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What Defines Quality Care and Who Can Afford It?

Interesting thoughts from The Happy Hospitalist:

How do you define quality care?…

If preventing 90% of in-hospital DVT’s with a medicine that cost $30 a day was quality, so be it.

What if you could prevent 99% of in hospital DVT’s with a medicine that cost $300 a day. Would the 90% be quality or the 99% be quality? What if it cost $3,000 a day to prevent 99.99% of in- hospital DVT’s?

Which effort would be considered quality? Who defines the cut off, and at what price?

Here’s what he has to say about Pay for Performance measures, and why they won’t add up to significant savings:

Unfortunately, the measures being undertaken for quality initiatives are, from my stand point, minuscule in terms of the overall potential cost savings to the system.

And the reason is simply, at least in my part of the medical physician spectrum, a very large chunk of health care expenditures comes in the form of evaluation, and not management…

In the medical profession, there exists a sense of universal freedom to order tests, xrays, labs, and procedures with a sense of unlimited funding. Somebody will pay for it. My patient sitting in front of me is the center of my attention and their needs supersede all other needs from a social/financial point of view of the nation…
Where are the government incentives for quality medicine in the evaluation of disease?
Where is your bonus payment for not ordering the heart cath?
For not ordering the CT Angiogram?
Where is your physician bonus payment for not ruling out a low probability DVT?
Or not ordering an EGD?
For choosing watchful waiting.
Where are your quality bonus payments for evaluation of illness?
They simply don’t exist. Because doing so would overtly ration the public and create a firestorm.

Is the storm coming nonetheless?This post originally appeared on Dr. Val’s blog at

Cultural Differences, Food, and Weight Gain

I lived in Texas from 1990 to 1994. I haven’t spent much time there since, although I’ve had my eye on Houston’s unfortunate distinction as “America’s fattest city” for the majority of recent years (though Chicago won the honors in 2006 if I recall correctly). Armed with this knowledge, I arrived in Houston today hoping that I wouldn’t let down the members of my weight loss group as I entered the “lions den” of poor eating habits and sedentary lifestyles.

I had missed lunch, and opted for an early dinner at the hotel restaurant. The menu surprised me in two ways: first, it featured quail and wild boar (this particular hotel chain is not known for culinary artistry – let’s just say that their recent “upscale service campaign” involved an email to me the day prior to arrival, asking if I might like anything special in advance of my arrival – like a 6 pack of Budweiser waiting for me on ice. I kid you not.) Second, they had made an attempt to highlight “heart-healthy food choices” on the menu. One item was identified as heart-healthy. Only one.

So I resisted the urge to try the local southern fare (fried catfish and hush puppies) and decided on the heart-healthy option. Here’s how the conversation went:

Server: “Welcome to XXX. May I start you off with something to drink?”

Dr. Val: [Shivering and somewhat surprised that the AC would be on so high] Well, yes, I think I’ll have some hot tea. Do you have green tea? It’s quite cold in here, isn’t it?

Server: “It’s not cold. The lights above will warm you up real quick.”

Dr. Val: [Looking up towards the track lighting above me, wondering if they could function as a sort of heat lamp.] “Oh, ok.” [Server leaves to put a tea bag in a mug of hot water and returns with it on a napkin.]

Server: “Have you decided what you’d like to order?”

Dr. Val: “Well yes. I think I’ll have the heart-healthy fish, but I was wondering if I could have a side of greens with that?”

Server: “What kind of ‘greens?’”

Dr. Val: “Well, maybe a green salad or some broccoli?”

Server: “Did you see the salads on the menu?” [I can tell she thinks I'm one of those "high maintenance Yankee women" as her voice begins to tighten.] “We have spinach salad or perhaps a Caesar?”

Dr. Val: [Now fully aware that I'm being irritating but desperately wanting to make a healthy choice.] “Yes but those are entree-sized salads and they have bacon, egg, and cheese on them. Do you have something more plain? Or maybe some steamed vegetables…” [My anxiety grows as she stares blankly at me].

Server: “Well did you see the string beans side dish?”

Dr. Val: “Yes, but they’re wrapped in bacon, and [trying hard to help her to understand my quandary] I was hoping to order something healthy… you know what I mean?”

Server: Blank stare.

Dr. Val: Nervous stare.

Server: Sighing, “well I can ask the chef to make the beans without the bacon. Not sure if he can do it, though.”

Dr. Val: “Oh that would be great, thanks so much!”

Server: [Fake smile, whisks menu from my hand, waddles toward kitchen.] 10 minutes pass.

Runner: [Appearing with a huge plate on his shoulder] “Did you order the fish?” [Surprised that anyone ordered the heart-healthy dish].

Dr. Val: “Yes, I did.”

Runner: “Ok, here you go.” [Places gigantic plate in front of me with a separate bowl holding about a half gallon of stir-fried green beans in oil. The fish has cream sauce on top of it, about a quarter inch deep.]

Dr. Val: [Remembering the phrase "Texas-sized." I scrape off cream sauce and cut green beans into bite sized portions. I think to myself: how can anyone eat out in this state and hope to maintain a reasonable weight? I promise myself to go to the hotel gym after my meal...]

Yes my friends, the next 9 days at this conference are going to be interesting. I’ll keep you updated as I rekindle my cultural connections to Texas. And I have the utmost sympathy for Americans who live in places where eating out regularly can be hazardous to your health. Losing weight can be a fight, every step of the way, can’t it?This post originally appeared on Dr. Val’s blog at

Indoor Tanning: Is It Similar To Smoking?

Tanning salons are a $2 billion dollar industry in the U.S., and their bottom line has been damaged by the medical community’s warnings about the link between UV (ultraviolet) exposure and skin cancer. Recent studies have found that some Americans may have too little Vitamin D in their diets, and since the body can synthesize this vitamin when exposed to sunlight, the tanning industry is campaigning for the potential health benefits of UV exposure.  Vitamin D helps to keep bones strong, and may provide protection from osteoporosis, hypertension, cancer, and several autoimmune diseases.

Now, in the interest of full disclosure – I did use tanning salons in my late teens and early 20′s. I knew it could be harmful, but (like a moth to a flame?) couldn’t resist the sweet lure of changing my “glow in the dark” skin to a light shade of cream (no melanin is no melanin, friends). So,  I was more than curious to get an insider perspective on the tanning industry vs. medical professionals battle. I turned to a dermatologist whom I respect immensely: Revolution Health expert, Dr. Stephen Stone. I asked him the following questions:

1. Does exposure to ultraviolet light have health benefits?

Other than for treatment of disease (psoriasis for one, atopic eczema, cutaneous T-cell lymphoma, for example), the only known benefit is the production of Vitamin D in the skin – and adequate vitamin D can be obtained from food and supplements without the danger of UV exposure – and even in the worst climates, the sun is an adequate source of Vitamin D without resorting to tanning beds.

2. What amount of sun exposure is currently recommended?

There is no “recommended daily allowance” for sun exposure, and 15 – 20 min a day of unprotected sun on the arms (not total body) will allow peak production of  vitamin D.

3. Are there alternatives for good health?

UV is not needed at all for “good health.”

4. What evidence is there that exposure to tanning beds increases the risk of skin cancers?

The US dept of HHS and FDA officially classify UV as a “known carcinogen” and there are numerous articles supporting this: Gandini et al., Meta-analysis of risk factors for cutaneous melanoma, European Journal of Cancer,  Westerdahl et al.,  Risk of cutaneous malignant melanoma in relation to use of sunbeds, British Journal of Cancer (2000), Karagas et al., Use of tanning devices and risk of basal and squamous cell cancers, Journal of the NCI (2002).

5. How would you describe that risk?


6. What do you think of the recent ad campaign sponsored by the tanning industry?

Same as I think of cigarette ads!

7. What is your take-home message to patients about tanning salons?

If the cancer doesn’t get you, think of the wrinkles!  We focus on cancer, because that’s life and death, but no one can deny that the UV causes premature aging and wrinkles.

So there you have it, folks. Indoor and outdoor tanning are both harmful to your skin. Whether or not you get cancer, wrinkles are a sure result of excessive exposure to UV radiation (with a little help from our friend, gravity). So I’m going to keep up with my sunscreen (see Dr. Benabio’s blog post), get a skin check annually, and accept myself as the tanless wonder that I am. Or maybe I should create a pale people support group? Any joiners?This post originally appeared on Dr. Val’s blog at

Crazy Talk: Medical Misconceptions and Snake Oil

In my roaming around the blogosphere I found some fairly humorous tidbits. It’s amazing what people will believe, or what crazy “cures” are being sold on the Internet. I thought you enjoy some choice samples:

1. Demi Moore uses leeches to “detoxify her blood.” Dr. Ramona Bates offers a great summary of the potential medical uses of leeches along with some caveats (like a 20% chance of infection with leeches… and a way to keep them from wandering too far afield. Tie a string to their tails? Yikes.) If blood letting is good for detoxification, why not donate blood instead?

2. One snake oil site promises to cure “shock” and cardiac arrests with an herbal liquid that turns out to be mostly brandy. This cure is “also helpful for animals who have experienced mild trauma.” Funny stuff.

3. An Indian magician who claimed to be able to kill people with a magic incantation was unable to do so during a TV show segment. The host of the show offered to be killed though the incantation was unsuccessful. Reminds me of the guy who swore he could make his arm impervious to harm by a sharp sword. That didn’t work either.This post originally appeared on Dr. Val’s blog at

New Online Friends Create Intriguing Weight Loss Strategy

Just when you think you’ve seen it all… I read a charming discussion between two ladies in my online weight loss group. They were both understandably frustrated with the daily struggle to increase their activity levels, and were looking for some accountability and motivation. Apparently one has begun using a weighted exercise hoop for cardiovascular fitness, and offered to help the other to get back in the exercise groove.

That’s right, hula hoop your way to a thinner you! I’d never have guessed that I’d be saying this, but if the humble hula hoop is your exercise of choice, then by all means, use it to lose weight. I might just get one myself!

Anyone care to join us?This post originally appeared on Dr. Val’s blog at

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