June 24th, 2009 by RamonaBatesMD in Better Health Network, Health Policy
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I was in the “audience” of the phone conference today organized by Dr. Bob Goldberg, President, Center for Medicine in the Public Interest (CMPI). In addition to him, Dr. Val Jones (Founder and CEO of Better Health) and Dr Gary Puckrein (President, National Minority Quality Forum) were on the panel of speakers. The focus was to be on the risks of government-run healthcare.
It seemed to me that many good points were made, but the main one was that the focus of the healthcare discussion needs to be refocused on the patient and the care given rather than simply on the high cost of care/insurance and any cost savings to be gained short-term. As Dr Wes pointed out in his recent post (The $400 Billion Dollar Question), patients aren’t at the “table” of many of the discussions of healthcare reform that are taking place.
Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?
I would argue we must know.
After all, it’s we the patients who are not at the policy table, and you can bet that it’s the patients who will ultimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.
There were two links given by the CMPI as sources for factual information on the healthcare discussion: publicplanfacts.org and biggovhealth.org.
I went to both, but in an effort to keep this post at a reasonable length will highlight only a few from the first link. First this one —
- Public plan proponents are advocating a $1.25 per hour per employee tax to pay for the public plan. The Commonwealth Fund, “The Path to a High Performance U.S. Health System”, p. 29, February 2009.
I won’t comment on that one, but will this next one:
- Under the public plan, doctors and hospitals would see their reimbursements for providing medical care cut by as much as 30%. The Commonwealth Fund , “The Path to a High Performance U.S. Health System”, p.33, February 2009.
This decrease in reimbursement troubles me as I have watched the struggles many hospitals have experienced over the past several years with the current reimbursements. I think this trend will only get worse. Check out Barbara Duck’s series at Medical Quack on desperate hospitals. Here’s an excerpt from the May 24, 2009 post:
In Chicago, Illinois
The Loyola University Health System in west suburban Maywood on Tuesday said it will eliminate more than 440 jobs, or about 8 percent of its workforce, amid the recession and an economic downturn causing an influx of patients who cannot pay their bills.
The cost of patients who cannot pay has increased 73 percent, to $31.3 million from $18.1 million, from a year earlier for the nine months ended March 31.
“We have been hit by a number of things,” Dr. Paul Whelton, chief executive of Loyola University Health System, said in an interview. “We are having more trouble with charity care, and the money we are getting [from patients] is more slow to come in. But we have a mission to provide care in our communities and we are going to stick to it.”
In all this talk on healthcare reform, it seems to me and others at the phone conference that the quality of patient care rather than simply cost containment needs to be put back at the front of the discussion. Healthcare should provide care without being hampered by more and more rules and regulations in an effort to contain costs. We don’t need more rules like the Medicare’s 75% rule.
Saving money by providing an inferior “product” isn’t what any of us want. Is it?
*This blog post was originally published at Suture for a Living*
June 14th, 2009 by RamonaBatesMD in Better Health Network
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Recently the WSJ Health Blog posted “Should Doctors Say How Often They’ve Performed a Procedure?” written by Jacob Goldstein. It references another guest post by Adam Wolfberg, M.D — “Test Poses Challenge for OB-GYNs”
Dr. Wolfberg writes:
None of the published studies of CVS pitted seasoned physicians against novices; what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle? But several reports from individual hospitals demonstrate that the miscarriage rate declined over time as the hospital’s staff became more experienced.
These reports point to a dilemma: CVS mavens got that way by practicing, so their present-day patients benefit at the expense of previous patients.
When I first began my solo practice 19 years ago, patients often asked how long I had been in practice. They ask less often these days. I have never failed to answer.
Patients sometimes ask how many times I have done a procedure, but not often. Early in my practice, and sometimes even now, if it is a procedure I feel a bit uneasy with or haven’t done in a while I will bring the subject up without being asked. After all, some procedures you just don’t do every day or even every month. Some diseases you don’t see every month or even every year.
In my mind, many of the procedures I do are built on basic surgical principles. I withdrew my privileges for microvascular procedures more than 10 years ago. I didn’t get enough patients referred to me to feel that my skills were kept sharp. In private practice, unlike at a university, there are no labs to go do practice work in to maintain those rarely used skills. I have no doubt that I could regain them given the chance, but at what cost (financially or complications).
Because I gave up my privileges for microvascular procedures, it means I have limited my repertoire of reconstructive procedures important in hand, breast, and other work. I tell my patients about them. If a breast reconstruction patient wants a free TRAM flap, then she is referred to someone who does it. If she wants to keep me as her surgeon, is there the possibility she is short changing herself on the outcome? I suppose, but I try (TRY) to be upfront and fair to each patient.
The question asked “should doctors say how often they’ve performed a procedure?” may seem an easy one to answer. If asked, yes. If not asked, should it be part of the consent form? I’m not sure it should for most procedures, but for extremely complex ones, maybe.
What if I did 100 of one type of procedure, but my last one was over a year ago? What if I have done 50 of a second procedure that is closely related in skill-set? What if that number is only 15? What if I have never done one and don’t wish to now, but the patient needs the procedure and is not willing to travel to another hospital? Is it okay that I have “informed” them, but they want to take the risk? How do I define that risk for them?
How many of which procedure is enough to become proficient? How often does it need to be done to remain proficient? Who gets to define proficient? Who gets to define the “magic” number of how many is enough to be proficient? Who get to define how often the procedure needs to be done to remain “proficient”?
As Dr Wolfberg noted
What patient would agree to be randomly assigned to an inexperienced doctor holding a long needle?
So how will these questions be answered?
*This blog post was originally published at Suture for a Living*
June 13th, 2009 by RamonaBatesMD in Better Health Network, Health Tips
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Last Tuesday, this tweet from @AllergyNotes caught my eye.
Call cubital tunnel syndrome a “cell phone elbow” and you make the front page of CNN.com: http://bit.ly/RaXrt and http://bit.ly/TTRfg
Cubital tunnel syndrome I know, but I had not heard it called “cell phone elbow.” The first link is to the Cleveland Clinic Journal of Medicine article (full reference below). It is an excellent article and well worth reading. The second link is to CNN news article picking up the “cell phone elbow” line.
Cubital tunnel syndrome is a nerve compression syndrome (like carpal tunnel syndrome). In the case of cubital tunnel syndrome, the nerve involved is the ulnar nerve and the location is at the elbow. From the article
… the ulnar nerve as it traverses the posterior elbow, wrapping around the medial condyle of the humerus. When people hold their elbow flexed for a prolonged period, such as when speaking on the phone or sleeping at night, the ulnar nerve is placed in tension; the nerve itself can elongate 4.5 to 8 mm with elbow flexion……..
As with other nerve compression syndromes, the clinical picture is representative of the nerves enervation. In the case of the ulnar nerve, this involves numbness or paresthesias in the small and ring fingers. There may also be numbness of the dorsal ulnar hand which will NOT be present if the ulnar nerve compression is in the Guyon’s canal at the wrist level (distal ulnar nerve compression). If the compression is chronic enough, the symptoms progress to hand fatigue and weakness. The small intrinsic muscles of the hand are important in hand strength needed to open jars. More from the article
Chronic and severe compression may lead to permanent motor deficits, including an inability to adduct the small finger (Wartenberg sign) and severe clawing of the ring and small fingers (a hand posture of metacarpophalangeal extension and flexion of the proximal and distal interphalangeal joints due to dysfunction of the ulnar-innervated intrinsic hand musculature). Patients may be unable to grasp things in a key-pinch grip, using a fingertip grip instead (Froment sign).
It may be an old joke (Patient: Doctor, it hurts when I do this. … Doctor: Well don’t do it.), but in the case of cubital tunnel syndrome it fits. Prevention is key. Prolonged extreme flexion of the elbow (elbows bent tighter than 90 degrees) is not kind to the ulnar nerve. Switch hands or use a head set or blue tooth.
REFERENCES
Q:What is cell phone elbow, and what should we tell our patients?; Cleveland Clinic Journal of Medicine May 2009 vol. 76 5 306-308 (doi: 10.3949/ccjm.76a.08090); Darowish, Michael MD, Lawton, Jeffrey N. MD, and Evans, Peter J MD, PhD
Cubital Tunnel Syndrome: eMedicine Article, Feb 9, 2007; James R Verheyden, MD and Andrew K Palmer, MD
*This blog post was originally published at Suture for a Living*
June 9th, 2009 by RamonaBatesMD in Better Health Network, News
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I want to say these two stories were well done (both aired on June 1, 2009). I was actually interviewed, but not quoted, for the story on fat-grafting. I pointed Allison Aubry to Dr Scott Spear as her expert. He is involved in one of the U.S. studies on breast augmentation using fat grafting.
Sculpting the Body with Recycled Fat by Allison Aubry.
Doctors Still Unsure Of Long-Term Risks
Surgeons like Dr. Scott Spear of Georgetown University Hospital want to know more about the techniques used to transfer fat for breast augmentation.
“We’re at the beginning of the learning curve,” he says. He has initiated a clinical trial to answer some questions about the best way to perform the procedure and whether there are any measurable risks. To date, there are no published studies in the United States, so doctors are relying on their own clinical experience.
Silicone Injections May Harm Some Patients by Patti Neighmond
When people get injected with silicone at pumping parties, Gorton says “there is no way to verify if they’re using medical-grade silicone. You can go to hardware stores and buy a big tub of it,” he says. “The element is the same, but it’s just not the same safety or purity or quality.”
*This blog post was originally published at Suture for a Living*
June 4th, 2009 by RamonaBatesMD in Better Health Network
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My mother died last Tuesday. She had her coronary bypass surgery just one week before that day. It was during her CABG that she had her strokes. Yes, strokes, plural. She was one of those 1.5% who suffer macroemboli cerebral strokes during coronary bypass surgery.
I went looking for information on it earlier this week. I went through my training without ever seeing this complication. Like everyone, I never thought my family would be the one. I think it is better to go to surgery, NOT thinking you will be the “statistic” as far as complications go. Anyone having surgery, SHOULD go into it feeling hopeful and thinking everything will go perfectly.
The article referenced below is a good review of this complication – stroke during coronary bypass surgery. The study is a retrospective review of 6682 consecutive coronary bypass patients who only had the CABG procedure and not other simultaneous procedures, such as carotid endarterectomy.
They list the possible sources of the emboli as the ascending aorta, carotid arteries, intracerebral arteries, or intracardiac cavities. They state that they believe the most likely source is the ascending aorta, for the following reasons:
First, the ascending aorta is the site of surgical manipulations during CABG, whereas mechanical contact is not made with the other potential sources of emboli. Embolization of atherosclerotic debris is most likely to occur during aortic cannulation/decannulation, cross-clamp application/removal, and construction of proximal anastomoses. However, embolization of atherosclerotic debris may also occur when the aorta is not being surgically manipulated, due to the ‘sandblast’ effect of CPB.
Second, the majority of our independent predictors of stroke – elderly age, left ventricular dysfunction, previous stroke/TIA, diabetes, and peripheral vascular disease – are strongly associated with atherosclerosis of the ascending aorta.
Third, our chart review suggested that the most common probable cause of stroke was atherosclerotic emboli from the ascending aorta. Palpable lesions in the ascending aorta were noted in a large proportion of stroke patients.
The fourth reason we believe the ascending aorta is the likely source of macroemboli is because of ancillary autopsy data. …….
Note the second reason given above – the independent predictors of stroke. My mother was over 74 yr so fell into the elderly age risk factor group. She was also a type 2 diabetic. She was noted to have a small abdominal aneurysm and some renal artery stenosis on the angiogram (an accidental pickup). So she had three of the four independent risk factors.
REFERENCES
Stroke during coronary bypass surgery: principal role of cerebral macroemboli; Eur J Cardiothorac Surg 2001;19:627-632; Michael A. Borger, Joan Ivanov, Richard D. Weisel, Vivek Rao, Charles M. Peniston
*This blog post was originally published at Suture for a Living*
