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Pay For Performance – in a nutshell

I’ve blogged previously about how unhelpful most Pay for Performance measures are for improving healthcare outcomes and “rewarding” physicians who provide evidence-based care.  But this sentence (spotted by Kevin, MD) summarizes my pages of opinions perfectly:

Judging medical quality from claims data is like judging a restaurant by looking at its grocery bill.

And if that didn’t sum it up perfectly, consider this:

The amount of “pay” for performance is so small that it is not incentive enough for physicians (or hospitals) to change their clinical practice behavior.  In effect, as JAMA says, “the carrot is not big enough.”This post originally appeared on Dr. Val’s blog at

Thank Goodness for Nurses

In a bleary eyed state I misread a blog post by PandaBearMD.  He was on one of his well- written, sarcastic tears, and (jokingly) blamed nursing salaries for the rise in healthcare costs.  I didn’t get the humor of that, and proceeded to defend my nursing colleagues.  Of course, I took some hits for being unable to recognize sarcasm, but this event got me thinking about nurses…

I have always been grateful for the wonderful work that nurses do – and as I think back at all the amazing feats they’ve accomplished in front of my very own eyes, I thought I’d start a list:

NICU: can place an I.V. in a 1 lb preterm baby with veins the diameter of hair (but docs: don’t TOUCH the baby!)

ER: can put an I.V. in a 400 pound, anasarcic patient with no palpable pulses.

Psychiatric ED: can convince a fulminantly psychotic, violent patient  to sit quietly and play with a teddy bear while waiting for the doctor to see him

Medical Floors: can clean up a fecal mess so foul that even the anosmic wouldn’t have the courage to enter the room – and do it in such a way that the patient feels no personal embarrassment

OR Nurse: will anticipate the instruments needed for an unforseen surgical complication and have them ready for use before the doctor gets a chance to ask for them

Pediatric ED: can distract a small child with stuffed animals, toys, and picture books so successfully that they don’t notice sutures being placed in their hand.

Obstetrical Nurse: can withstand the force of a 200 pound leg pressing against her for hours on end as mom bears down to push the baby out of the birth canal

Rehab Nurse: can get any patient out of bed, single handedly, and with little obvious effort (while the rest of us call for the Hoyer Lift, and 3 resident physicians)

This is just the beginning of a long list of magical things that nurses can do… please share some of your favorites!This post originally appeared on Dr. Val’s blog at

10 Tips for a Healthy Wedding

Here’s a copy of the Press Release, for those interested…

As an experienced June bride myself, I can tell you that
your wedding may be one of the happiest times of your life, but for a number of
reasons, health problems can crop up on and around this special day.  But with some advance planning,
you can make sure that you and your guests remember the day for the right
reasons, and not the wrong ones.

1.      Beat the Heat – Many June weddings are
planned months in advance (at a cooler time of year), when the prospect of
being outdoors is inviting.  But when
June arrives, wedding guests find themselves spending hours exposed to peak sun,
heat, and humidity.  And since weddings
often involve older relatives and younger children, the risk from sun and heat
exposure is higher than many expect.  If
you’re getting married outdoors, keep an eye on the heat, especially for your
oldest and youngest guests.  Have
sunscreen and plenty of water available.
Consider moving older guests to a shaded area.  To recognize the signs of heat exhaustion, visit:
symptoms and find treatments for heat exhaustion

2.      The Size is Right – Many brides buy
their wedding dress a size smaller, with ambitious plans of weight loss – or
perhaps the dress fit well when it was bought, but  run up to the wedding (with the related stress),
has led to a slight weight gain.  Either
way, too many brides try crash dieting in the days and weeks before the wedding
to squeeze into that gown – and find failure, anxiety, and health problems.  If you want to lose weight for your wedding,
start in advance, and stick with a healthy, safe weight loss plan.  Crash diets are fittingly named:
you smack into a wall and find yourself worse off than before.  Brides also should keep an ear tuned to
bridesmaids engaged in crash dieting, and try to talk their friends out of such
bad habits.   Find
smart strategies for healthy weight loss.

3.      Sober Dialing – While many people don’t
think of drunk driving as a “health issue,” drinking and driving is one of our
county’s leading preventable causes of death.
A healthy wedding is one where the guests get home safe and sound.  Wedding planners should ensure that everyone
has a designated driver, arrange with a cab company to have a certain number of
cabs available at the end of the evening.
Or you can arrange for transportation to take guests back to their
hotel.  That way no one has to worry
about drinking and driving.  And make
sure you have plenty of non-alcoholic beverages for any guests who have alcohol
dependency issues

4.      Celebrate with a Healthy Meal
Everyone wants to treat their guests to a wedding meal to remember – but make
sure it is remembered fondly.  If you’re
holding your wedding outside, make sure that food, like potato salads and
shrimp, are properly cooled or kept on ice.  I know of a wedding where five of the guests got food poisoning from
this type of mistake.
And consider a lighter, healthier meal:
your guests will appreciate the chance to celebrate with you (without
needing to go on a diet the next week), and will find themselves feeling less
weighed down during the celebration.  Learn
about food poisoning and how to handle food safely.

5.      Get the Glow – Every bride wants to
look perfect on her wedding day.  But
that “glowing, radiant” skin can’t be had via makeup:  healthy choices make a big difference.  Try to keep your stress under control to
avoid an
acne breakout
.  And drink plenty of
water on the day before and the day of your wedding to keep your skin looking
great and your body feeling great. Check
here for more information on the importance of staying well-hydrated

6.      Dealing With Family Issues – Weddings
pose challenges not just to physical health, but emotional well-being,
too.  Unresolved family
issues have a not-so-funny way of erupting at a wedding, exacerbated by the
stress of the event
and intensified by the gathering of relatives who may
not often encounter one another.  Ask a
trusted relative to try to resolve these disputes before the wedding day, and if
you suspect they may nonetheless erupt at the wedding, have a “designated
diffuser” – a relative who can soften family conflicts or at least keep them
from ruining the celebration.

7.      Take Care of Yourself – You can’t have
a “healthy” wedding with an “unhealthy” bride.
Schedule some time to do things that help you relax.  Yoga, massage, a day trip, hiking or reading
a good book are all great ways to de-stress.
about other stress management tips.

As you prepare for your upcoming event, make sure you are getting 7-8
hours of sleep per night.  Being
well rested can help you avoid feeling irritable and anxious and can reduce
your chances of becoming ill

8.      Countdown
—  Maybe it’s not romantic,
but a comprehensive  physical exam is a
good idea for couples preparing for marriage.
Before you ask someone else to
say that they will love you “in sickness and in health,” you owe it to them to
know just where on that spectrum you stand.  Together you can plan to support one another
in long term, healthy lifestyle goals. Get a complete check up a few months
before the wedding, so you can understand and address any health issues before
you are at the altar.  Both women
and men
need complete and regular physicals.

9. A
Healthy Honeymoon
– Ok, you’ve made it all the way through the wedding in
good health, and now comes “the fun part:” the honeymoon.  But a surprising number of brides and grooms
wind up too sick to enjoy this first taste of wedded bliss.  Key tips:
make sure you don’t overindulge in food and drink at the wedding; plan
for the honeymoon like you would any other trip (with sunscreen for warm places
and precautions about drinking safe water and eating safe food); and make sure
you’ve had all necessary vaccinations well in advance of the wedding so you
aren’t suffering from vaccine side effects on wedding day.  Learn
more about health and travel

10.  Waiting to Exhale – Take a deep breath
and remember that in the end, marrying the person you love is more important
than having a perfect ceremony or reception.
The wedding is just the start of the marriage – and hopefully, not the end.  The happiest and healthiest wedding is the
one that leads to a happy, healthy marriage.  Check out some great
for keeping your marriage strong long after the wedding’s over.This post originally appeared on Dr. Val’s blog at

Eye infections caused by parasites

There’s a new contact lens solution scare this week.  Last year it was fungus, this year it’s parasites.  Apparently there has been an increase in amoebic infections in the eyes of those who use a type of moisturizing contact lens solution.  These amoebas are pretty common (and relatively harmless?) in the water supply, but put them in your eyes with a few moisturizing drops and you’ve got yourself a dangerous infection that can even result in blindness.  Scientists are puzzled as to why this mixture might increase the risk for infection – some speculate that the moisturizing chemical sticks to the amoebas and keeps them in the eye (rather than having them drop out in your tears).  But at this point, no one really knows why there have been increased infection rates, or what the contact lens solution has to do with it.

I guess my advice would be – never put tap water in your eyes or on your contact lenses, and switch to a different brand of contact lens solution than Advanced Medical Optics, Inc.’s Complete Moisture Plus until further notice.This post originally appeared on Dr. Val’s blog at

Women in medicine

Even though the gender gap in medicine is closing quickly (about 50% of medical students are female), young female physicians in practice are often viewed with suspicion.  Dr. Michelle Au, an anesthesiologist and graduate of my alma mater, is regularly asked if she’s “a real doctor” or if she’s the nurse or a student of some sort.  This week she blogged about her experiences, and there was a large volume of interesting responses.

I myself have had a rough time of it in the past (now I guess I look old enough to “be a real doctor”), and was routinely assumed to be a nurse, physical therapist, or even pharmaceutical rep.  I actually wasn’t that offended by being miscast – mostly because I took it as a compliment not to look like a doctor.  Although it’s somewhat unclear what a real doctor is supposed to look like, I have a feeling he’s older, balding, and paunchy.

But one day I was a little annoyed when my age and gender was equated with incompetence, which crosses the line for me.  Here’s how the conversation went between me and the parents of a toddler with a small cut on his forehead:

Me: “Hi, Mr. and Mrs. X, I’m Dr. Jones.  I see that Johnny bumped his head and will need a few stitches.” [Enter long history and physical discussion here].

Mrs. X: “Are YOU going to put in the stitches?” She asked nervously, scanning the ED for other physician suturing candidates.

Me: “Yes, I assure you I will be very careful.  I’ve sutured many similar lacerations.”

Mr. X: “Yeah, but don’t you think he needs a plastic surgeon?”

Me: Looking at the small cut that only required 2 or 3 sutures.  “I understand that you want the best possible cosmetic outcome for your son, but I assure you that this cut is so small that the plastic surgeon wouldn’t close it any differently than I would.”

Mrs. X: Spotting a tall, male intern fiddling with some bandages on a supply cart.  “Well, can’t he do it?”

Me: Viewing the clumsy medicine intern.  “Well, yes, he could.  Shall I ask Dr. Big Hands if he can come and suture your son’s forehead?  He’s never closed a lac before and has been dying to try one.”

Mrs. X: Um… Well, maybe you should just do it.

Outcome: I did a beautiful, delicate job of closing the small laceration, and the parents watched in awe as I used the tiniest needle and thread to create a seamless finish.

Mr. X: Thanks for your help.  You did a really great job.

Have any of you readers had similar experiences?This post originally appeared on Dr. Val’s blog at

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