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Latest Posts

Robot Performs Surgery For Obstructive Sleep Apnea: Is It Over The Top?

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I came across this article the other day regarding use of the daVinci robot to perform base of tongue surgery for obstructive sleep apnea.

For those who don’t know, the daVinci robot system made by Intuitive Surgical is a robotic system whereby the surgeon directs the arms of the robot to perform surgery in difficult-to-access areas of the body.

My feeling is that using a robot to perform sleep apnea surgery is way overkill akin to using a $50,000 sniper rifle to kill an ant on the wall.

Everything the daVinci robot can do can also be done without the robot with equivalent patient outcomes. In fact, Read more »

*This blog post was originally published at Fauquier ENT Blog*

Dosing Exercise: Choosing What’s Right For You

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It is risky.

Stay fresh. Avoid repeating yourself. Don’t rant. Never preach. These would be the ‘rules’ of supposedly good blogs.

And, of course, doctors that dare to take a stance on health issues risk being perceived as pretentious. I get this.

So it is with trepidation that I write a follow-up to last week’s CW post about right ventricular damage immediately after an extreme race effort. Notwithstanding the pompousness concern, I also wish to avoid being labeled anti-exercise. Few believe more strongly in the healing powers of exercise.

But last Wednesday’s comments (both on the blog, Facebook and here on Dr. Val Jones’ BetterHealth blog) were just too good to let rest.

On the assessment of studies: Read more »

*This blog post was originally published at Dr John M*

The Truth About Vitamins And Supplements: How To Protect Yourself

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Prepared Patient Publication Logo Vitamins, herbs and other dietary supplements are sold as natural alternatives to pharmaceuticals and many people turn to them in an attempt to improve their health. Others seek supplements to lose weight or after hearing that they can help with serious medical conditions. These products are now used at least monthly by more than half of all Americans—and their production, marketing and sales have become a $23.7 billion industry, according to the Nutrition Business Journal.

What Are Dietary Supplements and How Are They Regulated?
98-year-old Bob Stewart, a retired podiatrist and senior Olympian, credits his use of supplements for his healthy aging. Writer Betsy McMillan, a mother of two now adult children, however, nearly suffered permanent liver damage due to a supplement that contained potentially fatal levels of niacin.

Unlike pharmaceuticals—which must be FDA-approved as safe and effective before they can be marketed—supplements are considered as foods by regulators and assumed to be safe until proven otherwise. Although pharmaceutical manufacturers face inspections to ensure that the right dose is in the right pill without dangerous contaminants, supplements do not undergo such intense government scrutiny.

Despite many reports of health problems, Read more »

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

Study Suggests The Importance Of Maintaining A Low Resting Heart Rate

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When you sit quietly, your heart slips into the slower, steady pace known as your resting heart rate. A new study suggests that an increase in this rate over time may be a signal of heart trouble ahead.

Your heart rate changes from minute to minute. It depends on whether you are standing up or lying down, moving around or sitting still, stressed or relaxed. Your resting heart rate, though, tends to be stable from day to day. The usual range for resting heart rate is anywhere between 60 and 90 beats per minute. Above 90 is considered high.

Many factors influence resting heart rate. Genes play a role. Aging tends to speed it up. Regular exercise tends to slow it down. (In his prime, champion cyclist Lance Armstrong had a resting heart rate of just 32 beats per minute.) Stress, medications, and medical conditions also influence the heart rate.

In today’s Journal of the American Medical Association, researchers from Norway report Read more »

*This blog post was originally published at Harvard Health Blog*

Should A Salaried Physician’s Decreased Efficiency Be A Concern?

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For centuries, physician practices have been small  business enterprises built on the sweat equity of intensive medical training.  It was an economic reward system that often had physicians sacrificing family life for patient care.  It continues today as the  foundation of  fee for service.  We know it as the eat what you kill model of health care.

In the last ten years, physician practices have seen a dramatic shift from independent business practices to hospital owned practices. With that shift has come a titanic move toward the salary vs productivity  compensation model.

Is this a good thing?  Is a salaried physician better than a productivity based physician? That question can’t be answered because good depends on which part of the medical industrial complex you belong to and what you consider good.

As a physician, the answer on whether to become a salaried vs productivity based physician can only be answered after one defines what they value most.  We know, across the board, that physicians who work in a 100% productivity model earn Read more »

*This blog post was originally published at The Happy Hospitalist*

Latest Interviews

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…

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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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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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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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