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Latest Posts

Plastic Surgeon Outlines Ten Things You Should Know About Tummy Tucks

Tummy Tuck surgery is almost invariably greatly appreciated by the proper patient. These top ten facts might help you figure if you are such a person. ;)

(1) Tummy Tuck surgery is one of the largest scale operations a plastic surgeon can offer a patient.

(2) Patients who have lost a good deal of weight or completed child bearing involving large weight gain and loss are the most common candidates. Patients do not lose much weight from the operation itself in most cases….maybe a few pounds on average.

(3) Post-operative pain used to make it necessary to admit the patient to a hospital for narcotics.

(4) Pain pumps when properly utilized can Read more »

*This blog post was originally published at Truth in Cosmetic Surgery*

Plastic Surgeon Weighs In On Anti-Aging Medicine

Reader Question:

Do you do anti-aging medicine? I do not see it on your web site. If not, what is your opinion of it?

I am not a fan or follower of the anti-aging medicine fad in so much that it promotes what I believe to be a false concept. An older person cannot be made into a younger version of herself by boosting certain hormones. There is really no good evidence that it works. Patients don’t live any longer. It might also be found to be harmful in the long run.

Plastic surgeons will differ in their opinions as to what works with low risk to improve things. To me Read more »

*This blog post was originally published at Truth in Cosmetic Surgery*

The Best Thing A Patient Can Do Following A Heart Attack

I’ve been telling my smoking patients for years that nothing I do for them is going to make an ounce of difference until they quit smoking for good.  And the Italians are out to prove me right.  The American Journal of Cardiology reported July 11th, 2011 on the Effect of Smoking Relapse On Outcome After Acute Coronary Syndrome.

In a study of just under 1,300 patients,  Reuters reports that just over 1/2 the patients started smoking within 20 days of hospital discharge, despite in-hospital smoking cessation consultation for all patients.   Researchers also found that resuming smoking increased  death 3-fold compared with those that did not relapse and quitting smoking had a similar lifesaving effect as taking cholesterol and blood pressure medications.  And I’m sure these folks all landed themselves back into the hospitals for a very expensive dying process.

That’s why billing the patient or their insurance for smoking cessation (CPT® 99406 and 99407) is so important.  And that’s why I give many of my smoking patients my smoking lecture.  You know how much Medicare pays for a ten minute consultation to help cardiac patients quit smoking right now? Read more »

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

Are The Benefits Of Smoking Cessation Eclipsed By Obesity?

Epidemic by Tobyotter via Flickr and a Creative Commons license

Obesity is filling in for smoking as a cause of death in working class women, concluded researchers after reviewing mortality rates from a nearly 30-year study in Scotland.

In Europe, wealthier people either aren’t starting to smoke or are finding it easier to quit, which accounts for up to 85% of the observed differences in mortality between population groups, researchers noted.

Their analysis showed higher rates of being overweight or obese among those who’d never smoked in all occupational classes, with the highest rates in women from lower occupational classes. Almost 70% of the women in the lower occupational classes who had never smoked were overweight or obese, and severe obesity was seven times more prevalent than among smokers in higher social positions. Among women who had never smoked, lower social position was associated with higher mortality rates from cardiovascular disease but not cancer.

To investigate the relations between causes of death, social position and obesity in women who had never smoked, Scottish researchers conducted a prospective cohort study. They drew from the Renfrew and Paisley Study, a long term prospective community based cohort named for two neighboring towns in west central Scotland from which all residents then aged between 45 and 64 were invited to participate from 1972 to 1976.

Researchers reported their results online Read more »

*This blog post was originally published at ACP Internist*

Vitamin D For COPD: Why That Won’t Be Enough

I am frequently extolling the health benefits of Vitamin D because almost weekly there is a new study that correlates high vitamin D levels with reducing some disease.  The latest is from the American Journal of Respiratory and Critical Care Medicine and research shows that high doses of vitamin D supplementation improved respiratory muscle strength in patients with Chronic Obstructive Pulmonary Disease (COPD).  The patients that did not receive supplemental vitamin D had blood levels of 22.8 compared to 53.8 in the supplemented group.  The patients who were supplemented had improved respiratory function, strength and less shortness of breath.  It certainly didn’t cure or reverse COPD but the improvement was an encouraging trend in this terrible chronic disease.

In reading about this it got me thinking about COPD and the fact that it is one of the most common reasons for hospitalization and disability in the United States. It is a progressive disease that affects the alveoli (small air sacs that exchange oxygen) and small bronchioles of the lungs.  These airways and air sacs lose their elastic quality and become thick and inflamed.  Mucus forms and patients become progressively short of breath and eventually need supplemental oxygen just to breathe.  COPD is the fourth leading cause of death in the United States.

Did you know that most COPD is caused by Read more »

*This blog post was originally published at EverythingHealth*

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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