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Showing posts from June, 2008

How Much Does it Cost? I Dunno.

I can't think of too many services or products that a person would purchase without knowing how much it would cost. It is amazing that no-one knows the cost of their own health care services in advance...and furthermore, even we doctors have little clue about the charges and payments that our patients pay.

This odd phenomena is largely due to the fact that 3rd parties (insurance, government) pay the bill (or a fraction of the bill) so patients don't need to know. In fact, when I tell patients that it would be a waste of money to do a certain test...often the reply is "Oh do it anyway, my insurance will cover it."

Now that patients are paying more and more of the health care cost through high deductibles or Medical Savings Accounts, there will be more interest in what is billed.

I had a patient who came to me with unusually heavy menstrual periods. The diagnostic work-up and treatment led to an out patient surgery for a fibroid removal and D&C. The operation took…


Does anyone remember the old old Disney movie "Old Yeller"? I was just a kid when I watched this tear jerker, but what I remember most about it was that Old Yeller got rabies and died. Rabies was one of the first serious diseases I ever learned about as a kid. My first medical word was "hydrophobia".

In the U.S. and Canada, rabies is really rare. In Canada, only 24 cases of human rabies have occurred since 1924 and since 1970 six of the seven cases have been attributed to bats. In the U.S. 40 cases have been reported since 1990. Of those, 37 were caused by bats.

If a person is exposed to rabies, post exposure prophylaxis (PEP) is given. It consists of rabies immune globulin and a 5 dose series of rabies vaccine. An exposure is a bite, scratch or exposure of non-intact skin or mucous surface to saliva, tears or brain tissue. If the PEP is not given before the onset of neurologic symptoms, it will not work. After exposure, the usual incubation period for rabie…

Outside Hospital

Some of the comments on this video say the
general public will never "get it". I think readers of EverythingHealth will. Check it out.
(Hat tip to

Quit Rewarding Drug Impaired

I read this morning that a celebratory concert is bring prepared for Nelson Mandela's 90th birthday in London. He has had a glorious and influential career and is a master statesman known all over the world. How wonderful that he is being honored!

With so many talented performers to choose from, why is Amy Winehouse selected to sing at that concert? Her drug addiction and arrests are also known all over the world. Her husband is awaiting sentencing for attacking a pub owner and it is always a media event to guess if she can perform without falling off the stage.

I know addiction is a disease that progresses without treatment. I am sorry for the waste of talent and the problems Ms. Winehouse faces. She is now reported to have emphysema that will affect her ability to sing.

I'm just tired of seeing impaired "girls gone wild" held up as a shining example of success and to have her on the same stage with a hero like Mandela is just plain wrong.

Surgical Checklist for Patient Safety

When a pilot sits in the cockpit, she methodically goes through a checklist of all systems and equipment before the plane is fired up. Even if the pilot has flown that plane and route 1000 times, the items on the checklist are reviewed one by one and no-one would think of flying the plane without completing the checklist.
Now, the World Health Organization (WHO) has developed a checklist to be used in the surgical suite by every surgical team before the patient is put to sleep. Up to 16% of surgical procedures result in an unexpected complication. The death rate from surgery in developing nations is an astonishing 10%. A study in Lancet found basic safety measures were overlooked in hospitals around the world.
One of my favorite medical writers is Atul Gawande, a surgeon and Harvard University professor. He worked with WHO and more than 200 worldwide medical organizations to create the checklist.
"What we identified, was that the idea of a checklist to make sure the basic steps are…

California HMOs - Raking in the Dough

Health costs and insurance premiums are rising at a rate that is completely unaffordable to companies, the government and to patients who buy their own insurance. We've seen these escalating costs for years and everyone who is connected to health care, either as a provider or a buyer knows we are standing at the edge of a cliff with a steep drop off.

So how is it that in 2007, HMOs in California spent $6 billion on administrative costs, which included large CEO salaries? (and that is in addition to billions of dollars in profits) . Talk about waste. That is 6 billion dollars in high premiums. Six billion dollars that did not go toward vaccinations, or mammograms or surgery or nursing care.

UnitedHealth Group, the largest health insurer in the nation, paid it's CEO $124.8 million in 2004. After an outcry, his salary went down to a paltry $12 million in 2006. Anthem Blue Cross (previously Wellpoint) paid its CEO total compensation of $52.4 million in 2006. That's enough…

Fake Cancer Cures

It is sad when a patient is dealing with a diagnosis of cancer and believes there is a cure out there that the doctors don't know about or are keeping from them.

The internet provides more opportunities for a cruel form of greed where fake cancer cures can be dressed up as "scientific" and sold to desperate patients. Bogus cancer cures have been around for decades, but online searches can bring them right to the patient.

The FDA has published a list of "125 Fake Cancer Cures Consumers Should Avoid". Check it out here.

Firms that engage in cancer treatment fraud often use exaggerated claims that should be red flags to patients and families. Some of them are:

"Treats all forms of cancer""Skin cancers disappear""Shrinks malignant tumors""Non-toxic""Doesn't make you sick""Avoid painful surgery, radiotherapy, chemotherapy, or other conventional treatments""Treat Non Melanoma Skin Cancers easily and…

Painful Truth - Tim Russert

The medical blogosphere writers have been prolific in their speculation about Tim Russert's untimely death from a myocardial infarction last week. Did he have the right tests? Could more have been done to evaluate and prevent? How could a wealthy, intelligent guy who was under doctor care die from a disease we know so much about?

The best overall summary can be found today in The New York Times. Check it out.

ALS and Formaldehyde Exposure

Interesting information came from the Annual Meeting of the American Academy of Neurology held in Chicago in April. One presentation reported a link between workplace formaldehyde exposure as a risk factor for amyotrophic lateral sclerosis (ALS).

ALS (remember Lou Gehrig) is a rare, progressive and fatal neurodegenerative disease that hits during midlife. Only 5-10% have a genetic link and the majority of cases occur randomly with no known risk factors.

The American Cancer Society's Cancer Prevention Study II followed more than 1 million individuals over time. (a very robust study) They found that individuals who reported formaldehyde exposure in the workplace had a 34% higher rate of ALS than the no-exposure group and it was dose related. The occupations that are related to formaldehyde exposure are beauticians, pharmacists, morticians, chemists, laboratory technicians, physicians, veterinarians, dentists, firefighters, photographers, printers and nurses.

This is the first st…

Fun Friday Info

Shocking Stats 60% of doctors don't follow hand-washing guidelines.
Source: CDC Morbidity and Mortality Weekly Report

96% of doctors agree they should report impaired or incompetent colleagues or those who make serious mistakes, but ...

46% of them admit to having turned a blind eye at least once.
Source: Annals of Internal Medicine

94% of doctors have accepted some kind of freebie from a drug company.
Source: New England Journal of Medicine

44% of doctors admit they're overweight.
Source: Nutrition & Food Science; Minnesota Medicine

58% would give adolescents contraceptives without parental consent.
Source: New England Journal of Medicine

Anatomy of a Doctor's Bill

Just how much of the $100 your doctor charges for taking 30 minutes to investigate your stomach pain goes into his pocket? After paying the bills, he gets less than half. The breakdown, according to Robert Lowes, senior editor at Medical Economics:

$3.50 for malpr…

Shedding Hair in Men - What is Normal?

There has been no widely accepted method for assessing the number of hairs that are normally lost each day. Fresh from the Archives of Dermatology, we now know what a "normal" rate of hair shedding is in white men.

They used a method called the "60-second hair count". They studied white men with straight hair age 20-40 and another group of healthy white men age 41-60. Both age groups did the "60-second count" by combing the tops of their head (not the sides) from back to front over a pillow for 60 seconds. They used identical combs and shampoo for 3 consecutive days and did the combing on the 4th day. After combing for 60 seconds, they counted the number of intact hairs on the pillow and the comb. The test was repeated on 2 separate occasions.

The result? In the younger age group (20-40), average hair loss was 10.2 hairs and the older group (41-60) was 10.6 hairs, essentially the same.

The authors noted that the results may not generalize to women, …

We Need Young, Fresh Doctors

There is a lot to be said for the seasoned clinician. The gray haired physician with years of experience and wisdom and a noble demeanor. But I am here to say...I want to see some young doctors in my medical community who love practicing medicine.

Here is what young physicians bring to Medicine:
Availability (I am tired of referring my favorite patients to the ortho, or rheumatologist or neurologist and being told there is a 6 week wait)Availability (I am tired of having to beg a consultant to see a patient)Follow up consult note (When I take the time to send my work up notes, call ahead and arrange the appointment...I would like a follow up note from the consultant)Curiosity and interest ( I am a comprehensive internist and I only send patients who are a medical challenge. I want a doctor who is curious and interested in figuring things out. After the tests are done, I would like the consultant to work with me and the patient and come up with a solution, not just tell the patient t…

Medicare Fraud

A high school dropout named Rita Campos Ramirez was able to perpetrate the largest health care fraud against Medicare with the use of a laptop at her home. For four years she electronically submitted bogus claims for equipment and services to the tune of $105 million.

Finally busted, she is now helping the Inspector General bust other doctors and businesses that bilk us taxpayers out of an estimated $60 billion a year. Yes, that's $60 Billion (with a B).

It appears that Miami, Houston and Los Angeles are big fraud cities. HHS investigators discovered that nearly half of 1,581 medical equipment companies they visited in the Miami area weren't open during the day and didn't even have phone numbers.

OK, let's stop right there. Miami only has about 400,000 people (although the entire metro area is over 2.5 million). Doesn't 1,581 medical equipment companies sound excessive for that population size?

The South Florida region bills Medicare more than $2 billion each yea…

Happy Fathers Day

This is how your kids see you. Live up to the challenge.

Top Ten Ways to Identify a Doctor

1. He can tell you something really bad in a nice way.

2. She can't remember her own anniversary but she still remembers the blood results of all the patients.

3. He sees blood and guts and can still think about food.

4. She can sleep (on command) on any surface, at any hour of the day.

5. He can wiz through a 300 page book in a day.

6. She is unshockable and talks about body functions at the dinner table.

7. He keeps asking for things that will never get done.

8. She thinks she has every disease she ever studied.

9. He knows anatomy and what works and what doesn't.

And number 10...

She looks at a naked person on the beach and the first thing she notices is the scar on their abdomen.

(Hat tip to Dimitri for the ideas)

Telephone Medicine

Things are really getting bad in the realm of wacky patient expectations!!!

My medical assistant brought me a phone message and explained "This person says she is your patient (I've never seen her and my practice is closed with rare exception) and she has swollen glands and she thinks it is strept and she wants you to phone in Z-Pack". The pharmacy number was kindly provided.

My reply: "Are you kidding me? Call her back and tell her we will get her in today for an appointment". (Same day appointment for a new patient...quite an offer!)

Medical Assistant a few minutes later: "I spoke to her husband. He says she doesn't want to come in. They will find another doctor who will call in a prescription".

Me: "Hahaha. They will make tons of phone calls and won't even find a doctor who will take a new patient, let alone call in a prescription for someone they have never seen."

(What part of poor medical care, medical-legal risk, doctor s…


Imagine my surprise to see a new fancy red scrolling widget on the right side of my blog that said "Days since Barack Obama has visited Iraq". The hours and minutes were changing (much like the one I placed that highlights the price of addiction to foreign oil). When I clicked on the image it took me to ""...a republican site with lots of republican agendas.

Although it is really hard for me, I try to keep EverythingHealth non-political. There is good and bad with both political parties in the United States and politics itself is a pretty dirty, unhealthy business. But I am upset that hackers were able to get into my blog and actually post something on the template. Wow. Is nothing sacred?

I was able to remove the red widget. Everything else on my site is approved and I always appreciate controversial comments. I have never removed a comment.

But no more GOP propaganda, PLEASE.

Answer-Medical Challenge

The answer to the necrotic finger is #1 Thromboangiitis obliterans.

This is a vaso-occlusive disease that involves small- and medium-sized vessels of the upper and lower extremities. It is strongly associated with tobacco use. An angiogram of this patient's right hand demonstrated multiple chronic occlusions of the digital branches of the small arteries that were unresponsive to IV vasodilators, supporting the diagnosis of thromboangiitis obliterans.

Marantic Endocarditis is deposits of non-bacterial vegetations on the heart valves.
Brachial Entrapment Syndrome is muscular enlargement or compression in the arm that presses on arteries and nerves.Kawasaki Disease affects children and is a vasculitis that affects many organs like the heart, lymph nodes, and causes skin rashes.Takayasu disease is a rare arteritis that affects mainly the aorta.Thanks for taking the challenge! Don't you feel smarter now?

Medical Challenge - What's the Diagnosis?

Here we go with this weeks medical mystery from the New England Journal of Medicine. I got it right! The patient is a smoker and his fingers turn whitish every time he is exposed to cold. What is the diagnosis that caused this severe lesion?
(click on the image for a better view)

1. Thromboangitis obliterans
2. Marantic endocarditis
3. Kawasaki disease
4. Brachial entrapment syndrome
5. Takayasu's arteritis

Take your best guess. The answer will be posted tomorrow!

It's Getting Hot - Drink Water

Thanks to Mens Health for pointing me to the most unhealthy drinks in America. Don't be fooled by:

Glacaeu VitaminWater (any flavor 20 oz)- Pure deception at 130 calories and 33 grams of sugar. You might as well drink a Coke. Hey, this drink is made by Coca Cola! Surprise.Jamba Juice Peanut Butter Moo'd Power Smoothie (30 oz) 169 grams of sugar and 30 grams of fat will pack those fat cells on you. The only "power" will be cellulite.Arizona Kiwi Strawberry (23.5 oz can) - These cans always look healthy and cool and cost under $1 but they pack on 360 calories and 84 grams of sugar.Pina Colada - (you know the size) is the worst summer cocktail . They taste so yummy because they contain 625 calories and 75 grams of sugar. If you are trying to gain weight and don't care about empty sugar calories, this drink is for you.Baskin Robbin's Large Heath Bar Shake (32 oz). This is the #1 most unhealthy drink in America. It contains 2,310 calories, 266 grams of s…

Medical Research - Follow the Money

The use of psychiatric drugs in children has exploded over the past ten years. Powerful new medications for the treatment of attention deficit disorder and bipolar disorder have emerged on the market and we are now learning that three prominent researchers from Harvard have been paid millions by the pharmaceutical industry to promote these drugs for use.

University researchers are supposed to self-disclose consulting and speaker monies they are paid by pharmaceutical companies. They are required to supply conflict of interest forms but it appears they can write anything they want on them and there is little oversight. It has now come out that these physicians under reported their earnings by...are you ready for this....
Dr. Joseph Biederman -$1.6 million, Dr. Timothy Wilens - $1.6 million, Dr. Thomas Spencer - over $1million.

No wonder they wanted to hide it. They had lots to be ashamed of! When prominent and influential physicians publish articles and speak around the world at medi…

Blood Pressure - Whats the Goal?

Our ability to recognize and control high blood pressure has had a dramatic impact on people dying from heart attack over the last forty years. There are scores of different medications that can be used to safely lower blood pressure.

Patients are still confused about what the goal is for blood pressure. And we've learned that measuring blood pressure in the doctors office is not the best way to see if the goal is reached. Patient anxiety, lack of skill by the doctor or nurse and just poor hearing through the stethoscope can affect the results.

New guidelines have evolved and here they are:

Goal blood pressure for most patients younger than 80 years is lower than 140/90. The goal should be under 130/85 if the patient has diabetes, kidney disease or cardiovascular disease.

The patient should have their own automated blood pressure monitor that they use at home and if the majority of readings are not below 140/90, medication should be adjusted or added to reach the goal. Some pati…

Circumcision and STD - the jury is out

The evidence and medical research to support or refute circumcision in boys has not changed in the last 40 years! If you google "circumcision and STD" you will get thousands of search results and no clear science.

In 2006 a major study out of New Zealand showed circumcised men had less incidence of contracting sexually transmitted diseases than non-cut men. Score one for circumcision! Now a new study from New Zealand has been published in The Journal of Pediatricsshowing there is no difference in the incidence of catching a STD. (What's with New Zealand? Is this their contribution to the world's medical knowledge?).

Another study in the United States showed circumcised men had a slightly higher incidence of STD. And yet another study showed circumcised men masturbated more, at least once a month. That one defies common sense. Kinsey proved masturbation was universal in the 1950s. Speaking of masturbation, circumcision became widespread in the 1800's when physicians…

Medical Quiz - Answer

The answer to the image below is #4 - Bilateral peritonsillar abscesses
The picture (along with this one) shows swelling of the soft palate and the uvula (image below) is pushed forward by the enlarged tissue. These abscesses are a medical emergency because they can suddenly interfere with breathing and the patient can become septic. Emergency drainage of the abscess is needed, along with antibiotics to treat the infection.

Thanks for your guesses.

Medical Challenge- You make the diagnosis

You make the diagnosis:
The patient is a 25 year old man who has a severe sore throat, some drooling and difficulty swallowing for the past day. His temperature is 100 and he has no appetite. When you look in his mouth and ask him to say "ahhh"...this is what you see.

What is the diagnosis:
1. Ludwig's angina
2. Glossopharyngeal nerve palsy
3. Pharyngeal gonorrhea
4. Bilateral peritonsillar abscess
5. Infectious mononucleosis

The answer will be posted tomorrow. Click on the image for a better view.

History is Made

History is made as Barack Obama has secured the Democratic nomination for President of the United States. Amazing. This has been the longest primary and it was easy to forget how important this race really is. Let the battle begin!

Lets Learn from Massachusetts

Taking a bold step, Massachusetts decided to cover all its residents with universal healthcare in 2006. It is not a surprise to many of us (and certainly not to the medical bloggers out there) that they soon ran into a problem with primary care access. The community clinics have hundreds of newly insured patients on wait lists of two to four weeks to see a primary care physician.

Making matters worse, the clinics cannot recruit primary care physicians and have had openings for over two years. "What Universal Care has done is highlighted the crisis and the problem that we have with the primary-care workforce," said Dr. Bruce Auerbach, president of the Massachusetts Medical Society. According to a study conducted in 2006 by the society, 53 percent of patients who had an appointment with a primary-care physician were able to see a doctor within a week of initiating contact. Last year, only 42 percent were able to see a doctor within a week.

I believe we cannot even begin to talk …

Medicare - not lovable

Some of my fellow bloggers are so good, I just want to highlight their posts. I happily link you to
Dr. Rob and the 10 reasons he dislikes Medicare. I agree wholeheartedly with all ten.

Medical Journal Update

I scan the Journals so you can watch "reality shows" on TV. Here are some interesting findings in the world of Medicine and Health:

Genes and Anxiety: Anxiety disorders are complex and researchers have provided the first evidence that a gene (RGS2) that influences anxiety in mice is associated with phenotypes for human anxiety disorders including childhood temperament, adult personality and brain function.
They also found a genetic connection for introversion.
(Anyone who has several kids knows they come out with different personality is more confirmation for Nature as the core. I've always said some people in our family "just don't have the anxiety gene." It's nice to be proven right.)
Archives of General Psychiatry

MRSA after Face-lift Surgery: Methicillin-resistant staph aureus (MRSA) infection is an increasingly problematic issue with all surgery.This study looked at patients who underwent face-lift surgery and subsequently developed M…