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Skin Cream: "All Natural" Isn’t Always Better

I learned something interesting today from Dr. Benabio’s Derm Blog: bacteria love to grow in skin cream. He said that it was kind of like cream cheese – leaving it out at room temperature would cause it to go bad pretty quickly, were it not for the usual preservatives. He described an outbreak of a deadly bacterial infection in a hospital ICU – caused by nurses using “all natural” European (preservative-free) skin cream on their patients.

So there you have it folks – deadly bacteria are indeed “all natural.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Mandatory Adverse Outcome Reporting Makes Doctors Shy Away From Treating High Risk Patients

One of my favorite healthcare policy blogs is Dr. Rich’s Covert Rationing. In his most recent post he discusses a research study linking New York State’s public report card system to increased heart patient death rates. Doctors’ names are published alongside their procedure-related mortality figures, so if a patient dies while undergoing a risky (though potentially life-saving) procedure, the doctor’s grade suffers.

It’s no surprise that doctors are more hesitant to operate on high risk patients if their professional reputation is on the line. The result is that patients with heart problems in New York State are less likely to receive life saving therapies.

Now here’s where my outrage increased exponentially – Dr. Rich argues that report cards are actively promoted by payers (health insurance companies and the government) under the guise of patient empowerment (they deserve transparency about their doctors’ performance record, right?) But the real truth is that the payers are benefiting financially from the report card system. Fewer procedures mean lower pay outs, and if high risk patients die sooner, then they save even more on care costs.

Man, that’s depressing. So many reforms with “good intentions” result in unanticipated harm. Though strangely I can’t think of too many reforms that harm the payers. Can you?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Doctors: Whom Can You Trust?

I must have a really trustworthy face. No matter where I go, absolute strangers ask me for directions, they request that I watch their belongings, hold their place in line, they even ask me to help with their kids. I am continually astonished by the uninvited inquiries that I receive walking down the street, on the train, or even in foreign countries. I guess people think I’m both harmless and likely to know how to help them. They are right about the first part, and not quite as right about the second.

Just a couple of days ago I was settling into a train seat when the woman in front of me peaked over the head rest and asked if I’d mind watching her bags while she left to go to the restroom. I happily agreed to do so, wondering what I’d actually do if someone tried to take her bag. And as I mused about how on earth I’d won her absolute confidence without even making eye contact, I began to think about the idea of trust. How do patients decide whom they trust with their medical care?

I’d like to think that trust is earned – and many times it is – but there’s also something more primitive about it than that. Without knowing a person for long enough to judge his or her character, we often draw conclusions nonetheless. How successful are we at these snap decisions? Well, we might be quite good at it. I was amused to find an online test where you may judge the sincerity of a person’s smile just by looking at a 4 second video clip. Some of the models were asked to smile convincingly, and others were told a joke or were caused to laugh by some genuine means. Most people figure out which smile is contrived and which is natural most of the time. See how you do.

And so, when it comes to finding a primary care physician, or a doctor that you trust with your medical care, should you rely on your gut instincts or is there a better way to assess their competency?

I’ve wrestled with the idea of online physician ratings for a couple of years. Part of me thinks that it’s impossible to capture all the qualities of a good physician in some simplified form filled out by non-medical professionals. But another part of me wonders if a large collection of different experiences might add up to an opinion trend that’s on the mark. Whether or not you’re a fan of physician ratings, they are here to stay. Perhaps the best we can do is offer as many ratings as possible so that the average might provide high level, helpful information. Revolution Health has a free physician rating tool. Check it out.

How do you know whom to trust? Do you rely on your instincts or the referral of someone you know? Would online physician ratings be helpful, harmful, or simply limited in their utility?

Let me know… and if you see me on the street, yes, I’d be happy to watch your bags.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Lack of "Continuity of Care" Can Kill

For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.

Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:

Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.

Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.

So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.

Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.

How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.

There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?

This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.

I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.

What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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