Tuesday, January 31, 2012

EverythingHealth Anniversary

Thank you to loyal blog follower, KM, for this cute pic.  EverythingHealth is now getting over 4,000 page views a day from all over the globe.  That is just amazing to me and I have met so many wonderful bloggers over the past 5 years. I am fascinated by the power of the internet and how readily information can be found.

My goal of providing credible, up to date information without commercial content has guided me throughout these years.  I often forget my old posts until someone reminds me...then I am surprised all over again.  Researching and writing this blog keeps me on top of my game.

Thank you for visiting EverythingHealth.  Sign up on the right side for an alert and you will get a link for each new post.

Sunday, January 29, 2012

Romney Should be Proud of Massachusetts Health Care

I don't understand why Mitt Romney is running away from the Massachusetts health reform that was enacted in 2006 under his reign as Governor. They are in their 6th year and by any standards it can be considered a success.

The plan included Medicaid expansion, subsidized private health insurance, a health insurance exchange, insurance market reforms and requirements for individuals and employers. Is the fact that the Federal Accountable Care Act (Obama-care) has many provisions of Mass. health reform the reason Mr. Romney and the GOP want to bury it's success?

Oh, you didn't know it was a success?  How strange...

Let's look at the plan and what it has done for the citizens of that State. Insurance rates did not sky-rocket and employer-sponsored insurance is still strong. Access to health care remained strong and there were reductions in emergency department visits. Hospital stays declined and there were improvements in self-reported health status. Since the act, 94.2% of adults now have health coverage. That compares to 77.7% in the rest of the Country. Remember the scare that employers will drop insurance coverage when The Accountable Care Act is fully implemented?

In Massachusetts more than 2/3 of adults age 19-64 reported coverage through an employer, significantly higher than before health reform. Since Massachusetts Health Reform, more employees rated their employer sponsored insurance plans as very good or excellent. Patients also were more likely to have preventive care visits (up 5.9%), a specialist visit (up 3.7%), dental care (up 5%) and even have a usual place to go when they were sick or needed advice (up 4.7%). Also these patients were more likely to report that they got doctor care, tests and treatment when it was needed. Readers, this is amazing yet Mitt Romney and the GOP are running from it like Herpes.

OK, it's not all rosy. The Massachusetts 2006 health reform initiative did not tackle the high cost of health care in the state. Insurance premiums continue to rise and health care costs in Mass., just like the rest of the Country, continue to grow faster than inflation. Despite that, it did become more affordable because there was less out of pocket health care spending by patients (excluding premiums). There was no change in patients' problems paying medical bills before or after health reform.  Health Care in the United States just plain costs too much.

What does it say about Mr. Romney and the rest of the GOP that they wouldn't take this successful ball and run with it?

If I were on the Mitt Romney's team, I would tell him to change the dialog. He should be bragging about what was done in Massachusetts. He should take credit for it and reveal these statistics. With the political noise and posturing, American's deserve to know the facts.

If Mitt wants to run from something, try the dog on the car roof or his trickle down economics.  Now that would be something worth hiding. 

Wednesday, January 25, 2012

Heavy Menstrual Bleeding

Heavy menstrual bleeding is common and 10% of all women experience it in their reproductive years.  Women who are NOT in menopause and who have heavy bleeding that occurs during their regular cycle usually have a benign reason for the bleeding.   Fibroids and endometrial polyps are common causes of heavy bleeding periods.

Menorrhagia is the medical term for abnormally heavy periods.  This bleeding is often associated with severe cramps.  What is considered heavy?  Soaking through one or more sanitary pads or tampons every hour for several hours or needing to wake up during the night to change protection is heavy.  Bleeding for longer than a week or passing blood clots is abnormal also.  Menorrhagia should be evaluated by a physician to rule out polyps, bleeding disorders and other medical conditions like pelvic inflammatory disease, endometriosis or thyroid problems.

Once reversible causes have been excluded, most women respond to treatment with oral contraceptives to regulate hormones and minimize bleeding.  For women who do not want to go on the pill, nonsteroidal anti-inflammatory drugs (NSAIDS) are very effective in reducing blood flow and cramps.  The best choice is Naproxen at 500mg twice a day.  Ponstel is another drug that is effective for bleeding and hormone associated migraine headaches.

Women who took Naproxen were 10 times more likely to report an improvement in symptoms compared with placebo and there was a 30% reduction in blood flow.  Naproxen is cheap and does not require a prescription. (Aleve)

Tuesday, January 24, 2012

Migraine Headaches and Oral Contraceptives

Women who are taking oral contraceptives (Birth Control Pill) and develop new migraine headaches or increased severity of headaches after starting the Pill should be told to discontinue the Pill.  Women with migraine who use oral contraceptives are at a 2-4 fold increased risk of ischemic stroke compared to women who have migraines and are not on the pill. 

The risk of a young woman having a stroke is very small if she is not a smoker.   Smoking increases this risk and women who smoke should not take the Pill because it increases the risk of both heart attacks and strokes.  Even the low dose oral contraceptive is not completely safe in smokers. 

A  woman under age 35, who does not smoke and has longstanding migraine headaches without "aura" may be prescribed OCPs because the risk of stroke is small in this group.  New migraine, however, is an indication to stop the pill and use another form of birth control.

Monday, January 23, 2012

A Novel Approach: Ask the Primary Care Doctor

The government, academics and policywonks are always in the process of "redesigning" health care.  Patients with increased health care needs are considered "complex" and these patients consume the major health resources (translate: "money").  In fact 65% of total health care expenditures are directed toward the 25% of patients with multiple chronic conditions.  Eighty percent of Medicare spending is on patients with 4 or more chronic diseases.  For the first time a study has been done and published in The Annals of Internal Medicine  that actually asks primary care physicians (PCPs) what defines patient complexity.  Who better than the treating doctor to answer this question?

The researchers asked 40 primary care physicians to rate the complexity of 120 of their own patients and to document the characteristics associated with complexity.  Over 1/4 of patients were described by the doctors as "complex".  The doctors were not told what defined "complexity", but instead were asked to describe it in their view.  Once a patient was described as "complex" the doctor was given 5 domains to chose from, developed from previously published concepts.  The 5 domains were:
  • Medical decision making (cognitive effort needed to make appropriate diagnoses and therapeutic decisions)
  • Coordination of care (overseeing care involving others and for making sure that the medical system is working for the patient)
  • Patients personal characteristics (challenging patients)
  • Patients with mental health issues (includes substance abuse)
  • Patients socioeconomic circumstances (home and work issues, inability to afford medication)
Some characteristics of PCP-defined complex patients stood out.  They were more likely to be over age 60 and women.  They were more likely to have government insurance (Medicare/Medicaid) than commercial insurance.  They were more likely to be undereducated and had many office visits.  They took more than twice as many prescribed medications.

I find it fascinating that most of the PCP identified complex patients were not considered high risk by the Medicare model and other known models.  The algorithms that guide payment and other policy decisions didn't hold up.  The patients identified as complex by PCPs affect their workday and time, yet the known models would not have called them complex.  More than co-morbidity and other case-mix definitions, factors like inadequate insurance, alcohol related problems, prescriptions for anxiety and other mental health issues were all associated with increased complexity per the physicians.  These patients generated more visits, more high cost procedures and more need for mental health services.

The fact that doctors are finally being asked about their work is promising.  It is predicted that 32 million uninsured Americans will come into the primary care system with the passage of the Patient Protection and Affordable Care Act.  This at a time when fewer medical school graduates are entering primary care and many PCPs are leaving clinical practice due to work related stress and decreased job satisfaction.

These results actually provide insight that should be considered in designing a health care system that works for patients and care-givers.  It should influence payment mechanisms, office support and allow the extra time it takes to care for complex patients.  These changes would go a long way to increasing the work satisfaction for PCPs.

The fact that this was the first study that actually defined complexity from the PCP perspective is amazing.  Let's hope it is the start of something that will ultimately improve the health care system for patients and PCPs.

Friday, January 20, 2012

The Many Faces of Psoriasis

This 26 year old female noticed that her nails had been changing over a 6 month period.  Note the small pits and separation of the nail plate from the nail bed.  This lifting is called onycholysis.  There is only one disease where both of these findings are seen together and that is psoriasis.

Most people think of psoriasis as a skin disorder with patchy silvery plaques that form on the elbows, arms, knees and back.   But it is a genetic condition that can also affect the nails and 1/3 of patients develop psoriatic arthritis.  It is actually a very common disorder with wide variation in skin, joint and nail involvement.   The condition can come and go and there are a number of treatments to control symptoms, but no cure.

severe psoriasis
Before and after treatment
Psoriasis is not contagious and you cannot "catch" it.  The National Psoriasis Foundation conducted a survey of patients with psoriasis in 2008 and 71% said psoriasis was a difficult problem for them with self consciousness and embarrassment about the condition.  More than a third said they limited social activities and limited intimate interactions.

Education is the key.  If everyone understood the skin and nail changes of this condition they would know there is nothing weird about it and nothing to fear.

Bone Mineral Density Tests

The recommendations for when and how often women should be tested for osteoporosis with bone density testing (DXA Scan) has been vague.   Many women are tested in their early 50s when they go through menopause with follow up tests as frequently as every year.  Others break a hip without ever being tested.

 A new study published in The New England Journal of Medicine states that bone loss develops slowly and women who have a  normal test when they are 65 do not need to be retested for 15 years!  Even women who show some bone loss can wait many years before they are tested again, according the the study authors.

The study followed 5,000 women over age 67 for over 10 years.  These women did not have osteoporosis at the beginning and they found fewer than 1% of women with normal beginning bone density developed osteoporosis over the next 15 years.  Only 5% of women who started with mild bone loss developed osteoporosis.

This study points to the fact that we have been over testing normal women who would not develop significant bone loss.  But there are a few aspects of the study that are important to note.  They only studied women with normal or slightly low Bone Mineral Density (BMD).  Women who have had prior broken bones, or who have significant bone loss at the time of screening should be followed more closely...perhaps every 3-5 years.

Not everyone agrees with the 15 year recommendation either.  "An interval of 15 years is too long", says Felicia Cosman, MD, senior clinical director for the National Osteoporosis Foundation.  She cites flaws in the study design.

Here is what I recommend for patients.  Get a screening BMD test at age 60-65.  If you are a smoker, take corticosteroid drugs,  are thin and fair, or have a mother or sister with osteoporosis or a broken hip, have the first screening test within 5 years of your last menopause period.  If that first DXA test is in the normal range,  there is no reason to repeat the test for at least 10 more years.  If the first test shows mild to moderate bone loss, repeat in 3 years to assess stability.  The most important test is the first one to establish a baseline and further testing should be tailored toward each individual woman.

There is an easy online tool that can help women and men calculate their risk of having a fracture in the nest 10 years.  It can help guide us to when we need to get a Bone Mineral Density (BMD) test by taking account of certain known risk factors.

Saturday, January 14, 2012

Skin Conditions With Aging

Patients often have growths or skin changes that they wonder about.  After examining them, in many cases I say "happy birthday"...it's a manifestation of getting older.  Aging leads to a number of skin and hair changes and when you add the effects of sun, smoking and the environment,  the changes can be profound.
Over time the epidermis thins and by age 60 the dermis is 20% thinner than before.  It is even thinner in areas that have been exposed to the sun.  But even skin that has not been exposed to ultraviolet radiation has 50% fewer mast cells and reduced blood flow, not to mention diminished elastic fiber and collagen.

Pictures are worth a thousand words so here are some to show the changes.
Fine and deep wrinkles are evident on this face.  Thin skin around the eyes causes bags and drooping of the eyelid.

Actinic Keratosis are benign, dry, reddish, crusty lesions that appear on sun exposed ares like the face, ears, hands, chest and arms.  Sometimes a biopsy is needed to differentiate from a squamous cell carcinoma but sun protection from an early age is the best way to avoid them.
 Senile Purpura is really just bruising in older skin.  These dramatic purple blotches form because the blood vessels are fragile and the skin is so thin.  It does not indicate vitamin deficiency or any bleeding disorder.

Healthy skin can be maintained by avoiding cigarettes and sun.  Those are the two most damaging influences for skin and blood vessels.

Thursday, January 12, 2012

Haiti Remembered

This is the 2nd anniversary of the terrible Haiti Earthquake that measured 7.0 on the scale. The disaster killed 316,000 people and displaced 1.5 million more.  Even now more than 500,000 people are still in makeshift shelters and only half of the aid pledged for reconstruction has been spent. 

My organization sent medical teams and supplies to the disaster zone and our doctors and nurses continue to support a hospital with teaching and supplies.  I led a team of dedicated caregivers to Port-Au-Prince where we served under the most austere conditions.  Supplies were non existent.  There was no running water in the hospital and the magnitude of the health problems required infrastructure that was not there...and still is not there.  

The following is a reprint of a blog I did on 3/20/2010.

I can't get the stories of Haiti out of my mind.

A patient showed up at the Port Au Prince hospital ward with a massive left sided paralysis, an obvious stroke. This 48 year old woman had collapsed the day before and was now accompanied by her three grown daughters, who were most attentive and worried. I examined her in the bed with other patients and families gathered around. (There is no sense of privacy and even an exam seems to be everyone's business in Haiti). One daughter spoke broken English but I had a good translator that helped me get the information I needed.

It was a sad story. They had been on the 5th floor when the Earthquake hit. They fell straight down and dad was killed. One of the children had a crush injury to his leg and the entire remaining family was now "on the street". Just surviving must have been such a strain. Then...mom has a massive stroke.

As I was examining the patient further, one daughter handed me a quickly scrawled note. It read. "I have a problem She have a AIDS" In this private way, the daughter wanted me to know her mom had AIDS.

In a country with such poverty, lack of health care and lack of education, it is not a surprise that HIV and AIDS remains a significant problem and Haiti is the Caribbean island most affected by AIDS. There also remains a stigma and HIV infection is a big secret. Once I asked my Haitian interpreter to ask an emaciated patient if he was HIV positive and the interpreter couldn't even ask the question. It is just not done. It was a real act of bravery for that daughter to pass me the secret note.

Needless to say, AIDS will be the least of this family's problem. I can't begin to imagine how a woman with a stroke, who will likely not receive any rehabilitation, can live on the street. By the time I left, she needed 2 people to assist her out of bed into a chair...where she could not sit straight. 

This is the continued tragedy of the Earthquake and the aftermath of human misery it left.

Tuesday, January 10, 2012

Patients Owning Their Medical Records

Traditionally, the patient chart stayed in the doctors office and rarely did a patient get a glimpse of anything in the record.  Photocopying the chart is expensive and no physician would let a chart leave her office because the record must be held safely for a minimum of 7 years.   Now more and more offices are doing away with clunky paper charts and electronic medical records are becoming the norm.  With electronic portals, is there any reason a patient shouldn't have access to their own medical record?

A study published in the Annals of Internal Medicine reported that up to 97% of patients queried thought the ability to have "open visit chart notes" was a good thing.  Doctors weren't quite so eager.

The study found that doctors worried that open visit notes would result in greater confusion and worry among patients and they anticipated more patient questions between visits.  But the patients overwhelmingly wanted to see the notes and were not worried about being confused.   They thought seeing their own record would provide information that would help them be healthier.  They could see the treatment plans and the test results directly.

One of the study authors, Dr.  Joann Elmore at University of Washington School of Medicine, said that access to records is important for indigent patients or people who move frequently for continuity of care.

It is a new world of sharing of information and there is no reason medicine shouldn't be part of the change.  Patients have access to research studies on-line as well as multiple medical websites  to look things up. (Some  are just junk and filled with ads).   If open records helps create a dialog about good health and allows patients to understand and take ownership of their own life it can only be a good thing.

I do worry a bit about the overly obsessive patient who might misinterpret every slight lab value that is outside of normal.  They will need to understand that not everything carries the same weight in medicine and slight variations of normal can in fact be...normal.

What do you think?  Do you want to see your medical record?

Tuesday, January 3, 2012

Nail Trauma Paronychia

My patient welcomed in the New Year by doing a midnight 21 mile run through the streets of San Francisco.  It was a clear, crisp night and what a healthy and invigorating way to celebrate New Year's Eve!  The next day, however, her 2nd toe looked like this.  It was throbbing and tender to the touch.  She did not remember any specific trauma.

By the looks of the photo, it is a paronychia, an infection around a fingernail or toenail.  This infection is probably the result of repeated trauma as her foot struck the ground and the top of the nail struck her shoe.  A little bacteria (staphylococcus) was able to take hold in the skin as it broke through the protective cuticle.

Because she is healthy, without diabetes or other immune problems, I advised frequent hot water soaks to increase blood flow and (hopefully) promote natural immune healing.  If the swelling worsens or pus appears, it can be cured by excising it to drain.  Topical antibiotics are of no use and rarely are oral antibiotics needed unless the infection is worsening.

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...