Gruesome costumes abound at Revolution Health today. Characters from popular horror movies seem to be a favorite, some employees even toted plastic chainsaws and spouted red ink/blood. As I was chased down a hallway by a ghoulish colleague who pretended to amputate one of my arms, I began to think - maybe this could be the subject of an interesting blog post? [Enter awkward segue here.]

Did you know that one in every 200 people in the United States has had a limb amputation of some kind? While the majority of amputations occur due to poor circulation (usually related to diabetes), some are caused by trauma, cancer, or birth defects. Limb loss is not a fictional issue, but a real concern for more people than you think. The good news is that most folks do very well with prostheses and rehabilitation programs. But since this is Halloween, I couldn’t resist discussing a potential complication of limb loss: phantom pain.

“Phantom pain” is the term used to describe pain sensations in a missing limb. Although this may sound impossible at first (how can a person feel pain in his foot when that same leg was amputated already?) the reality is that the brain takes some time to adjust to limb loss. The human brain has entire sections devoted to sensing input from and delivering movement messages to our arms and legs. When an arm or leg is lost, that part of the brain continues to function for several months or more. And so as the local brain cells lack the usual input from the nerves in the absent limb, they fire in a spontaneous manner that is perceived as cramping, aching, or burning.

How on earth can you treat this kind of pain? As you can imagine, it’s quite tricky. Some of the more successful approaches involve helping the brain to adjust to the loss of sensory input by touching or massaging the stump and walking on a limb prosthesis. These new sensations help the brain to adjust to the body’s changes. In fact, imagining moving the lost arm or leg can result in some relief of the perceived pain. This is the one case I can think of where imaginary exercise can be of real benefit to your body!Some folks do require special pain medicines (tricyclic antidepressants, seizure meds, and beta blockers can help modestly) to cope while their brain adjusts to the new input. However, most amputees experience the sensation that their limb is still there, but without any pain or unpleasantness. Phantom sensations and phantom pain almost always resolve with time - which is a testament to the amazing flexibility (or “plasticity“) of the human brain.

That being said, I hope you each have a safe Halloween - and that your only potential injury comes from a ghoul with a plastic chain saw.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

I spent several months working with men and women recovering from severe traumatic brain injuries (TBIs) in an inpatient hospital unit. I remember afternoons spent at Burke Rehabilitation Center, gathering wheelchair-bound patients for afternoon snacks in a white corridor. I gazed out at the men and women sitting there, some with large cranial defects (half of their skulls were surgically removed in an attempt to make more room for swollen brain tissue) causing their heads to look like dented metal toys. Many were non-verbal, some were having difficulty controlling their saliva, others appeared aware of their circumstances but unable to plan smooth motor movements. Each had been through a life changing accident - they survived, but their bodies did not seem to house the person they were before. I watched as their loved ones occasionally peered into their eyes, searching for a connection that was not reciprocated.

Although these severe TBIs are the most dramatic, and few rarely recover completely (one of the most miraculous recoveries I’ve witnessed is that of TV news anchor Bob Woodruff), there is a growing population of milder TBI patients who have gone virtually unnoticed amongst the more obviously wounded.

A recent analysis of soldiers serving in Iraq suggests that as many as 20% of them may have suffered at least a mild TBI due to exposure to roadside bombs and IEDs. While concussions are included in the category of mild TBI (and people generally make a full recovery from them), the line between mild and moderate injury can be blurry - and long term disability can occur in this gray zone. Memory impairment, difficulty concentrating, mood alterations, personality changes, dizziness, seizures, and chronic headaches can plague those who’ve suffered TBIs, though because they function relatively normally (or have no obvious physical injuries), their injuries may be dismissed or misunderstood.

According to an essay in the New England Journal of Medicine, there are over 5.3 million Americans living with TBI related disability.

The Department of Veterans Affairsis now planning for the large influx of veterans with TBIs from the current conflicts who will need continuing care during the coming years. “These are people who are going back into our communities all across the country, who are potentially goingto be struggling,” said Warden. “Keep in mind, these patients,because of the nature of their brain injuries, can be the ones at highest risk of falling through the cracks.”

“Not all of them recover,” noted Colonel Jean Dailey, a nursing supervisor on the neuroscience unit. “It can wear on you.” Dailey added that nurses on her unit have higher turnover rates thanthose on the hospital’s orthopedic ward, which chiefly treats soldiers with limb injuries. Unlike the young amputees, she said, “these guys’ personalities are not the same” as before they were injured. In fact, she says, “they may never be the same.”

Sometimes wartime injuries such as amputations or cosmetic defects are easier to bear than the pain of a personality change or an inability to think clearly. TBI creates a kind of “lost boys syndrome” where the injured can be present and yet never themselves. Awareness of this problem may be the first step in demonstrating compassion for the millions who are trying to regain normalcy in the face of potentially permanent cognitive deficits.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Thanks to a tip from the Cheerful Oncologist, I’ve been made aware of a potentially frightening new way to give patients inaccurate information about physician quality. The Attorney General for the State of New York as well as the President of the AMA have spoken out against health insurance companies who are planning to rate doctors based upon how few tests, procedures, and medication they give out. The insurance companies may say that they are measuring adherence to “evidence based medical standards” but in essence the basis of the rankings is financial. Those doctors who spend less of the insurance company’s cash are rewarded by being rated as outstanding clinicians - and in the end the patients are routed towards physicians who are less likely to provide a full compliment of treatment options.

This trend further underscores the importance of “considering the source” of information you receive.  Physician ratings by patients (such as those that you’ll find at Revolution Health) can give insight into a doctor’s bedside manner and office practice friendliness and efficiency, while ratings generated by companies like America’s Top Doctors poll peers regarding clinical excellence. Each rating system has inherent limitations and biases. In the end, word of mouth will often trump ratings by strangers when it comes to selecting a physician. The good news is that most doctors are competent and well meaning, and the bad apples are quite rare. If you ever feel that your doctor is not giving you excellent or appropriate care, by all means seek a second opinion, especially when it comes to the treatment of life threatening conditions.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Dr. Alan Dappen is available to his patients 24 hours a day, 7 days a week, by phone, email and in person. Visits may be scheduled on the same day if needed, prescriptions may be refilled any time without an office visit, he makes house calls, and all records are kept private and digital on a hard drive in his office.

How much would it cost to have the luxury of a personal physician on-call for your every whim?

Would you believe only about $300/year?

What’s Dr. Dappen’s secret to success? He accepts no insurance, keeps his overhead low, offers full price transparency, has physician extenders who work with him, and charges people for his time, not for a complex menu of tests and procedures.

“I believe in doing what is necessary and not doing what is not necessary. The healthcare system is broken because it has perverse incentives, complicated reimbursement strategies, and cuts the patient out of the billing process. When patients don’t care what something costs, and believe that everything should be free, doctors will charge as much as they can. Third party payers use medical records to deny coverage to patients, collectively bargain for lower reimbursement, and set arbitrary fees that reward tests and procedures. This creates a bizarre positive feedback loop that results in a feeding frenzy of billing and unnecessary charges, tests, and procedures. Unlike any other sector, more competition actually drives up costs.”

After building a successful traditional family medicine practice in Fairfax Virginia, Dr. Dappen felt morally compelled to cease accepting insurance so that he could be free to practice good medicine without having to figure out how to get paid for it. He noticed that at least 50% of office visits were not necessary - and issues could be handled by phone in those cases. Phone interviews, of course, were not reimbursable by insurance.

“The physical exam is a straw man for reimbursement. Doctors require people to appear in person at their offices so that they can bill for the time spent caring for them. But for longstanding adult patients, the physical exam rarely changes medical management of their condition. It simply allows physicians to be reimbursed for their time. Cutting the middle man (health insurance) out of the equation allows me to give patients what they need without wasting their time in unnecessary in-person visits. This also frees up my schedule so that I can spend more time with those who really do need an in-person visit.”

Health insurance is certainly necessary to guard against financially catastrophic illness. And the poor need a safety net beyond what Dr. Dappen can provide. But for routine care, “concierge medicine” can make healthcare affordable to the middle class, and reduces costs by at least 50% while dramatically increasing convenience. For the right patient, this is a welcome relief from having to wait to be seen by in-network providers or from being billed non-preferred rates as an uninsured individual. I applaud Dr. Dappen for his efforts in healthcare reform, and look forward to a movement where costs are driven down by putting patients back in the payer seat.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

My new mantra - “don’t think about chocolate!” is sure to be a failure. I had hoped that increasing my resolve against the lure of Halloween treats would improve my chances of making it to Christmas a little slimmer in the sneakers. But I’m afraid that new research has proven my strategy quite foolhardy.

One hundred and thirty-four subjects were randomized into two groups: half were asked to either suppress all thoughts about chocolate, or talk about how much they liked it. Women who tried to suppress their cravings ate on average eight chocolates, while those who talked freely about it ate five.

So in the spirit of losing weight for the holidays - let’s discuss which chocolate items we like best. I like anything with chocolate hazelnut centers - or Nutella. I also love caramel-chocolate combos. How about you?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.