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

Latest Posts

False Positives And The Dangers Of Too Much CT Scanning

On the US News & World report website, Dr. Kenny Lin writes as a physician and a concerned observer about “Dangers of Incidentaloma: Why To Think Twice Before Getting a CT Scan.”

It’s an important issue. Give it a look.

Lin’s blog, “The Common Sense Family Doctor,” is also worth visiting. Recently he cited one of my alltime favorite essays, “The Last Well Person,” by Dr. Clifton Meador, who wrote in 1994:

“The demands of the public for definitive wellness are colliding with the public’s belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combined with clinicians whose tools are powerful enough to find very small lesions, is a setup for diagnostic excess. And false positives are the arithmetically certain result of applying a disease-defining system to a population that is mostly well. … If the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick. Like the invalids, we will all be assigned to one diagnosis-related group or another. How long will it take to find every single lesion in every person? Who will be the last well person?”

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

CT Scans For Kids: Is The Radiation Exposure Dangerous?

There was an interesting study published this week in the journal Radiology:

Rising Use of CT in Child Visits to the Emergency Department in the United States, 1995–2008 (Abstract)

The results are not surprising to anyone who has been working in medicine in the US over the last fifteen years. Basically, in 1995, a kid visiting the ER had a 1.2% likelihood of getting a CT scan, and by 2008, that number was 5.9%.

I had written about this general phenomon not too long ago, in defense of the general increase of CT utilization in the ER, largely on the basis that CT is a better tool: it provides diagnoses in a rapid and timely manner, and excludes many potential life threats, saving lives and mitigating malpractice risk. That was largely relevant to the adult population, though, and kids are not, as they say, just little adults. The increase in scanning children is more dramatic, especially given the generally lower incidence of disease in kids compared to adults and the chonrically ill. Read more »

*This blog post was originally published at Movin' Meat*

Some Physicians Fear Airport Scanner Radiation, Despite Evidence

In preparation of Internal Medicine 2011 in San Diego this week, the unavoidable choice to make isn’t which sessions to attend, but even before arriving: Will you pass through the airport’s security scanners, or opt for the pat down?

Physicians themselves are split on the issue, with some physicians opting out of repeat scanning in favor of the pat down search.

“I do whatever I can to avoid the scanner,” one physician told CNN. Other physicians interviewed were split on the issue one way or another. But as a frequent flier, this doctor was concerned about the cumulative effect. “This is a total body scan–not a dental or chest X-ray. Total body radiation is not something I find very comforting based on my medical knowledge.” Read more »

*This blog post was originally published at ACP Internist*

CDC Brain Injury Guidelines For Physicians: When To Scan A Concussion

By Richard C. Hunt, MD, FACEP

Centers for Disease Control and Prevention

A 17 year-old athlete arrives on the sideline, at your office, or in the emergency department after hitting her head during a collision on the sports field and is complaining that she has a headache and “just doesn’t feel right.”

Can she return to play? If not, when can she safely return to school, sports, and to her normal daily activities? Does she need immediate care, a Head CT or MRI, or just some time to rest?

Do those questions sound familiar?

Each year thousands of young athletes present at emergency departments and in the primary care setting with a suspected sports- and recreation-related concussion. And every day, health care professionals, like us, are challenged with identifying and appropriately managing patients who may be at risk for short- or long-term problems.

As you know, concussion symptoms may appear mild, but this injury can lead to significant, life-long impairment affecting an individual’s ability to function physically, cognitively, and psychologically. Thus, appropriate diagnosis, referral, and education are critical for helping young athletes with concussion achieve optimal recovery and to reduce or avoid significant sequelae.

And that’s where you come in. Health care professionals play a key role in helping to prevent concussion and in appropriately identifying, diagnosing, and managing it when it does occur. Health care professionals can also improve patient outcomes by implementing early management and appropriate referral.

As part of my work at CDC, and as a health care professional, I am committed to informing others about CDC’s resources to help with diagnosing and managing concussion. CDC collaborated with several organizations and leading experts to develop a clinical guideline and tools for the diagnosis and management of patients with concussion, including:

For more information about the diagnosis and management of concussion, please visit www.cdc.gov/Concussion/clinician.html.

Also, learn more about CDC’s TBI activities and join the conversation at: www.facebook.com/cdcheadsup.

Microsoft Kinect Helps Surgeons Review Radiology Images In The OR

2whae44.jpgEngineers at Toronto’s Sunnybrook Hospital have been trialing a new system that uses Microsoft’s Kinect to allow surgeons to browse through diagnostic images without having to physically touch any controls. Using the system surgeons can manipulate images without losing sterility, without any assistance from a nurse or other person in the OR, all while not having to move away from the patient.

Here’s a report from The Globe and Mail:

More from The Globe and Mail: Toronto doctors try Microsoft’s Kinect in OR

Flashbacks: Microsoft Kinect 3D Camera for Hands-Free Radiologic Image Browsing;

*This blog post was originally published at Medgadget*

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…

Read more »

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 »

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 »