April 27th, 2009 by DrRob in Better Health Network, Humor, Quackery Exposed
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Somehow the medical community has missed a very important news Item. In her website goop.com (dang, I was going to go for that domain), movie star Gwyneth Paltrow weighed in on a very frightening medical subject.
Shampoo.
“A couple of years ago, I was asked to give a quote for a book concerning environmental toxins and their effects on our children.
“While I was reading up on the subject, I was seized with fear about what the research said. Foetuses, infants and toddlers are basically unable to metabolise toxins the way that adults are and we are constantly filling our environments with chemicals that may or may not be safe.
“The research is troubling; the incidence of diseases in children such as asthma, cancer and autism have shot up exponentially and many children we all know and love have been diagnosed with developmental issues like ADHD [Attention Deficit Hyperactivity Disorder].”
Apparently, she went on to point the finger at shampoo as a potential major problem in our society and raised a possible link between shampoo and childhood cancers. Now, I am not sure how one can use shampoo on the head of a foetus (or a fetus, for that matter), but we have to tip our hat to celebrities for bringing such associations to the forefront.
So I did a bit of science myself to assess the voracity of her claims. I too was seized with fear when I noted the following:
- All of the kids in my practice who have ADHD have used shampoo.
- All of the kids with cancer have also used shampoo.
- I used shampoo as a kid (but not as a fetus), and I have ADHD.
- The projection is that 100% of the people now using shampoo will die.
Whoa.
This really backs up my misgivings about shampoo. I have always wondered at the claims these so-called hair-care products make so boldly. Here are some examples of lies spread by the shampoo industry:
Clarifying shampoo – What are they claiming with this? Is there such thing as unclear hair? Do some people look as though they have a giant blob of hair-like substance on their head instead of many separate hairs? Does clarifying shampoo make each individual hair once again visible on these people?
pH Balanced – What is pH imbalance? Is it when the pH sometimes is so acidic that it burns your hair off? That would be terrifying if true.
Volumizing shampoo – I was not aware volumizing was a word (nor was my spell-check). This means that the shampoo volumes things. How can you volume something? Does each hair get a separate volume, or does the hair suddenly get very loud. Personally, I am afraid to open the bottles of these shampoos for fear of going deaf.
Shampoo for stressed hair – I have never thought about the emotional state of my hair. I was not aware that it worries about things. Perhaps it worries about being volumized or burned by non-pH balanced shampoos. Perhaps it worries about being put on a foetus. Does this type of shampoo contain a hair version of valium?
Vitalizing shampoo – At least vitalizing is actually a word, but would you really want vitalized hair? My dictionary defines this as “giving life and energy to.” Hair is dead, as we all know. Does this “hair resurrection” cause your hair to scream every time it is brushed or cut? Does it move about on your head independently? What if it decides it wants to become a mullet?? Thank you, but I prefer my hair dead.
Self-adjusting shampoo – Instead of the hair having independent action, this type of shampoo seems to have an intelligence of its own. How would it self-adjust? Does it have a computer chip embedded in it or does it somehow have sentience? How do we know if it will adjust in a way we want? It could adjust to pH imbalance or de-volumization, couldn’t it? What if this self-adjusting shampoo, which clearly has some degree of autonomy, gets ideas and causes other shampoos to break the shackles we humans put on it and forms a shampoo revolution? An even scarier thought is if a self-adjusting shampoo comes in contact with vitalized hair! What will happen then? Will they fight, or will they conspire against the shampooee?
Baby shampoo – What is the life-cycle of a shampoo? How do they find these baby shampoos and why would they steal them from their parents? This is probably what is causing the shampoos to become self-adjusting. I will say, shampoos do seem to multiply in our bathroom. We probably have 16 bottles of different kinds of shampoo in our shower right now. I just recently noticed some baby shampoo, but I thought my wife had just bought it. I see now that we should not let the bottles touch each other if we want to have room in our shower to bathe.
So you see, while Miss Paltrow’s fears about shampoo are clearly far short of the whole story, at least they bring attention to this frightening situation. Shampoo manufacturers are clearly in cahoots and have eyes on world domination. The condemnation of this celebrity’s claims by “scientists” are clearly a smoke-screen to keep us from noticing the obvious plans for the destruction of humanity.
No more shampoo for me!
Gotta go now. It’s time for my colon cleanse.
April 23rd, 2009 by DrRob in Better Health Network
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Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject. While my post was just a gripe about the problem, the comments were mainly focused on solutions. How do you fix the problem? I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.
You have to realize that I’m basically chicken (as are most doctors). I like to point the finger and avoid the fingers of others. It’s much easier to gripe than to fix things. It’s much easier to criticize than it is to say things that can be criticized. But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured. Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.
So here are my suggestions:
1. The government has to take on tasks that are in the best interest of the public.
Preventive healthcare should be paid for. This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.
There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears). Simply building a relationship between people and primary care physicians also has benefits by itself.
The overall goal is to improve the overall health of the American public. Promote behavior that deals with problems when they are still small or before they happen at all. Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.
2. Promote proper utilization
One of the main costs to any system, public or private, is overutilization of services. Any solution that does not somehow look at utilization will automatically fail. More care costs more.
Here are areas of increased utilization:
- Emergency room visits for non-emergencies.
- Visits to specialty physicians for primary care problems.
- Unnecessary tests ordered – more likely in a setting where the patient is not known.
- Patient perception that “more care is better.”
- Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital. This causes duplication of tests.
Solutions to these problems include:
- Better access to primary care or other less costly care centers
- Increase the ratio of primary care to specialists
- Care management for high utilizing patients
- Public education (not through the press but through better public health).
- Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
- Make the malpractice environment less frightening to doctors. A large amount of questionable care is given to protect physicians from lawsuits. (A good example is PSA Testing. Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).
How does this help the problem of the uninsured? It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.
3. Fix problems with Pharma
Medication costs are a huge problem to my uninsured and insured populations. There are many reasons for this, but some of them are simply due to a bad system. For example:
- Medication discount programs cannot include Medicare patients. Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
- High cost of generic drugs. When a drug goes generic, there is usually only a slight drip in the price. The system allows only limited competition for price, so the cash price remains high. Encourage cost competition.
- Drug Rebates. This raises the overall cost of drugs to everyone. Rebates are sent to insurance companies by drug companies for inclusion on the formulary. It pretty much looks like extortion. The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate. These need to be eliminated.
- Get rid of direct to consumer marketing of drugs. This is pure capitalism that encourages over-utilization.
All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.
4. Address Conflicts of Interest
Insurance companies are largely publicly-traded companies. This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue. Having them the ones managing care is like putting the kid in charge of the cookie jar. Insurance companies should get back to the business of insuring. Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).
Insurance companies promote themselves as healthcare companies. They don’t provide care, and they shouldn’t. Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.
How does this help the uninsured? It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance. It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place. If insurance costs less, there are less uninsured.
5. Focus on the “uninsurable”
5% of Americans account for over 50% of the overall cost of care (reference). These are the uninsurable people – those who are truley expensive to treat. There needs to be very close management of these people. Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government. It also leaves them unmanaged. Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition). These people need management, either in a “medical home” or by some sort of care management.
There you have it. Follow these rules and everything will be fine.
Yeah, right. Alright everyone, have at it! Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.
*This blog post was originally published at Musings of a Distractible Mind.*
April 9th, 2009 by DrRob in Better Health Network, Quackery Exposed
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I got this in the mail today.
The spam filter didn’t work 100%. I know.
Why even post it? Just to comment on a society where people ask me “is it safe?” when I prescribe a medication for them and yet value the fact that people in Hollywood do something. Most of the people in Hollywood are idiots and are surrounded by more idiots.
Let me reassure you:
- Your body is not “full of toxins.” When it is, your liver and kidneys are designed to handle those “toxins” and will do so far better than anything someone tries to sell you.
- Diets only work when they restrict calories.
- Your colon is fine and does not deserve to be regularly “cleansed.” Colonics have been around since the early 1900’s (maybe earlier) and the fact that they are still being used is only evidence of the gullibility of humans.
- Never trust something that claims to “strengthen the immune system.” It is an impossible claim to prove or disprove, and so is made with impunity.
- Look for the word “supports.” Phrases such as “supports prostate health” or “supports a healthy immune system” are big signs that you are being BS’d.
- I never give patients medicines I would not take myself in the same circumstance. I know no doctors who do. It is fine to say “why do I need this medicine?” or “Is this medication really necessary?” but to ask “is it safe?” or “doesn’t this destroy the liver?” is kind of insulting.
- I guarantee that any plan like this one will cause significant weight loss…in your wallet.
Sorry. Had to rant about this. People believe many dumb things and will until the world’s end. I feel bad for the people brought in by this and am angered at the hucksters that are fattening their wallets and misleading the uninformed.
End of Rant
*This post was originally published at Musings of a Distractible Mind.*
March 31st, 2009 by DrRob in Better Health Network
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Our office has been on Electronic Medical Records (EMR) for nearly thirteen years. We see a high volume of patients, keep our overhead down, and are able to be quite successful financially. All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office. We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.
Not that it was easy; we went through many years of struggle to get to where we are today. We struggled mainly because we were exploring unknown territory. We had very few other successful EMR implementations to learn from. We used slow computers and programming developed in the pre-Internet era. We made huge mistakes and struggled at times to make our monthly budget.
But we did it, and practices implementing now can learn from my and others’ success. Probably the main lesson we learned is to put office function ahead of implementation. Since we are a business, we must stay profitable while implementing. Since we are practicing medicine, we must never compromise quality in the process. This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.
Now we are at the position I thought might never come: survival is no longer in question, so we can dream. We don’t have to act defensively, we can push the envelope. We can afford to ask the question: “How can we build the best medical experience for our patients?” We can imagine a destination and actually attempt to get there.
The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end. Obviously I don’t want to make things harder for our practice, I want to make things easier. But the goal of care is ultimately centered on the patient, not us. So is there a way to accomplish both goals? I think there is, and I think that our EMR is the tool that makes it possible.
Here are our goals in the process:
- Simplify how things are done
- Always have the right information available
- Make communication clear and easy
- Achieve the highest quality possible
I’m sure some think this is just idealism and can’t happen in reality. I agree and disagree. No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made. The best way to show that is to get down to specifics. Here is where our practice is heading:
Simplify
The thing that takes the most time away from actual patient care is documentation. Doctors are paid by the volume of documentation, not its quality. Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room. Unfortunately, the patient is continually changing, so some information is only accurate for a short time. Has the patient seen a specialist or been in the hospital? Have the medications been changed, or just not taken? Have they changed jobs, quit smoking, or gotten married? Did their sister just get diagnosed with cancer? The task of keeping this information up to date is extremely difficult.
Patients are the ones who know these things best, but they are only passive participants in the process. To keep the record accurate, I must ask them all the right questions on a regular basis. This cuts into time that should be devoted to care. So why can’t the patients be allowed to maintain this part of the record? Why shouldn’t they have access to parts of their record and the ability to correct errors? Here is how we see this happening:
- Certain parts of the record should be available for patients to review online. Basic demographics, medications and allergies, family history, and lifestyle information is a good start. If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
- If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room). Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
- Patients should be able to communicate important information to the office online. If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.
Another area of potential gain is the gathering of information for a visit. When a person comes to the office, they have to answer a series of questions related to the visit:
- what are the symptoms the are having?
- Are there any other symptoms?
- How have they been since the last visit?
Gathering this information is essential, but it is one of the main causes of delays. Here is how we want to employ technology to improve this process:
- Put kiosks in our waiting room where patients can provide information, such as:
- History of their present illness. If they are sick, then what are the symptoms and how long have they gone on?
- Review of systems. What other things are going on in their health?
- Medication and demographic review (if not done already online).
- If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).
Even 50% participation by patients in this process will have a huge impact on our office workflow. The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced. Will there be problems? There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience. Why should medicine be different?
I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead). Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.
And this is just the start.
**This post was published originally at Musings of a Distractible Mind blog.**
March 21st, 2009 by DrRob in Better Health Network
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Electronic Medical Records are coming. The economic stimulus bill (furious spinning kittens notwithstanding) assured this.
Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.
Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.
(From Fierce Health IT)
There will be even more money for implementation. We look forward to our checks (and are not counting on them yet).
Now it is time for the flies to start gathering. Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in. Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares. It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.
Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam. It’s like saying “easy solution to the Mideast unrest,” “obvious way to bring world peace,” or “makes exercise easy and fun.”
Run away quickly when you hear this type of thing.
Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort. It’s not impossible to become a doctor, but it isn’t easy. With EMR adoption, the most important factor in success is the implementation process. A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder. A well implemented EMR doesn’t just function, it improves quality and profitability.
How do I know? Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians. EMR allows us to practice good medicine in a manner that is much more efficient.
So how’s a doc to know who to trust? What product should he/she buy and whose advice about implementation should they follow? There are many resources out there. Here are a few I think are especially worthwhile:
- Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future. The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
- The American Academy of Family Physicians’ Center for Health Information Technology and the American College of Physicians both have tools to help member physicians decide on an EMR. Your own specialty society may, too.
- Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
- Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.
The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully. This office should be as close in make-up to your office as is possible. You should be able to look at how they do it and see yourself in that situation. Never buy a product before visiting at least one office like this (no matter how good the sales pitch). When you visit, make sure you ask them about the implementation process. How did they do it and how hard was it?
Which EMR do I recommend? Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around. You hear raves and horror stories with every product. Here is some basic advice:
- Get a solid CCHIT-approved brand that has been around for a while
- Don’t pay as much attention to price as you do function. Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
- Realize you are paying for a company, not just a product. It is not like buying a car, it is more like having a child or getting married. REALLY research that side of things. A good EMR with a bad company behind it should be avoided like the plague.
- See how connected the user-base is as well. A solid user group will do much to make up any deficiencies in the product and/or company.
So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning. That’s OK, because like medical school, the effort put in gives a very worthwhile product.
**This post was originally published at Dr. Rob’s blog, Musings of a Distractible Mind.”
