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

Latest Posts

One Lucky Canadian

Today an elderly physician friend of mine woke up with some very mild abdominal pain. He is a stoic man, and never complains about anything – not even the pain associated with a dislocated/shattered hip and multiple bone fractures from a car accident (he was very nonchalant about that event 2 years ago).

So when I heard that he was going to see a doctor about his belly pain – I knew that something serious was afoot. His doctor ordered an abdominal x-ray series, noted a tumor, and sent him to the O.R. within the hour.

In the O.R. the surgeons found a perforated colon (it must have ruptured minutes to an hour or two prior) without signs of peritonitis. There was a cancerous mass (without metastases) that they were able to remove completely. They washed his peritoneal cavity extensively to remove all fecal matter and potential cancer cells and transferred him to the ICU for observation overnight and IV antibiotics.

So far it seems that my friend will make a full recovery – and there is no evidence of remaining cancer, though we’ll need to be vigilant with follow up.

I can’t get over how lucky he was to have discovered the perforated colon within hours of it occurring, that the surgeons took care of him immediately, and that the cancer seems to have been contained and removed. I don’t know if his “luck” was partially due to his physician’s intuition about his own body, professional courtesy extended to him by peers, or that the Canadian healthcare system is not as burdened in his part of the country (Nova Scotia) as it is in others where there may be longer wait times.

All I can say is that my friend is one lucky Canadian!

Counter Point: American Healthcare Is Not The Best In The World

Let’s get honest, OK? America does not have the best health care in the world. Europeans and Canadians are not flocking to our borders to get to our health care. It is time we realize that we can learn from our neighbors and we don’t have to claim we are the “best” at everything. It makes us look really stupid in the eyes of the world.

Here are some facts. We do spend the most money on health care in the world. We do spend the highest percentage of Gross National Product (GDP) on health care and we do spend more dollars per capita than any other country on Earth.

The claim that the United States has the best health care in the world has been proven false by every broad metric used. The World Health Organization and the nonpartisan Commonwealth Fund rankings rate the U.S. last of the Western industrialized countries. The WHO ranks us 37th of all measured countries.

The Commonwealth Fund says, “Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care.”

The U.S. also lags in information technology. (We have been awaiting a robust electronic medical record for 10 years) and in coordination of care and in measured quality outcomes.

One of the ways we improve in health care is when we face the brutal truth. How can you make improvements if you don’t know where you are starting from? If you truly believe you are the best in the world…there would be no need for health care reform.

Perhaps that is why these myths and lies are being propagated.

*This blog post was originally published at EverythingHealth*

Canadians Are Turning To Market-Based Healthcare Solutions

Many Americans look to Canada, as an example of a government-run health care system that works.

But is that really what it is?

Health care in Canada is funded mostly publicly, but is provided mostly privately.  That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.

Americans often call this system “single payer,” but it’s really not true.  There are many other payers.

For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums.  Millions of  Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services.  There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost.  As much as 30% of Canadian health care expenses are funded through these non-government payers.

However paid for, supply (and funding) for health care has not been able to keep up with increasing demand.  The result has been well-documented: long waits for health care services.  Waiting is a normal part of the Canadian health care experience, with provincial governments publishing  information on wait times and working to fix them.  The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”

And so an interesting dynamic has emerged.

Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles.  But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet.  As wait times have grown, so has a burgeoning private market.

Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day.  So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis.  While politically controversial, it made it possible to serve more patients without the need for additional government funding.

These types of ideas have grown, extending now to stand-alone diagnostic centers.  A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary.  This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work.  So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources.  They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face.  Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system.  And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.

Other kinds of private centers have opened up as well.  Some operate almost as membership-only medical practices, offering much of what might be considered primary care.  Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis.  For certain specialties like orthopedics, some even offer complete hospital surgical services.

The Canadian system remains very different from the American one.  Canadians do not want their system transformed into anything that reflects American “rugged individualism.”  And yet the natural human desire to look after oneself and ones family poses dilemmas.  When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.

We’re all entitled to that kind of help — Americans, Canadians, whatever.

The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.

*This blog post was originally published at See First Blog*

Wait Times And Rationing Care In Canada

You may think all is well in Canada. A land where FREE=MORE has been granted a birth right. It has been said many times before: You have three endpoints for which to strive for. Cheap, Quality or Quick. Pick any two. You can not have all three. It seems that Canada has decided to sacrifice Quick. You can always guarantee cheap health care. You simply stop paying for it. That’s called rationing. Getting in line and waiting is a classic form of rationing used by governments all across this land of ours.

In fact, as a resident in training at a VA facility, I saw first hand how rationing of care occurred using waiting as the tool of choice. Schedules blocked at 5-8 patients. Leaving when the clock struck 4. Scheduling dead patients. Yes folks, that actually happened. As an inpatient, technologists would finish their day on their terms. Getting studies after hours was impossible. Patients would wait for days to get an echo or a doppler. I once had an xray technologist refuse to come in, from home, in the middle of the night to take a chest xray on a crashing ventilator patient. The fact that the VA would not staff an overnight xray technologist was simply ridiculous. Try to get anything done on a holiday. Not only impossible but the hoops one had to travel through to attempt it would make Obama cry if he had any idea what the government run care was doing to his Vets.

Wait times is rationing, no matter how you look at it. You can find the link to the Fraser Institute on Canada’s Wait times here at Dr Hal Dall’s blog. I want to thank him for pointing it out. It is a fascinating look into the discrepancies in Canada’s health care, in spite of the equality for all mantra of social solidarity. Here is an excerpt from the research.

Finally, the promise of the Canadian health care system is not being realized. On the contrary, a profusion of research reveals that cardiovascular surgery queues are routinely jumped by the famous and politically-connected, that suburban and rural residents confront barriers to access not encountered by their urban counterparts, and that low-income Canadians have less access to specialists, particularly cardiovascular ones, are less likely to utilize diagnostic imaging, and have lower cardiovascular and cancer survival rates than their higher-income neighbours. This grim portrait is the legacy of a medical system offering low expectations cloaked in lofty rhetoric. Indeed, under the current regime—first-dollar coverage with use limited by waiting, and crucial medical resources priced and allocated by governments— prospects for improvement are dim. Only substantial reform of that regime is likely to alleviate the medical system’s most curable disease—waiting times that are consistently and significantly longer than physicians feel is clinically reasonable.

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

The Canadian Health Care System: Just Like Ours

Why paying for health care is so difficult:

a gigantic, complex raft of billing codes which are seemingly designed to haunt you in your sleep. With thousands of codes, and with frequent revisions to the fee schedule, it’s difficult to imagine a bureaucratic system. . . more challenging to decipher.

American health care?  No, Canadian.

Some problems are inherent to health care, regardless of who pays for it.

*This blog post was originally published at See First Blog*

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…

Read more »

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…

Read more »

See all interviews »

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.

See all cartoons »

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…

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 »

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…

Read more »

See all book reviews »