Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

How Sprained Ankles Can Lead To Cancer Drug Rationing

New York Times blogger Tara Parker Pope describes how her daughter was recently “the victim” of excessive medical investigation. Apparently, the little girl twisted her ankle at dance camp and experienced a slower than normal recovery. Four weeks out from the sprain, Tara sought the help of a specialist rather than returning to her pediatrician. The resulting MRI led to blood testing, which led to more testing, and more specialist input, etc. until the costs had spiraled out of control – not that Tara cared much because (as she admits) “I had lost track because it was all covered by insurance.”

Instead of any twinge of guilt on the part of Ms. Pope for having single-handedly called in the cavalry for an ankle sprain, she concluded that her daughter was a victim of medical over-investigation. But what would any physician do in the face of a concerned pseudo-celebrity parent (with a huge platform from which to complain about her medical treatment)? The doctor would leave no stone unturned, so as to protect herself from accusations of “missing a diagnosis” or being insufficiently concerned about the ankle sprain.

The responses to Ms. Pope’s personal “horror story” about over-treatment (and the waste of billions of dollars inherent in the US medical system) were amusing. One commenter writes, “Why not think of the unnecessary $210 billion as a fiscal ‘stimulus?’ Makes as much sense as any other program in the Age of Obama/Krugman.” And another, “[Of course there's over-treatment] because the federal government subsidizes it! Medicaid, Medicare, and third party private insurance all promote the use of wasteful health care spending. And Obamacare will put that process on steroids.”

Whether or not you agree that socialized medicine reduces healthcare costs, it seems to me that we all have a responsibility not to over-utilize medical resources so that they will still be there when we really need them. Over-investigating every pediatric ankle sprain will simply drain our collective resources, ultimately resulting in further healthcare rationing. New York Times writer Peter Singer has argued that rationing is inevitable and decisions about cancer drug treatment will become the purview of US government agencies as time goes on. I’m pretty sure he’s right.

That being the case, why spur on rationing? Ms. Pope’s victim mentality demonstrates her lack of insight into the true causes of rising healthcare costs – one of which is patient demand. Ms. Pope herself is contributing to the healthcare waste she despises by requesting excessive testing in an environment where physicians are afraid to say no due to legal pressures (or a NYT writer’s bully pulpit). Demand drives costs, and there is a finite limit on our resources. Personal responsibility must play a role in healthcare utilization, just as efforts to protect our environment and scarce resources require participation by individuals. Ultimately, one child’s ankle investigation comes at the price of another patient’s cancer treatment.

Was it the physicians’ responsibility to put the brakes on her daughter’s over-testing? Maybe, but I’d prefer to live in a world where patients can invoke additional testing when their personal judgment suggests that it’s important. Ms. Pope knew better, but requested the additional testing because her insurance paid for it. Free care leads to more care – especially more unnecessary care. Ms. Pope’s daughter was not a victim of over-testing, but a beneficiary of that luxury that may soon evaporate.

We can create a healthcare system where no ankle gets more than a physical exam and ibuprofen (so we can forcibly prevent over-utilization), or we can teach people to use healthcare resources responsibly. Unfortunately, that will require that patients have a little more financial skin in the game – as Ms. Pope has demonstrated. The alternative, a distant oversight body regulating what you can and can’t have access to in healthcare, is where we’ll probably end up. Some day in the future Ms. Pope will recall the day when she was able to get unlimited medical investigations for her daughter without question or cost, and she’ll marvel at how that freedom has been lost. By that time, I suppose, I’ll be one of those people who is being denied cancer treatment by my government.

Are Women More Motivated By A Chubby Fitness Trainer?

I was taken aback by a recent conversation I had with a gym owner. She is interested in encouraging middle-aged women to come to the gym for beginner-level fitness classes and was planning a strategy meeting for her staff and key clients. I asked if I could join and she said that I was expressly un-invited. Slightly miffed I asked why that was so – after all, I’m a rehab physician who has devoted my career to getting people moving.

“You’re too advanced.” She said. “Beginners wouldn’t relate to the way you work out, we’re really more focused on creating a less intimidating environment for women.”

“You mean, like the Planet Fitness ads? The ones where athletes are not welcome?” I asked, confusedly.

“I don’t like those ads but the idea is the same. Beginners feel deflated by working out with people who are in far better shape. They don’t even want their instructor to look too fit.”

“You’re kidding me. Women would actually prefer working out with a chubby trainer?”

“Yes. In fact, I’ve had some women come to the gym and actually request NOT to be paired up with some of our personal trainers specifically because they look too fit. They are afraid they will be asked to work too hard, beyond their comfort zone.”

“So why are they coming to the gym in the first place?” I asked. “What is motivating them if they don’t want to work out hard or change their bodies in the direction of athletic-looking trainers?”

“They’re just interested in staying the way they’ve always been. Maybe they’ve started putting on weight after they hit their 40′s and 50′s and just want to get back to where they were in their 30′s. They’re not interested in running marathons or lifting the heaviest weights in the gym. They don’t want to be pushed too hard, and they prefer trainers who look healthy but not extreme.”

Medically speaking, it doesn’t take extreme effort to be healthy. Many studies have shown that regular walking is adequate to stave off certain diseases, and weight loss success stories (chronicled at the National Weight Control Registry for example) usually result from adherence to a calorie-restricted diet and engagement in moderate exercise.

In a sense, these women who “don’t want to work that hard” are right – they don’t have to perform extreme feats to be healthy. However, I am still fascinated by the preference for “average looking” trainers and the apparent bias against athleticism. This must be a fairly common bias, though, because national gym chains (like Planet Fitness) have picked up on it and made it the cornerstone of their marketing strategy. “No judgments” – except if you’ve got buns of steel, I guess.

When I choose a trainer I am looking for someone who embodies the best of what exercise can offer. An athlete who has practiced their craft through years of sweat and effort… because that’s my North Star. Sure, I may never arrive at the North Star myself, but I like to reach. And that’s what motivates me.

But for others, having a professional athlete for a trainer may be a mindset misfit. If your aspiration is to be healthy but not athletic, then it makes sense to find inspiration in those who embody that attitude and lifestyle. The important thing is that we all meet the minimum exercise requirements for optimum health. According to the CDC, that means:

* 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week


* muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest,  shoulders, and arms).

How you get there, and with whom you arrive, is up to you. Chubby or steely – when it comes to health and fitness the best mantra is, “whatever works!”

Should Patients Have Access To Lab Test Results Before Their Physician Reviews Them?

Six weeks ago I had a skin lesion removed by a plastic surgeon. About 7 days after the biopsy, I received a letter from the pathology lab where the sample had been analyzed under a microscope. I eagerly opened the letter, assuming that it contained test results, but was disappointed to find a bill instead. As a physician, it felt strange to be in a position of having to wait for a colleague to give me results that I was trained to understand for myself. However, I knew that in this case I was wearing my “patient hat” and that I’d need to trust that I’d receive a call if there was an abnormality. I haven’t received a call yet, and I assume that no news is good news. But what if no news is an oversight? Maybe there was a communication breakdown between the path lab and the surgeon (or his office staff) and someone forgot to tell me about a melanoma? Unlikely but possible, right?

Patients experience similar anxiety in regards to lab tests on a constant basis. In a perfect world, they’d receive results at the same time as their doctors, along with a full explanation of what the tests mean. But most of the time there’s a long lag – an awkward period where patients have to wait for a call or make a nuisance of themselves to office staff. Shouldn’t there be a better way?

The New York Times delves into the issue of “the anxiety of waiting for test results,” with some helpful tips for patients in limbo:

As patients wait for test results, anxiety rises as time slips into slow motion. But experts say patients can regain a sense of control.

  • Start before the test itself.
  • Because fear can cloud memory during talks with doctors, take notes. If you can, bring a friend to catch details you may miss.

Some pretest questions:

  • What precisely can this test reveal? What are its limitations?
  • How long should results take, and why? Will the doctor call with results, or should I contact the office?
  • If it’s my responsibility to call, what is the best time, and whom should I ask for?
  • What is the doctor’s advice about getting results online?

Do I think that patients should have access to their results without their physician’s review? While my initial instinct is to say “yes,” I wonder if more anxiety may be caused by results provided without an interpreter. There are so many test results that may appear frightening at first (such as a mammogram with a “finding” – the term, “finding,” may mean that the entire breast was not visualized in the image, or that there was a shadow caused by a fatty layer, or -less commonly – it can also indicate that a suspicious lesion was observed). I’m not arguing that patients can’t understand test results on their own, but medicine has its own brand of jargon and nuances that require experience to interpret.

Consider the slight deviations from the mean on a series of blood tests. They can be perfectly normal within the patient’s personal context, but may simply be listed by the lab as high or low. This can cause unnecessary anxiety for the patient. And what about PAP smear results that are listed as “ASCUS” – atypical squamous cells of undetermined significance? These can occur if the patient merely had recent sexual intercourse, and are not necessarily indicative of cancer at all.

And what about the “ambulance chasing lawyers” out there? Will there be additional frivolous law suits created by lab test results reported direct-to-consumer as abnormal in some way (when they really aren’t, given the full clinical picture) and patients assuming that their physician was negligent by not reporting the abnormality to them sooner? It could happen.

In the end I think that physicians all need to make a concerted effort to forward (with an explanation when necessary) lab test results to patients as quickly as possible. But since doctors are the ones ordering the tests in the first place, they do have a right to see them (before the patient when appropriate) – and an obligation to pass on the information in a timely and fully explained manner. That’s the value of having a physician order a test – their expertise in interpreting the results are part of the package (and cost). When patients order their own tests (and in some cases they can) then they should be first to receive the results.

As for me, I’m going to have to resort to “office staff nuisance” to get my results confirmed… just like any other regular patient. Oh well. ;-)

Ultraviolet Radiation Damage Can Have Long Term Consequences For Your Eyes

If you were invited to be part of a nuclear radiation clean up crew, I bet you’d want to wear protective gear. Not just the white hazmat bunny suit, but the gloves, goggles, mask and booties as well, right?  But when it comes to ultraviolet radiation exposure, we often put on “half a suit” as it were. We cover our skin with sunscreen (maybe) but we don’t regularly protect our eyes. I’m not sure why we forget this step, but it’s time to get serious about eye protection.

In a recent interview with dermatologist, Dr. Jeanine Downey, and optometrist, Dr. Stephen Cohen, we discussed the long term damage that UV radiation can cause to the skin and eyes. I hope you’ll listen to our entire conversation here:

Sun damage of the skin has a familiar appearance – dark spots, wrinkles, thinning, and enlarged pores.  UV radiation causes visible damage to the eyes as well – yellowish corneas (the “whites” of the eyes), scars (called pterygia), and crow’s feet. Over time, eyelid skin can become cancerous from sun exposure, while eyeballs develop cataracts and macular degeneration (which can lead to blindness). The risk of these diseases and conditions can be greatly reduced with sun protection measures. And it’s not that hard to do…

Some quick tips to protect your eyes:

1. Wear a wide-brimmed hat to protect your face and eyes from the sun.

2. Wear wrap-around sunglasses that absorb at least 99 to100 percent of both UVA and UVB rays for maximum eye protection.

3. If you wear contact lenses, ask your eye doctor about whether or not your lenses have UV protection. ACUVUE® OASYS® Brand Contact Lenses offers the highest level of UV blocking available, blocking at least 90 percent of UV-A rays and 99 percent of UV-B rays. Although UV-blocking contact lenses provide important additional protection for wearers, they do not completely cover the eye and surrounding area, and should not be considered as a substitute for UV-blocking sunglasses. For maximum protection, UV-blocking contact lenses should be worn in conjunction with high-quality, wrap-around, UV-blocking sunglasses and a wide-brimmed hat.

4. Remember that UV rays are more intense when reflected from water and snowy surfaces. Just because it’s the winter time doesn’t mean you don’t need to wear your sunglasses.

So next time you reach for your sunscreen, please remember to take your hat and sunglasses with you too! Fortunately, bunny suits and booties are still optional for UV radiation protection. ;-)

Disclosure: Dr. Val Jones is a paid consultant for VISTAKON® Division of Johnson & Johnson Vision Care, Inc.

The Ten Worst Hospital Design Features: A Family Member’s Perspective

An ICU Bed False Exit Alarm

I just spent the last 8 days in the hospital, at the bedside of a loved one. Although I squirmed the whole way through a tenuous ICU course and brief stop-over in a step-down unit, it was good for me to be reminded of what it feels like to be a patient – or at least the family member of one – in the hospital. The good news is that the staff were (by and large) excellent, and no major medical errors occurred. The bad news is that the experience was fairly horrific, mostly because of preventable design and process flaws. Having worked in a number of hospitals over the years, I recognized that these flaws were commonplace. So I’ve decided to tilt at this great hospital design “windmill” on my blog – with the hope that someone somewhere will make their hospital a friendlier place because of it.

Most of these design and process flaws have one thing in common: they prevent the patient from sleeping. In some circles, sleep deprivation is an organized form of torture reserved only for the most dangerous of terrorists. In other circles, it is hospital policy. And so, without further ado, here is my top 10 list of annoying hospital design flaws:

#1: False Alarms. Every piece of hospital equipment seems to be designed to beep for a complex list of reasons, many of which are either irrelevant or unhelpful. I snapped a photo of a particularly amusing (to me anyway) alarm (see above). This was a bed alert, signaling the “patient exit” of an intubated and sedated gentleman in the ICU. Not only was the location of the alert sign curious (if you could get close enough to the alert screen to read the text, you would surely already have noticed that the patient was AWOL) but it was triggered by mattress pressure changes that occurred when the patient was repositioned every 2 hours (as per ICU pressure ulcer prevention protocol).

The I.V. drip machines are probably one of the worst noise pollution offenders, beeping aggressively when an I.V. *might* need to be changed or when the patient coughs (this triggers the backflow pressure alarm, leading it to believe that a tube is blocked). Of course, I also thoroughly enjoyed the vitals monitor that beeped every time my loved one registered atrial fibrillation on the EKG strip – a rhythm he has been in and out of for years of his life.

#2: Intercom Systems. Apparently, some hospital intercom systems are wired into every patient room and permanently set at “full volume.” This way, every resting patient can enjoy the bleating cries for housekeeping, tray pickup, incoming nurse phone calls,physician pages, and transport requests for the entire floor full of individuals undergoing the sleep deprivation protocol.

#3: The Same Questions Ad Nauseum. Over-specialization is never more apparent than in the inpatient setting. There is a different team of doctors, nurses, PAs, and techs for every organ system – and sometimes one organ can have four teams of specialists. Take the heart for example – its electrical system has the cardiac electrophysiology team, the plumbing has the cardiothoracic surgery team, the cardiologists are the “minimally invasive” plumbers, and the intensivists take care of the heart in the ICU. Not only is a patient assigned all these individual micro-managing teams, but they work in groups – where they rotate vacations and on-call coverage with one another. This virtually insures that the sleep-deprived patient will be asked the same questions relentlessly by people who are seeing him for the very first time at 20 minute intervals throughout the day.

#4: Inopportune Intrusions. There are certain bodily functions that benefit from privacy. I was beginning to suspect that the plastic urinal was attached to the staff call bell after the fifth time that someone summarily entered my loved one’s room mid-stream. Enough said.

#5: Poorly Designed Tubing. Oxygen-carrying nasal cannulas seem to be designed to maintain a slight diagonal force on the face at all times. This results in the slow slide of the prongs from the nostrils towards the eye. Since the human eye is less efficient at absorbing oxygen than the lungs, one can guess what might happen to oxygen saturation levels to the average, sleep-deprived patient, and the resulting flurry of nursing disturbance that occurs at regular intervals throughout the night (and day). My loved one particularly enjoyed the flow of air pointed directly into his left eye as he attempted to rest.

#6: The Upside Down Call Bell. In an age of wireless technology, where almost every American has a cell phone and/or a flat screen television, it is odd that the light, TV, and nurse call bell control system must be tethered to a short  cord positioned just outside of the patient’s reach. The controller is also designed so that the cord comes out of the box’s farthest point, causing it to remain upside down in the hands of anyone lucky enough to reach it from a chair or bed.

#7: Excessive Hospital Bands. In addition to multiple rotating IV access points, my loved one’s wrists and ankles were tagged with not one but four hospital band identifiers, including one neon yellow band sporting the ominous warning: “Fall risk.” If that little band is the only way that a staff member can ascertain a patient’s risk for falling down unassisted, then one is left to wonder about their powers of perception. In a moment of rare good humor, my loved one looked down at his assorted IV tubes and three plastic wrist bands and concluded, “I’m one stripe away from Admiral.”

#8: The Blank White Board. Sleep-deprivation-induced delirium can be rather disorienting. To help patients keep track of their core care team names, most hospital rooms have been outfitted with white boards. Ideally they are to be filled out each shift change so that the patient knows which activities are scheduled and the names of the staff that will be performing them. Filling out these boards is tiresome for staff members (not to mention that the dry erase markers are usually missing) and so they remain blank most of the time. This has an anxiety producing effect on patients, as the boards boldly proclaim that no nurse is taking care of them, and no activities are scheduled.  I also noted that the size of the board lettering was a fraction smaller than a person with 20/20 vision could make out from the distance of the bed.

#9: The Slightly-Too-Tight Pulse Oximeter. Because being tethered to a bed with IV tubing, telemetry cords, and a nasal cannula is not quite irritating enough, hospital staff have devised a way to keep one unhappy finger in a constant, mild vice grip. This device monitors oxygenation status and helps to trigger alarms when nasal cannulas achieve their usual peri-ocular destination every 30 minutes or so.

#10: The Ticking And Creaking IV Drip. During the few rare moments of quiet, we did not enjoy any sort of blissful silence, but rather the incessant ticking of the I.V. drip machine. My loved one remarked that he felt as if he were trapped in an endless recording loop of the first 5 seconds of the TV show “Sixty Minutes.” And so if the alarms, tethering, interruptions, PA announcements, tubing, or white boards didn’t drive you mad, the auditory reinforcement of a ticking time bomb next to your head could bring you close to tears.

And so, because of all these nuisances (not to mention the ill-fitting hospital gowns, inedible food, and floors covered with various forms of “seepage” that penetrated patient socks on hallway ambulation attempts) we had one of the most unpleasant experiences in recent memory. All this, and no dissatisfaction with the surgical team or the primary procedure performed during the hospital stay. In the end, it’s the little things that can drive you crazy – or make you well.

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

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…

Read more »

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…

Read more »

See all book reviews »