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Can the Internet save primary care?

I’ve been thinking a lot lately about the plight of family physicians – reimbursal for their services continues to decline, overhead steadily increases, and pressure to see a minimum of 30 patients a day can drive them to near despair. Family physicians want to provide quality care for their patients, but are exhausted by volume demands and paperwork.

If you missed this article about the primary care crisis in America in the New England Journal of Medicine, it’s an excellent read. Here are some excerpts:

Excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care, partly because half of all patients leave their office visits without having understood what the physician said.

These problems are exacerbated by the system of physician payment. Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression…

These factors add up to an unsurprising result: fewer U.S. medical students are choosing careers in primary care. Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent…

Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs… Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.

A recent article in the Wall Street Journal sent ripples through the blogosphere. It was about how a few family physicians found a way to drastically reduce overhead – by being a solo practitioner and using technology to replace office staff and automate billing as much as possible.

Drs. Charlie Smith and Joe Scherger are family physicians here at Revolution Health who are leading the charge towards high tech solutions for family physicians. Charlie explains his philosophy in his recent blog post:

Having practiced primary care for over 30 years, I’m convinced the model of receiving in office care for every problem is not working well. I really like the ideas espoused by Don Berwick in changing the model of care in the doctor’s office to that of seeing patients in groups, treating them by phone or by e mail, rather than in the office. Using phone calls or e mails to sort through the patient issues, the doctor can decide to see the ones who really need to come into the office and the others can be taken care of without an office visit. This is a MUCH more efficient method, allows you to take care of many more people that need care, and gets people the care when they need it, rather than forcing them to wait until they can fit into a slot in your office.

The ideal way to partner with your doctor to use the health care system in the most effective way possible is to call or e mail him whenever possible, use the internet to research all of your health conditions, and only go into the office when you require in office care, such as exams, procedures, lab tests or x rays. Become an e patient!

I personally believe that Revolution Health can substantially improve the life of family physicians through innovative technologies designed to automate their practices as much as possible (thus reducing overhead and time spent on paperwork), as well as educating patients about the management of their diseases and conditions, (thus improving outcomes and increasing pay for performance bonuses), and triaging low acuity issues through online physician emailing services and retail clinics (thus helping patients receive the care they need without excessive use of office time).

Who will take up the cause of primary care (asks the NEJM)? Revolution Health will. Let’s work together to improve the quality of life for physicians and patients alike.

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

Circumcision reduces HIV transmission in Africa

Recent research suggested that circumcision may reduce the rate of HIV transmission by 50% (foreskin cells are particularly vulnerable to infection with the virus). In response to this news, adult men in Uganda and Kenya have been undergoing the procedure in the hope of reducing their risk of HIV infection.

Some young boys in Kenya were actually expelled from school for not being circumcised. Their parents were asked to bring them back to school once the deed was done.

HIV rates have decreased in Uganda from 15% to 5% after aggressive public health initiatives raised awareness of the importance of safe sexual practices. This is an incredibly positive achievement.

One would hope, however, that circumcision in infancy would become the preferred target age for future procedures.

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

Can we cure malaria with blood pressure medicine?

Malaria is caused by a crafty little parasite that has become resistant to many medicines. But now researchers at Northwestern University have discovered a chink in its armor – a blood pressure medicine called propranolol. Who knew that a common beta-blocker used to treat hypertension might provide the death blow to such a scourge?

Usually, malarial parasites infect their host’s blood stream through a mosquito bite, and then congregate in the liver and pounce on red blood cells as they pass by. They have a way of adhering to the red blood cells via certain surface receptors (beta 2 adrenergic receptors linked to Gs proteins). They latch on to the red cells and then burrow into the cell and hijack it in order to reproduce inside it. Then, like the horror movie Alien, once they’re fully grown (into “schizonts”) they burst out of the cells and roam free to repeat the process all over again.

Now propranolol happens to block the Gs proteins, which effectively makes it impossible for the parasites to attach themselves to the red blood cells (which they need to use to reproduce themselves).

So what’s the caveat to of all this? Well, folks don’t know they have been infected with malaria until they have symptoms, and the symptoms include high fevers and low blood pressure… so giving someone a medicine that lowers their blood pressure even further might not be a good idea.

The other caveat is that propranolol works like a charm in the test tube, and in mice, but we haven’t yet tried it out in humans who have malaria.

Still, it seems to me that a little bit of propranolol might go a long way to preventing malarial infections in at risk populations. I’ll be interested to see what further studies show!

And if you’re interested, I’ll create a few more blog posts about parasites and other creepy crawly human invaders… Just let me know if you can handle more of this!

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

Sexism and Sexualization of Women: East vs West

I really couldn’t help but feel saddened by three recent news stories about the continued attitudes that are so harmful to women. If these media reports are right, Japan’s leadership appears to be way off target, referring to women as baby machines and refusing to apologize for enslaving and raping ~200K women in World War II.

America has a more insidious version of sexism that can harm young minds – exposing children repeatedly to age-inappropriate sexually explicit images and ideas. As we expand our understanding of neuronal plasticity, it is becoming more and more clear that what we see and experience can imprint itself on our brains and literally change the way we think and feel. We spend a lot of time worrying about what we put in our bodies (e.g. avoiding trans fats, food chemicals, etc.) I wonder if we should think a little bit more critically about what we let into our minds?

Here’s what I’m talking about:

Japanese health minister says women are “birth-giving machines”

In a report in which the health minister explained how dangerous the low birth rate is for Japan’s economic future, he suggested that women are a rate limiting factor. There are only so many “birth-giving machines… and all we can ask is for them to do their best.”

There has been an outcry in Japan against the health minister though it’s unclear if he’ll resign.

Japan refuses to apologize for crimes against women

Japan admits its army forced women to be sex slaves during World War II but has rejected compensation claims.

Historians believe at least 200,000 young women captured during World War II were forced to serve in Japanese army brothels.

A large number of the victims – who were known as comfort women – were Korean, but they also included Chinese, Philippine and Indonesian women.

The media’s portrayal of young women as sex objects harms girls’ mental and physical health, US experts warn.

Magazines, television, video games and music videos all have a detrimental effect, a task force from the American Psychological Association reported.

Sexualisation can lead to a lack of confidence with their bodies as well as depression and eating disorders.

For more information on kids and sexualization, see Dr. Stryer’s recent blog post.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

So you want to be a sperm donor?

In a recent article in the New York Times the process of sperm banking was described in a fairly whimsical way, but the real bizarreness of the business could be found between the lines. Apparently sperm banks compete with one another as they go to all kinds of lengths to tout the quality of their donors:

“It’s kind of an arms race,” explains William Jaeger, director of Fairfax Cryobank, in Fairfax, Va., which, along with California Cryobank, based in Los Angeles, is among the largest sperm banks in the country.

“One year someone adds a personality profile, the next year someone adds something else,” Mr. Jaeger says. “If one of your competitors adds a service, you add a service.”

Certain donor profiles are particularly popular, making it difficult for the supplier to keep up with the demand.

The most-requested donor is of Colombian-Italian and Spanish ancestry, is “very attractive, with hazel eyes and dark hair,” and, Ms. Bader adds, is “pursuing a Ph.D.”

The bank’s files have one man, Donor 1913, who fits that description.

Donor 1913, the staff notes in his file, is “extremely attractive,” adding in a kind of clinical swoon, “He has a strong modelesque jaw line and sparkling hazel eyes. When he smiles, it makes you want to smile as well.”

Donor 1913 is an all-around nice guy, they say. “He has a shy, boyish charm,” the staff reports, “genuine, outgoing and adventurous.”

He also answers questions, including, “What is the funniest thing that ever happened to you?”

Donor 1913 relates an incident that occurred when he asked his girlfriend’s mother to step on his stomach to demonstrate his strong abdominal muscles.

“As she stepped on top of my stomach, I passed gas,” he writes.

Is Don Juan the gas-passer also the most popular donor at Fairfax Cryobank?

The sperm banks say that they only accept 1-3% of donors, but the criteria that I could glean from the article seemed to be:

  1. You’re not overweight
  2. You’re tall (unless you’re a doctor or a lawyer, then you can be as short as 5’7” to 5’8”)
  3. You’ve got a college degree
  4. You have high SAT scores
  5. You are good looking
  6. You have healthy sperm

Apparently, the most requested sperm donor in one of the California banks is a tall man who was in college at the time of his donations, but who later dropped out and took up residence in a mobile home park and made a living walking other people’s dogs.

So, who were the other 97% who didn’t make the cut?

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

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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.

***

Click here for a musical take on over-testing.

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