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

Latest Posts

Can Patients Choose A Good Doctor Online?

The following op-ed was published on October 27th, 2010 in USA Today:

When I ask new patients how they found me, frequently they say on the Internet through search engines such as Google.

Out of curiosity, I recently Googled myself. Numerous ads appeared, promising readers a “detailed background report” or a “profile” of me. Among the search results was information about my practice, whether I was board certified, had any lawsuits against me, and reviews from online doctor rating sites. Thankfully, most were favorable, but some were not.

Can patients reliably choose a good doctor online?

People already choose restaurants, movies, and their college professors based on what they read on the Internet, so it’s inevitable that many will research their doctors on the Web as well. But there are some good reasons consumers should be wary of the information they find online about doctors.

Random information?

An Archives of Internal Medicine study in September found that most publicly available information on individual physicians — such as disciplinary actions, the number of malpractice payments, or years of experience — had little correlation with whether they adhered to the recommended medical guidelines. In other words, there’s no easy way to research how well a doctor manages conditions such as heart disease or diabetes. That kind of relevant performance data are hidden from the public. Read more »

*This blog post was originally published at KevinMD.com*

What’s Going On Behind Closed Doors In Washington On Healthcare Reform?

bill-novelliToday there was a Fiscal Responsibility Summit held at the White House. Bill Novelli, CEO of the AARP attended the summit as part of the work group on health. Bill reported what he observed in his work group (which consisted of notables such as Senators Baucus, Rangel, and Specter, Nancy Pelosi, Nancy Nielsen, MD, Becky Patton, RN, Rich Umbdenstock and others) on a special media conference call today.

The over-arching theme of the work group discussion, according to Bill, was prevention and wellness. The group agreed that the key to improving Americans’ quality of life and controlling the costs of chronic disease lies in preventive health efforts. In addition to this belief, the group agreed that:

1. Healthcare reform must be achieved as quickly as possible. The path to long term entitlement sustainability requires healthcare reform. Simply expanding access to a broken system is not the solution.

2. The American people need to be engaged in reform efforts – not just as patients, but as tax payers and voters. They need to understand what they will gain and lose.

3. We must reward adherence to best practices and healthcare quality.

4. A public-private partnership is critical to achieving reform.

A few interesting points were raised by various stakeholders in the meeting:

1. Arlen Specter – believes that changes in medical approaches to end-of-life care could decrease costs substantially. He called for more advanced directives, and education about end-of-life care options.

2. Dr. Nancy Nielsen – called for Medicare to fix the physician fee schedule.

3. Becky Patton – called for increasing the nurse and healthcare workforce.

4. Rich Umbdenstock – requested that more attention be focused on pay for performance and administrative simplification initiatives.

I asked Bill how many providers were included in his work group, and he mentioned three (Nielsen, Patton, and Umbdenstock – not really a provider himself). Best I could tell, there was only one physician and one nurse at the meeting. And that is fairly shocking to me.

If healthcare reform is happening without much input from the primary providers of care (doctors and nurses) – will the reform decisions made by these well-intentioned individuals make good clinical sense?

Another reporter asked Bill what he thinks will happen with healthcare reform in the near term. His answer was telling: “We don’t know.”

AMA President Dr. Nancy Nielsen At The Medicare Policy Summit

nancy-nielsen-ama1I attended my very first Medicare Policy Summit conference today – and it was truly riveting (wonk alert). I took copious notes and will do my best to summarize some key points in a series of blog posts. This first post is devoted to the presentation by AMA President, Dr. Nancy Nielsen.

Dr. Nielsen began her lecture with an amusing story. She said, “congressional hearings are pure theatre” and described what she’d experienced three months ago at a meeting with Pete Stark. The conversation went something like this:

Stark: I’m sick of rich doctors driving up in their Porsches saying ‘I’m pulling out of Medicare.’

Nielsen: [Thinking to herself: First witness please?] I drive a GEO jeep.

Then Dr. Nielsen looked out at the Medicare Policy Summit audience and asked, “are there any doctors here?” I raised my hand enthusiastically at the back of the room. Then she responded, “Oh thank God. Well, you know we’re in the lion’s den…”

[Parenthetically, I didn't see anyone else raise their hand - which is the subject for another conversation.]

What Is The AMA’s Current Agenda?

1. To expand coverage for the uninsured

2. To reform the physician payment system

3. To improve the quality and safety of healthcare

4. To improve public health

What Is The Bee In Nielsen’s Bonnet?

Nielsen explained that the sustainable growth rate is unsustainable. She stated:

“We can’t go through the annual death dance with congress over this. There is another 21% across-the-board cut in Medicare reimbursement scheduled for January 2010. And this cut will affect a group of small business owners (aka physicians) whose reimbursement has not increased since 2001 while their costs have increased 20%.”

What Does Nielsen Propose We Do?

1. Reform the system so that it reimburses for care coordination and prevention

2. Craft solutions based around patients’ needs

3. Rebase the SGR

4. Bundle services to increase value and reduce costs

5. Invest in disease prevention and wellness

6. Use comparative effectiveness to inform clinical decision-making (but NOT as a basis for coverage decisions)

7. Bring physicians into the policy decision-making process

Closing High-Five to Nurses

Dr. Nielsen closed with an amusing anecdote about inauguration day. Apparently she was standing in the sidelines of the parade route where Biden got out of his limo to greet the crowd. He gave a big hug to some nurses standing next to her and said, “I love nurses. They’re so much better than doctors.” Dr. Nielsen then had the opportunity to introduce herself to Biden and he responded, “Doctors saved my life, but nurses gave me the will to live.”

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 »