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Normal People Have Abnormal Brain MRIs

A recent research study suggests that as many as 7% of adults over 45 have had a stroke without even realizing it. Researchers performed brain MRI scans of 2000 “normal” (asymptomatic) Dutch men and women between the ages of 45 and 96, and found that 7.2% of them (145 people) had evidence of an infarct (stroke), 1.8% (36 people) had small aneurysms, and 1.6% (32 people) had benign tumors (usually a small malformation of the blood supply to the brain).

Interestingly, they also found one person with a primary brain cancer, one person with a previously undiagnosed lung cancer that had metastasized to the brain, one person with a life-threatening subdural hematoma (brain bleed), and one person with an aneurysm large enough to require surgery. So altogether, they found 4 people out of 2000 who needed urgent medical intervention.

Although the authors of the article emphasized the point that many “normal” people have harmless brain abnormalities – I was a bit surprised by the fact that they found 4 asymptomatic people unaware of a ticking time bomb in their brains.

Keep in mind that the study was conducted on middle class Caucasian adults in the Netherlands – so we cannot generalize these findings to more diverse populations. But I do think it’s a bit of an eye-opener.

MRI scans are quite expensive (well over $1000 in most cases) and are therefore not offered to the general population as a screening test. But it does make you think about saving up for one. Your radiologist may find something unimportant, or she may find something that you hadn’t bargained for. Or maybe one day the technology will be inexpensive enough to offer as a screening test in a primary care setting. But that’s not going to happen any time soon.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Abnormal Mammograms Often Terrify Women Unneccesarily

A dear friend of mine sent me a panicked, cryptic email late on a Friday night: “call me immediately” (followed by her cell phone). As a doctor, I usually know that these kinds of requests are triggered my medical emergencies, so I anxiously picked up the phone and called my friend, hoping that I wasn’t going to hear some alarming story about a tragic accident.

And low and behold the story was this: “I got home from work late and picked up the mail. There was a letter in there from the radiologist’s office. It said that my mammogram was abnormal. Do you think I have breast cancer? Am I going to die?”

Remaining calm, I asked what sort of abnormality was described. She read the letter to me over the phone:

“Dear [patient],

Your recent mammogram and/or breast ultrasound examination showed a finding that requires additional studies. This does not mean that you have cancer, but that an area needs further evaluation. Your doctor has received the report of your examination. Please call us at XXX to schedule the additional examinations.”

I knew immediately that this was a form letter (heck the letter didn’t even distinguish between whether or not my friend had had a mammogram or an ultrasound) and it made me angry that it had frightened her unnecessarily. I knew that as many as 40% of women who have mammograms have some sort of “finding” that requires further testing. Usually it’s because the films are too dark or too light, the breasts are particularly large or dense, or there is some cyst, calcification, lymph node, or shadow that the radiologist picks up. And in a litigious society, a hint of anything out of the ordinary must be reported as an abnormal “finding” until proven otherwise.

I did my very best to reassure my friend – to tell her that if the radiologist were truly concerned about what he or she saw on the mammogram s/he would have called the physician who ordered the test right away. Receiving a vague letter like this is reassuring, because it’s an indication of a low index of suspicion for a malignancy. I also told my friend that if a true mass were found on the mammogram, that a biopsy of that mass still has an 80% chance of being normal tissue.

But even though I did my very best to reassure her, my poor friend didn’t sleep well that night, and worried all weekend until she could speak to her physician on Monday. As I thought about her experience, and the unnecessary fright that she was given… I began to wonder about how common this experience must be. How many other women out there have lived through such anxiety?

Personally, I think that women who get mammograms should be warned up front that there is a high chance that the radiologist will find something “abnormal” on the test, and that these abnormalities usually turn out to be any number of typical breast characteristics. They should be told not to worry when they receive a letter about the abnormality, but come back for further testing in the rare event that the finding is concerning.

I decided to do a little research about this phenomenon (women receiving scary letters out of the blue about their mammogram results) and interviewed Dr. Iffath Hoskins (Senior Vice President, Chairman and Residency Director in the Department of Obstetrics and Gynecology at Lutheran Medical Center in Brooklyn, N.Y.) about her experiences.

Please listen to the audio file for the full conversation. I will summarize her opinions here:

Q:  How common are abnormal mammograms?

Mammograms are considered “abnormal” in some way in up to 40% of cases.

Q:  What sorts of things are picked up as abnormal without being true pathology?

Overlapping tissues in women with larger or heavier breasts, fibrocystic breast tissue, calcium deposits or the radiologist doesn’t have the last mammogram to compare the new one to and sees some potential densities.

Q:  What happens next when a woman has an abnormal mammogram?

It may take a week or two for the patient to get scheduled for follow up tests. Usually the physician will choose to either repeat the mammogram with targeted views of the area in question, request a breast ultrasound, biopsy the mass, or remove the concerning portion of the breast tissue surgically.

Q:  When would a physician choose a biopsy?

A biopsy is indicated if the mammogram and follow up tests all are consistent with the appearance of a concerning lesion. Sometimes the physician will do a biopsy on a lump if a woman says that it’s unusual, new, or tender and the mammogram result is equivocal.

Q:  What percent of biopsies confirm a malignancy?

It varies from physician to physician because some have a lower threshold for performing biopsies (so therefore the percent of biopsies that are malignant is lower). But on average only 10% of biopsies pick up an actual cancer.

Q: What does a radiologist do when he or she finds an abnormality on a mammogram?

First of all, the patient must be notified of the abnormality. Secondly, the radiologist reports the abnormality to the referring physician, usually by fax. They do it either in batches, or one at a time. If the person reading the film has a serious concern about the breast tissue – or if it appears to have the characteristics of a malignancy, the radiologist will personally call the referring physician right away.

Q: What advice would you give to a woman who receives a letter in the mail indicating that she’s had an abnormal finding on her mammogram?

Please try not to be concerned yet. Wait for the doctor to fully evaluate the mammogram and do further testing before you make any assumptions about the diagnosis. Although it’s almost impossible not to feel anxious, you must understand that the vast majority of “abnormal findings” on a mammogram are NOT cancer.

Listen to the full interview here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Why Do People Go To The ER For Primary Care Services?

Emergency departments are splitting at the seams, uninsured patients fill the waiting rooms, and Emergency Medicine physicians are crying “uncle” on a national level.  We assume that gaps in health insurance coverage force patients to seek treatment in the ED, but the reality is that many insured patients seek treatment there as well.  Why?  Because the ED is a crowded, but one-stop shop whose convenience cannot be denied.  PandaBearMD explains why one well-insured patient (who has a regular PCP) still chose to see him in the ED:

“As my patient related to me, in order to see his doctor he has to
make an appointment which is often weeks to months in the future. On
the day of his appointment, even if he shows up on time he will usually
have to wait an hour or two because the doctor is always running late.
Then he will spend a brief ten to fifteen minutes with his doctor who
will order a slew of tests and imaging studies, many of which will have
to be completed at a different location. He may, for example, have to
drive across town for a CT scan and it is usually scheduled for a
different day, often weeks in the future.

Then, as my patient explained, he must wait several weeks for his
next appointment where his physician will explain the results and
finally initiate either definitive treatment or, as is often the case,
referral to another specialist who will repeat the time consuming
process…

My patient also confided to me that even getting the results of studies
and imaging was not guaranteed. Although we are all quick to relay bad
news, apparently follow-up is not that pressing to many physicians if
the results are normal…

Consider now a visit to the Emergency Department. First, my patient did
not need an appointment. While it is true that he was triaged to a low
acuity and had to wait a while, at certain times of the day the waiting
times are not that much longer than the typical wait for his delayed
primary care physician. Second, the lab tests he needed were drawn on
the spot and the results reported within an hour even though he was a
low acuity patient. Our goal, you understand, is to discharge or admit
as fast as possible. Likewise his imaging studies were obtained, read,
and reported quickly. Finally, if anything serious has been discovered
he would have been admitted within hours. More importantly to my
patient, since everything was all right he knew fairly quickly instead
of biting his nails for a couple of months.”

This is a perfect illustration of how Americans value convenience over cost, and how health insurance can be an enabler for inappropriate ER use.  The solution here is in IT.  Primary Care Physicians need the tools to automate a lot of what they do, thus making care more convenient for their patients and themselves.  A common, secure PHR-EMR, synched with online scheduling, radiology suites and laboratories, health news alerts, care pages and vibrant community, chronic disease management tools, and comprehensive, credible, patient education will go a long way to keeping people out of the ER.  Revolution Health is working on such a system, and we have high hopes that the creation of America’s first integrated, digital medical home will improve the quality of life of patients and physicians alike. Achieving this goal will require cooperation and patience from all sectors in healthcare.  I hope we’ll find a way to work together as rapidly as possible or else the PCPs and ER docs are going to crack.  Hang in there, guys – help is on the way, though it might be a few years out…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Grand Rounds 3.38 Immediate Release

Welcome to the latest round up of the best of the healthcare
blogosphere. Today it is my pleasure to offer you your weekly dose of Grand
Rounds, optimized for your state of mind.
I believe that there are two basic types of blog readers, and so you’re
getting Grand Rounds 2 ways (with a dash of cartoons thrown in for extra “feel
good” measure):

  1. Just
    the Facts
    : Distractible, hurried, currently in between seeing patients –
    or perhaps your kids, cats, dogs, llamas are begging for attention… or
    maybe you’re an ER nurse or surgeon who has no patience for long winded
    stories?  You’re category one and
    should proceed directly to Grand Rounds IR (immediate release – below).
  2. All
    the Details
    : Calm, peaceful, you enjoy good prose and a cup of chai
    latte.  You like reading all the
    juicy details of a grand rounds line up and will spend hours picking
    through the references – or maybe you’re an Internist or Psychologist who
    knows that the best medicine is found in the details?  You’re category two and should proceed
    directly to Grand Rounds XR (extended release – next post).

Many thanks to Nick Genes, father of Grand Rounds (who acts
behind the scenes to ensure the success of each host), and please check out
next week’s Grand Rounds at Code Blog: Tales of a Nurse.

Grand Rounds IR (asterisk
= honorable mention for great writing)

Happy Posts

*Starbucks Caters to Diabetics

Woman Saved by Bush Pilot in Frozen Tundra

*CEO Says He’s Sorry

Prayer Can Reduce Arthritis Risk?

*Disaster Unpreparedness [Cartoon]

Med School Graduation Ceremony [Cartoon]

Nurse uses Star Trek Mentor to Set Course for Kindness
Galaxy

Shrink Rap Podcast: Prank Call with Dr. Phil McGraw &
More
[Cartoon]

*Cape Cod Vacation Derailed by Flood, Stroke, Famine & Infection

The Evils of Hand Washing

Sad Posts

Triage in the ED [Cartoon]

*Sad Cases in ED

Elderly at Risk of Death From Tranquilizers [Cartoon]

Life as a Nurse Assistant in Vermont

Hot Topics

Infanticide

Hucksterism

Healthcare Outsourcing (podcast)  [Cartoon]

Blog Censorship A

Blog Censorship B

Arrogant Docs [Cartoon]

Should Kim See Sicko?

Helpful Tips

To Fend off Bears

To Get the most out of Medicine, Web 2.0 style

To Get into Medical
School

To Avoid Kidney Damage from Contrast Agents

To Perform A Pyloromyotomy [Cartoon]

To Diet Successfully – Gluten Free [Cartoon]

Case Reports

Wii-itis

Rare pancreatic tumor

Uncategorized

Cost-benefit analysis of genetic testing

Commencement Speech for Harvard Medical
School Graduation

New Alzheimer’s Research [Cartoon]

New Genetic Research

Book Recommendation for Type 2 Diabetes

For the full text version complete with cheerful commentary, please go to Grand Rounds XR
(next post)


This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Are physician salaries too high?

I am opposed to millionaires, but it would be dangerous to offer me the position.

–Mark Twain

As we consider the wastefulness of the healthcare system, I have heard many people complain that physician salaries are one of the main culprits in escalating costs.

Dr. Reece compares the average income of some of the highest paid physician specialists, with that of hospital executives, medical insurance executives, and fortune 500 CEOs. Check this out:

Highest Paid Physicians

1. Orthopedic, spinal surgery, $554,000
2. Neurosurgery, $476,000
3. Heart surgeons, $470,000
4. Diagnostic radiology, Interventional, $424,000
5. Sports Medicine, surgery, $417,000
6. Orthopedic Surgery, $400,000
7. Radiology, non-interventional, $400,000
8. Cardiology, $363,000
9. Vascular surgery, $354,000
10. Urology, $349,000

Executive Pay for Massachusetts Hospital CEOs

1. James Mongan, MD, Partners Healthcare, $2.1 million
2. Elaine Ullian, Boston Medical Center, $1.4 million
3. John O’Brien, UMass Memorial Medical Center, $1.3 million
4. David Barrett, MD, Lahey Clinic, $1.3 million
5. Mark Tolosky, Baystate Health, $1.2 million
6. James Mandell, MD, Children’s Hospital, Boston, $1.1 million
7. Gary Gottlieb, Brigham and Women’s Hospital, $1 million
8. Peter Slavind, MD, Massachusetts General Hospital, $1 million

2005 Total Annual Compensation for Publicly Traded Managed Care CEOs

1. United Health Care $8.3 million
2. Wellpoint, Inc, $5.2 million
3. CIGNA, $4.7 million
4. Sierra Health, $3.4 million
5. Aetna, Inc, $3.3 million
6. Assurant, Inc, $2.3 million
7. Humana, $1.9 million
8. Health Net, $1.7 million

Top Corporate CEO Compensation

1. Capital One Financial, $249 million
2. Yahoo, $231 million
3. Cedant, $140 million
4. KB Home, $135 million
5. Lehman Brothers Holdings, $123 million
6. Occidental Petroleum,, $81 million
7. Oracle, $75 million
8. Symantec, $72 million
9. Caremark Rx, $70 million
10. Countrywide Financial, $69 million

But the real story here is the salary of our primary care physicians – those unsung heroes of the front lines. KevinMD pointed out a recent news article citing $75,000.00/year as the average salary of the family physician in the state of Connecticut, and that their malpractice insurance consumed $15,000.00 of that. Although this is certainly below the national average for pediatricians (they start at about 110,000 to 120,000), I’ve seen many academic positions in the $90,000 to 100,000 range.

Now I ask you, does it seem fair that the vast majority of physicians (the primary care physicians) are making one tenth of the average hospital executive salary? Should doctors really be in the cross hairs of cost containment?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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