diet.  (contact me for a diet coach referral if needed)
  • Get rid of sugar and soft drinks.  Stevia is a natural sweetener that is safe and yummy.  The average American eats 160 lbs of sugar a year. Break the sugar habit in 2012
  • Stop smoking. For motivation go here.
  • Relax your mind.  Start yoga, meditative dance, meditation.  These practices have been shown to lower blood pressure and general stress.
  • Send one thank you note a week.  That is 52 notes in 2012.  You can send it to your child, co-worker, grocer, doctor, spouse or even an acquaintance.  The act of thanking and reaching out to others is healing for both sides.
  • Become an activist.  Find one cause that you feel passionate about and get fully involved. Here are some to consider,  but there are hundreds of other great organizations and it has to be your own interest.
                                                            (micro loans to people around the world)
          Women for Women International.    (adopt a sister in a war torn nation.  Many of these women  have suffered atrocities, have no money and support many children.  If you help the women, you raise the standard for the whole community)
         U.S Humane Society  (They do wonderful work to protect animals, expose inhumane and unhealthy farming and promote legislation to make humans and animals safer)
         Foster Children -  (You don't need to adopt,  but you can get involved in a number of organizations that help these kids transition out of foster care into adulthood.  When they reach 18 the system is "done" with them.  Can you imagine your own 18 year old making it alone?  Check in your own community for programs and mentorships.)
Happy New Year to all of my readers!!!!

Friday, December 30, 2011

Top EverythingHealth Books of 2011

We at EverythingHealth love end of the year lists and we love reading.  Here is our pick for the best read Health (and everything)  books in 2011.  (not in order...all are terrific)
  • The Immortal Life of Henrietta Lacks, by Rebecca Skloot
  • Cutting For Stone,  by Abraham Verghese
  • Outliers,  by Malcolm Gladwell
  • The Help,  by Katheryn Stockett
  • The Checklist Manifesto,  by Atul Gawande
  • Middlesex,  by Jeffrey Eugenides
  • The Known World,  by Edward P. Jones
  • Complications,  by Atul Gawande
  • The Curious Incident of the Dog in the Night-Time,  by Mark Haddon
  • A Short History of Nearly Everything,   by Bill Bryson
If you have other favorites, let us all know.

Answer to Medical Challenge

The answer to the CT scan image medical challenge is #3, Intercostal Muscle Rupture.

The image shows subcutaneous emphysema and an intercostal muscle defect between the ribs.  the patient recovered after repair of the intercostal hernia.  Subcutaneous emphysema is air under the surface of the skin. 

It is not unusual for these muscles between the ribcage to be strained or even get small tears with sports, extreme coughing or trauma.  It is very unusual for the tear to be this extreme and affect the pleura around the lung and the lung itself.

Thanks for your diagnoses.

Wednesday, December 28, 2011

Medical Challenge

For my non medical readers, this is an abnormal CT scan.  The CT scan takes a transverse image sliced through, so you are looking at the patient sliced in half transversely.  This is the chest area. I will orient you:

The whitish circle and v-shaped part is the vertebral column.  So you know that is the back.   Bone shows up whiter than organs.  The small whitish lines in a circle are the ribcage (more bone) sliced through.  Air shows up dark so the big dark areas are the lungs.  Notice there is darkness streaking on one side and not the other.  As my 16 year old would say: "That is messed up".  What ruptured to allow air to penetrate the muscle area? (click on the image for a better view)

1.  The diaphragm
2.  The esophagus
3.  An intercostal muscle
4.  The interventricular septum
5.  The pericardium

Medical professionals and others:  Make your diagnosis.  The answer will be posted tomorrow.

High Ratings for Personal Physicians

It's time for some good news!   A study that looked at online patient ratings  about their physicians from 2004 through 2010 showed that the average physician rating was 9.3 out of 10.  That is amazingly high and shows that patients (at least the ones who posted on Dr.Score) are very content with the care they receive from their doctor.  Even though some patients will post a nasty comment about the doctor, the overall patient satisfaction is high.  Seventy percent of doctors earned a perfect 10.

The survey asked patients to rate physicians on attitude, the thoroughness of the visit,  how well the doctor communicated and how long they sat in the waiting room.  It is not a surprise that the longer patients waited, the lower was the rating.  Forty two % of doctors were primary care physicians and the remainder were specialists outside of primary care.

Patient satisfaction is finally getting attention in medicine.  More than 60% of health care organizations are using patient satisfaction scores to determine physician incentive payments and large medical groups measure satisfaction and give the doctor feedback on a regular basis.  Medicare will also link patient satisfaction with hospital payments and hospitals who do not rate high will lose revenue. 

We read a lot about the problems in health care in the United States but those issues are usually concerned with cost and access.  In fact a November Gallup poll found that 82% of adults say the quality of health care they receive is "good" or "excellent".  A 2010 study by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems found that 94% of nearly 42,000 patients rated their physicians a seven or higher on a 10-point scale.  (that group needs a new name)

Another study I read shows that 90% of physicians feel stressed nearly every day.  It is good news that that stress is not being felt by the patients and that we are delivering the patient-centered care that we pledged when we took our oath.

Monday, December 26, 2011

Holiday Dinner from the Boss

Marney is bossy.  Click to read her instructions for the Thanksgiving Potluck and be glad you aren't invited.

EverythingHealth tip:  Stay out of the stores today.  Rest, play games with the kids, Take a long walk in nature with the entire family and the dog and then drink the rest of the Christmas wine.

Saturday, December 24, 2011

Happy Holidays EverythingHealth

I get a lot of pleasure out of being a health blogger and it is only possible because of you, the reader.  Thank you for visiting EverythingHealth and allowing me to keep my mind sharp by researching articles and healthy living for you to read and enjoy.

Merry Christmas, Happy Hanukkah, Happy Holidays, and may we all have a wonderful 2012, no matter where we live on Earth. 

Wednesday, December 21, 2011

Kwashiorkor in Northern California Means Fraud

Kwashiorkor in Niger
Is it plausible that one small hospital in rural Northern California treated 1,030 cases of Kwashiorkor within a two year period?

Before you answer that, let me explain what Kwashiorkor is.  It is a severe form of protein malnutrition...starving to death actually.  It is the type of starvation you see in African children.  It is so severe that the patient needs special nutritional support including special re-feeding with vitamins and it occurs mainly in children ages 1-4.   Adults can starve to death, but they do not develop classic Kwashiorkor.

Medicare pays hospitals a flat rate based on diagnosis codes for patients.  Patients with more severe coded illnesses get paid at a much higher rate.  Shasta Regional Medical Center, located in Redding, Shasta County, California is under the microscope for billing Medicare (our tax dollars at work) for 1,030 cases of Kwashiorkor to the tune of $11,463 for each diagnosis.  This medical center is a 246 bed facility in a town of about 90,000 people.  The entire county is less than 200,000 population.  The median home price in 2010 was $245,000 and the average household income is $62,222.  Hardly the demographics for Kwashiorkor.

Patient described as kwashiorkor
Prime Healthcare Services owns 14 California hospitals, including the one in Redding.  After they took over the hospital in 2008, the diagnosis of Kwashiorkor exploded.  One of the patients that they billed Medicare for was interviewed and she said she was never malnourished and was never told she had Kwashiorkor.  She had diabetes and kidney failure and, according to her daughter, was actually overweight. There was no notation in her chart about edema swelling or nutritional consult.  She received no vitamins. 

A former medical coder at another Prime Healthcare Hospital told California Watch that she was pressured to write up patients for kwashiorkor if they had low albumin levels and were diagnosed for ordinary malnutrition.  Low albumin is very common in hospitalized patients and it can accompany a number of medical illnesses.  Coding these as kwashiorkor is fraud, plain and simple.

Most hospitals across the Country are doing their best to take care of patients and function with the byzantine regulations of Medicare and hundreds of insurance companies.  The majority of hospitals lose money on Medicare patients.   Flagrant abuse in billing, such as is suspected at Shasta Regional Medical Center, gets no sympathy from me.  I hope the CEO ends up in stripes and that all of the Prime Healthcare Hospitals are closely investigated.

Monday, December 19, 2011

Strange Compulsion

Pica is a medical term that refers to people who eat substances that are not nutritious like clay, dirt, paper or starch.  Lithophagia is the eating of rocks or pebbles.  The Xray above is from a 48 year old homeless man who came to the emergency department with abdominal pain, constipation and intermittent blood in his stool for 2 weeks.  The abdominal Xray showed small radio-opaque pebbles and gravel that the patient admitted eating over the last 9 months.  He believed that "God might turn it to bread in his belly."  He was given the diagnosis of nonspecific delusional disorder.

The patient underwent a purge with polyethelene glycol electrolyte solution.  (It is the same solution that is used for bowel prep before a colonoscopy).  Some of the pebbles had to be manually removed under general anesthesia.  His symptoms improved and follow-up Xray showed compete removal of the stones.  Unfortunately the patient was lost to follow-up after discharge from the hospital.

Geophagia is the eating of clay or dirt and it is not uncommon in the setting of famine and poverty.  There have only been 2 cases of lithophagia reported in the medical literature.

(Case from University of Wisconsin School of Medicine and Public Health, ConsultantLive)

Wednesday, December 14, 2011


Severe osteoarthritis of the hands
One of my patients came to see me today with severe right knee pain.  This is not a new problem, and in fact, we have been dealing with flare ups of  her osteoarthritis for years.  It mainly affects her knees and hands and today her right knee was swollen and felt like the "bone was rubbing together" with each step. She could hardly walk because of the pain.

Osteoarthritis is also known as degenerative arthritis and it is one of the most common maladies of aging joints, affecting millions of people.  The cartilage in joints wears down and inflammation causes the bones to build up spurs and small micro tears.  It affects women more than men and  the cause is unknown.  There are likely genetic factors as it tends to run in families.  Arthritis can occur in any joint but the most common are the fingers, wrists, hips, neck and spine and knees.  Stiffness (especially in the morning) and pain are the main symptoms that limit mobility.

You can see the bony changes that have occurred over time in my patient's hands. (click on the photo for a better view)  Note the swelling at the wrists and the way the thumbs angle inward.  She cannot stretch those thumbs out and there is wasting of the intrinsic muscles in her hands.  Surprisingly, she was not experiencing any pain in her hands or wrists today, although in the past it has been a problem.  Today it was the knee.

Because arthritis is chronic and affects millions of people, there are many purported "cures" and treatments.  Many of them are a big waste of money.  Here is what has worked for many patients:
  • Stay active and keep weight down.  Work on flexibility and range of motion.  For severe arthritis pain, aquatic exercise helps without causing more pain.
  • Yoga
  • Heat on the painful area alternating with ice as anti-inflammatory.
  • There is no proof for the "anti-inflammatory" diet, but eliminating sugar, glycemic white flour and processed foods increases energy levels and helps with weight control.  If you aren't exercising you probably need very few calories and they should be mainly fruits, vegies, grains and protein.
  • Trial of gluten free diet
  • Pain relievers like Nsaids, tylenol and aspirin can help
  • The evidence is still not clear for glucosamine or other supplements.
  • Cortisone injections
  • Hot tubs/hot baths
  • Joint replacement
A cortisone shot will hopefully help this patient and quite down the flare up in the knee.  Osteoarthritis is truly a pain and it requires a lot of attention.

Tuesday, December 13, 2011

Affordable Health Care Act Provides Senior Benefits

While the courts and politicians wrangle about the Affordable Care Act (ACA, "Obamacare"), some of the benefits have kicked in for Medicare beneficiaries.  The Act empowered the Center for Medicare and Medicaid Services (CMS) to eliminate co-payments for a number of preventative services and to cover services that were not included before.  Patients on Medicare now receive:
  • Bone mass measurements
  • Cervical Cancer Screening
  • Cholesterol and other cardiovascular screening
  • Colorectal cancer screening
  • Diabetes screening
  • HIV tests
  • Annual influenza, pneumococcal and Hep B vaccines
  • Mammograms
  • Medical Nutrition therapy
  • Prostate Cancer screening.
Previously Medicare did not cover screening tests or required co-pays.

It's not just seniors who have benefited from ACA.  It also allows young adults to stay on their parents' health plan until age 26 years.  These young adults do not need to live with their parents or be listed as a dependent on the tax return to be eligible.  This alone allows 1.2 million more Americans to be covered by insurance.

Unfortunately people with conditions such as diabetes who cannot find affordable health insurance will have to wait until 2014, when it will be unlawful for insurance companies to discriminate against preexisting conditions.  For now there is a temporary program to act as a bridge for patients until 2014.  There is a preexisting Condition Insurance Plan (PCIP) that can provide insurance for someone who has been uninsured for at least 6 months, has a preexisting condition or has been denied health coverage because of a condition.  For an estimated premium range for a given state, go to

Americans should be embracing health care reform and demanding their legislators come together to understand the complicated law and change it if needed and strengthen it to make it better.  We understand that it does nothing to address runaway costs, although there are many provisions to educate and reinforce healthier diets and lifestyle.  The plan is complicated and includes provisions that few legislators have taken the time to understand.  In the meantime, health plans across the U.S. are posting record profits and raising rates up to 60% a year.  There is nothing that has occurred in the ACA that can be blamed for this. 

As I have said before.  Why do Health Insurance Companies raise rates?  Because they can... and Wall Street rewards them handsomely for doing so.  They are only doing what we have asked them to do. 

Saturday, December 10, 2011

Women Don't Need As Many Pap Tests

Women have been told they should have screening for cervical cancer with a pap test every year.  The visit to the gynecologist or internal medicine physician has been a right of passage for most young women and most are very compliant with that annual visit throughout their lives.

Well, the times they are a-changin' because new guidelines issued by the US Preventative Services Task Force and the American Cancer Society say women should undergo screening NO MORE OFTEN than every 3 years starting at age 21.  To further strengthen this recommendation, even the American Society for Clinical Pathology (those folks that read the pap smears) agrees with the recommendation.  They also recommending stopping routine pap smears after age 65 for women who have had 3 negative Pap test results in the past 10 years.  These women are just not at high risk.

So why the change?

The pap smear is a screening test for cervical cancer.  Evidence shows that more frequent screening than every 3 years doesn't find more cancer and we now know that cervical cancer is the result of infection with Human papillomaviruses (HPVs).  Women that have not been exposed to HPV are not at risk of cervical cancer.  Furthermore, out of 150 related viruses, of which 40 are sexually transmitted, only certain ones are high-risk, oncogenic (or carcinogenic) HPVs.    Persistent infections with these high-risk HPV types can cause cell abnormalities that are picked up on pap tests.  But the majority of infections with even high-risk HPV types go away on their own and do not cause cancer.  Two types of HPV (types 16 and 18) cause 70% of all cervical cancers and they are very slow growing.

When a pap test detects cervical cell changes, an HPV DNA test is usually done.  If the HPV test is negative, a women is safe from cervical cancer for many years.    Even if a pap test shows equivocal changes, if the HPV test is negative, it is recommended she be re-tested in 3 years.

Despite these recommendations, annual testing remains a common practice in most gynecology offices.  Even in women who have been tested for HPV and found negative, less than 15% of physicians recommended that patients wait 3 years before repeat testing.  Women are still being told to come back annually.


Some doctors may not know about the guidelines, even though they are also supported by the American College of Obstetricians and Gynecologists.  Doctors as well as patients are in the habit of "the annual pap test".  Doctors are also concerned that if they don't recommend pap smears, women will not come in for an annual exam and other preventive screening.   But doing unnecessary testing is not a way to have women come in.

For most women this will be a welcome change.  Stretching out those gynecologic screening exams will save time, money, false positive tests and unneeded follow-up.   Keep in mind this only refers to non-symptom screening.  Women who have any gynecologic symptoms (unusual bleeding, discharge, pain, pressure) or any other  concern or questions should see their physician.

Friday, December 9, 2011


Let's see how much you know about fingernails?  The arrow points to what part of the fingernail?
1.  Lunula
2.  Eponychium
3.  Cuticle
4.  Nail groove
5.  Proximal nailfold

If you answered #1, you would be correct.  The lunula is most noticeable on the thumb.

Did you know that nails on your dominant hand grow faster than nails on the nondominant hand?  As you age, nails are usually thicker and they grow more slowly.  A six month old will grow a new fingernail in 3 months.  A 70 year old will take twice as long.

Toenails take 12-18 months to regrow.

Photo and info credit to Medscape

Thursday, December 8, 2011

Unhealthy Food at Childrens Hospitals

A study published in the journal Academic Pediatrics reveals that 93% of California children's hospitals offered unhealthy food to outpatients, visitors and staff in the cafeteria and snack bars.  Said another way, only 7% offered healthy food.  What did these foods consist of to be called "unhealthy"?  Try fried food, sweetened beverages, burgers and lots of sugary sweets.

The study found that 81% of the cafeterias placed high-calorie, high-sugar items like ice cream right by the cash register, a well known marketing plan to tantalize and increase selection.  Forty four percent didn't even offer low calorie salad dressing and fewer than 1/3 had no nutrition information.

Health care workers, like the rest of America, suffer from increasing obesity.  One study showed over 54% of nurses are overweight and both stress and shift work can contribute to unhealthy eating and weight gain.  If the cafeteria offers high calorie food, it is no surprise that obesity will prevail.  The study didn't mention it, but I wonder how many of these hospitals use contracted food vendors.  Sugar, fat and empty carbohydrates are, unfortunately, cheaper than fresh, nutritious food.  We have seen the results of this in cafeteria school programs across the United States.

This study should wake up hospital administrators and they should choose only vendors that care about and supply healthy food.  If you work at a hospital...check out your own cafeteria and speak up if changes need to be made.

Tuesday, December 6, 2011

Don Berwick Says Medicare is Wasteful

I was thrilled when Dr. Don Berwick took over as head of the Center for Medicare and Medicaid Services (CMS).  It was a politically charged appointment and the GOP wasn't standing for his type of medicine.  He would have never been confirmed and now he is saying goodbye to Washington.  Dr. Berwick admits Government is more complex than he realized and said "Government decisions result from the interactions of many internal stakeholders-different agencies and parts of government that, in many cases, have their own world views."  Ya think?

He also said the GOP criticism of him and his policies was "purely political, a world of sound bites" and that they "completely distorted his meaning."

Berwick reflected on his 17 months in office and said these are the ways we waste money in healthcare:
1.  Over treatment of patients
2.  Failure to coordinate care
3.  Complex administrative restrictions on the health care system
4.  Burdensome rules; and
5.  Fraud

I would say 9/10 physicians queried would agree 100% with this assessment.  As Berwick says, "Much is done that does not help patients at all, and many physicians know it."  The problem is that patients don't know what is helpful and what is wasteful.  They depend upon our judgment and ethical decision making to know. 

Items 3 and 4 regarding the complexity and burdensome rules placed on caregivers is also true.  The complexity of treating patients is enough without jumping through government and insurance hoops that add no benefit to anyone.  Despite the restrictions, Fraud is rampant and more rules and regulations will not stop it.  Simplify the system and it will be easier to detect fraud.

We truly do need health care reform, not just health insurance reform.  Obama is headed in the right direction by insisting we have 100% coverage for all opt out of the system.  Can we at least agree on that and work together to improve health care for everyone?

Ciao, Dr. Berwick.  Thanks for trying.

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...