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What does a twinkie have in common with your car?

Well, twinkies are made of petroleum (among 38 other ingredients), and gasoline is also a type of petroleum product! This gives “food as fuel” a new meaning.

Dr. Charles, a young family physician, reviews the ingredients of twinkies in his recent blog post amusingly called “Reduce Twinkie Consumption and Dependence on Foreign Oil.”

This reminded me of the shock I felt when watching a documentary about America’s oldest citizens recently. I clearly remember them interviewing a man who was about 105 years old, who lived alone and used a golf cart to get around outdoors. The interviewer couldn’t resist asking the man why he thought he had lived so long in such good health.

The man said, “Well, I eat pretty good, get enough sleep, and I don’t worry about much.”

The interviewer then asked a probing question, “What do you eat?”

And I leaned in towards the TV screen, curious as could be.

And the elderly gentleman said, “Well, I eat a bowl of cornflakes for breakfast and then I usually eat a twinkie later on…”

Either the segment didn’t plan enough seconds for further investigation, or that was the sum total of his nutritional advice.

I was dumbfounded. For some people, it seems, good genes and good luck take them a long way.

But I’m still not going to eat petroleum products.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The dark side of measuring healthcare quality?

Improving quality in healthcare is an important fundamental goal. New “pay for performance” measures initiated by the Center for Medicare and Medicaid services is a well meaning attempt to provide financial incentives to physicians who demonstrate improved patient outcomes. Unfortunately, this incentive program could backfire.

A recent article in Medical Economics (via Kevin MD) raised the question of “cherry picking and lemon dropping” your way to higher pay. In this frightening scenario, physicians would be tempted to select healthier, more compliant patients for regular treatment in their practices. In this manner, they can demonstrate better outcomes, since the sicker, poorer, or less compliant patients no longer factor into their performance measures. And with the upcoming physician shortage, it really is a seller’s market.

It is critically important for the government programs to allow physicians to accurately risk stratify their patients so that they are not financially penalized for taking care of sicker patients bound to have below average outcomes. The same goes for surgeons, who should not be discouraged from undertaking potentially lifesaving surgeries for patients who are critically ill.

Dr. Kellerman, the president of the American Academy of Family Physicians, reminds us that quality of care is vastly improved by having a central medical home (i.e. one physician who can coordinate care for patients, so they’re not left with a group of disconnected specialists ordering duplicate tests and prescriptions). I personally think that a centralized EMR/PHR controlled by the patient (and located at an Internet based “medical home” complete with disease management tools and the ability to email a physician as needed) would go a long way to improving quality.

What do you think?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Sleeping man bitten by rabid bat

A Canadian news story piqued my interest today – apparently, a man living near Edmonton, Alberta was bitten by a bat during his sleep. Curiosity got the better of me as I tried to recreate the scenario in my head. First of all, “vampire bats” (the kind that feed on the blood of livestock) don’t live in Canada, so this little guy was probably a generic “brown bat.” Brown bats are shy creatures who live on insects primarily, so we know that this bat was in a pretty wacky frame of mind to boldly mistake a sleeping human for a beetle.

Stranger than the behavior of this culinarily confused little mammal, was the behavior of the sleeping victim. Apparently he was unconcerned by the bite and went back to sleep afterwards, never seeking medical attention. I don’t know about you, but if I woke up in the middle of the night with any wild animal sinking its teeth into my flesh, I’d probably not shrug and roll over.

Anyway, the sad news is that this man didn’t get his life-saving rabies shots. Rabies is a very serious condition with a 50% mortality rate! The rabies virus (transmitted through infected animal saliva) wreaks havoc on the brain and nerves. The CDC describes it:

Early symptoms of rabies in humans are nonspecific, consisting of fever, headache, and general malaise. As the disease progresses, neurological symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation, difficulty swallowing, and hydrophobia (fear of water). Death usually occurs within days of the onset of symptoms.

Isn’t it strange that “fear of water” is part of the rabies syndrome? I’d like to get an explanation of that one from a neurologist…

Anyway, human cases of rabies are quite rare (about 7000 cases/year in the US) and are usually caused by raccoon or skunk attacks. So if you come face to face with a raccoon or skunk “gone wild” my advice is to run away. But if you do get bitten, please go to the hospital immediately and get your rabies shots. You can prevent progression of the disease.

Now, if you’re curious to see if you’re in a rabies “hot zone” check out the CDC’s skunk and raccoon tracking maps (can you believe that someone’s job is to create these?)

And for a good spoof of dangerous animals – check out Dr. Rob’s recent warnings against the common goat. You can tell that he must enjoy Monty Python style humor.

Are you an animal lover? Know of some funny websites or links about animal antics? Do share!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Healthcare’s coding system: no pain, no gain for docs

Dr. Rob, the author of “Musings of a Distractible Mind,” is really good at explaining difficult concepts. If you haven’t read his description of healthcare’s coding system, you should take a peek. It explains why documenting care is so complicated, how doctors try to “game the system” and what happens to them if they do.

Here’s a small excerpt:

“You see, what you get paid for an office visit is not based on what you do at that visit, it is based on what you document. The more you can document, the higher you can bill… There are several responses to this situation by physicians:

· Undercode to avoid the accusation of fraud

· Use EMR to document more and bill at a more appropriate level

· Code at the higher level without documenting higher and risk audit, jail, etc.

· Stop accepting insurance and just accept cash up front based on your own criteria

· Do other things besides office visits – such as surgical procedures, labs, x-rays, or other procedures that pay much better than the office visit. The pay for EKG with interpretation is nearly as high as that of the decision making that the physician makes that may save the life of the patient.”

So next time your doctor is delayed in seeing you… she’s probably trying to document all the right check boxes and codes for the last patient she treated!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What are orthopedic surgeons worrying about?

I had the chance to speak with Jim Herndon recently about how the current healthcare climate is affecting orthopedic surgeons. He said that there are 3 things that worry orthopods:

  1. Decreasing Medicare reimbursement. In 1990, reimbursement for a total hip procedure was $2,200. In 2007, the reimbursement is $1,190. Medicare is planning to further cut reimbursement 30% in the next 4-5 years.
  2. Increasing malpractice insurance costs. Premiums are steadily increasing. In Boston, the average malpractice insurance is about $50,000/year. In Philadelphia, the cost is $150,000. And if you’re an orthopedic surgeon specializing in spinal surgery, malpractice insurance premiums can start at $250,000/year.
  3. Pay for performance. No one really knows how this will be applied specifically to surgeons (other than the obvious infection rates), but fears are mounting regarding how to show the best possible performance in one’s practice.

Let’s say that a typical surgeon in Philadelphia pays 33% in overhead (the hospital facilities, staff, etc.). Let’s say that he is also taxed 33% on his income. That means that he’d have to perform 382 hip replacements per year, just to pay his malpractice insurance. That’s almost 2 surgeries/day, 5 days a week, 11 months/year.

So what are surgeons doing? They are reducing overhead by setting up outpatient surgery centers (Dr. Herndon estimates that 60% of orthopedic surgery can be performed in an outpatient setting), they are increasing the volume of surgeries they perform, they are buying radiology facilities where they send their patients for XRays, MRIs etc. (Dr. Herndon explains that Stark Laws don’t prohibit this, so long as the physician takes on the risk of the facility – i.e. that he can potentially make or lose money), and they are financing physical therapy practices that supply therapy to their patients.

Orthopedic surgeons in private practice have become very business savvy in order to survive in this climate. But somehow I feel saddened by all this – the business of medicine is a grim reality that can create a wedge between the physician-patient relationship. A patient is left to wonder about the motivations behind tests and therapies – and perhaps even behind recommendations for the surgery itself.

I guess the second opinion has become more important than ever before?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

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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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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