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Judging Illness Severity And The Financial Implications Of Dialing 911

Nora misjudged the height of the stair outside the restaurant, stepped down too hard, jammed her knee and tore her meniscus.  Not that we knew this at the time.  All we knew then was that she was howling from the pain.

There we were on a dark, empty, wet street in lower Manhattan, not a cab in sight, with a wailing, immobile woman.  What to do?  Call 911? Find a cab to take her home and contact her primary care doctor for advice?  Take her home, put ice on her knee, feed her Advil and call her doctor in the morning?

Sometimes it is clear that the only response to a health crisis is to call 911 and head for the emergency department (ED).  But in this case – and in so many others we encounter with our kids, our parents, our co-workers and on the street – the course of action is less obvious, while the demand for some action is urgent.

The question “which action?” has become more complicated of late because:

  • In some communities, there are alternatives to an ambulance or a drive to the nearest ED, such as Urgent Care centers.
  • Disincentives exist for going the route of the ED: in many cash-strapped municipalities we are charged for the cost of ambulance ride; we risk not having our ED visit covered by insurance if we make the wrong decision or fail to notify our health plan in a timely manner.  Or we don’t have insurance and the ED care is expensive.
  • Some of us have a number of clinicians who could guide us about ED versus self care on any urgent health matter, plus our health plan may have a nurse advice line that could do the same.  Which among them to call?  How long will it take to get an answer in the middle of a busy workday or a late night?
  • Many of us have no primary care clinician to call. Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

When Regular Medicine Doesn’t Pay: Doctors Turn To Cosmetic Work

This MSN article states that doctor-owned hospitals are on the rise. In California, the opposite is the case. The hospital business is a lousy business in which to be. I would rather open a surgical facility. I had an opportunity to be a part of a group that bought a hospital a few years ago and passed.

In California, real medicine is going into the toilet as doctors realize that the work they have put in to get educated makes practicing fairly unrewarding. Niche markets and gimmicks are replacing the conventional medical landscape. That’s the reason we have so many non-plastic surgeons turning to cosmetic work. The bottom line is that you need to pay doctors enough so they can make a decent living or they will find something else to do.

Sad but true.

*This blog post was originally published at Truth in Cosmetic Surgery*

Why Double Mastectomies Are Popular: Watchful Waiting Is Too Difficult?

The rise of prophylactic double mastectomy in women with increased risk of breast cancer has been a topic of recent discussion. In particular, this trend has been observed amongst women with the diagnosis of unilateral carcinoma in situ, or pre-invasive breast cancer. While it has been known that in women with genetic cancer syndromes, including BRCA1 and BRCA2, double mastectomy reduces risk, the efficacy of the approach is uncertain in women with other risk profiles, yet more women and surgeons seem to be doing it.

Knowing when to test, treat and act is part of art of medical practice. The ability to convey this information effectively is also an art. Both patients and doctors may have a hard time embracing watchful waiting with respect to many forms of cancer and pre-cancer. In the case of cancer of the cervix, it is known that infection with human papillomavirus (HPV) is causative in cancer development. However, only a small percentage of those infected actually go on to get cancer. Low grade dysplasia, a condition that is early in the cervical cancer development continuum, frequently spontaneously resolves without treatment. Fortunately, in the case of cervical cancer, there is now a vaccine to prevent high risk HPV infection.

“Watchful waiting” has been most discussed as a treatment strategy for prostate cancer. Read more »

*This blog post was originally published at ACP Internist*

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Latest Book Reviews

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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