June 24th, 2009 by Paul Auerbach, M.D. in Better Health Network
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Ciguatera fish poisoning involves a large number of tropical and semitropical bottom-feeding fish that dine on plants or smaller fish that have accumulated toxins from certain microscopic dinoflagellates. Therefore, the larger the fish, the greater the toxicity. The ciguatoxin-carrying fish most commonly ingested include the barracuda, jack, grouper, and snapper. Symptoms, which usually begin 15 to 30 minutes after the victim eats the contaminated fish, include abdominal pain, nausea, vomiting, diarrhea, tongue and throat numbness, tooth pain, difficulty walking, blurred vision, skin rash, itching, tearing of the eyes, weakness, twitching muscles, incoordination, difficulty sleeping, and occasional difficulty in breathing. A classic sign of ciguatera intoxication is the reversal of hot and cold sensation (hot liquids seem cold and vice versa), which may reflect general hypersensitivity to temperature. Unfortunately, the symptoms persist in varying severity for weeks to months. Victims can become severely ill, with heart problems, low blood pressure, deficiencies of the central and peripheral nervous systems, and generalized collapse. Anyone who displays symptoms of ciguatera fish poisoning should be seen promptly by a physician.
It was reported this spring that ciguatera fish poisoning has been linked to pain during sexual intercourse. Despite the sensational coverage that this announcement received by the press, the phenomenon has been known for quite some time. It is indeed a fact that a person affected by ciguatera fish poisoning may suffer symptoms of pain during sex. These symptoms include painful ejaculation in men, and a burning sensation during and after (for up to 3 hours) intercourse. What was interesting about this most recent report, which was generated by observations made in North Carolina, was quantification of the duration of the uncomfortable symptoms. One male reported that his symptoms lasted a week, and two of the women said that they were affected for a month. The fish implicated in this particular cluster of cases was amberjack.
Treatment for ciguatera fish poisoning is for the most part supportive, although certain drugs are beginning to prove useful for aspects of the syndrome. An example is intravenous mannitol for abnormal nervous system behavior or abnormal heart rhythms. These therapies must be undertaken by a physician. Prochlorperazine may be useful for vomiting; hydroxyzine or cool showers may be useful for itching. There are chemical tests (such as Cigua-Check® Fish Poison Test Kit) to determine the presence of ciguatoxins in fish, but there is not yet a specific antidote.
This post, Ciguatera Poisoning and Sex, was originally published on
Healthine.com by Paul Auerbach, M.D..
June 24th, 2009 by KevinMD in Better Health Network, Health Policy
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It’s not because of what you think.
The common thought is that health insurers will quiver at the sight of a government plan, with the public option offering lower premiums to patients due to leaner administrative burdens.
But Charlie Baker, CEO of Massachusetts’ Harvard Pilgrim Health Care, isn’t so worried about that. Instead, he first wonders about the government’s competence in handling another large bureaucratic program:
I worry less about the impact of having the federal government writing the rules and competing directly with plans like Harvard Pilgrim for business, and more about the federal government’s ability to do this at all, much less do it well. Merely coordinating basic demographic information between Social Security, Medicare and Medicaid – three big federal programs that millions of Americans belong to – can be a chore for beneficiaries, their children, and their health plans. It’s not unusual for our members to spend six months or so trying to get this stuff corrected before they call us and ask us to step in on their behalf.
And next, he has zero confidence that the government will be fiscally disciplined administering such a plan. With how it handled the General Motors fiasco as an example, Mr. Baker wonders how any proposed public plan “will negotiate with providers for a mutually agreeable fee . . . will balance its books every year . . . will have to cover its costs of doing business – just like the private plans do – [but] won’t add to the federal deficit.”
Is that even possible?
*This blog post was originally published at KevinMD.com*
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 24th, 2009 by EvanFalchukJD in Better Health Network
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Steven Pearlstein actually wrote that in the Washington Post on Wednesday, right after (another) long rant against physicians. At the end, he offers doctors an olive branch. Or maybe its an offer he thinks doctors can’t refuse:
The choice for doctors now is quite clear: They can agree to give up a modest amount of autonomy and income, embrace more collaboration in the way they practice medicine and take their rightful place at the center of a reform effort that will allow them to focus more on patient care. Or they can continue to blame everyone else and remain — stubbornly — a part of the problem.
After reading Pearlstein’s columns, I’m still sure not why he has such a problem with doctors. I am beginning to think it’s because he just misunderstands them.
Pearlstein is convinced that doctors go into medicine for the same reasons investment bankers go to Wall Street: to make money.
Docs seem to take it as a given that physicians in the United States should earn twice as much as doctors in the rest of the world — and five times more than their patients, on average. Mention these facts and you are guaranteed to get a lecture about the crushing debt burden that young docs face upon completion of their medical training. Offer to trade free medical education for a 20 percent reduction in physician fees, and you won’t find many takers.
Pearlstein has no source for these claims, but let’s assume they’re true, and do the math. The government says that there are 633,000 doctors in the United States, and they earned median salaries between $135,000 and $320,000 a year. If we take a number in the middle — say $200,000 — that means that American doctors earn about $125 billion a year. A big number, but total health care expenses in the United States are over $2 trillion, which means doctors represent about 5% of the total. Can physician salaries really be driving our health care problems?
It seems unlikely. But Pearlstein is desperate for it to be true, so he keeps trying to discount all of the other possible causes of our problems as examples of conspiracies or arrogance or sloppiness:
For example, medical malpractice litigation is a problem…
But one of the reasons malpractice suits are still necessary is because doctors have transformed local professional review boards, which are supposed to protect patients, into nothing more than mutual protection societies
The “infelixible bureaucratic processes” that insurers impose are a problem….
But given that there is overwhelming evidence that doctors tend to order up tests, perform surgeries and prescribe treatments whose costs far outweigh the benefits, you can hardly blame the insurers.
We think it is good to have “clever and creative” doctors…..
but . . . we could all have better health at a lower cost if docs were less inclined toward the medical equivalent of the diving catch and simply were more disciplined about kneeling down for routine ground balls.
Doctors should be applauded for embracing evidence-based medicine…
however, practicing physicians still think that nothing should interfere with the sacred right of doctors and patients to make all medical decisions, even when they are wrong.
Pearlstein’s views on how doctors think are fundamentally flawed. He thinks of them like stock brokers, pushing questionable stock to make commissions for themselves. He’s thought of all the different ways doctors are abusing the system to their own advantage, but he doesn’t seem to have thought that maybe, possibly, he’s wrong.
So, yes, some doctors abuse the privilege of being asked to help their patients. But the overwhelming majority don’t. They want to spend as much time as they can with their patients, collecting information, thinking about their problem, and offering good, sound advice. They are bothered by the involvement of the insurance company or the government or the plaintiff’s lawyer not because they believe they have a “sacred right” to total independence. Or because they think the way to fix health care is to give them “free rein to treat their patients . . . run the hospitals and set their own fees.”
No, it is because these things actually interfere with the doctor’s ability to think, process and decide with their patient on the right things to do.
Pearlstein and other would-be reformers of our health care system need to reconsider their assumptions on what motivates doctors. Maybe it’s something Pearlstein should ask some of his friends about.
*This blog post was originally published at See First Blog*
June 24th, 2009 by AlanDappenMD in Primary Care Wednesdays
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For 18 years, primary care providers steadily have been eclipsed by “specialists.” It is no longer rare to hear calls for these competent generalists to drive straight to the scrap heap in order to be refitted as procedural, money-making Humvees. What may be implied by this scenario is that primary care providers are selling out so as to allow nurse practitioners to be a more economical, efficient and smarter primary care provider. In fact, such ideas are not impossible if primary care doesn’t take control of their own destiny and invest in their own future. Technology will prove such a pivotal investment.
In my June 10 post, I discussed the five cornerstones of 21st century medical care as presented by a book published by the Institutes of Medicine entitled Crossing the Quality Chasm: A New Health Systems for the 21st Century. The first cornerstone presented a communication-centered medical practice and abandoned the traditional brick-and-mortar idea that “the answers to all medical questions must be delayed until the patient is seen in the office.” Rather than the doctor being the last person to know what’s happening to a patient, a communication-centered model puts doctors at the front of the office, answering phones, emails and internet-generated questions through the day, allowing the practitioner to be the first ones to know what’s happening with our patients. This model could eliminate up to 66% of today’s office visits while simultaneously improving speed of delivery of care, convenience, access, quality and reduce costs.
The second cornerstone that primary care needs to invest in and build is an advanced information management system, which still does not exist. An electronic medical record (EMR) that replaces a paper chart does not adequately explain the real potential of a tool that could transform the generalist.
Information in the communication-centered practice is managed differently than in traditional models. The health care provider, surrounded by phones and computers, is linked to a powerful network with electronic medical records, health information databases, sensitivity-specificity measurements, medical literature, and information about local facilities such as laboratories, pharmacies x-rays, and consultants and their costs, just to name a few linkages.
Imagine information no longer limited by what is in the doctor’s head, but rather, doctors who can access and find the answer to any medical question within seconds by having bookmarks that extend through an entire medical library, and searching for answers would be as easy as: The evidence based guidelines treatment for this problem is “click”… The differential diagnosis for night sweats is “click”… The medicines known to cause “weird smells” as a side effect are “click”… The cost of that test is “click”… The three labs closest to your home where I could fax the order are “click”…The sensitivity and specificity for this test or that symptom or that physical finding to be associated with lupus is “click”…The recommended treatment for this fracture is “click”…The three best articles for helping patients manage and educate themselves about their cholesterol are “click”… The telephone number to arrange setting up the test is, “click”… The facts and comparison for this medicine is… “click” The video link demonstrating the Canalith repositioning maneuvers is in your email box… “click.” Primary care providers help patients work through this information, discerning what is of utmost importance to their medical situation and issue. As it is said, “The role of the expert is to know what to ignore.”
Excellent primary health care requires continuous communication between doctors and patients so as to respond through the evolving and unpredictable twists and turns of illness and treatment . Doctors likewise need connection to the highest quality information and recording systems so as to actualize the science of best “healers”. The idea that doctors should always know the answer to a problem by using memory alone is as misguided as insisting mathematicians return to pencil and paper calculations to prove that they are “real” mathematicians. Despite the potential, primary health care has remained timid to challenge the unexamined assumptions behind the limits of Hippocrates medical practice. Were Hippocrates to return today I imagine him asking, “What have you done?”
Our patients need doctors to step up to the plate and go to bat for them. We as doctors need it too.
Until next week, I remain yours in primary care,
Alan Dappen, MD
Ciguatera fish poisoning involves a large number of tropical and semitropical bottom-feeding fish that dine on plants or smaller fish that have accumulated toxins from certain microscopic dinoflagellates. Therefore, the larger the fish, the greater the toxicity. The ciguatoxin-carrying fish most commonly ingested include the barracuda, jack, grouper, and snapper. Symptoms, which usually begin 15 to 30 minutes after the victim eats the contaminated fish, include abdominal pain, nausea, vomiting, diarrhea, tongue and throat numbness, tooth pain, difficulty walking, blurred vision, skin rash, itching, tearing of the eyes, weakness, twitching muscles, incoordination, difficulty sleeping, and occasional difficulty in breathing. A classic sign of ciguatera intoxication is the reversal of hot and cold sensation (hot liquids seem cold and vice versa), which may reflect general hypersensitivity to temperature. Unfortunately, the symptoms persist in varying severity for weeks to months. Victims can become severely ill, with heart problems, low blood pressure, deficiencies of the central and peripheral nervous systems, and generalized collapse. Anyone who displays symptoms of ciguatera fish poisoning should be seen promptly by a physician.
