Sunday, December 30, 2007

2008 Resolutions for Patients and Doctors

#1 Doctor: Resolve to let patient speak without interruption and describe their symptoms.
Patient: Resolve to focus on the problem I am seeing the doctor about and not come with a list of 10 complaints for a 15 minute visit.

#2 Doctor: Resolve to keep a pleasant tone of voice when answering night and weekend calls from the answering service or nurses.
Patient: Resolve to get my prescriptions filled during office hours, not forget my medications while traveling and to use nights and weekend phone calls for emergencies only.

#3 Doctor:
Resolve to exercise a minimum of 4 times a week for better health.
Patient: Ditto

#4 Doctor: Resolve to train my staff and model excellent customer service for patients.
Resolve to understand that getting an instant referral, prescription, note for jury duty, letter to my insurance from the doctor is not my god-given right and I will stop bitching.

#5 Doctor: Resolve to give at least one compliment a day to my office staff, child and spouse.
Patient: Ditto

#6 Doctor: Resolve to apologize when I am late seeing a patient who has been waiting.
Patient: Resolve to not complain when the doctor is late because I understand that another human being needed attention. It might me me in the future who needs extra time.

#7 Doctor: Resolve to do one new thing a month that is novel that I would put off ( a play? travel? special activity with a child or spouse? computer skill? music? see a friend?)
Patient: Ditto

#8 Doctor: Resolve to review all insurance payers and drop contracts that are not paying market rates for my skills and education. I will not go bankrupt.
Patient: Resolve to try and understand the medical economics that require my doctor to drop my insurance. If my doctor isn't worth paying a little more for the visit I will find a new doctor.

#9 Doctor: Resolve for each new prescription I write I will explain 5 things. The name of the medication. The reason for the medication. The side effects. How to take it. And how long to take it.
Patient: Once the doctor has prescribed a medication, I will take it as prescribed.

#10 Doctor: I will give thanks that I have a wonderful profession where I can help people in a special way.
Patient: I will not underestimate the many years of training and sacrifice my doctors have gone through and I will appreciate that they are trying their hardest to help me stay healthy.

Saturday, December 29, 2007

Patients Who Google

I read an article in Time Magazine from a Dr. Haig who couldn't tolerate a patient who "googled" him, her health conditions and treatments. It made me stop and think about patients who "google". They often send me articles they have discovered about their illness or bring information they have downloaded. Many times the information is not exactly evidence based nor well researched. There are a plethora of experts with "Doctor" in front of their name that tout research that was published in an obscure journal. Other times it is anecdotal or advertisements. The internet can be a wonderful thing but one needs the ability to sift through the junk. When it comes to health, that is my role.

Despite the fact that there is very little a patient can bring me that I don't already know...I don't disdain the effort. An involved patient is one I can work with. I try to show respect for whatever product or treatment they are asking about but I don't hesitate to give "the other side of the story" if there is evidence against it. Many times it wont hurt anything but their pocketbook and I tell them so.

Here is what I don't like, however. I don't like it when a patient wants me to research something obscure. If they have heard of a new medication or treatment that is not yet proven, I ask them to get the information and I'll review it. According to a recent study in Annals of Internal Medicine, primary care physicians already spend almost an entire DAY a week doing unreimbursed work between patient visits. I want the patient to do the "googling", not me. I'll do the interpreting, if asked, at the time of the next office visit.

Tuesday, December 25, 2007

Giving Thanks

The darkness has settled in on this Christmas Day and the dishes are almost done. Wrapping paper is in the recycle can, the dog and cat are sleeping and everything is peaceful. For this and many things, I give thanks:

  • That my family is relatively well and my son's strept throat (or could it be mononucleosis?) has turned the corner.
  • That I am a physician and can actually treat these illnesses on holidays without bothering another doctor.
  • That we are warm and have a nice home and a full refrigerator...something 3/4 of the world's population does not have.
  • That my mom is still alive and has a good man to spend her life with.
  • That I am a physician and can offer a healing touch to others.
  • That my husband is a great partner and loving person.
  • That I live in a place with trees, the ocean, mountains and beauty.
  • That I am blessed with fantastic and interesting friends.
  • That we have great garbage pickup. I can't imagine life without it.
  • That Steve Jobs invented the ipod.
  • That my patient got better and was discharged from the hospital so I didn't need to go in and make rounds.
  • That there is a free application called "stat counter" that lets me see where people come from that have visited my blog. Hello Iceland, South Africa, Ireland and Australia. Greetings Botswana, Isle of Man, Canada, Jordan and Brazil. It is a miracle that we can all communicate with each other.
  • That "This American Life" on NPR is a free podcast since I never get to hear it when it is on the radio. I love it.
What do you count as your blessings? It is cathartic to really think about it. Merry Christmas!

Sunday, December 23, 2007

Track Santa's Progress Across the World

It is almost Christmas Eve and that means Santa will be starting his 'round the world magic ride. How does he do it? We can't always explain the magic of Christmas but with modern technology we can track Santa via Norad space stations. So if you have children or are just a child at heart, don't forget to Track Santa.
You can begin on Christmas Eve!

Saturday, December 22, 2007

Bad Habits

With the New Year looming, I always start getting more introspective. There is something about starting a new year that makes me think "change" is possible and I can be fresh and new.

Marshall Goldsmith has written a book called "What Got You Here Won't Get You There" with some simple tips for successful people. His premise is that simple bad habits keep us all from achieving what we could in life and we are often unaware of what we do. It applies to home and family as well as the workplace. Here are a few that may sound familiar:
  • Passing Judgement
  • Making destructive comments
  • Starting sentences with "no", "but" or "however". These terms are progress stoppers.
  • Failing to give recognition
  • Clinging to the past
  • Failing to express gratitude
  • Not being able to say "I'm sorry"
  • Making excuses - not owing up to our own actions
  • Goal obsession - getting so caught up that we don't focus on what is important.
Goldsmith says you can't overestimate the results of just plain "being nice". Listen to others without interupting. Give credit to others and don't be a limelight hog. Apologize when you do something wrong or hurt someone. Be positive when someone else expresses an idea or plan.

It seems like common sense and just good manners, but it's amazing how many times these little bad habits can creep up. I'm going to try and be aware of all of them for 2008!

Friday, December 21, 2007

Answer-Quiz #5

The answer is #3 - Ehlers Danlos Syndrome. This rare genetic condition causes hypermobility and extreme extension of joints due to abnormalities in collagen synthesis and connective tissue. Like many medical conditions, it was named after two doctors from Denmark and France who discovered it at the turn of the century. Thanks for playing.

Wednesday, December 19, 2007

Medical Quiz-How Smart Are You #5

I saw Cirque du Soleil this week. It is a wonderful acrobatic extravaganza and one act had three beautiful girls who did amazing, flexible things with their bodies that looked absolutely unreal.
I am sure they had this condition. Can you name it? Click on the image for a closer look.
Answer will be posted tomorrow.

Hearing Aids and Insurers

I blogged a few days ago about the fact that hearing aids are not covered by Medicare or by private insurance. Dr. John Ford at California Medicine Man wrote a thoughtful analysis about that question. Check it out!

Tuesday, December 18, 2007

Grand Rounds This Week

To see the best of this weeks medical blogs go to Shiny, Happy Person and marvel at the haiku theme. EverythingHealth was mentioned too by this clever British Psychiatrist.

Monday, December 17, 2007

Superbugs and Farming


A recent issue of JAMA addressed the issue of antibiotic resistance and the effect of farm practices on creating resistant "superbugs". This topic has been reported on for decades but more and more scientific evidence is emerging that cannot be refuted. Now researchers have found, in two distinct studies of humans, that bacteria are developing resistance to antibiotics on poultry farms and that these resistant bacteria are colonizing humans. The studies showed that the mutated strains of bacteria were identical in the animals and the humans who ingested the food.

Farmers have been feeding antibiotics to pigs, chickens and cattle for the past 50 years. Seventy percent of antibiotics used in the U.S. are given to food animals because they grow up 5% faster and use less feed if they are given antibiotics. This is not done to treat disease.

Bacteria are very adept at evolving genes that allow them to live, despite our amazing array of antibiotics. Antibiotic resistance evolves over time through natural selection and mutation and when antibiotics are overused, resistant superbugs emerge.

One half of staph aureus are resistant to our common antibiotics...the result is MRSA ...methacillin resistant staph aureus.

What is the answer? First recognition that this is a health issue that affects everyone. Antibiotic use for farm animal growth should be banned worldwide. (Some countries have already done this). We should start with the U.S. and forbid imports from countries that use antibiotics for growth. Factory farming must be humane and animal healthy. Overcrowding, over breeding, filth and hormone/antibiotic laced grain is obscene and dangerous. It is clear if you watch the attached video that factory farming must change.

Sunday, December 16, 2007

Hearing Aids - Surprise! You're on your own.

I learned something yesterday from a patient (and friend) that was a surprise to me! I did not know that hearing aids are generally excluded from insurance coverage and Medicare (insurance for Americans over 65) also does not cover hearing aids. I argued "No, that can't be true" but, sure young friend who suffered sudden hearing loss was correct. She should know as she had experienced the need to price compare and get the best deal at Costco.

Do any readers find this shocking? Hearing aids cost hundreds of dollars up to $2500. One study found that 55% of senior citizens not using hearing aids found cost to be the barrier. What about children that are hearing impaired?

Hearing aids are not a luxury. I've never known anyone to "fake" deafness just so they could wear an aid. Even the many hypochondriacs that doctors treat don't use lack of hearing to go from doctor to doctor or get lots of expensive tests. If you have hearing loss, it is easily diagnosed and treated with hearing aids. It is a medical condition.

The NHS in England offers free hearing aids to everyone who needs one. There can be an 8-14 week wait for a hearing aid. Or the patient can buy one from a private dispenser with a 2 week wait.
I don't know why this is excluded from coverage in the USA. Probably has something to do with cost, profit, lack of will. I don't know.

Saturday, December 15, 2007

The Uninsured - Everyones Concern

It's election time (the longest election in history)! Today's post will be a primer in who are the Uninsured in America that we hear so much about.

  • 45 Million people under age 65 lacked health insurance. (Over age 65, Medicare kicks in and Medicare is government sponsored. If you are a billionaire, you get Medicare too)
  • Eight out of 10 (8/10) came from working families and 70% worked FULL TIME.
  • 59% have gone without health coverage for 2 years or more.
  • Minorities ( translate: "lower income") make up the uninsured. (1/3 Hispanic, 1/4 Native American, 21% African American, 18% Asian American, 13% white).
  • 79% of the uninsured are American Citizens.
  • Having insurance improves health overall and could reduce mortality for uninsured by 10-15%.
I'm sure most American readers of EverythingHealth have health insurance of some type and wonder why 45 million don't? Are they lazy? Are they irresponsible?

61% of Americans get their health insurance from their employers and that has been eroding steadily throughout this decade. Employer sponsored health insurance is sensitive to changes in health insurance premiums and we have had double digit healthcare inflation since 2001. Employer sponsored health insurance is voluntary and fewer employers are offering health insurance as a benefit. Low paying jobs (which has been the job boon of this decade) do not usually pay health insurance. Over 80% of the uninsured are in blue collar jobs where the wages are low.

If you don't get your insurance through your job you pay huge rates and if you have any chronic health condition, no one will insure you. Only 5% of Americans purchase their own insurance.

Those are the facts! Future posts will explore solutions and compare what the candidates are proposing for Health Care in America.

Answer to Quiz #4

The answer is #5 - Calcinosis. These lumpy bumps are soft tissue calcium and phosphate deposits due to chronic renal failure. The parathyroid glands help regulate calcium in the body and these bumps resolved after she had her parathyroids removed. (NEJM)

Thursday, December 13, 2007

Tuesday, December 11, 2007

Grand Rounds-Check it Out

Grand Rounds this week is at Odysseys of George.
It is really great with beautiful diving photos and great links to the medical blogosphere. EverythingHealth is one of the featured links. Check it out.

Monday, December 10, 2007

Kids Fail Physical Fitness Test

The California Department of Education reports that more than two in three California public school students failed to meet State physical fitness standards. They measured over a million fifth, seventh and ninth graders in six areas:
  • Cardiovascular endurance
  • Body fat percentage
  • Abdominal strength and endurance
  • Trunk strength and flexibility
  • Upper body strength and endurance
  • Overall flexibility
There is a little good news here...compared to 2006, the scores increased 2% for fifth graders (to 27.1%), 1% for seventh graders (30.9%) and 3% for ninth graders (30.1%)

These numbers are a bit of a shock when you see them in black and white. California has great weather, lots of open space and, I thought, a more health minded population. Could it be the video games and TV? Is it lack of physical education in schools? The report didn't discuss the reasons but the results speak for themselves. Get these kids outside doing activities or we are going to be faced with a very unhealthy adult population in a few years. Hey Arnold, where are you?

Sunday, December 9, 2007

Physicians Roles at Guantanamo Bay

Hundreds of prisoners at Guantanamo Bay, Cuba have gone on hunger strikes to protest their indefinite detention without legal process and inhumane treatment. When this happens, 6-point restraints have been and are still being used to immobilize prisoners and nasogastric tubes are inserted for force feedings.

Force feeding of competent prisoners who have refused food is a violation of the Geneva Conventions, International human rights law and medical ethics. The World Medical Association has recently updated the Declaration of Malta with guidelines on care of hunger strikers. They have stated that if the hunger striker is not being coerced, either by other prisoners, officials or outside influences, forcing treatment on competent people is wrong.

"Forced feeding contrary to an informed and voluntary refusal is unjustified...Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment."

The International Tribunal for the former Yugoslavia ruled in 2006 that force feeding of a prisoner in handcuffs with a rubber tube "constituted treatment of such a severe character warranting the characterization of torture".

A Physician's duty to the patient is always the highest priority. Because all ethical rules for treating hunger strikers require the cooperation of physicians, physicians should prevent the force-feeding of competent prisoners by refusing to approve or participate in these activities.

Friday, December 7, 2007

It's Flu Season - Why in Winter?

The New York Times ran a great article about a study that answers an age old question. Why does the flu (influenza) season always happen in the winter? We seldom see flu in Summer or even the Fall. In the tropics flu doesn't even exist.

There have been hypothesis that it was from overcrowding in schools and homes, or in the winter people are stuck inside and can pass the germs. But people are crowded in the Summer too and travel on vacations in planes and we don't see influenza.

A clever researcher, Dr. Palese from Mt. Sinai School of Medicine in New York conducted studies on guinea pigs and found that the flu virus thrives and is passed through the air at low temperatures. At 41˚the animals passed the virus more readily and longer than at 68˚. The virus was passed at low humidity but not at all at 80% humidity.

Since you really can't do anything about the weather, the best way to prevent flu is to get a flu shot or move to the tropics. Mom was almost right when she said "Put on that coat and gloves or you'll catch your death". It is amazing that it took this long to get some scientific evidence about a virus that is so common.

Thursday, December 6, 2007

Wonder Where the Money Goes in Healthcare?

Here is the answer:
Breaking News: UnitedHealth Group’s former chairman and chief executive officer, William McGuire, M.D., will forfeit more than $400 million under agreements reached with the company and the Securities and Exchange Commission over an options backdating scandal, on top of $200 million he has already relinquished.

Answer to Quiz #3

The answer is # 5 Dupuyten's contracture

The flexion contractures of Dupuytren's involves the flexor tendons of the hands and creates a contracture that is not painful. The cause is unknown and treatment is surgical release of the tendons.

Wednesday, December 5, 2007

Medical Quiz - How Smart Are you #3?

This middle aged man comes to the office wondering what is wrong with his hands. He has no pain. What is the diagnosis? (Click on image for a close up view)
Answer will be give tomorrow.

Tuesday, December 4, 2007

Grand Rounds This Week

For great links to great medical blogs check out this weeks Grand Rounds, hosted by Dr. Geek. Thanks for including EverythingHealth, Dr. Geek. The reading choices are eclectic!

Monday, December 3, 2007

New Changes in Dental Prophylaxis

The American Heart Association has published the new recommendations that will spare thousands of patients from loading up on antibiotics before a trip to the dentist. For decades certain patients have been taking antibiotics for protection before dental procedures but now the rules have changed.

Infective endocarditis is a rare but life threatening condition that was thought to be prevented by patients taking antibiotics before dental procedures. I never knew that there was no scientific evidence on which to base those recommendations, but there wasn't. Doctors were taught to prescribe five days of antibiotics to certain "at risk" patients and in 1997 it was changed to a single dose of antibiotics. Many doctors still gave several doses despite the lack of evidence.

The new guidelines are a huge change from current practice. The only people who are recommended to receive the SINGLE DOSE of antibiotic are:
  • Patients with prosthetic heart valves
  • People with prior infective endocarditis
  • People with unrepaired cyanotic congenital heart disease (rare, rare, rare)
  • People with completely repaired heart disease with a prosthesis or catheter insertion within the past 6 months
  • People with a repaired valve with residual defect on or near the repair
  • People who have heart transplant who have developed a valve abnormality
THAT'S IT! For people with heart murmers, mitral valve prolapse or other conditions that previously took are off the hook.

This is welcome news to us primary care doctors and probably to dentists all over the world. It means no more letters and faxes from the dentist asking us to rush a prescription for antibiotics or sign off on the letter. It means no more echocardiograms to prove the murmer is "benign".

It proves that medicine is constantly evolving and changing and this is a change that will save both time and money for patients, dentists and physicians.

Saturday, December 1, 2007

RBRVS-For Primary Care No Good Work Goes Unpunished

The results are in - Medical Residents are not choosing to enter the Generalist fields of medicine in the United States. With current trends, less than 10% of those training in Internal Medicine will work as general internists. Compare this with JAMAs report that all European countries have a broad Generalist foundation comprising 70-80% of practicing physicians. The consequences of our failing primary care infrastructure will be higher costs, greater inefficiencies, lower quality, more uninsured and inability to get care even if you have insurance. If you think we have problems with financing health care now, you don't even want to see what is coming in the future!

In the U.S., current reimbursement substantially favors procedures and technical interventions and offers financial advantages for expensive care. This applies to all medical services, both hospital and physician. Hospitals are quietly closing routine care services all across the country in favor of specialty ortho (joint replacement, exotic spine treatment) and cardiac interventions. Routine obstetrics, pneumonia, diabetes and emphysema care are financial losers for the hospitals. The ever expanding preventions, vaccines, need for evaluation, counseling, talking with patients and guiding their health are financial losers for doctors.

What is the origin of these gross payment inequities? The Centers for Medicaid and Medicare Services (CMS) determines the reimbursement for professional services using a resourced base relative value scale (RBRVS). This complicated system is then adopted by health insurance payers also so it drives all reimbursement.

The committee that decides the value that determines $$ is called the RUC. It is made up mainly of specialists from the specialty societies. Only 3/30 seats have term limits. Specialties that account for a very small portion of all professional Medicare billing such as neurosurgery, pathology, otolaryngology, urology and plastic surgery sit in the seats that determine reimbursement. The proceedings are proprietary and are not publicly available for review.

This committee is a powerful force in the US medical economy. They create more and more incentives for specialty care and fail to accurately assess the practice expenses of primary care.
The new Medicare Part D drug benefit has created more non-reimbursed time and expense for primary care as they endeavor to match formularies for their senior patients. The RUC doesn't have a clue what it takes to practice primary care in America.

Residents are walking with their feet and who can blame them? The system is designed to get the result is is getting. Goodbye Primary Care! Hello expensive procedures and medical spas on every block.

We talk about universal coverage and health care reform without understanding that there will not be a solid base of physicians to deliver care to the population. A large portion of the population will not be able to have continuous and personalized care provided by Generalist physicians who have excellent clinical skills and good bedside manner. Having an insurance card (government or not) is not the same as receiving care.

Friday, November 30, 2007

Answer to Medical Quiz

The answer is # 5:
Black hairy tongue (lingua villosa nigra) may be associated with the presence of chromogenic organisms (e.g., C. albicans) and the use of certain medications (e.g., doxycycline and bismuth). The pathophysiology is thought to be due to proliferation of the filiform papillae of the tongue, which stain black with porphyrin-producing chromogenic bacteria or yeast.

I take exception to the statement from New England Journal of Medicine, however, that this photo is "commonly associated" with Candida. I have treated thousands of C. albicans mouth infections ("thrush") and have never seen a condition that looked like this from Candida. The staining comes from the medications used with it.

Wednesday, November 28, 2007

Medical Quiz - How Smart Are you?

Which condition could cause this type of finding in the mouth? (Click on illustration to get a close up view ). Answer will be posted tomorrow.

Tuesday, November 27, 2007

Grand Rounds

This weeks "Grand Rounds" of medical blogs is being hosted by Prudence, MD.
I'm happy to report she found EverythingHealth worth a mention in her review of the weeks best blogs. Check her out for great blogging links

Monday, November 26, 2007

Germs- A Traveler's Companion

I read an article about the top places to find "germs" and travel is a big exposure.

I am not afraid of germs because I know they are ubiquitous and there is no way to eradicate bacteria, but having just returned from an overnight in a Hotel...I realize I have been in the midst of a virtual hothouse of germs. Think about these bacteria and virus infested environments:

  • Hotel room remote control: The first thing I grab when I get to a hotel is the remote control and I check out the TV. Guess what? Hundreds of other travelers have done the same thing and the buttons are never cleaned. A travelers pack of alcohol wipes can save the day. Wipe the phone, remote, door handles and light switches to remove traces of that guy with the cold that checked out before you arrived.
  • ATM buttons - Who doesn't get cash from an ATM? That's the point. Everyone has touched those buttons and they are never cleaned. A small container of alcohol based hand gel will kill the viruses and bacteria on my hands after using the ATM.
  • Airplane bathrooms - Don't you always feel a little grubby in the airport or airplane bathroom? They are cramped, overused and experts have found excess amounts of E. coli and other bacteria on the surfaces. This is another place for the alcohol hand cleaner. Also try to flush the toilet with the lid down to avoid the volcanic flush. Get out as soon as possible.
  • Hotel bedspreads -If you are lucky enough to stay at a 4 or 5 star hotel, they have wonderful washable duvet covers and have dispensed with those nasty bedspreads. Bedspreads have been found to have semen (ick) and bacteria on them because they are not washed between guests. Peal those bed spreads off. Don't sit or lay on them and whenever possible stay in a 5 star hotel.
The worst place to find germs is right at home in your own kitchen. That sponge that you use over and over is a bacteria growing farm. Put the sponge in your dishwasher and let the 150 degree temp do its magic. Fill a spray bottle with 1/4 bleach and 3/4 water and use that to clean your surfaces. Congratulations! You have just reduced germs by a significant amount.

There is no need to be paranoid about germs. A little common sense and good hand washing with soap will usually protect us.

Saturday, November 24, 2007

High Intensity Interval Training

Now that the big feast is over, many people turn to exercise to try and burn off those extra calories. High-Intensity Interval Training (HIT) is one way to rev up your metabolism and get aerobic benefit in short bursts of time.

HIT is repeated sessions of relatively brief, intermittent exercise that is done with "all out" effort. A single HIT can last from a few seconds to several minutes, followed by a few minutes of rest or just movement. This basic concept is advantageous because it can be applied to almost any level of initial fitness. There is no need to maintain a certain heart rate or speed.

Even though the time of the exercise is small, a few brief sessions of intervals can benefit you as much as prolonged periods of continuous moderate exercise. You can do HIT every other day and reduce the training time.

The good news about HIT is that it dispels the myths that you must reach a "fat burning zone" that only occurs after the first 30 minutes. With HIT the energy expenditure continues even during the rest cycles and studies have shown that only seven sessions of high-intensity
interval training over two weeks increased fat burning during exercise by more than 30%.

Here is an example of a HIT program for a beginner:
  • Warm up: five minutes of walking at 3.5 mph
  • Speed up and walk at 4.0 mph for 60 seconds
  • Slow down and stroll at 3.0 mph for 75 seconds
  • Repeat steps 2 & 3 five more times
  • Finish with 5 minutes of walking at a comfortable pace to cool down.
For the advanced athlete you can substitute running or cycling at all 80-90% of out effort for 60 seconds. Slow down to 30% of effort and repeat as above.

HIT is not better than traditional endurance exercise, but as an alternative or just a way to start exercising when you have been putting it off, it can get the metabolism and muscle strength going.
(Summarized from Martin Gibala, Phd, McMaster University, Ontario Canada)

Friday, November 23, 2007

Dennis Quaid's Twins-Preventable Error

Hollywood and the tabloids were rocked this week with the report of actor Dennis Quaid's two week old twins receiving a lethal dose of Heparin at the prestigious Cedars-Sinai Medical Center in Los Angeles.

It shows that VIPS are not immune to preventable hospital errors, no matter how much staff attention, privacy and spa-like treatment they receive from hospitals (and they do!)

This case is not unusual. Heparin is a blood thinner. The nurse accidentally cleared the line with a solution of 10,000U/ml rather than 10U/ml. A neonatal unit should not even have the stronger solution on the med cart, so the error was in having the dose stored in the wrong place as well as the nurse not double checking the label.
To the credit of Cedar-Sinai Hospital, they recognized the error and quickly administered protamine sulfate - a drug that reverses the effects of Heparin. There should be no long term bad effects once the drug is reversed completely.

Heparin is one of the top 5 drugs commonly associated with errors in hospitals. The others are Insulin, Morphine, Potassium chloride, and Warfarin (another blood thinner). These five account for 28% of all drug errors and have a high risk of injury if administered incorrectly.

The way to prevent these errors and "near-misses" is to put processes into place in health care like we do in aviation safety. Make it hard to do the wrong thing. Labels should have "red alerts" to show different strengths. The background colors on the bottles should be different and the font size needs to be increased. Look alike drug names should be differentiated by using TALL LETTERS. (glipIZIDE vs. glyBURIDE). The bottles should look completely different so it is obvious to every care giver...whether stocking a med cart or administering a medication.

I trust the Quaid twins will be fine. The high profile cases such as this show us we have a long way to go in providing safe care for all patients.

Wednesday, November 21, 2007

Thanksgiving Day Relaxing Medical Trivia

Here is more EverythingHealth trivia to read, marvel at, and appreciate just how wacky and wonderful our world is:
  • You have 10 quadrillion cells inside your body. The mitochondria in each cell are so tiny that you can pack a billion into a grain of sand.
  • Given an adequate supply of nutrients - a single bacterium could produce 280,000 billion offspring in a day. (Wash your hands please)
  • If you compare your genes with any other human being, they will be about 99.9% the same. It's the endless recombination of genes that make us what we are!
  • How fast a man's beard grows is partly a function of how much he thinks about sex. (Because thinking about sex causes a testosterone surge)
  • The average distance between stars is 20 million million miles.
  • Americans drink 17.5 ounces of sugary beverages a day. (No wonder we are fat. Stop it!)
  • 79% of Americans feel that current American culture makes it hard to exercise regularly and maintain a healthy lifestyle.
  • $10,402 is the average cost of a broken leg. (Make sure you don't lose your health insurance)
  • Netflix mails out 1.6 million DVDs a day (I'll be watching all weekend!)
I give thanks to "A short History of Nearly Everything" by Bill Bryson for many of these interesting facts.

I also appreciate all the readers and comments for EverythingHealth because writing this blog keeps me on my toes and prevents Alzheimer's by making me think!

If you are reading this from another aren't celebrating the pilgrims and turkey, but give thanks anyway for something wonderful in your life.

Tuesday, November 20, 2007

Grand Rounds is Up

The Medical Blog Carnival, "Grand Rounds" is hosted this week by Mexico Med Student and EverythingHealth was a featured blog. Check it out for good medical links!

Sunday, November 18, 2007

China - Recycled Condoms

It's amazing what dangers and weirdness one can find on the world wide web! The latest comes from China Daily and New Express Daily which reports used condoms are being reprocessed into rubber bands and hair ties. They are being sold at local bazaars and even beauty salons.

First we have poisoned dog food, followed by "date rape" tainted kids toys and now used condoms? It goes without saying that this is a serious public health risk from viruses, HIV and Hepatitis. It's both disgusting and dangerous.

I'm happy to report that "an official from the Guangzhou administration of industry and commerce said it was against the law to make or sell goods from used condoms." That is reassuring.

China better get it together before the Olympics. When hair twisties are dangerous, there isn't much left.

Friday, November 16, 2007

Christmas - Too Early for Joy

It makes me a little crazy to see Christmas ornaments and music before Thanksgiving. Way before Thanksgiving. I saw some displays before Halloween.

I like my holidays to fall sequentially. It makes me feel like there is a natural order to things. Labor day should be hot and school should start AFTER Labor day. Our kids schools start the Wednesday (can you believe they start school on a Wednesday?) BEFORE Labor day. That means no family travel on that last long weekend. It means using that week to buy school supplies and make sure the kid has closed toed shoes. It's obscene.

Halloween should be all about the kids and crazy costumes and high fructose corn syrup..I mean candy. I'm OK with the commercial Halloween shops and scary decorations and it is a time that grownups can "get their freak" on also.

But when I see Santa and the reindeer right behind the pumpkin display, it is disorienting. Is it not enough to receive 20 catalogues a day to stimulate the buying frenzy? Do we have to double up on our commercial holidays just to squeeze another credit card buy from the consumer?

The fake snow and "Happy Holidays" are turning me off. I'm not ready for glitter or sparkly lights or Santa. There should be a natural progression that goes with seasonal and emotional changes.

I refuse to partake in the frenzy and the fake.

Thursday, November 15, 2007

Cardiac Rehab - Proven but Underused

Cardiac rehabilitation for patients who have had a heart attack or procedure is proven to reduce new cardiovascular complications just as well as medication. Published guidelines since 1995 have recommended a comprehensive approach to cardiac rehab, including exercise training and lifestyle interventions. Despite this benefit, less than 30% of eligible patients are referred to cardiac rehab programs by their doctors. Under 14% of patients over age 65 who have had a heart attack have rehab. What is going on?

Somehow, physician awareness lags behind the evidence. Marjorie King, MD, the coauthor of the cardiovascular performance guidelines published this month in Circulation was quoted in JAMA : "The biggest factor is that physicians just plain don't think about it-we're detailed by drug companies all the time; we're not detailed by rehab clinics. It's just not part of the algorithm for treatment."
("Detailing" is when drug reps pitch their drug to doctors)

Other barriers to patients getting needed cardiac rehabilitation are that Medicare only pays about $20 per session so hospitals aren't eager to offer or expand this service. It is good for patients and good for public relations, but they can't break even on it.

Researchers found that these are the patients that would benefit from cardiac rehabilitation:
  • Acute Myocardial Infarction (heart attack)
  • Coronary Artery Bypass
  • Heart valve or heart transplantation surgery
  • Stent placement or any coronary intervention
The recent findings of low usage should act as a wake up call for clinicians as well as create awareness of the need for rehab by patients who have had a coronary event.

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Wednesday, November 14, 2007

SCHIP - Nasty Politics Affect Our Children

I say "our children" because we should all care about providing health care for the youngest, most helpless members of our society. It's not "them" is "us".

SCHIP (State Childrens Health Insurance Program) is a Federal and State government program that provides health insurance for families who earn too much for Medicaid but are near the poverty level and cannot begin to afford health insurance. Each State can determine the design, eligibility, benefit package and payment levels for coverage. Some States cover pregnant women or families and some have gone above the 200% of poverty level for a family of four ($37,700)

The bipartisan congressional bill to expand SCHIP to cover 4 million more children by 2012 was vetoed by George Bush who believed it would "Federalize Health Care". Despite SCHIP, which was started in 1997, the number of uninsured children continues to rise and 68.7% of new kids without health insurance came from families who are above the 200% of poverty level. We all know what has happened over the past 10 years with rising insurance costs and employers dropping coverage. Just saying "no" hurts families and children in America. Have you priced health insurance lately? A family of 4 would pay a minimum of $600/month if they could even get coverage! It's an impossible situation.

I was at a meeting this week where physician leaders of medical groups were discussing the SCHIP veto and how they would handle children in their practices who will lose coverage. They wanted to develop a policy of continuing to provide free care, even though there would be no reimbursement. It brought tears to my eyes to hear them discuss in earnest how they could do this...especially when they are already providing care for Medicaid children at a financial loss. Government programs (Medicare and Medicaid) are a form of "charity care" for most physicians who lose money on these patients. The physicians were determined to do whatever they could to prevent children from having no medical home.

As a practicing physician, I hear the stories and see the faces of people that are struggling to make ends meet. On the ground it is not a statistic, but a child with asthma or a broken leg or needing immunizations. Americans are not opposed to seeing their tax dollar used for health or education. We all hate waste and incompetence and fraud and SCHIP is none of those. SCHIP was originally started by a bipartisan republican congress and has been a successful program that helps our neediest citizens. What a shame that our Country cannot find the will and the resources in 2007 to cover poor children and pregnant moms and (oh gasp!) even poor parents.

Monday, November 12, 2007

Grand Rounds

A nod and thank you goes out to Dr. Anonymous for featuring EverythingHealth in this weeks Grand Rounds for outstanding health blogging. Check it out for lots of good health links.

Testicular Cancer- Basics to Know

Testicular cancer is rare but curable when diagnosed early so there are a few facts everyone with an adolescent son or relative should know.

It is the most common cancer in young adult men between age 15-35. It is very rare in African American men and is more common in men who have an undescended testicle. Testicular cancer is almost always detected by the patient himself. Young men entering adolescents should be taught how to examine their own testicles just like women learn breast exam.

Testicles are smooth and easy to examine, unlike breasts that change with menstrual cycles. The self-exam is best performed after a shower when the scrotum is relaxed and easy to palpate. Men should be alert for nodules, swelling, enlargement or tenderness. Pain is only present 50% of the time so a painless lump should be seen by the doctor.

Testicular cancer has three stages. Stage 1 involves just the testes. Stage 2 patients have disease that has spread through lymphatics but remains close to the pelvis. Stage 3 patients have disease that has spread to other organs or distant lymph nodes. Even Stage 3 patients have a good chance of cure with modern treatment of orchiectomy (testicle removal), radiation and chemotherapy.

The take home message for testicular cancer early detection is to educate young men about self exam just like we educate young women. Most testes nodules are NOT cancer but every change from smooth should be promptly evaluated by a physician. It is a highly curable disease and one of the successes of modern medicine.

By the way, for a really inspiring read, pick up "Its Not About the Bike" by Lance Armstrong.

Saturday, November 10, 2007

The Purple Pill for Reflux? Choose the Cheapest

Proton Pump inhibitors (PPI) are one of the most widely prescribed medications in the world. Why are there 5 different PPIs on the market to treat acid reflux? Is one better than the other? Is the cheaper generic (Omeprazole) as good as Prevacid? or Protonics? or Aciphex? or Nexium?

With the help of The American Family Physician Journal, let me dispel the confusion. First, there are different brands of the same drug because it is a multi million dollar market and a tiny percent of that market is real $$$. It's called market share.

In reviewing the 41 studies comparing the various PPIs that were used to treat peptic ulcers or gastroesophageal reflux disease (GERD), the authors found no differences among any of the drugs.

Let's look at the monthly price differential between these products:
Nexium 20mg --- $158
40mg --- $137
Prevacid 15mg --- $153
30mg --- $147
Protonics 20mg --- $128
40mg --- $125
Prilosec 10mg --- $115
20mg --- $136

Omeprazole (Generic Prilosec) 10mg ---$27
20mg ---$21

In summary: All PPIs are effective in equipotent doses. Go for the least expensive!

Wednesday, November 7, 2007

Professional Freedom Beckons

I have now received three amazing solicitations from MDVIP. This is the Boca Raton corporation that will set a doctor up to do concierge, retainer medicine. The letters invite me to join a few exceptional physicians who seek "professional freedom, personal freedom and financial freedom". One invite came in a bottle with sand and seashells inside, inviting me and my guest to all expense paid trip to Florida. This week, I am invited to California and they will feed me and my guest, treat us to museum exhibits and pay me an honorarium.

The invitations are sexy, appealing and seem to be coming at a rapid clip. MDVIP is one of a handful of companies that know primary care physicians are in demand and they know patients are fed up with the long waits, quick visits and difficulty in even seeing the doctor. They know the doctor is burned out, disgusted with the hassles of insurance paperwork and discount rates. The dream of caring for the patient has turned into the nightmare of patient "panels" of 2500 people.

The solution? The patient pays a retainer ($200-1500/month) and the physician limits her practice and is available to see the patient and spend more time with each patient. Prompt phone calls and email communication is part of the deal. Usually the retainer fee covers the primary care visit also so there is no insurance billing or hassle. Labs, referrals to specialists, Xrays, hospitalization and procedures are usually not included. For those services, the patient's regular insurance applies.

Concierge medicine is taking off in Urban areas where affluent patients meet up with frustrated physicians. MDVIP helps the doctor make the transition into the new mode of practice. They take a cut and everyone is happy.

I get it. I understand it. I have many friends and colleagues who are now concierge physicians and they are rested, happy, fulfilled and off the treadmill.
It is not the answer for what ails health care and it further worsens the doctor shortage, but at this time, I'm sure MDVIP has many takers. It represents the free market at work and doctors are just saying "enough" with the patients who are saying "enough" right along with them.

Tuesday, November 6, 2007

Costs Rise Faster than Revenue

The Medical Group Management Association (MGMA) does an annual cost survey of medical offices. It won't be a surprise to any practicing physician who runs an office that practice costs increased by 7.4% while revenue rose only 1.8%. Family practice, cardiology and general surgery fared the worst with even lower revenue gains against losses from last year. Pediatrics and orthopedic surgery were among the specialties with a positive picture of revenue to cost. The MGMA cost survey is based on data submitted by more than 38,460 providers.

I can tell you that receptionists, filers and medical assistants want raises each year. The cost of insurance and rent goes up annually. The answering service is charging more. Supply cost goes up, even though we try to use various vendors and get the best price. I won't even mention the fact that our exam tables are looking pretty shabby and should be replaced. We bought new computers this year...ouch!

In the meantime, Wellpoint, Aetna, UnitedHealth and HealthNet are posting record profits for their investors. They are the wall street darlings which tells me that the medical cost ratio is low. According to Wikipedia the "Medical cost ratio (MCR) is a metric used in managed health care to measure medical costs as a percentage of premium revenues. It is calculated by dividing those premiums allocated for fully insured or self-funded health care coverage into the total expenses for inpatient, professional (physicians and other licensed providers), outpatient, and pharmacy. (Briefly, MCR = Costs/Premiums.)"

Lest you think I am picking on the big for-profit insurers...Medicare is a huge issue also. The waste and bureaucracy create expensive hoops that physicians must jump through just to get paid a rate that doesn't cover the cost of business.

Physicians are at the losing end of the MCR. When physicians lose, so do the patients. Note my prior post on the looming shortage of physicians. When practice costs increase faster than revenue, we have a situation that cannot continue.

Perhaps many readers of EverythingHealth are business people. You get it, right?

Sunday, November 4, 2007

The Doctor Shortage

Merritt and Hawkins is one of the largest healthcare recruiting firm in the U.S. They published the results of a study that showed 48% of the physicians age 50-65 years of age are planning to cut back their office hours or retire within the next 1-3 years. The disturbing fact is that 1/3 of ALL physicians are in this age group.

To prepare for the physician shortage, new medical schools have opened and there is a small increases in the number of medical students in training. But there is a 8-12 year lag between training and practice and with the aging population it isn't hard to see what is around the corner. At a time when people want and need more medical care, there will be a serious shortage. Universal health coverage won't matter if there isn't anyone to take care of you. Having insurance and having access are not the same thing. Ask anyone on Medicaid or people who live in rural communities.

There is already a near crisis in California to find doctors to cover the Emergency Room. A wealthy community in Northern California cannot find a surgeon to be on call. Neurosurgery, ortho, ENT, opthalmology are all in short supply for ER call. Hospitals are paying large fees to doctors just to be available. It is traditionally younger, eager physicians who take ER call but there are no young, eager doctors in many places. According to this study we won't have any old tired ones either.

The largest decline in physicians is the primary care specialties (General Internal Medicine, Family Medicine, Pediatrics). I have written before about these specialties being grossly undervalued in our society. At the very least, it is time to recognize this and ensure that primary care specialties, with the the cognitive and coordinating value they bring, are reimbursed on par with procedural specialties. This is the only way young doctors will choose these specialties. THE ONLY WAY!

The unintended consequence of ignoring these facts will adversely affect our nations healthcare for decades to come.

Friday, November 2, 2007

Worst Health Care Scams

Open any magazine and you will see them. A miracle product that will make you thinner, sexier, healthier, live longer, more virile or more beautiful. Here is my vote for the years Worst Health Scams. They have no scientific merit but are great examples of compelling advertising.

1. Hoodia (Hoodia Gordonii) - When they say "As mentioned on Oprah" a red flag should go up. I don't know if this rare plant from Africa works when boiled down, but the capsules are definitely a scam. My favorite Hoodia ads say "Don't believe the scam..we have the real Hoodia". If Hoodia worked, we wouldn't be so fat.

2. Cellulite Creams - Rubbing creams or herbs on the skin does not break down cellulite (darn!!)
Cellulite is fat. You can't rub fat away.

3. Blue Green Algae - This swamp weed doesn't give you energy, cure allergies, cut sugar craving or cure your cat of leukemia. Trust me.

4. Colon Cleansers - I have good news for you. Your colon is not "toxic". Your colon does not have huge worms living inside. Your fecal matter is not stuck to the colon for months or years. If you want your GI tract to work well, eat more fiber and natural food. Period.

5. Penis Enlargements - Here is the truth. None of them work.

6. Breast Enlargement Cream - Here is the truth. None of them work. (But ladies, we can have an advantage here with surgery, unlike the guys. Sorry guys!)

7. Royal Jelly - This has been around for decades. I have always wondered how you would ever know it is "Royal" from the queen bee. It doesn't matter. There is no evidence that it does anything except cost a lot.

There are hundreds of scams out there. Save your money for a massage and a glass of wine. That is something that DOES work.

Medical Quiz

The answer is Cocaine. The hole you are looking at is on the hard palate which is the floor of the nasal passage. Excessive cocaine snorting has created this perforation, which is permanent.

Thursday, November 1, 2007

Drug Quiz- How Smart Are You?

This quiz from New England Journal of Medicine will test your knowledge of adverse drug effects. What is your answer? Check in tomorrow for the correct answer.

Tuesday, October 30, 2007

The End of Polio

A medical student today will go through their entire career without ever seeing a case of polio. The polio virus was feared throughout the early 20th century, leaving millions paralyzed or dead. During Summer and Autumn, polio epidemics spread human to human with this highly contagious disease. In the 1940's and 50's, negative pressure ventilators called the "iron lung" were used to support patients with paralyzed respiratory muscles. In 1952 the worst polio epidemic struck the United States, with 58,000 cases and 3,145 deaths. Over 21 thousand victims were left paralyzed.

By 1964, the oral polio vaccine, developed by Albert Sabin, had become the recommended vaccine. It was easy to administer and large populations could be vaccinated.

The effort to eradicate polio was launched in 1988 and involved the World Health Organization, Rotary International, the CDC and UNICEF. Through everyone pulling together, more than 210 polio endemic countries were targeted for childhood vaccination. Today only 4 countries - Afghanistan, India, Nigeria and Pakistan have polio. Fewer than 2000 children were paralyzed by the disease in 2006.

If the Global Polio Eradication Initiative is able to stick to its strategic plan, polio will be completely eradicated from the human population. This shows that political will and governments and industry working together can achieve wonderful things for mankind. This initiative had corporate support, pharmaceutical support, non governmental organizations (NGOs), the Gates Foundation and many small countries involved with donating funds to stop polio. Ireland, Bangladesh, Russia, Norway Canada, Germany, the U.K. ,India and the United States were all heavy contributors.

This success story shows that political will, oversight and responsibility are the ingredients for saving our planet. Let the End of Polio show us that we can work together successfully for a common good.

Sunday, October 28, 2007

It's Post Secret Day

Every Sunday the new Post Secrets are online. They only last a week. Don't miss out at this sad, amusing, wonderful look at mankind.

MRSA- it's tiny microbes

With all of the continued interest in MRSA (methacillin resistant staph aureus), it is a good time to remember just how bacteria work. According to author Bill Bryson..."if you are in good health and averagely diligent about hygiene, you will have a herd of about one trillion bacteria grazing on your fleshy plains-about a hundred thousand of them on every square centimeter of skin. You are for them the ultimate food court, with the convenience of warmth and constant mobility thrown in. By the way of thanks, they give you B.O."

Trillions of Staph Aureus microbes live on your skin and in your nasal passages. These bacteria are not harmful, and in fact, we depend upon them, living in harmony with other bacteria to keep our bodies and our planet in check. We think because we have invented antibiotics and disinfectants, that we can wipe out bacteria. What we have done, however, is just allowed them to evolve into another type that is resistant to our drugs and become penicillin (methacillin) resistant.

Your body's natural defense system will try to keep bacteria from hurting you. Millions of white blood cells are designed to identify and destroy a particular sort of invader. When the bacteria (or virus) obtains entry through catheter or a break in the skin they can invade another part of your body where they shouldn't be. Your white cell scouts call for reinforcements and the white cells, like little soldiers, come marching in to deactivate the bacteria.

Getting "sick" is a sensible response to infection. Sick people go to bed and are less likely to spread infection to others. When you rest, your body's cells can focus on the infection.

The phone call I hate the most is a patient who says, "I feel like I'm getting sick and I need antibiotics because I just can't be sick because I am getting on an airplane and I have to go to New York because I have a very important meeting and I just can't be sick."

Come on! You have to give your body a fighting chance because the microbes do become resistant to antibiotics (witness MRSA) and a stressed, tired body just can't mount the defence against infection. We would have been much more successful with bacteria if we saved our best weapon against them - antibiotics- for serious infections.

Our best defense against MRSA is good handwashing and alcohol wipes on surfaces. In a hospital, where patient's immune systems are down, it is critical for caregivers to wash hands between patients and to replace catheters using established infection control protocols.

Again, to quote Bill Bryson in the must read book, "A Short History of Nearly Everything", "It is worth remembering that most microorganisms are neutral or even beneficial to human well-being." We need to help our own natural defenses by resting when we are ill, and save antibiotics for the serious infections.

Thursday, October 25, 2007

Rate Your Doctor

I think the internet will have a huge impact on patient satisfaction of how they are treated by doctors. The idea of internet sites that rate doctors and hospitals has been around for about 5 years. In the past the sites have been difficult to view, some cost money and they were not user friendly. But like anything may now have reached a tipping point.

I logged onto and was surprised to see how easy the site was to navigate. It was free and you could look up doctors by name or city. I looked for my name...not there. But I found ratings on many of my doctor colleagues and 12 ratings on one of my "larger than life" medical school pals who now practices in Southern California. Wow he better make some improvements. It sounds like he is running a factory and the patients are none too happy. With a 5 point scale (5 being excellent) patients could rate doctors on punctual, helpful and knowledgeable and leave comments.

I found only a few surprises. In any medical community, we know who is outstanding and who was probably in the bottom third of their class. We know who is weird but brilliant and who has mediocre skills and a bad personality. The ratings of the doctors I know seemed to fit what I would imagine their patient interaction skills were.

The criticism of these sites is that only the very happy and the very unhappy patient will take the time to post a comment. That is probably valid...but it is still useful information for the person looking to find a doctor. Patients often have nothing to go on except a list of names. Another criticism is that it is not a good way to judge quality. I agree with that, but we don't seem to be providing any alternative. Until we can define, measure and report on quality, we are stuck with patient satisfaction. The quality experience is what a patient wants and these sites give a glimpse into that experience.

Tuesday, October 23, 2007

Patient Safety- Run the OR Like a Jet Plane

We all know about the poor patient who goes in for a right kidney operation and ends up having the "good" left one removed instead. Or the patient with the allergy who is given the wrong anesthesia and has a reaction. Or the patient who is given the wrong blood type. These things happen despite the fact that doctors and nurses are doing their very best to heal under really tough circumstances.

I saw a film at a conference that really impressed me about how we need to fundamentally change how we address patient safety and live up to Galen's dictum of "primum non nocere" ("first do no harm.")

The film showed an operating suite, with the scrub nurses, anesthesiologist, surgeon, medical student, radiology tech all gathered around the patient lying on the operating table. Instead of just starting the operation, they stopped for a required "time out". The protocol was rigid.

The circulating nurse identified the patient by name, birthdate, age and what the operation was for. She identified that the preop exam was on the chart and mentioned the allergies. Next the Surgeon formally gave the patient's brief history, other health risks and what his intent was for the operation. The scrub nurse identified herself and pointed out that she had the equipment ready and the specific tools the surgeon would require. The anesthesiologist went next with his name (they are all behind masks, you know) and mentioned the anesthesia was on board. He introduced the medical student and then said the operation could begin.

The formal time out was over and the operation began. It was very proscripted and weird to see, but it was immediately obvious to me that this is how it should be done. A pilot does the same thing before she takes the responsibility for the passengers lives in her hands. All systems are checked and verified formally with the control tower and the co-pilot. Even though the plane has been flown hundreds of times on the same route, a protocol is followed before takeoff.

If I or my family or my patients are scheduled for surgery, I want a team that does a formal "time out" and treats it as seriously as flying a jet plane.

Saturday, October 20, 2007

Transparent Pricing for Patients

There is a big push toward having patients be smarter consumers of health care as a way to control costs. Employers are pushing for medical savings accounts (where the patient has a pot of money they spend on health care or just save) and more and more insurance products have high deductibles and more cost sharing by the patient. The simple way of explaining it is that if someone else is paying the bill (insurance, medicare, the government) people will just use lots of care and testing and medications and procedures and have no regard to cost.

In a normal market, lower cost, high quality products would prevail. The medical market should operate that way but it doesn't because the incentives aren't aligned. The person receiving the benefit ( the patient) is often far removed from the true cost.

The only way a true market could work is if the consumer (patient) KNOWS WHAT SOMETHING COSTS! Here is the rub. It is near impossible for a patient to find out ahead what the cost of a test or operation or even a doctors visit will be. The system is so complicated, answering that easy question is not so easy.

Hospitals don't have one pricing method. They have contracts with each insurance company (there are hundreds) and each is written in a different way with different discounts for each service. A colonoscopy can cost $800.00 at one place and $6500 someplace else. Can you believe that range? The price is often not what the provider gets paid anyway. That price may or may not include the medications given or the gastroenterologist portion of the bill. In a hospital setting the price may differ if you are covered by one of hundreds of insurance plans or by Medicare. There are laws that say a provider can't charge less than it's lowest price contract and they don't want to charge less than what they could be paid by the highest price contract. There are also trade secrets so they aren't disadvantaged the next time they contract with an insurer. Are you dizzy yet?

There is no other industry where the consumer receives a service and doesn't know the cost. But there is no other industry that is so over regulated with such complicated payment methods either. There is no other industry where a product (service) is given and the government payment doesn't cover the cost of that product.
(How long would Blackwater contract with the government if they didn't get paid their cost? Why are other industries so eager to tap into the taxpayer's bank? Ah, but that is another blog)

Our industry- American Health Care- needs to get a grip and solve this problem. It isn't easy and I'm not blaming hospitals or doctors. Heck I am part of the problem too. Doctors also have to inflate their charges to cover the government payments that don't cover the cost of care. But it is insane to expect patients to be frugal purchasers of health care when they aren't told what something will cost.

Wednesday, October 17, 2007

Surgical Model

In my medical training, oh so many years ago, we learned from cadavers. While this was a good way to learn basic anatomy, the physiology of how the body worked was a slower process. Thanks to Unbounded Medicine for this look at the way students can learn now. This reproduction of a patient was crafted with animal organs that really give the student a much better idea of how the body functions.

Tuesday, October 16, 2007

MRSA - It's preventable

Everywhere I turned today, I was engaged in discussions about methicillin resistant staph aureus (MRSA) and tonight I read a new article in JAMA that says it is twice as prevalent as we thought.

MRSA is a common skin bacteria-Staphylococcus aureus-that has become a "bug on steroids" and is resistant to penicillin, methicillin and other drugs that used to kill it flat. It has developed over time and 85% of infections are associated with hospitals and long term care centers. When it enters the skin barrier through incisions or IV lines, it can cause serious internal infections and is a leading cause of death.

Staph aureus is found in the nose and respiratory tract and healthy people can be carriers. It can live on clothing and curtains and (I've heard but not verified) that in England they are prohibiting physicians from wearing ties because of possible contamination.

MRSA infections are preventable and the bacteria is killed by topical alcohol.We've known that hand washing saves lives since Philip Ignaz Simmelweis discovered clean hands save lives in Vienna in 1847. He was fired, by the way, for such an outlandish idea that physicians should wash before they deliver babies or do surgery!

Topical alcohol based hand rubs, hand washing between patients, using infection control protocols for IV and line placement and screening for and isolating carriers of MRSA are all ways to drop this infection rate to zero. Paul Levy, the blogging CEO at Beth Israel Boston has been openly revealing his hospitals efforts to reduce MSRA and all hospital acquired infections. This is something that we should openly discuss, tackle as health providers and each of us help our colleagues remember to wash so we can drop these infection rates pronto.

Monday, October 15, 2007

Healing Environments

While the housing market has bombed, new hospital buildings are the rage in California due to a law that says they need to be seismically (earthquake) safe. As hospitals are planning the hospital of the future, many are using architectural design to reduce stress and promote safety and healing.

What type of building promotes safety and healing? We know what doesn't work. I've practiced in hospitals where the beds are so close together I could examine two patients at once without moving my feet. One wall mounted TV services two patients, so if you don't want to watch another episode of "Cops" while you are recovering from surgery, you're out of luck. And what about those bed trays on wheels that hold your food, your medication, your cards from relatives and your personal grooming supplies all together... clutter does not promote healing or good sanitation.

Most hospitals are hip to the fact that "noise" is a problem for patients and they try to keep the nursing station area quiet. It usually doesn't work. Phones are ringing, trays are clacking, nurses and doctors are talking and the best a patient can do is treat it like "white noise".

Here is what I would like to see in a healing environment:
  • Windows looking out into nature with black out curtains. (The best sleep I ever get is in a hotel. Where do they get those curtains?)
  • Bathrooms that are designed to prevent falls. Bars on walls, plenty of room to maneuver an IV pole or walker. Toilets that are higher than usual for ease of sitting.
  • Standardized room designs so nurses can be efficient and have all of their supplies and medications handy and in identical locations. Wall computers in every room for nurse and physician charting. Cabinets to hide supplies and a closet for patients belongings.
  • Window bed for family to spend the night.
  • Priority on patient privacy. Private rooms, private conference rooms for family.
  • Warm and very clean play area for children and their parents to hang out. Updated magazines, coffee and tea, water and computer in the family area.
  • Garden/Atrium for patients, family and staff to be with nature quietly.
  • Nutritional, organic food for patients and staff.
  • Non-smoking inside and out.
  • Absolutely no eating or food at the nursing station. Cold pizza and stale Sees candy...ugh!
  • Nursing stations designed with input of nurses and their workflow to capitalize on efficiency, safety and patient centered care.
I don't think any hospital administrators should design a hospital without getting patient, nurse and physician input. I mean real input. Ask patients and their families what they would change. Query them while they are in the hospital and make them part of the design team. Nurses should work with the architect from the beginning. They are the backbone of the hospital and to design without their input is folly.

Friday, October 12, 2007

Plastics and Chemicals That Can Harm

The chemical, bisphenol-A (BPA), is used to produce polycarbonate plastic and epoxy resins and is found (get this!) in water bottles, baby bottles, food containers, compact discs and dental sealants. The chemical can leach into foods, be inhaled or enter by other routes and the US Centers for Disease Control and Prevention found this chemical in the urine of 95% of people they sampled. BPA is an estrogen mimic and may interact with estrogen receptors.

Numerous animal studies have been conducted for years that link BPA with diseases and they have identified a mechanism where BPA exposure in pregnant rats causes genetic changes that persist through the life of the offspring. They also found neurological effects of BPA exposure that caused the mother rat to groom the pup less. The findings were species specific, but they involve areas of the brain that play a role in hormonal regulation and sex-related behaviors across species.

The complex factors, both environmental and genetic, that affect health are difficult to sort out. It is hard to extrapolate from animal studies to humans and the complexity of hormones makes cause-effect relationships almost impossible to prove.

But, we are facing a worldwide increase in obesity, diabetes, prostate and breast cancers, autism and attention deficit hyperactivity disorder.

As I look around the changes in society... plastic bottled water everywhere, clear plastic containers for food, plastic bags, plastic toys, plastic backpacks...I certainly support the toxicologists and environmental scientists in this work and if there is an inkling that BPAs are harmful to humans...they should be banned everywhere.

Congratulations to Al Gore who just won the Nobel Peace Prize.
A man of courage and integrity, Al Gore has opened the world's eyes to just how small planet Earth is. In the entire universe, it is the only place where life exists. Lets get it right.

Thursday, October 11, 2007

Withdrawl of Kid's Cough Medicines

McNeil Pharmaceutical has stepped up to the plate and done the right thing by voluntarily withdrawing a number of cough and cold preparations that may be harmful to kids under the age of 2. Recent findings show these medications can be overused by parents and there are no safe guidelines for tiny tikes and these preparations. McNeil has begun by informing physicians of the following:

We have decided to voluntarily withdraw the following over-the-counter (OTC) infant cough and cold medicines from the market:

Concentrated Tylenol® Infants' Drops Plus Cold
Concentrated Tylenol® Infants' Drops Plus Cold & Cough
PediaCare® Infant Dropper Decongestant
PediaCare® Infant Dropper Long-Acting Cough
PediaCare® Infant Drops Decongestant (containing pseudoephedrine)
PediaCare® Infant Dropper Decongestant & Cough
PediaCare® Infant Drops Decongestant & Cough (containing pseudoephedrine)

We believe the decision to voluntarily withdraw these products may help to reduce these instances of misuse among children under 2 years of age.

This voluntary withdrawal does not include:
Children’s Tylenol® cough and cold medicines for children over age two
PediaCare® Children’s cough and cold medicines for children over age two
Infants’ and Children’s Tylenol® pain relievers and fever reducers
Infants’ and Children’s Motrin® pain relievers and fever reducers

This is an example of a large company putting patient safety before profit. Kudos to them!

Tuesday, October 9, 2007

Sport Concussions

One of my most "googled" blogs was "A bump on the head". Falls and head injuries are common and an estimated 300,000 sports-related concussions (also known as mild traumatic brain injury) occur annually in the United States. Researchers estimate that 63,000 of those occur in high schoolers playing football.

The tough thing about concussions is that there is no marker or test to know if a person has one. With new technology like functional MRIs (fMRI), doctors can see changes in brain function and link those changes to the recovery time needed for injured athletes. With a concussion, fMRI identifies abnormal hyperactivation in specific brain regions that control cognitive process, such as memory. They can provide the first understanding of how a concussion affects the brain.

fMRI machines are scarce and found only at academic medical centers and the cost for a scan can run up to $1200. Until the technology becomes more common, we are left with arbitrary guidelines that are shifting toward a more conservative treatment of young athletes. Coaches, trainers and parents are thinking twice about sending a kid back into play too soon. Any insult to the head that results in a temporary or transient change of mental state (even if there is not loss of consciousness) needs to be labeled a concussion.

The problem remains that there are no symptoms or signs that can predict when it's safe to return to play. We don't have any evidence to guide us but if early studies with fMRI are an indication, recovery may take longer than we originally thought.

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...