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Is The ER Really The Best Place to Get Primary Care Quicker?

In 1986, when Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals and ambulance services were mandated by law to stabilize anyone needing emergency healthcare services regardless of citizenship, legal status, and/or insurance status.

This was instituted at the time to prevent the prevalent practice of “dumping” — refusing to treat patients because of insufficient insurance or transferring or discharging patients on the basis of anticipating high diagnosis and treatment costs. While the implications of this law are indeed very noble in providing undifferentiated care to all patients based solely on healthcare needs and not financial status, it has unfortunately led to many patients presenting to the emergency department (ED) for primary care issues.

The misconception is that the care in the ED is similar if not better (because of increased access to consult services and imaging) and quicker than waiting to see your primary care physician (PCP). A 2010 study published in Health Affairs found that 14 percent to 27 percent of visits to hospital EDs are nonemergent, such as minor infections, strains, fractures, and lacerations. The study found that all of these cases could have been appropriately triaged in urgent care centers or retails clinics.

England has a model that may be a potential solution. The healthcare goal of the National Health Services (NHS) is to “treat the right patients in the right place at the right time.” The NHS employs nurses and paramedics to handle 999 (their equivalent of our 911) triage calls with more appropriate triaging of patients based on acuity. Read more »

Cranberry Juice For Urinary Tract Infections? Evidence Is Still Lacking

It always somewhat surprises me how some interventions never seem to die. One therapy that refuses to be put to rest, or even to be clarified, is the use of cranberry juice for urinary tract infections (UTIs). PubMed references go back to 1962, and there are over 100 references. Firm conclusions are still lacking.

There is a reasonable, but incomplete, basic science behind the use of the cranberry juice for UTIs. E. coli , the most common cause of UTIs, causes infection in the bladder by binding to the uroepithelial cells. To do this, they make  fimbriae,  proteinaceous fibers on the bacterial cell wall. Fimbriae are adhesins that attach to specific sugar based receptors on uroepithelial cells. Think Velcro. Being able to stick to cells is an important virulence factor for bacteria, but not a critical one — it is not the sine qua non of bladder infections.

Are all E. coli causing UTIs fimbriated? No. It is the minority of E. coli that cause UTI that have fimbria, and the presence of fimbriae may be more important for the development of pyelonephritis (kidney infection) than cystitis (bladder infection). Read more »

*This blog post was originally published at Science-Based Medicine*

Why “The End Of Internal Medicine As We Know It” Might Be A Good Thing

A recent post on the Health Affairs blog proclaimed “The End of Internal Medicine As We Know It.” What the post is really asking about is the future of primary care in the world of healthcare reform and the creation of accountable care organizations (ACOs). While doctors should be naturally concerned about change, I don’t completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient’s or employer’s health insurance premium, something that is sorely lacking in the current health care structure. These were recently created and defined in the healthcare reform bill.

Yet the author seems to suggest that this is a step backwards:

Modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions.

Not true. Successful organizations are ones that are tightly integrated, like Apple, FedEx, Wal-Mart, and Disney.

The author talks briefly about how Europe in general does better than the U.S. in terms of outcomes and costs and has a decentralized system. All true. However, contrasting Europe and America isn’t relevant. After all, who isn’t still using the metric system? Therefore solutions found outside the U.S. probably aren’t applicable due to a variety of reasons. Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago — like labeling primary care doctors (internists and family physicians) as “gatekeepers” rather than what we really do — never happen. Read more »

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

Who’s More Pessimistic About Healthcare Reform, Physicians Or Patients?

While public opposition to healthcare reform has diminished since its passage, physician opinions are still negative, especially among specialists who see their value to the healthcare system decreasing as reform emphasizes primary care.

A survey reports that 65 percent of nearly 3,000 physicians in all specialties said the quality of healthcare in the country will deteriorate in the next five years. Seventeen percent of respondents believe the quality of healthcare will stay the same and 18 percent believe it will improve. Meanwhile, 30 percent of healthcare consumers believe that the quality of healthcare will improve.

Physicians cited as reasons for their pessimism personal political beliefs, anger at insurance companies and a lack of accurate planning in the reform act. Other reasons include that primary care physicians won’t have the time to keep up with the extra workload, forcing more patients to depend upon nurse practitioners for primary care. When asked who will likely handle the 32 million Americans expected to receive healthcare following passage of the reform, 44 percent said primary care physicians will handle the load and 44 percent said that nurse practitioners will see them. (Physicians could vote for more than one category; options include physicians assistants and specialists, for example.) Read more »

*This blog post was originally published at ACP Internist*

Remembering Gene Goldwasser: Discoverer Of EPO, A Cure For Anemia In Dialysis Patients

balloon illustration

Gene Goldwasser died last week. He was 88, and he was my friend.

I wrote previously about a series of conversations I conducted with Gene and Rabbi A.J. Wolf a few years ago. I met Gene one spring day after calling to invite him to sit in on a class I was teaching to a small group of medical students about social issues in healthcare.

I’d read about him in a book called “The $800 Million Pill,” by Merrill Goozner. In the book, Goozner writes the story of Gene’s two-decade hunt to isolate the hormone erythropoietin (EPO).

Part of the story relates how Gene tried to interest traditional big pharma companies in his discovery, only to be brushed aside. Instead, Gene wound up sharing his discovery with what became Amgen. The company went on to make a windfall from recombinant production of the hormone and licensing it as a drug for patients with anemia and kidney failure. Read more »

*This blog post was originally published at ACP Internist*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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