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Navigating Cancer Post-Treatment: Who Will Help You?

It is completely understandable if you associate the term “cancer survivor” with an image of glamorous, defiant Gloria Gaynor claiming that She. Will. Survive. Or maybe with a courageous Lance Armstrong in his quest to reclaim the Tour de France.  Or perhaps it is linked for you with heroic rhetoric and pink-related racing, walking and shopping.

Phil Roeder from flickr.com

I never call myself a survivor because when I hear this term, I recall my experience following each of four cancer-related diagnoses. It has not been triumphant. It’s been terrifying and grueling.  It hasn’t taken courage to get through the treatment.  It’s taken doing the best I can. I am not still here because I am defiant.  I am here because I am lucky, because I am cared for by good clinicians who treated my cancers based on the best available evidence, and because on the whole, I participated actively in my care. But mostly I am here because each successive diagnosis was made as a result of being followed closely with regular checks and screenings and because my doctors responded effectively to questionable findings and odd symptoms.

There are 12 million Americans living today who have been treated for cancer. Not only are we at risk for recurrences but, as Dr. Julia Rowland, director of the Office of Cancer Survivorship at the National Cancer Institute, notes, “Research shows that there are no benign therapies.  All treatment is potentially toxic and some therapy may itself be carcinogenic. Today, people are living long enough to manifest the health consequences of efforts to cure or control their cancer.”

Who amongst our clinicians is responsible for helping us watch out for those consequences for the balance of our lives? Read more »

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

Choosing The Best Health Care For You: What Information Helps You Decide?

Our ailing economy has boosted the number of people who are unemployed, without health insurance or with minimal coverage. The popularity of high deductible health plans is soaring as employers and individuals look for affordable insurance.  Twenty-nine percent of bankruptcies are said to be caused by medical bills. Many of us now choose health care services and providers carefully, trying to stay within tight budgets.

The American people, long protected from the price of health care by insurance, are now forced to act as consumers.  This situation is a free marketer’s dream.  According to this model, we will rationally calculate the price/quality trade-offs of each doctor visit, procedure, test and drug.  We will stop overusing services. We will demand better care. And the result will be reduced health care costs for the nation while the quality of care and the health of individuals will remain the same, if not improve.

There’s nothing like a good theory.

But the theory can only be tested if a) It’s easy to find publicly reported, relevant quality information about the services we need, matched with what we would pay out of pocket; and b) We use that information as the basis of our health care decisions. Neither of these conditions can be met today.

A new Cochrane review Read more »

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

Expert Shows Concern: Is It Possible To Choose The Best Health Care For You?

This interview is the ninth and final of a series of brief chats between CFAH president and founder, Jessie Gruman, and experts—our CFAH William Ziff Fellows—who have devoted their careers to understanding and encouraging people’s engagement in their health and health care.

Trudy Lieberman is concerned that despite all the rhetoric, choosing the best hospital, the best doctor, the best health plan, is simply not possible.  Some of the so-called best might be good for some people but not others, and the information available to inform/guide choices is just too ambiguous.

Ms. Lieberman is a CFAH William Ziff Fellow.

horizontalline

Gruman: What has changed in the past year that has influenced people’s engagement in their health and health care?

Lieberman: Costs have risen a lot, and employers and insurers have made consumers pay higher deductibles, co-pays and coinsurance.  The theory is, Read more »

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

How Contagion Shows Us The Importance Of Science In Today’s World

Contagion is a thriller about a virus that rapidly spreads to become a global epidemic. There aren’t enough coffins. Gangs roam neighborhoods like ours because police have abandoned their posts, fearful of exposure. Garbage fills the streets because sanitation workers are dying. As scientists work feverishly to understand the virus and develop a vaccine, public panic unravels the fabric of civil society, fueled by terror and rattled by false claims of a homeopathic cure promoted by a charismatic charlatan.
The movie has grossed $76 million worldwide since it opened on September 9th.  It has all the elements a successful movie needs: a just-believable dystopian vision of the future, flawed good guys, an evil schemer, suspense, heroic action…the works.

And while it’s an action-thriller first and foremost, you don’t have to concentrate hard to notice that it also shows:

  1. Why the Federal government is necessary: its authority to communicate, negotiate and work with other nations to solve a global problem; its ability to exert authority across state lines and to marshal resources immediately to protect its citizens from peril with no expectation of profit.
  2. How scientific research is iterative and complicated, not bumbling or malicious. Research is conducted by scientists—normal people with normal lives—who are Read more »

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

Using Your Mobile Phone To Change Behavior Patterns

There is excitement in the air about how mobile phones are the breakthrough technology for changing health behavior.  Last Saturday, I was convinced this must be true. In two short hours, I:

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

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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…

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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.

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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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