Monday, December 31, 2012

Remembering 2012 - Top Ten Health

 As 2012 draws to an end,  EverythingHealth will reflect on our top 10 health and medicine events to remember.  

1.  The world did not end on December 21 as predicted by the Mayan Calendar,  but a new Age of    Enlightenment may just be beginning!!!   "Be the change"

2.   The Supreme Court upheld the Affordable Care Act ( ObamaCare) and President Obama was re-elected to carry out the most significant health care legislation since the creation of Medicare.

3.   As of this writing the United States "fiscal cliff" has not been averted and an automatic 26.5% cut in Medicare pay for physicians is part of that cliff.  Not good for seniors!

4.   Deaths from fungal meningitis and joint infections continue to be announced as the result of contaminated injectible products from the New England Compounding Center.  More stringent regulations and authority to the FDA will likely result.

5.   Nine Medical Societies published a compendium of 45 clinical tests and procedures that are not rooted in evidence-based medicine, greatly drive up costs and bring no value to patients.

6.   The US Preventive Services Task Force recommended against PSA prostate cancer testing in healthy men, regardless of age.

7.   A soda a day was found to raise cardiovascular heart disease risk by 20%

8.   Researchers found breast tumors fell into four major subtypes. The knowledge could translate into changes in the way doctors treat breast cancer for different patients.

9.   Scientists discovered that "insignificant" portions of DNA are really the metabolic switches that regulate how and when genes function and when they manufacture certain proteins.  Future discoveries may allow us to control or even cure diseases by focusing on these portions of the human genome.

10.  New dialog about gun violence and gun safety is beginning, sadly because of the deadly shootings that are ravaging our society.  Various medical societies are joining with The American Academy of Pediatricians and urging physicians to be strong leaders in gun reform.

Happy New Year to all my faithful readers across the globe and new readers to EverythingHealth.  May 2013 be magical for all of you!

Hillary Clinton and Subdural Hematoma

 Addendum to the post below:  New reports show she may have a venous blood clot in a vein that goes to the brain, rather than a bleed under the skull known as a subdural hematoma.  The treatment is quite different as venous thrombi (clots) are treated with blood thinners.  The information below is still quite accurate but may not apply to Madame Secretary Clinton.....



Secretary of State,  Hillary Clinton has been hospitalized with a subdural hematoma after fainting, hitting her head and suffering a concussion less than a month ago.  Here is a repeat of a blog I did a few years ago about "a bump on the head".

Even a minor blow to the head can lead to serious trouble. A close relative of mine is an active, sharp guy in his 80's. He was hospitalized a few weeks ago with an infection and like many older folks, he wasn't aware of how weak he was and he tried to get out of the hospital bed and go to the bathroom and "whoops", he slipped and fell. Hospitals all have procedures in place to prevent falls and they monitor the number of patient falls and try very hard to get to zero. But, try as they do ...falls happen. OK, he got a bump on the forehead and a bruised shoulder but, fortunately no broken bones.

Fast forward 4 weeks. One weekend Allen was slurring his words and not walking well. You would think they would rush to the hospital to get things checked out, but they decided to wait and see if he was better the next day. This is a HUGE mistake. In a prior post I wrote about stroke and the need to seek immediate attention for any change in speech or one sided weakness. I am always surprised at how many patients do not seek medical help and instead wait to see if things will improve on their own. Ten out of ten times, symptoms like this do not improve.

Allen and his wife finally went to their doctor and he was immediately admitted to the hospital. A computed tomography (CT) scan revealed a large hematoma on his brain. The fall that occurred several weeks earlier had caused bleeding around the brain. Blood vessels can be damaged when the skull receives a blow, especially when the head hits a hard surface like the pavement. A hematoma is caused by a bleeding vessel and a subdural hematoma occurs when blood collects in the small space between the brain and the skull. The blood clot presses against the brain and the resulting pressure can severely damage the brain unless a neurosurgeon removes the blood. Fortunately, blood and blood clots are easy to detect with a CT scan.

After the subdural hematoma was diagnosed, Allen was rushed to surgery and the blood clot was removed. He has a large "s" shaped scar where the skull was removed (and replaced) and he is now home and doing great. His speech is back to normal and he continues to improve each day. Without surgery, Allen would not have made it. It is always nice when a story has a happy ending.

There are several take home messages here:
1. Any sudden change in speech or weakness or trouble walking needs immediate attention at the Emergency Department of the closest hospital.

2. Any fall that causes facial bruising or loss of consciousness needs evaluation.

3. Any time the head smacks against a hard surface, there is a chance of brain trauma because the brain can strike the inside of the skull.

4. Symptoms can show up weeks after trauma so don't ignore changes in personality or behavior, especially in older folks.

Sunday, December 30, 2012

Lactose Intolerance in the Genes

National Public Radio (NPR) reported on a fascinating theory of Mark Thomas, an evolutionary geneticist at University College London.  He points out that we human beings all started out being unable to digest milk's dominant sugar, lactose, after childhood.  In fact, most adult mammals do not drink milk.  But 20,000 years ago,  people of Northern and Central European descent and certain African and Middle Eastern populations began developing lactose tolerance.  He theorizes that there was a strong natural selective pressure to allow those lactose tolerant genes to survive.  Drinking milk was an advantage to our species.

According to Thomas, milk was a "superfood" to early man.  It contains protein, calcium, fat and carbohydrates.  The ability to digest milk without developing diarrhea would give it's drinker an evolutionary edge.  The people who had the lactase mutation genes would survive the harsh winters, famines and even other illnesses that caused early death.  Those genes would survive and be passed on to further generations and create more lactose tolerant milk drinkers.  Other scientists have speculated that fresh milk provided a more pure fluid alternative as water was often contaminated or difficult to find in arid climates.   Milk  may have also given people a fertility advantage.  We know that women need a certain amount of body fat to produce children so the lactose tolerant women may have produced more offspring.

I was surprised to learn that only about 35% of the adult population worldwide can drink milk without a problem.  East Asians and Indigenous North Americans may be 80-100% lactose intolerant yet the Brits in the UK run a rate of  only 5-15%.  

Lactose intolerance is not an allergy, but is caused by lack of the  enzyme, lactase.  There are a number of genes that contribute to lactase and the ability to break down the milk lactose into glucose and galactose. 

 People with lactose intolerance frequently get symptoms of nausea, cramping, bloating, diarrhea and gas about 30 minutes to 2 hours after drinking milk.  But the symptoms can vary and some individuals can drink small quantities of milk or other dairy products without a problem.   The intolerance can also change during pregnancy. Lactose intolerance may be the culprit in many instances of "Irritable Bowel Syndrome".

If you don't have the lactase gene (and are lactose intolerant), you can still use lactaid free milk in baking and eating.  Three lactose free milks tested by ConsumerLab - Lactaid Fat Free Milk, Land O' Lakes Dairy Ease Fat Free Milk and Organic Valley Lactose Free Organic Fat Free Milk all tested as having no lactose.

For ice-cream lovers, Breyers makes a lactose free ice-cream as does Turtle Mountain and Lactaid.

Sunday, December 23, 2012

Happy Healthy Holidays

I Wish That I Could Wrap Up Christmas

I wish that I could wrap up all the love and Holiday cheer
That comes along with Christmas and with New Year's every year,
Pack it in a pretty box and put it on my shelf
And pull it down again each year and give it to myself.
I wish that I could tie up all my favorite carols with twine,
Wind around some ribbon, too, and for twelve months call them mine
Until the next Yuletide came when the sounds again could be unfurled
And untie every single one then give them to the world.

Monday, December 17, 2012

Medical Fraud - Lock 'em Up

When most Doctors and care-givers are trying to deliver "value" and keep costs down, it really chaps my hide to read about Medicare Fraud.  Here is the latest:

Dr. Michael Reinstein, psychiatrist in Chicago,  submitted at least 50,000 claims to Medicare and Medicaid, falsely stating that he provided "pharmacologic management" for patients at more than 30 area nursing homes and long-term facilities.  If that weren't enough, he also accepted kickbacks from Novartis, IVAX and Teva Pharmaceutical companies to medicate elderly patients with serious anti-psychotic medication.

The kickbacks go back as far as the 1990's and Dr. Reinstein had more than 1000 patients at a time on a rarely used medication called Clozaril.  Clozaril is typically used only as a last resort in treatment-resistant psychotic patients and is of particular risk to the elderly.  It is extremely rare to have a nursing home patient on Clozaril.   Reinstein was the largest prescriber of Clozaril to Medicaid recipients in the United States and at one nursing home 75% of the residents were on Clozaril.  It should only be used for severely schizophrenic patients that have failed other treatment,  yet in 2000 and 2001 Dr. Reinstein prescribed more Clozaril than the next 9 top prescribing physicians in the United States combined.

Even after the Novartis patent for Clozaril expired in 1998, Dr. Reinstein, who was still receiving payments, kept hundreds of patients on the brand name drug and refused to switch to the generic form.  He only switched to the generic clozapine when Novartis stopped making the drug and he struck a new kickback deal with IVAX Corp, maker of a generic clozapine.  He then became the largest prescriber in the country for the generic form.

Dr. Reinsten's kickbacks included cash, trips for himself and his entourage, support of his pharmacy owner wife, support of his assistant, research support, boat cruises and tickets to sporting events.  He also received annual speaker fees for promoting the drug to others.

There are so many things wrong with this case that go beyond fraud and greed.  This is a dangerous drug and by 2009 allegedly 3 of his patients died of clozapine intoxication. One 50 year old man had 5 times the toxic level of clozapine in his blood when he died.

But there are no criminal charges here, simply civil penalties. It is unknown if the pharmaceutical companies involved will face charges relating to anti-kick-back laws.  In my opinion, fines are not enough.  I think jail time is warranted.

If you want to read the full False Claims Act complaint from the Illinois Eastern Division Court go here.

Addendum:  I'm not an investigative reporter but if I had time I'd look into the illegal kick-backs from Astra Zenica Corp also.  It seems Reinstein was also the top prescriber of Seroquel and was paid over $490,000 in 2000-2001 for that honor.  Thanks to the internet it wasn't hard to find confidential communication between him and Astra Zenica.   Astra Zenica admits that Reinstein and his partner are not respected by their peers and that they do bad research on patients, but then said is a "win-win" to fund them.  The internal document says, if they don't give him the money, Reinstein will switch patients off Seroquel to a competitor.  They are an "important source of business" for Astra Zenica.

For more on Reinstein:
See Pro-publica here

 I feel so sorry for the patients.

Sunday, December 16, 2012

Health and Weapons

There have been eight mass shootings in the United States this year and at least 61 since 1982.  The Connecticut community of Newtown is grieving for it's 20 slain children and 6 adults.  The towns of Columbine, Tucson, Aurora, Oak Creek, Minneapolis and Clackamas, to name a few, are still  grieving for their lost children and adults to gun violence.  Now is the time to stop this craziness.

As president Obama said, "Surely we can do better than this."  This cannot be a political, Blue vs. Red, North vs. South, Right vs. Left issue.  It is every one's issue now.  As a nation we are not doing enough to keep our children safe.

The rifle used by Adam Lanza, the mass murderer in Connecticut and by James Holmes, who killed 12 people in a movie theater in Colorado in July and by Jacob Roberts who killed two people in a shopping mall last week,  was an AR-15 semi-automatic weapon. This means it can rapidly fire multiple high-velocity rounds.  These rifles, along with glock semiautomatic pistols (also found at the scene) are efficient killing machines and are completely legal to buy in gun shops and online.  The pistol costs less than $500 and you can buy both online and "add to your cart", oh so easily.  Sadly, the guns used by Lanza were legally owned by his gun enthusiast mother.  
The NRA attorney, Stephen Halbrook, argues that the number of people unlawfully killed with these semi-automatic weapons is "really quite small."  When you add in the violence in our poor neighborhoods with millions of these weapons in circulation, is is not a convincing argument.

The National Rifle Association (NRA) has 1.7 million Facebook fans. After the shooting in Connecticut, the NRA facebook page has gone dark and there has been no public statement.

Gun makers, sellers, ammunition companies, and gun accessories are big business and the NRA may care more about protecting the money flow than by protecting citizen rights to bear arms.   Our failure as a Nation to regulate (and outlaw) dangerous firearms is literally killing us.  Surely no-one needs a semi-automatic weapon for hunting or for self-defense.  There is no justification that would make any sense to a rational person.

Beware of the NRA coming forth after their moment of silence to defend these weapons by saying (as they did after the Denver movie theater massacre),   "The future of your Second Amendment rights will be at stake. And nothing less than the future of our country and our freedom will be at stake.”

This has nothing to do with freedom and everything to do with protecting law-abiding citizens. We have regulations that keep us safer in cars, safer with our food supply, safer with medical care and pharmaceuticals and even regulations for schools and pre-school.  Now we need regulations that keep us safer from gun violence.

We cannot prevent unbalanced people from existing but we can make it harder for them to massacre and then take their own life (as often happens).

 Now is the time for banning semi-automatic weapons and large rounds of ammunition.  Join EverythingHealth and make your voice heard.

Monday, December 10, 2012

RxTimer Cap

EverythingHealth get's PR pitches on a daily basis...companies and PR agencies wanting me to cover their latest product, book, speaker or start-up.  You can't buy your way into my endorsement but I have found something that I tried and I want to share it with you.  It is a new smart cap that fits on a regular prescription pill bottle and it is called RxTimer Cap:

I know how hard it is for patients to keep track of their medications and it is the number one cause of preventable medical harm.  Medications are prescribed "once a day", "twice daily", "every 8 hours", "AM and PM with meals or any number of confusing regimens.  Many patients are taking 10 or more prescription medications A DAY!  Of course it is confusing.  I take just one prescription pill a day and even I forget if I already took it or not.  That's where Timer Caps come in.

They come in various sizes and just become the new cap on any pharmacy pill bottle.  Each cap has a built-in LCD timer that works like a stopwatch and tells the patient how long it has been since they last took their medication.  Wonder if you took that noon pill?  Just look at the cap.

The battery in the cap is programed to last up to one year.  Although they recommend a new cap for each prescription, I have been using mine for 3 months and just putting it on the new month bottle.

I really like the RxTimer Cap and think it is a great innovation to help patients adhere to medications.
Check it out.  It might make a good Holiday present (along with some good Chocolate or Wine) for that friend or relative who takes lots of pills.

Saturday, December 8, 2012


Acquired Keratoderma
The answer to yesterdays image challenge is #2 - Keratoderma.  This scaly condition affects hands and feet and can be congenital (passed on by genes)  or acquired.  There is a yellowish thickening and scaling of the skin and deep fissures can occur.   There are a number of different types of inherited conditions that have keratoderma and they are difficult to treat.  

Hereditary Keratoderma
Acquired keratodermas can be caused by eczema, lichen planus, psoriasis, Reiter's syndrome, drugs, internal malignancy and AIDS.   Besides treating the underlying disorder, the keratoderma is treated with topical solutions (salicylic acid 5%, lactic acid 10%, urea 10-40%) and topical retinoids.  Ulraviolet A (PUVA) may be needed in severe cases.

Wednesday, December 5, 2012

Be the Doctor and Make the Diagnosis

The EverythingHealth ever popular image challenge from New England Journal of Medicine is good this week because the photo is so interesting (and challenging).  Be greatful your feet do not look like this.  Please make the diagnosis in the comment section and check back tomorrow for the answer.  Is the condition?

1.    Nephrogenic systemic sclerosis
2.    Keratoderma
3.    Poikiloderma
4.   Punctate psoriasis
5.   Verrucae

You be the diagnostician and have bragging rights at your next cocktail party.

Sunday, December 2, 2012

Primary Care - Trying to Do Right

Winter is officially here and  we are in the cold and flu season.  This is the time that patients get sick with viral illnesses and primary care doctors get even more frustrated as they try to do the right thing for patients.  What is the right thing?

 First of all we want to relieve suffering.  But we also want to do that without causing harm.  We  want to practice the best evidence-based medicine.  And evidence shows us that antibiotics and extra testing does not help the time course of a virus.  In fact, overuse of antibiotics drives drug resistance, increases the overall cost of health care and causes unintended side effects. 

I've seen comments on the internet that doctors are part of the "Business of Medicine" and they order tests and use "big pharma" drugs so they can "make money".  Well, folks, Primary Care Doctors make no money ordering tests or prescribing drugs.

 Zero!  In fact, it actually costs us money to do both.  Blood and imaging tests (X-rays) require documentation, follow-up,  time informing patients and can even lead to more testing if something is "borderline".  We don't get a dime for this time consuming work that occurs after the patient is long gone from the exam room.

But even with the extra time it takes to order and follow-up on tests and order prescriptions, it takes even more time to explain to a patient WHY  these things are not needed for a viral illness.

Believe me, I get it.  I know how miserable a virus makes you.  I know how nights are worse and how hard it is to sleep with a sore throat or congestion.  I also understand the false hope that taking a pill will make it all better in a day or two.  I know we all want instant cures.   Here is how a typical scenario goes...usually on a weekend phone call:

Patient: "Doctor, I really need to be on an antibiotic.  I get sinus infections every year and I'm congested now and last night my throat was burning and I couldn't swallow and I couldn't sleep all night long  and I just know this will turn into a sinus infection because I get them every year and I need something called in RIGHT AWAY because I have to go to New York on business on Thursday and I just CAN'T BE SICK".

This phone call will take about 20 minutes because I will get more details and then explain, as kindly as I can,  that this illness will probably last 7-10 days no matter what we do.  I will offer  my suggestions for comfort care, rest, pain relief and natural healing methods and the opportunity to re-evaluate if things get worse.

At the end of this phone call, the patient is usually frustrated and may be even angry with me because they really don't believe what I have said and they really do feel miserable.

This scenario plays out multiple times, day in and day out during the winter season.  Sometimes I just give in and prescribe the antibiotic.  I can only try to do the right thing so long.

Wednesday, November 28, 2012

Differences in Ethics of UK vs. US Physicians

 A new report has come out from Medscape comparing marked ethical differences between United Kingdom physicians and US physicians.  The study surveyed over 25,000 US and UK  doctors on their beliefs about futile care, patient confidentiality, full disclosure to patients, and even informing patients about bad doctors.  It was surprising to me that doctors who are trained so similarly, have such divergent views when it comes to ethical issues.

On many of the questions the responses across the Atlantic were similar.  Only 10% (US) and 14% (UK) of physicians would hide information from a patient to bolster their spirit.  About a quarter of doctors on both continents might ration care to a younger, sicker patient rather than an older one.

An analysis of the findings points to differences in how doctors are paid as possibly driving the different values.  US doctors face more malpractice costs and face more litigation.  More US doctors work independently in a "fee for service" environment.  UK physicians are mainly funded by the country's socialized National Health Service (NHS) and decisions are less driven by financial concerns.

Here are the results of the survey:

Table. Differences in Attitudes Between US and UK Physicians, Medscape 2012 Ethics Report
Question US Physicians UK Physicians
Would you ever go against a family's wishes to end treatment and continue treating a patient whom you felt had a chance to recover? Yes: 23% Yes: 57%
Is it ever acceptable to perform "unnecessary" procedures due to malpractice concerns? Yes: 23% Yes: 9%
Is it right to provide intensive care to a newborn who either will die soon or survive with an objectively terrible quality of life? Yes: 34% Yes: 22%
Would you ever hide information from a patient about a terminal or pre-terminal diagnosis if you believed it would help bolster the patient's spirit? Yes: 10% Yes: 14%
Would you give life-sustaining therapy if you believed it to be futile? Yes: 35% Yes: 22%
Should physician-assisted suicides be allowed in some situations? Yes: 47% Yes: 37%
Would you inform a patient if he or she were scheduled to have a procedure done by a physician whose skill you knew to be substandard? Yes: 47% Yes: 32%
Is it acceptable to breach patient confidentiality if a patient's health status could harm others? Yes: 63% Yes: 74%
Would you ever decide to devote scarce or costly resources to a younger patient rather than to one who was older but not facing imminent death? Yes: 27% Yes: 24%

Thursday, November 15, 2012

Hearing Impaired Tattoo

I love the creativity here.  This young lady has bilateral hearing impairment.  Great tattoo!!

Monday, November 12, 2012

Subdural Hematoma-One Patient's Experience

This email came from one of my patients  this morning.

I read your blog about technology helping you and wanted to share this story with you. 
 My husband has had ongoing migraines for weeks that never really stopped. Meds at home were not working to control the pain. He was suffering and his docs recommended a trip to the ER for stronger meds to stop the headache.

Friday night we drove to the Hospital where they got him into a bed right away and soon did a CT scan. The scan showed a large subdural hematoma on the left of his brain. All his symptoms were attributable to the pressure being applied to his brain.

He underwent an emergency left temporal craniotomy on Saturday. The operation was successful, although the origin of the bleed  is not known. There had been no head trauma.

Today he said my name and tonight he was more lucid and wanted to watch 60 Minutes. He could see the wall clock at 6:55 and knew the show was about to begin. I hadn't even been aware of the TV on the wall. Amazing that he had brain surgery yesterday and was so alert tonight.

His neurosurgeon said he does 2-3 of these same procedures each week. This is much more common that I would have imagined.

Go to the ER for a headache, and end up getting emergency brain surgery! I am grateful beyond measure for CT scan imaging technology, radiation or no.

Oh, I used my iPhone  camera to capture an image of his hematoma from the computer screen as The doctor showed me the whole picture. Then we took that image to the bedside so that his doc could show him what I had seen. Really useful technology once again.

Much to be grateful for. And thank you for all that you write in support of patient care and wellness. 

For more information on Subdural Hematomas, see my prior blog post.

Technology and Medicine

I love technology that lets me be a connected doctor and saves my patients time and money.  I got an email from Justin last weekend because his foot was painful and swollen and it included the following photo:

Wow. this was obviously a serious infection that was spreading beyond the big toe to the entire foot.  He needed immediate attention and was sent to the ER.  He was given pain medication, two antibiotics and the toe was drained.  The next photo looked was this:

Clearly better now that it was opened up but the swelling remained and he was not out of the woods.  Rather than  have him come into the office, when he really needed to keep it elevated, I had him check in with me with daily updates:

Clearly improved.  Notice the redness on the other toes is disappearing as is the streak that was going up the foot.  The wound looks really clean.  I advised hot soaks and continued antibiotics and elevation and it continued improving:
All was going well until today.  His pain was gone and Justin thought he was ready to go back to work but one week later the toe looked like this:

Oops, that fresh pus shouldn't be there.  Overall the healing is great but now I suspect a foreign body that might be keeping a nidus of infection.  Unfortunately he will need further debridement to see what is causing that continued oozing.

Tomorrow I'll get him hooked up with a surgeon who can take a look at it. 

Tuesday, November 6, 2012

Americans are Trying to Lose Weight

More than half of Americans (55%) say they are trying to lose weight according to a study by The International Food Information Council Foundation.  From 1960 to 1980 the obesity rate remained stable at about 15%.  Since that time it has risen to 36% in 2010 and is still on the rise.  Despite the fact that we are getting healthier in many other ways, the obesity epidemic stands to wipe out all of the other health gains.

Body weight is the result of genes, metabolism, behavior, environment, culture and socioeconomic status.  But genes and metabolism have not contributed to the rapid obesity rise in the U.S.  The other factors are at play here.

If you think it is from the proliferation of fast, easy available food, cheap junk food calories and the fact that fewer people cook at home anymore, you would be correct.  Just look around at how easy it is to find food.  Every mini-mart, drug store, public place has vending machines and available junk food.  And serving sizes have grown along with our waistlines.

 Physical Ed has been eliminated from schools and our society doesn't let kids go out and play alone anymore.  When they do play organized sport the moms bring treats and snacks for the whole team on a rotating basis. 
Just about everything in our culture is poised AGAINST healthy eating and maintaining a healthy weight.  Jaimie Oliver was on TV for awhile with his food revolution, promoting healthy diets for school kids.  But we are fickle with our TV habits and he is off the radar now.  We need to bring that information back and keep promoting healthy eating for our kids. We need to create environments that promote health and education is a place to start.

Back to the survey that reported 55% of us are trying to lose weight.  Unfortunately our fast-food culture isn't helping much,  but change has to start at the beginning and eliminating soft drinks, processed carbohydrates and sugar would go a long way to restoring health and reversing this worrisome trend. 

Monday, October 29, 2012

Getting Used to Electronic Health Record

From this...
To this

I will start with full disclosure.  I still use paper charts.  While I think my practice of medicine is "uber"-up-to-date...the truth is it could be 1950 when you look at my patient records.  Charts are huge and some  patients I've seen for decades are on volume 3, just to make them manageable.  So this very week I am coming on board with a full blown, state-of-the-art Electronic Health Record.

The government is pushing EHRs and, in fact CMS (Center for Medicare and Medicaid Services) has already imposed a 1% penalty on  doctors  that are  not doing e-prescribing of prescriptions.   The penalty goes up to 1.5% in 2013.  There are also some large incentive dollars connected with "Meaningful Use".  It is a complicated set of criteria put out by CMS that pushes physicians toward investing in the EHR.

With all of these incentives why haven't more physicians converted?  For one it is darn expensive and the best systems require large groups or hospital funding to make it financially feasible.  Staff needs to be trained, equipment purchased, software and licenses purchased,  Internet technology (IT) support is needed and the doctor's productivity and ability to see the same number of patients declines. And it totally changes how you and your staff do your work. 

The advantages are numerous, however.  Having access to instant, legible information all in one place, shared by all of the caregivers is huge.   The EHR gives easy access to consultant notes and all tests.  When I am on call at night or weekends I can see my patient's information and it will prevent medical errors.  The EHR can be programed to give "alerts" for drug reactions, needed screening tests and medical information.

So it is a no brainer that we all need to switch to the 21st century and start using technology to help us deliver better care.

I have already gone through an entire day of training and will be using more of my "free" time this week to abstract my old charts, learn the system and develop my own practice templates in the new EHR.  I will need "at my side" IT support when I first start using it with patients.  I think my patients will understand if it is clumsy at first.  And they will surely like the ability to see their own lab tests and make office appointments on-line.

I am looking forward to the change but also wary of what is ahead.  Internal Medicine is already a grinding specialty with low pay and long hours.  Spending more hours with an EHR is not appealing but I hope the benefit to patients and safety makes it worth it in the long run.

The graph below is on a scale of 1-5.  1=poor, 3=neutral and 5=excellent.  You can see that none of the EHRs scored very high with the Physician users.

                           Satisfaction with EHRs by Employed Internists in large Practices

Criterion Rating Averagea
Easy to learn 3.62
Ease of data entry 3.57
Overall ease of use (intuitive) 3.45
Ease of EHR implementation 3.43
Reliability 3.99
Adequacy of vendor training program 3.55
Vendor continuing customer service 3.63
Interactivity with other office systems 3.29
Value for the money 3.46
Physician overall satisfaction 3.51
Staff overall satisfaction 3.55
Appearance/overall usefulness of the end product (eg, notes, consultations) 3.68

Wednesday, October 17, 2012


The answer to yesterday's medical challenge was #1 angioedema.  The patient had progressive swelling on the face and had previously had swelling of the larynx, trunk and extremities.  A diagnosis of hereditary angioedema was made from a blood test.

Angioedema just means swelling under the skin.  Spots of angioedema are called "hives" and they are usually from an allergic reaction.  Histamines and other chemicals are released by certain types of white blood cells when an allergen is detected.  This can occur because of insect bites, animal dander, pollen, food allergies, and certain medications.  People with hereditary angioedema, a rare condition,  lack a certain protein (C-1 esterase)  that is part of the body's immune system.  The swelling can come on quickly and be dangerous if it limits breathing through the larynx.

For more common hives (urticaria) or angioedema, antihistamines are the best treatment and avoidance of the allergen.

Thanks for your diagnoses.  

Monday, October 15, 2012

EverythingHealth Diagnostic Challenge

Hello Readers,
This weeks Image Challenge from The New England Journal of Medicine is a good one.  Also it is pretty common.  The patients symptoms developed over a few hours and she came to the Emergency Room.  Is it:

1.  Angioedema
2.  Facial palsy
3.  Frey's syndrome
4.  Parotid adenoma
5.  Parotitis

 Make your best diagnosis in the comments section and the answer will be posted tomorrow.

Saturday, October 13, 2012

Fallen Hero-Lance Armstrong

Reading the daily updates about the Lance Armstrong bicycle team doping scandal is like watching a train crash.  It gets worse and worse and there is no turning back for America's sport hero, Lance.  I read his book "It's All About the Bike" and even wrote a book review on it, praising his true grit story and come-back from being on death's door from testicular cancer.  Lance Armstrong, the boy next store with his good looks, amazing athleticism and cancer charity (Livestrong) has fallen off his pedestal.

The reports that are now being disclosed by his bike team aide, Emma O'Reilly  show that Lance and his team ingested and injected a boatload of illegal substances to improve performance over their entire successful careers.   The one that caught my eye was injectible testosterone, a performance enhancing drug when used in high quantity.  I thought back to his diagnosis of testicular cancer and the rapid spread of the disease before he was even diagnosed.

Testicular cancer is highly curable when caught before it spreads.  There are different types of testicular cancer but the most common originates in the germ cell, which are the cells of the testicle or gonads.  These are the cells that produce sperm and are also triggered by the male hormone testosterone.

Could the testosterone he injected along with other performance enhancing drugs have contributed to his cancer?  I've not seen this analyzed yet in the medical literature but it should be an obvious question.

There are no easy answers to this because testicular cancer is a rare disease of young men between the ages of 20-39 years. Young men do not ordinarily encounter exogenous testosterone (translated: young men do not get testosterone from outside their own body production).  But Lance Armstrong used large quantities of testosterone to boost performance.  Since testosterone has its effect on these very cells that turned into malignancy, the question must be asked.

Mr. Armstrong continues to deny his involvement in doping but he has accepted the life-long ban from biking and the stripping of his tour de france titles.   We all love heroes and watching them fall is both sad and disappointing.

Wednesday, October 10, 2012

Different Roles in Health Care

I was working late this week; making patient call backs, filling prescriptions, reviewing labs and finishing charts from the day.  It was dark out and the medical office was quiet and empty.  The janitorial crew started their work of emptying trash, picking up the scattered debris from the busy patient flow and sanitizing surfaces.  I looked up and a beautiful Latin woman, age about 30,  wearing latex gloves, was emptying the overflowing trash can.

"You are working overtime", she said with a heavy Hispanic accent.  I laughed, realizing how late it was and how tired I was and still had more work to do.  Then I stopped and really looked at her.  She was busy putting liners in cans and dusting surfaces.  She was working fast because there were many other offices ahead of her that also needed cleaning.

"You are working overtime too", I said.  "Yes", she replied, "I will work until 12:30"  (that's AM)

"I bet this is a second job for you", I guessed, and she replied "Si, I will go to my job at the food court in the morning".

"Thank you for what you do here", I said.  "Without the work you do at night we could not take care of our patients.  Coming to work and seeing everything so spotless lets us take care of people so I thank you."

I have thought about this short interpersonal connection many times and how important it is to stop and really look at another person.  I had been feeling "put-upon" with my workload, which was nothing compared to the work this young woman had in front of her.  In our society a minimum wage job is not enough to live.  People need two back to back jobs to survive.  Yet she was working with grace and dignity and without complaint.  In fact she was noticing that I was there late.  Amazing!

Taking the time to realize that others are facing challenges in their lives and learning from the grace they bring to life is an important touchstone for grounding us in our work.

Monday, October 1, 2012

Knee Replacements on the Rise

According to a new study in JAMA, knee replacement surgery could reach 3.5 million a year by 2030 in the United States.  Wonder why health costs are rising?  We have new expensive technology that improves quality of life but may also break the Medicare bank!

The study showed that the number of knee surgeries performed more than doubled from 1991 to 2010.  Fortunately, length of stay in the hospital (a major driver of cost) decreased from 7.9 days to 3.5 days.  In the 90's more patients were discharged to institutions for  rehab and now patients are discharged to home with home health services.

The researchers attribute the potential increase in demand to aging baby boomers and a rise in conditions that contribute to arthritis - namely obesity.  Also there are more trained orthopedic surgeons that perform the surgery and it is becoming more mainstream.

Total knee replacement (TKR) will be a key driver of health care costs in the future.  Many studies have demonstrated that TKR is cost-effective because it improves patients' activity and health-related quality of life.

The total cost for TKR in the United States (including hospital, pre-op tests, medical supplies, OR fee, Xrays and physician fees) runs between $35K - $60K.  For best results, patients should find a surgeon that specializes in TKR and runs a "focus factory" with strict protocols and a comprehensive treatment team for quick ambulation and rehabilitation.
My own TKR

Saturday, September 29, 2012

Skin Rash-Pityriasis rosea

My 17 year old son showed me the strange rash that was developing on his chest and back.  It was itchy and each day seemed to be getting worse and worse.  The rash spread around his back and under the arms but spared his face and arms and legs.  After examining the pattern, I was sure of the diagnosis...Pityriasis rosea.

This strange rash occurs in the spring and the fall and mainly strikes young adults. (I did diagnose it once in a 35 yer old woman).  We think it is a virus but it doesn't seem to spread from person to person and it is usually quite isolated.

The symptoms start with a "herald patch", one larger spot that develops into a wider, pinkish, scaly rash over a week or so.  The red, raised spots can last for up to 12 weeks but usually resolve by 4-8 weeks.  As seen here, it is mainly on the body trunk.

There is no treatment for Pityriasis rosea except patience and antihistamines for itching. 

For you wordophiles- Pityriasis comes from the Greek "bran" and refers to flaking or scaling of the skin.  Rosea comes from the latin word meaning "pink" or "rose-colored".  The condition was first described in 1860 by French physician Camile Gibert.

Monday, September 24, 2012

Obama vs. Ryan at AARP

President Obama and Vice-pres nominee Paul Ryan went head to head at the recent AARP convention in New Orleans and addressed the group on Medicare and the Accountable Care Act (aka: Obamacare).  Their appearances were back to back.

Ryan told the audience,"The first step toward a stronger Medicare is to repeal "ObamaCare" because it represents the worst of both worlds".  He argued that the federal health reform law would "funnel $716 billion out of Medicare to pay for a new entitlement we didn't even ask for."  He also said that Romney's plan to transition Medicare into a premium support program "empowers future seniors to choose the coverage the works best for them" and is "designed to guarantee that seniors can always afford Medicare coverage."

The response from the group was lackluster with little applause and many boos during his speech, according to the Washington Post.

It was no surprise that Obama, who addressed the convention via satellite, defended Obamacare and told the crowd that the GOP plan would leave them "at the mercy of insurance companies."  He also addressed Ryan's remarks that $716 billion was cut to fund ACA and said, "It's simply not true.   Those savings are part of what allows us to close the doughnut hole, provide the preventive care, and is actually going to extend the life of Medicare over the long term."

AARP is a nonpartisan organization that is the nation's largest and most powerful senior's lobby.  AARP has supported the Affordable Care Act.

Sunday, September 23, 2012

Reduce Your Risk of Cancer

Imagine reducing the risk of getting cancer!

There are an estimated 1,638,910 new cases of the dreadful disease diagnosed in 2012 in the United States, not including nonmelanoma skin cancers.
Cancer is not just one disease but is a term that represents more than 100 diseases with different causes. The basic unit of life is cells, and cancer always begins in cells. When the normal process of cell growth and division is altered, these abnormal cells divide without control and can form tumors and invade nearby tissue. It is a frightening diagnosis to even think about for most people.

Hundreds of studies link lifestyle and “daily habits” to the risk of developing cancer, and researchers at a recent meeting of the Union for International Cancer Control World Cancer Congress 2012  reported that more than 50 percent of cancer could be prevented if people simply implemented what is already known about cancer prevention.
Some of these are lifestyle changes and some are interventions and discoveries that have been proven to prevent certain cancers.
The No. 1 lifestyle factor for causing cancer is smoking. Tobacco use causes cancer of the lung, esophagus, larynx, mouth, kidney, bladder, pancreas, stomach and cervix. Twenty-two percent of cancer deaths per year are caused by tobacco use, so stopping smoking brings the biggest benefit to both men and women. And the benefit starts as soon as you stop.
Other proven cancer preventions are:

*Limiting fats in the diet and keeping body mass index in a normal range. BMI is calculated using your height and weight.  A BMI between 18.5-24.9 is considered normal.  Overweight is 25-29.9 and over 30 is obesity.  This is another way of saying don’t get fat. Obesity increases the risk of prostate, liver, gallbladder, pancreas, stomach, ovary and cervical cancer. High fat diets are linked to colon, lung and postmenopausal breast cancer.

*Implementing widespread infant and childhood immunization programs targeting two viruses: Human papillomavirus (HPV) and Hepatitis B.  Hepatitis C does not yet have a vaccine but early detection and treatment can prevent liver cancer. HPV causes cervical cancer and chronic hepatitis can lead to liver cancer.

*Taking tamoxifen and raloxifene, which in high breast cancer risk postmenopausal women,  reduced the risk for invasive breast cancer by 50 percent.  Additionally weight loss after menopause reduced breast cancer risk

*Daily intake of a low-dose aspirin which reduced mortality from colon cancer by 40 percent. Aspirin also limits spread of cancer through its action on platelets. Screening for colorectal cancer also reduced mortality because small pre-cancer polyps can be removed before they become a problem.

*Minimizing occupational exposure to asbestos, formaldehyde, arsenic and diesel and certain environmental chemicals like BPA that is found in reusable plastic food containers.

*Limiting alcohol binging or over-drinking. Heavy drinking is responsible for 4.6 percent of cancer cases in men and is the sixth-biggest risk for women.  More than three drinks a day is considered dangerous drinking . And  yes, that includes beer and wine.

*Avoiding excessive sun exposure and tanning salons.  You only need 10-20 minutes of partial sun exposure during the high sun 10-2 time period to get enough Vitamin D a day.  So the average person just walking around outside  with sunscreen will get enough sun without even trying.  If you have had a skin cancer, there are no safe levels after that.  Everyone should protect with sunscreen and clothing during the high risk time.

None of these lifestyle changes or interventions will guarantee a cancer-free life if done independently of the others or erratically. But there is ample evidence that healthy living with a diet high in fruits, vegetables and fiber, no smoking, exercise and limited alcohol really does lower the risk of cancer and heart disease in all people. Other interventions like aspirin, immunizations, colorectal screening and hormone blockers are beneficial after a discussion with your doctor, taking into account your own risk factors.

The good news is that it’s not “all in the genes.” Cancer risk can be lowered.

(This article was first published in The San Francisco Chronicle)

Friday, September 14, 2012

The Battle Sign

The answer to yesterdays NEJM diagnostic challenge was #2 - Fracture of the temporal bone.  This patient has ecchymosis (bruising) behind the left ear.  This is the classic "battle sign" that is seen with underlying trauma to the temporal bone of the skull. 

My patient had struck her head very hard on a metal cabinet...hard enough to sustain a concussion and a small skull fracture with blood that is pulled down by gravity in the tissue plane behind the ear.

These fractures heal by themselves but we need to be on guard for subdural hematoma or any change in mental functioning.

Thanks for your guesses.

Wednesday, September 12, 2012

What is the Diagnosis?

I love this weeks Image Challenge from The New England Journal of Medicine because I had a patient with these exact findings about a month ago.  You be the doctor and make your best guess for the diagnosis.  Post a comment and check back for the answer tomorrow.

This patient presented with hearing loss and left ear fullness.  What is the diagnosis? (click on the image for a better view)

1.  Cholesteatoma
2.  Fracture of the temporal bone
3.  Ochronosis
4.  Otomycosis
5.  Relapsing polychondritis 

Winner gets bragging rights at your next cocktail party!

Tuesday, September 11, 2012

The Best Jobs in Health Care

The health care sector is a good place to look for job opportunities and to plan career goals.  The workforce is expected to increase 27% through 2014, compared with 14% for all industries combined, according to the Department of Labor.  But special education is needed to enter the health work force and now CareerCast has posted the top jobs based on stress level, solid job security, work environment, training and income.  Here is how the list came out:

1.  Dental hygienist
2.  Audiologist
3.  Occupational therapist
4.  Physical therapist
5.  Optometrist
6.  Pharmacist
7.  Physician assistant
8.  Chiropractor
9.  Primary Care Physician
10. Registered Nurse

Dental hygienists were first based on a median salary of nearly $70,000/year, low stress, a job growth outlook of 38% by 2020 and a small educational investment in a two year associates degree.  They set their own schedules, work in comfortable environments and never have to take their work home!

Compare that to a Primary Care Physician who makes more than $200,000 on average a year but they pay expensive malpractice insurance, have patient demands 24/7, have high stress levels and can incur training debt of over $200,000.  Additionally the post graduate training after a college degree is another 7 plus years, delaying any income potential that can never be caught up.

Occupational therapy and Physical therapy also have  high rankings and with the baby boomer's aging, the growth potential is strong.   But the physical demands are higher and patience is needed as they are dealing with injuries and disabilities.

The stress level for a Registered Nurse was ranked higher than the PCP.  The stress level for a chiropractor was as low as the dental hygienist and the audiologist has the most stress free job of all.

Friday, September 7, 2012

Primary Care Payment Struggles

The way doctors bill and get paid is a byzantine process and it is no wonder the "private practice" doctor is an endangered species.  It takes a keen sense of business, a love of medicine-not money, and a sense of humor to survive.  Here is my latest story.  You can't make this stuff up....

I saw a patient in September 2001  (note the date...11 years ago).  I billed her insurance company, Employers Mutual, LLC for $185.00.  I never got paid.

Now fast forward to September 2012.  I received a document from an attorney who informs me that he is a receiver in a class action suit and $48 million in unpaid claims is being claimed.   It appears I am a Category B creditor and will receive a pro-rata share.  He recovered $16, 559, 576.88 and took $4,831,214.40 in attorney fees.

It looks like in the future (?) I may receive a check for $37.00.  No promises are given.

I remember my practice back in 2001.  I worked about 80 hours a week and never even had enough money to fund a retirement plan for myself.  Getting paid a fraction of my charges was common and getting stiffed by insurers completely was also par for the day.

 I am happy for the windfall of $37.00 for the work I did 11 years ago.  I still see patients in a private practice but my main income now comes from my employed administrative position.  Waiting 11 years for a fraction of payment is not a sustainable business model.

Bedbug Bites

The answer to yesterday's medical diagnostic challenge is #1 - Bedbug bites.  Bedbugs frequently attack exposed areas of the skin and are attracted to humans' high body temperature.  Cutaneous (skin) reactions to bedbug bites are characterized by erythematous (red) or "hive-like" papules.  Lesions observed in a linear or cluster formation are typical. 

This patient's bites responded to treatment with topical glucocorticoids.

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...