August 14th, 2007 by Dr. Val Jones in Announcements
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I watched the final episode of “Hell’s Kitchen” last night – a cooking show where a mean chef berates young chef hopefuls in a series of competitive cooking contests. The host of the show was almost as vicious as my vascular surgery preceptor in medical school… you docs out there know what I mean.
Anyway, I had the pleasure of being the sous chef for Chef Rock at a recent charity event for celiac disease awareness. GastroGirl (Jackie Gaulin) and I helped him whip up a delicious, gluten free meal and CNN’s Heidi Collins taste tested our dish. Although our shrimp and grits lost to a rival “coriander encrusted skate” I always thought that chef Rock was a winner.
And here he is: the top chef of Hell’s Kitchen. Congratulations, Rock! I’d be delighted to work as your sous chef in Las Vegas… see you at the B. Smith’s victory party!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 14th, 2007 by Dr. Val Jones in Expert Interviews
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In a recent study conducted by the Agency for Healthcare Research and Quality (AHRQ), it was argued that better primary care could prevent 4 million hospitalizations per year. This staggering potential savings – on the order of tens of billions of dollars – seems like a good place to start in reducing some of the burden on the healthcare system (and reducing unnecessary pain and suffering). I interviewed Dr. Joe Scherger, Clinical Professor of Family & Preventive Medicine at the University of California, San Diego School of Medicine (UCSD) and member of the Institute of Medicine, to get his take on the importance of prevention in reducing health costs.
Dr. Val: What do the AHRQ
statistics tell us about the role of primary care in reducing healthcare
costs?
Volumes!
Primary care works with the
patient early in the course of illness, maybe even before it has developed, such
as with prehypertension and prediabetes. Primary care focused on prevention
with patients keeps people healthier and out of the
hospital.
Dr. Val: What can individual
Americans do to reduce their likelihood of having to be admitted to the
hospital?
Prevention begins with the individual,
not the physician. 60% of disease is related to lifestyle. Bad habits such as
smoking, overeating, not being physically fit, and stress underlie most common
chronic diseases. If Americans choose to be healthy and work at it, we would
save tremendously in medical expenses.
Dr. Val: Are there other studies
to suggest that having a medical home (with a PCP) can improve
health?
The medical home concept is new and lacks
studies, but the work of Barbara Starfield and others have confirmed the
importance of primary care and having a continuity relationship with a primary
care physician. The more primary is available, the healthier the population.
The opposite is true with specialty care.
Dr. Val: Why did the
“gatekeeper” movement (promoted by HMOs) fail, and what is the current role of
the family physician in the healthcare system?
The
“gatekeeper” role failed because it restricted patient choice. Patients need to
be in control of the health care, which is what patient-centered care is all
about. HMOs put the health insurance plan in charge, something which was hated
by patients and their physicians.
Dr. Val: In your work with the
IOM (specifically in Closing the Quality Chasm) did the role of primary care and
preventive medicine come up? If so, what did the IOM think that PCPs would
contribute to quality improvement in healthcare? Did they discuss (perhaps
tangentially) the cost issue (how to reduce costs by increasing preventive
measures?)
Just before the IOM Quality Reports
came out, the IOM did a major report on the importance of primary care. The
importance of primary care and prevention are central to improved quality. In
the “Chasm Report”, the focus was more on the patients taking greater charge of
their health care, and the realization that primary care is a team effort, and
not just a role for physicians. The reduction in costs comes from making health
care more accessible (not dependent on visits) through health information
technology and the internet. Preventing disease, and treating it early when it
comes, are the keys to quality and cost reduction. Revolution Health is a
vehicle for this, consistent with the vision of the “Chasm Report.”
Dr. Val: How can patients be sure that they’re getting the best primary care?
First take charge of your
own primary care. The traditional patient-physician relationship was, “Yes
doctor”, “Whatever you say doctor”. Your care would be limited by the knowledge
and recall (on the spot) of your doctor.
Much better is a “shared care” relationship with your primary care
physician and team. After all, the care is about you. Be informed. Make your
own decisions realizing that the physician and care team are advisors, coaches
in your care. You may agree with them, or disagree and do it your way. By
having your own personal health record and being connected to resources like
Revolution Health, you are empowered to get the care you want and need.
Finally, choose your primary care wisely. Not just anybody will do. Your
primary care physician is as important a choice as your close friends. You need
to like and trust this person. Have a great primary care physician who knows
you and cares about you and your health care is in real good shape. But, no
matter how good she or he is, you still must take responsibility for your care.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 13th, 2007 by Dr. Val Jones in Expert Interviews
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I came across an interesting weight loss invention this weekend that proposes to allow people to have their cake and eat it too. Scientists have constructed a kind of plastic intestinal condom to block digestion of food. Since gastric bypass surgery essentially reduces food absorption while decreasing stomach size, this removable plastic lining could act as a sort of non-invasive alternative to such a permanent procedure. Sounds intriguing?
Well, before we get our hopes up, it’s always best to check with the gastroenterologists. I dropped Dr. Brian Fennerty a note to ask him what he thought of this proposed weight loss solution. His response was enlightening – “The Endobarrier Gastrointestinal Liner is potentially very dangerous as it may block the pancreatic duct and cause pancreatitis, dislodge resulting in bowel obstruction, or ulcerate. There are no comparative trials and as such I would consider it investigational at best.”
Why is blocking the pancreatic duct scary? The pancreas is a little organ that should get a lot more respect, in my opinion. It produces enzymes that are secreted into the intestine to break down food – I like to think of the pancreas as a bag that contains acid as strong as Alien blood (those of you who’ve seen the movie will get that reference). Basically, the pancreas can liquify a steak – so plugging up the exit route for those enzymes is a really bad idea. You can imagine why pancreatitis is so painful.
And then there’s the risk of the liner getting loose and wadding up in a plastic ball and blocking your bowels, or the risk of the plastic irritating the intestinal lining and causing an ulcer which could bore a hole straight through your gut.
Well, I don’t mean to resort to scare tactics here… but honestly, this procedure has serious risks that one doesn’t really get from the media’s article on the subject, “New Procedure Could Help Millions.” So be careful out there folks – always check with your doctor before you try something new to lose weight. I’m afraid that diet and exercise are really the safest options out there.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 12th, 2007 by Dr. Val Jones in True Stories
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This week’s host of medical grand rounds invited individuals to submit blog posts that feature stories about “sudden change.” As I meditated on this theme – I realized that one of my patients played a key role in my sudden career change from academic medicine to joining a healthcare revolution.
As chief resident in PM&R, I spent a few days a month at an inner city clinic in the Bronx, helping to treat children with disabilities. The clinic was dingy, overcrowded, largely windowless, and had waiting lines out the door starting at 8am. Home health attendants generally accompanied the wheelchair-bound children to the clinic as many of them were orphans living in group home environments. The kids had conditions ranging from cerebral palsy, to spinal cord injury from gun shot wounds, to severe spina bifida. They sat together in a tangled waiting room cluttered with wheelchairs, walkers, crutches, and various prosthetics and orthotics. There were no toys or even a TV for their amusement. The air conditioning didn’t work well, and a lone clock ticked its way through the day with a bold black and white face.
The home health aides were eager to be called back to the examination rooms so that they could escape the oppressive conditions of the waiting room. I opened the door to the room and called the name of one young man (we’ll call him Sam) and an aide leapt to her feet, knocking over another patient’s ankle-foot orthosis in the process. She pushed Sam’s electric wheelchair through a series of obstacles to the exit door and back towards the examining room.
Sam was a teenager with cerebral palsy and moderate cognitive deficits. His spine was curved into an S shape from the years of being unable to control his muscles, and he displayed the usual prominent teeth with thick gums of a patient who’d been on long-term anti-seizure medications. He looked up at me with trepidation, perhaps fearing that he’d receive botox injections for his spastic leg muscles during the visit. His wheelchair was battered and worn, with old food crumbs adhering to the nooks and crannies.
“What brings Sam here today?” I asked the home health aide, knowing that Sam was non-verbal. She told me that the joystick of his electric wheelchair had been broken for 10 months (the chair only moved to the left – and would spin in circles if the joystick were engaged), and Sam was unable to get around without someone pushing him. Previous petitions for a joystick part were denied by Medicare because the wheelchair was “too new” to qualify for spare parts according to their rules. They had come back to the clinic once a month for 10 months to ask a physician to fill out more paperwork to demonstrate the medical necessity of the spare part. That paperwork had been mailed each month as per instructions (there was no electronic submission process), but there had been no response to the request. Phone calls resulted in long waits on automated loops, without the ability to speak to a real person. The missing part was valued at ~$40.
I examined Sam and found that he had a large ulcer on his sacrum. The home health aid explained that Sam had been spending most of his awake time in a loaner wheelchair without the customized cushioning that his body needs to keep the pressure off his thin skin. She said that she had tried to put the electric wheelchair cushion on the manual chair, but it kept slipping off and was unsafe. Sam’s skin had been in perfect condition until the joystick malfunction. I asked if he’d been having fevers. The aide responded that he had, but she just figured it was because of the summer heat.
Sam was transferred from the clinic to the hospital for IV antibiotics, wound debridement, and a plastic surgery flap to cover the gaping ulcer hole. His ulcer was infected and had given him blood poisoning (sepsis). While in the hospital he contracted pneumonia since he had difficulty clearing his secretions. He had to go to the ICU for a period of time due to respiratory failure. Sam’s home health aide didn’t visit him in the hospital, and since he was an orphan who was unable to speak, the hospital staff had to rely on his paper medical chart from the group home for his medical history. Unfortunately, his paper record was difficult to read (due to poor handwriting) and the hospital clerk never transferred his allergy profile into the hospital EMR. Sam was violently allergic to a certain antibiotic (which he was given for his pneumonia), and he developed Stevens-Johnson Syndrome and eventually died of a combination of anaphylaxis, sepsis, and respiratory failure.
When I heard about Sam’s tragic fate, it occurred to me that the entire system had let him down. Bureaucratic red tape had prevented him from getting his wheelchair part, poor care at his group home had resulted in a severe ulcer, unreliable transfer of information at the hospital resulted in a life-threatening allergic reaction, and a lack of continuity of care ensured his fate. Sam had no voice and no advocate. He died frightened and alone, a life valued at <$40 in a downward spiral of SNAFUs beginning with denial of a wheelchair part that would give him mobility and freedom in a world where he had little to look forward to.
Sam’s story was the last straw in my long list of frustrations with the healthcare system. I began looking for a way to contribute to some large scale improvements – and felt that IT and enhanced information sharing would be the foundation of any true revolution in healthcare. And so when I learned about Revolution Health’s mission and vision, I eagerly joined the team. This is a 20 year project – creating the online medical home for America, with complete and secure interoperability between hospitals, health plans, healthcare professionals, and patients. But we’re committed to it, we’re building the foundation for it now, and we know that if successful – people like Sam will have a new chance at life. I can only hope that my “sudden change” will have long lasting effects on those who desperately need a change in healthcare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 11th, 2007 by Dr. Val Jones in Health Tips, Quackery Exposed
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How do we know when a drug, supplement, or herbal remedy causes harm? Most people assume that clinical trials provide the only mechanism for determining adverse outcomes but actually, consumers can report concerns directly to the FDA as well.
Did you know that the FDA accepts reports from consumers and healthcare professionals alike on their website, MedWatch Online Reporting?
Herbs, supplements, and “natural” medicines are bioactive substances that many people use to treat diseases and conditions. They are not regulated for safety and efficacy, and are only now being scrutinized for accuracy of their contents. Since we’re behind the ball on rigorously testing supplements (though it’s great that NCCAM is evaluating as many of them as their resources allow), it’s important for consumers of herbs and supplements to report adverse outcomes (like allergic reactions, harmful side effects, etc.) to the FDA. How else will your fellow consumers find out about these unwanted side effects?
MedWatch also welcomes reports about adverse outcomes from prescription and OTC medications, medical devices, or cosmetic products. I think this is an underutilized resource and could greatly improve public safety if we all pitched in and reported concerning events when they happen.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
