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The Role of Adult Mentors: If You See Something, Say Something

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I recently had the opportunity to spend five days with seven amazing teen women doing community service at the Howling Acres Wolf Sanctuary in Oregon. My eldest daughter has arranged this annual camping trip since she was in middle school and I tag along to drive, cook, provide first aid, reminders about bug spray and sunscreen, and do a lot of dishes.

This year I also gave some feedback to a couple of new teens that was not well-received and the experience set me to thinking about the role of adult mentors in the lives of teens. I think as adults, it is easier to just watch teens, make our own judgments about their behavior, but unless they are our own, refrain from helping them reflect on those behaviors.

Sadly, I think this lack of feedback from adults does not benefit youth. I am of the mind that teachers, doctors, counselors, and actually all adults spending time with teens are ethically responsible for giving them feedback about their behavior – to provide an opportunity for them to reflect on a person’s perception of their behavior and his or her response to it.

The flip side of this is hearing the feedback given back, so yes, I heard when I was “snippy” and did have to apologize several times for losing patience – but it is all good and we are never too old to “engage” in relationships.

Teens really are blessed if they spend time with adult who will talk with them honestly and give them feedback, but the teen has to make the decision to hear the feedback and not just feel criticized and withdraw – which is the hard part of honest relationships. This group of girls was a new group, with four new members, and a wide age range – 12 to 17 – so there were several mini-lectures about judgment and being self-centered, which of course were translated into “she does not like me.”

I have to say it is hard to have conversations with teens who do not want to hear, but if they can hear that the feedback is about being perceived as the type of person they want to be, then there is hope. For example, if a teen says something negative about a person we pass or interact with in the community, I am likely to say, “whoa, that is really judgmental – are you sure you want to judge her without knowing more about her?” Or, maybe, “I hope you do not judge me solely on my appearance,” and if focused, I might add that people tend to shy away from people who are negative or judgmental, which is usually not what we want, which is to attract people.

Reactions range from silent sullen and angry to a brief nod and maybe “I am sorry,” but I think the process is the important part. Teens are going to be adults soon, and then feedback gets really rare except from friends, family, and bosses (which have consequences attached), so it is important to give the feedback and help teens hear it.

This post, The Role of Adult Mentors: If You See Something, Say Something, was originally published on by Nancy Brown, Ph.D..

Will The CDC Recommend That All Boys Should Be Circumcised?

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There appears to be some controversy brewing. The New York Times is reporting that the CDC may recommend just that in an effort to protect the boys against HIV as they become sexually active:

The topic is a delicate one that has already generated controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control and Prevention by the end of the year, has yet to be released.
The American Academy of Pediatrics is currently neutral. As a result, many state Medicaid programs do not pay for the procedure. But it sounds like that may be changing, with a policy indicating circumcision has health benefits beyond HIV prevention.
And the Daily Dish reports that:
Hundreds of commenters wrote into the New York Times today to complain about “child abuse” and “genital mutilation” and one “religious sect’s agenda of control” (i.e. Jews).
I don’t see what the big deal is. Everyone seems to be piercing and tattooing their bodies these days. What’s wrong with a little circumcision?
Perhaps you could mandate the same kind of prevention that schools do with their vaccination requirements. What do you think? Should all boys be circumcised?

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

Weird Medical Problem Of The Week: Infected Umbilicus

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Occasionally I post something that scores high on my weird sh!tometer (here, here and here). It seems this is such an occasion.

I thought of this incident recently when I was privy to some doctors complaining about stupid referrals. This was the only one I could think of. In reality it was more a moronic patient than a moronic referral.

As usual it was late at night. The casualty officer said he thought the patient had an enterocutaneous fistula (connection between bowel and skin). I asked why someone with something like that would wait for the middle of the night to turn up in casualties when the condition was almost always chronic. He gave a nervous chuckle and agreed. When I started asking about possible disease processes which could give rise to this condition (which pretty much can’t just happen spontaneously) he had no answers. In his voice I could almost hear him saying:

“Come on. I’m tired. It is a stupid thing to come into casualties for at this hour but here she is. Just come down and see her so it is no longer my problem.” I answered before he was forced to actually say these words.

“Ok, I’m on my way.”

The patient was an old Indian lady fully-clad in her robe-like traditional garb. I asked her what the problem was. She was quite a bit less than forthcoming. I asked her to show me the problem if she couldn’t describe it. She lifted her robe. I was not prepared.

She presented a disfigured torso and abdomen. It seems when she was younger she had been severely burned by hot water. Those areas that had been burned were devoid of fat and had skin attached directly to the underlying muscle. Between being young and the present she had become obese. Actually that is only partly accurate. Only the unburned areas had become obese. She had areas of supreme obesity interspersed by a network of amazingly slim. On one of the fat areas, towards her flank was an opening which was oozing pus. The smell was unearthly. I may have gagged a bit. But something was missing.

“Where is your umbilicus?” I asked. She looked sheepishly away. She was determined to not be forthcoming. A more direct approach might work, I decided. I pointed to the suppurating hole almost on her flank and asked:

“Is this your umbilicus?” She nodded. The burn wounds interspersed with severe obesity had dragged her umbilicus to her flank leaving behind a long oozing tunnel. I was annoyed. She knew what the problem was from the beginning. She also knew that it wasn’t something to come into casualties for in the middle of the night. She had been taking us all for a ride. But what could I do? She was there and I had to do something. Something, I decided, would involve double gloving.

I inserted my finger into the oozing hole. As expected, now that I knew what it was, It tracked towards the midline where the umbilicus had been many years before. At its base I felt a tennis ball sized mass of old debris. This time I did gag. This mass I scooped out bit by bit until the umbilicus was something it hadn’t been for years…clean. Annoyance fell away to disgust. I almost couldn’t speak because of my gag response, but I forced myself.

Fortunately all I really had to say was:

“Have you heard of soap?”

*This blog post was originally published at other things amanzi*

Counter Point: American Healthcare Is Not The Best In The World

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Let’s get honest, OK? America does not have the best health care in the world. Europeans and Canadians are not flocking to our borders to get to our health care. It is time we realize that we can learn from our neighbors and we don’t have to claim we are the “best” at everything. It makes us look really stupid in the eyes of the world.

Here are some facts. We do spend the most money on health care in the world. We do spend the highest percentage of Gross National Product (GDP) on health care and we do spend more dollars per capita than any other country on Earth.

The claim that the United States has the best health care in the world has been proven false by every broad metric used. The World Health Organization and the nonpartisan Commonwealth Fund rankings rate the U.S. last of the Western industrialized countries. The WHO ranks us 37th of all measured countries.

The Commonwealth Fund says, “Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care.”

The U.S. also lags in information technology. (We have been awaiting a robust electronic medical record for 10 years) and in coordination of care and in measured quality outcomes.

One of the ways we improve in health care is when we face the brutal truth. How can you make improvements if you don’t know where you are starting from? If you truly believe you are the best in the world…there would be no need for health care reform.

Perhaps that is why these myths and lies are being propagated.

*This blog post was originally published at EverythingHealth*

The Difference Between Short and Long Term Medicare Savings for Health Care Reform

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Robert Blendon, Professor of Health Policy and Political Analysis at the Harvard Kennedy School of Business, speaking on funding for Health Care Reform, July 8, 2009

“Potential sources for this (health care reform) are new taxes on people or businesses, substantial short-term savings from the existing Medicare and Medicaid programs, or increasing the deficit”

After Last week’s passage of Health Care reform plans by committees in the House and Senate, attention has turned to the Senate Finance and House Commerce Committees to see how congress will pay for reform in a deficit neutral way, as mandated by President Obama.  The price tag over ten years–$1.2 Trillion–is paired with the observation that a shortage of $240 billion currently exists.  This assumes that $948 billion already has been found.

The only way to ‘find’ $948 billion without increasing the deficit is to increase taxes on businesses and the wealthy or by reimbursing less for services provided through Medicare and Medicaid.  I will leave the never-ending tax-rate argument for political pundits, and instead focus this post on short and long-term savings from Medicare and Medicaid because I believe paying less for services than it costs to provide them will negatively impact the quality of medical care in this country.

I was surprised to learn of a battle being waged between the executive and legislative branches on the issue of “long-term savings” from Medicare, as it relates to “Medicare Payment Authority”.  White House Chief of Staff, Rahm Emanuel, has called Medicare payment Authority, “the least talked about, most important issue on the table” and clarified its’ importance by stating, “Structures that fundamentally alter the long-term costs are a must for real health-care reform.”   This issue does not follow party lines with a mix of Republicans and Democrats being in opposition or support of the President, irrespective of party affiliation.

Our Congressional Representatives have the power to set Medicare Payments, outside of any pre-set rules or regulations by simply passing legislation.  The Washington Post describes this power as “one of their most valued perks….a powerful tool on the campaign trail”.  President Obama’s administration wants to either transfer payment authority to MedPac (the Medicare payment advisory commission) or create an independent Medicare Advisory Council, reporting to the executive branch so lawmakers can no longer tailor Medicare spending to address local concerns.

Before leaving office, Senator Ted Stevens secured a permanent 35 percent increase in Medicare payments for Alaskan physicians only.  The political benefits to an incumbent running for reelection need not be explained while it is easy to see the inefficiency in such a system.  At a time when politicians are admonishing those working in the Health Care Field to be more efficient, I would urge congress to take a dose of their own efficiency medicine and support the current administration in their efforts to curtail long-term spending by surrendering this power.

According to the White House, $622 of the $948 billion will come from short-term savings squeezed out of existing Medicare and Medicaid programs through one of two ways: by improving efficiency (309 billion) or enacting policy changes (313 billion).  The Medicare Fact Sheet posted on the White House website, states that one policy change will have the added benefit of encouraging efficiency:  “incorporate productivity adjustments into Medicare payment updates”.  This policy change measures the productivity of the entire U.S. economy, as measured by subtracting the hours worked from the amount of product created and extrapolates it to Health Care (a profession which does not produce “products”).  This idea justifies the withholding of 110 billion dollars from “providers” with an unexplained benefit stated in the closing sentence describing this policy, “This adjustment will encourage greater efficiency in health care provisions”.

I found it difficult to believe that anyone could suggest paying less would encourage greater efficiency in caring for the infirm and old until Boston Medical Center, a hospital serving thousands of indigent residents, sued the state of Massachusetts one week ago, charging that the state is now reimbursing only 64 cents for every dollar spent treating those covered under Medicaid or Commonwealth Care (the state subsidized insurance program for low-income residents).  This should be of great concern to us all since the House’s plan adds 11 million people to Medicaid and cuts funding while reformists tout Massachusetts as an example worth following, being the only state with universal coverage today.  Before state wide reform was enacted this hospital had operated for 5 years without a loss.  However, when the hospital showed losses over two years of 138 million dollars, state officials observed the hospital had a 190 million dollar reserve (not for long it appears) and suggested that Boston Medical could reduce costs by operating more efficiently.

The above example demonstrates the willingness of government bureaucrats, inexperienced in providing actual medical care, to give flippant advice while failing to appreciate how fiscal efficiency, doing more with less, impacts medical efficiency, caring for the ill effectively.  To be sure, something must be done to curtail run-away costs in health care and I agree with the president when he says, “The status quo is unsustainable. Reform is not a luxury, but a necessity”.  However, reform needs to focus on sustainable Short-term and Long-term savings in such a way that prevents hospitals and doctors from having to make a choice between providing sub-standard care or going out of business.  Furthermore, I would hope that Congress take an honest look in the mirror regarding long-term savings before only enacting short-term savings which could negatively impact the care available to us all.

Until next week, I remain yours in primary care,

Steve Simmons, MD

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