Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

Grand Rounds 3.38 Extended Release

…continued from Grand Rounds 3.38

GRAND ROUNDS XR
(asterisk = honorable mention for great writing)

Happy Posts

*Kerri from Six Until Me tells the heart-warming story of a
Starbucks Barista who understood her diabetic needs and treated her with
special care.

Traveling Doc from Borneo Breezes Blog, submits a post about
the bush pilots of the Canadian north.
Even though it’s summer time you’ll shudder at this arctic tale of a
native woman whose life was saved by a bush pilot and an Australian surgeon.

Tony Chen of Hospital Impact submits a post by Nick Jacobs, the CEO of Winder Medical Center.
In it Christopher apologizes for being ill tempered and snapping at a
woman who posted a paper sign on the wall.

Dr. Jolie Bookspan of the Fitness Fixer Blog offers a
fascinating look at the physical healing power of prayer.  Jolie reports that the movements involved in
Muslim prayer (including standing, bowing, kneeling, and sitting) can promote
flexibility, increase quad strength, and burn up to 80 calories/day.  She explains that similar prayer posturing
(found in Russian Orthodox prayer and some forms of yoga meditation) may be
equally useful.

Rita Schwab at MSSP Nexus Blog writes a really funny post
about disaster preparedness.  She muses
about how she had been taught to hide under her school desk in case of a
bombing, and even then (at the tender age of 8) wondered how the desk vs. bomb
equation would really pan out for her.
But the real amusement comes when you click on her link to the CDC’s
recommended communication releases on such plagues as tularemia.  Yes, the bacterium found in rabbits and
rodents (that perhaps 125 hunters succumb to each year in this country) is not
contagious from human to human and causes flu-like symptoms.  I’d give this a fear factor of 1 out of 10.  [Cartoon]

Dr. Bruce Campbell of Reflections Blog describes the medical
school graduation ceremony – the first time “doctor” is officially tied to the
graduate’s name.  [Cartoon]

Mother Jones, RN from Nurse Ratched’s Place, confesses to
being a trekkie.  She did find a good
role model in nurse Chapel, though.  Now
here’s my confession: I’ve been known to utter a few “Damn it, Jim-s!” when
asked to do non-medical related work at my current job.

Roy
at Shrink Rap pulls a “Jerky Boys” style practical joke on Dinah.  He uses prerecorded audio clips of Dr. Phil
McGraw to simulate a live Skype conversation with her, and gets Dr. Phil to ask
Dinah outrageous questions and give her bizarre advice such as, “I want you to
live as a gay woman.”  Poor Dinah falls
for it for a short time… and it’s rather funny, especially if you enjoyed the
Jerky Boys prank call to Hooters with Arnold Schwarzennegger clips.  [Cartoon]

Laurie at a Chronic Dose tells a hilarious story of 3 chronically ill family members who experience a comedy of errors during a vacation in Cape Cod.  Somewhere between the brain aneurysm, flood, sunburn turned staph cellulitis, and cell phone lost in the ocean, there’s humor in the midst of tragedy.

Susan Palwick from Rickety Contrivances of Doing Good describes the evolution of hand washing requirements for all staff (including chaplans) at her hospital.

Sad Posts

ERnursey from ERnursey: Stories from an Emergency Room Nurse
gives us an eye-rolling perspective on exactly how emergency departments are
abused by drug-seekers and non-emergent cases of ridiculousness.  Triage ain’t easy.  [Cartoon]

*Type B Pre-med from the blog by the same name, offers a
tear jerking slice of life from the ED.
A woman with breast cancer finds out that it has metastasized to her
brain while a 9 year old sexual assault victim waits for the doctor to see him
next.

Christian Bachmann from Med Journal Watch reminds us that
tranquilizing medications are associated with shorter lifespans in the demented
elderly population.  [Cartoon]

Matthew at Path Lab tells the sad story of a bariatric patient’s woes in the hospital, and what daily life is like for nurse assistants.

Hot Buttons

Dr. Tara Smith at Aetiology, discusses the tragedy of
infanticide, and the events that led up to the recent murder of a newborn in Iowa.  She asks whether designated “safe havens”
(where mothers can drop off unwanted babies, no questions asked) are not
promoted enough by the media or if the state of mind of a woman who has just
given birth to an unwanted baby wouldn’t be receptive to that messaging.

Dr. Hsien-Hsien Lei interviews the CIO of Suracell Personal
Genetic Health to try to get to the bottom of whether or not nutrigenomic
testing is a form of hucksterism.  This
quote followed an objection about nutrigenomic supplements costing more
than similar products in health food stores: “Well, our clients like paying
more for what they believe is something better than the cheaper versions.”  Orac should take a look at this.

David Williams of Health Business Blog submits a
thought-provoking podcast of a recent interview he conducted with the founder
(founded in 2002) and creator of Planet
Hospital, Rudy
Rupak.  Rudy starts the podcast
explaining that his company arranges surgical treatment for travelers who need
emergent care in foreign countries, but later on explains that the primary
income stream for Planet
Hospital involves
healthcare outsourcing for American women who are “too wealthy for Medicaid and
too young for Medicare” and want cosmetic procedures or IVF done at a lower
price.  Rudy then explains that he has a
program called “the best of both worlds” where plastic surgeons travel overseas
to perform their procedures for cash – outside of malpractice laws and with
lower overhead. [Cartoon]

Henry Stern, at InsureBlog comments on the recent loss of
Flea and other medical bloggers.  He says
that “There’s a creeping reticence in the blogosphere… and maybe that’s a good
thing.”

Amanda from It’s All About the Walls marries her frustration
with her own health issues with some frustration at the apparent censorship of
certain bloggers.

N=1 from Universal Health offers this challenge – doctors
should try to get outside of their egocentric shells and get to know (and learn
from) all of the knowledgeable, competent allied
health professionals around them, especially nurses. [Cartoon]

Kim at Emergiblog expresses deep inner conflict about going to see Michael Moore’s new movie, Sicko.  If she goes, she donates $10 to his cause, if she doesn’t go she’ll be left out of a hot topic of conversation.  This is a tough call, fair sister.

Helpful Tips

Dr. Auerbach from Healthline describes how to handle
encounters with bears.  I didn’t realize
that humans should respond differently, depending on the kind of bear.  Check out what to do if you run into a
Grizzly versus a Black Bear.

Bertalan Meskó from Science Roll lists some “Web 2.0”
activities for patients and physicians alike.
But Bertalan forgot about Revolution Health!

Sarah (a bubbly Aggie from Texas A&M) has some
practical tips on how to get into medical school.

Dr. Joshua Schwimmer from Healthline explains that
Gadolinium used to be the contrast agent of choice for patients with kidney
disease (since the regular iodine-based agents can cause “contrast
neuropathy”) but now new cases of a scleroderma-like condition (called
“nephrogentic systemic sclerosis”) have been associated with Gadolinium.   Bottom line: if you have kidney disease, any
sort of contrast dye is risky!

Dr. Lisa Marcucci from Inside Surgery offers up the
technical how-to’s for an open pyloromyotomy to repair baby stomachs.  Some little ones are born with a narrow,
thickened area in the junction between the stomach and the intestine so food
can’t pass through.  But thank goodness
for surgeons like Lisa who can fix them in a jiff!  [Cartoon]


Chronic Babe describes her impulsive eating habits and what
she’s going to do to try to avoid chocolatey, salty days in the future.  [Cartoon]

Case Reports

Dr. Ves Dimov of Clinical Cases and Images – Blog –
discusses the New England Journal’s recent case report of Acute Wiiitis
(contracted as an overuse injury from the Nintendo video game Wii remote
control).  He rightly points out that as
far as medical nomenclature is concerned, “itis” is more appropriately appended
to the name of the affected body part (e.g. tendon-itis).  As far as we know, a Wii remote is not part
of the human body – though one can see how the NEJM editors couldn’t resist
accepting the resident physician’s title selection.

Dr. Iñarrito-Castro from Unbounded Medicine presents a
fascinating case report of an exceedingly rare pancreatic tumor.  Beautiful imaging and photos.


Uncategorized

Dr. Keith Robison of Omics! Omics! Blog describes his
thought process of what it might take to determine the underlying genetic cause
for one little girl’s unknown syndrome.
In the end he suggests that it might cost $1 million (to map her entire
genome) and result in no clinically useful benefit.  In this cost-benefit analysis, it looks as if
mom got it right – love the child as she is, and spend your money on mobility
enhancing equipment.

Dr. Joe Wright submits his commencement speech (for
Harvard’s graduating class of MDs and DDSs) for your consideration.

Girlvet from Madness: Tales of an Emergency Room Nurse
describes some promising research in Alzheimer’s Disease and how her own mom died in a nursing home from complications of the disease.  [Cartoon]

Nurse JC Jones from Healthline, highlights the recent
Wellcome Trust announcement of significant advances in the genetic
underpinnings of several major diseases. She includes a recent photograph of
James Watson (of Watson and Crick fame), who is now 79 years old.

Rachel from Tales of My Thirties highly recommends a book
about Type 2 Diabetes.

SPECIAL BONUS POSTS

Now, because Dr. Val has a keen eye and is very meticulous, she has rounded up some savory morsels that she found on her own – these posts were not formally submitted to Grand Rounds 3.38, but will be included because she’s sure their authors wouldn’t object:

Dr. Richard Reece from MedInnovationBlog summarizes Regina Herzlinger’s arguments for consumer driven healthcare.

PandaBearMD explains why he believes that Chiropractors are quacks – and other controversial issues.

Kevin, MD points out that while websites designed to allow patients to rate doctors are gaining acceptance, websites that allow clients to rate lawyers are causing a legal meltdown.

Dr. Stanley Feld (former President of the American Association of Clinical Endocrinologists) takes a very well argued swipe at Dr. Steve Nissen’s recent article about Avandia in the New England Journal of Medicine.

Dr. Charles exposes the quackery of Dr. Heimlich (of the Heimlich maneuver).

Dr. Au from the Underwear Drawer accidentally summarizes the difference between men and women in a conversation with her husband about whether or not to save an old medical school name tag.

Dr. Rob from Musings of a Distractible Mind offers some hilarious genetic explanations for male/female differences.

Hallway Four captures a fascinating disconnect between what a patient thinks a doctor is doing and what a doctor is actually doing.

Dr. Hildreth at the Cheerful Oncologist gives us 8 ways to cope with a malpractice lawsuit.

Dr. Scalpel presents a case of a scratch (plus toenail fungus) sufferer presenting for a work excuse.

#1 Dinosaur argues that obese doctors are more empathic counselors for obese patients who wish to lose weight.

TBTAM recounts a sexual history dialogue in which a patient had condoms delivered at 5am from a local deli.

Ian from ImpactEDnurse continues the condom refrain with an interesting analogy: how practicing “safe nursing” is like practicing safe sex.

FLASHBACK:  And for the all time coolest classic blog post… let’s go back to GruntDoc circa 2004 for a look at the scariest menace in the ED: “Some Dude.”

Thanks for reading!  Hope you’ll tune in for our regular Wednesday feature of Revolution Rounds – the best of the 27+ person Revolution Medical Blogger team posts, organized and served up friendly by yours truly.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Pay For Performance – in a nutshell

I’ve blogged previously about how unhelpful most Pay for Performance measures are for improving healthcare outcomes and “rewarding” physicians who provide evidence-based care.  But this sentence (spotted by Kevin, MD) summarizes my pages of opinions perfectly:

Judging medical quality from claims data is like judging a restaurant by looking at its grocery bill.

And if that didn’t sum it up perfectly, consider this:

The amount of “pay” for performance is so small that it is not incentive enough for physicians (or hospitals) to change their clinical practice behavior.  In effect, as JAMA says, “the carrot is not big enough.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The case of a predator in the hospital

Several years ago I was taking care of a pleasant elderly woman with a heart condition on an inpatient unit. One morning I went into her room to check on her and I found her sitting up in bed, clutching her purse and crying.

“What’s wrong, Mrs. Johnson?” I asked, perplexed.

She blew her nose in a Kleenex and replied, “Someone stole my insurance cards, my money, and my credit cards! They were in my wallet just yesterday evening – and this morning they’re gone.”

I paused for a moment, considering the order of priority in which she reported the missing items, glanced at her telemetry monitor (her rhythm was regular though her heart rate was elevated from crying), and asked if she knew how this might have happened.

She told me that she suspected that a certain patient had sneaked into her room in the middle of the night and removed the items from her wallet.

“How do you know it was that patient?” I asked, growing suspicious.

“I’ve seen her sneaking around at night in other people’s rooms – a couple of nights ago she was in here digging through my roommate’s dresser drawers.”

The suspect was a 38 year old woman with a known history of heroine abuse, who was admitted to the General Surgery service (conveniently boarded on our Internal Medicine floor) from the Emergency Department to complete an acute abdominal pain work up. This woman had already terrorized the surgical intern assigned to her case (as I had heard on rounds the day before) by chasing her around the hospital room with a hypodermic needle. Security had come to restore order and had found a stash of heroine and some needles in her bathroom that had been brought in by her visitors the night before. The team decided not to discharge her because they had discovered a large abscess on her ovary (from an advanced and untreated sexually transmitted disease) that they felt obligated to drain and treat her with antibiotics. Of course, on the morning of her scheduled surgery she ate breakfast, making it unsafe to put her under general anesthesia. These games continued (sneaking food before surgery, refusing surgery or medications, then changing her mind, then claiming to be homeless with no safe discharge plan, etc.) so that her length of stay grew from days to weeks.

“And now,” I thought to myself, “she’s using our hospital as a flop house, victimizing MY patients on the same floor – stealing their belongings in the middle of the night?!” This was the last straw. I told Mrs. Johnson that I would get to the bottom of the matter.

And so I waited for the victimizer to leave her hospital room for a scheduled test – I sneaked into her room and went through her bedside table drawers. Lo and behold, my patient’s ID and credit cards were stashed in a box with a bunch of other IDs that clearly didn’t belong to the woman.

I called hospital security, and we reviewed all the items that she had stolen. As it turned out, she was admitted to the hospital under a stolen Medicare card (the woman had claimed to be on disability). Her name matched with our records of a 67 year old woman, so we knew that she had been admitted under another’s name – and the admitting clerk had not noticed the age discrepancy. A careful record search turned up the drug user’s previous admissions under this alias. This predator had been gaming the system for years, eluding detection!

I asked the security guards to help me interview other patients on the inpatient unit to see if they had experienced anything out of the ordinary over the past few weeks. What we found was astounding. Several frail elderly patients described similar night terrors (being unable to stop the woman from going through their personal items at night) and one gentleman with advanced AIDS, who was admitted for treatment of severe pneumonia, reported that the woman had attempted to molest him in the middle of the night when she was high and in a hypersexual state.

Thanks to our investigation, many patients had their belongings returned to them (though some of their jewelry was not recovered – the woman probably sold it for heroine to her visiting dealer), and I heard that the predator was caught by the city police after choosing to leave the hospital against medical advice.

I don’t know what happened to this woman after that, and I doubt that the police were able to detain her for very long. I felt horrible for the patients who had been victimized in their ill and vulnerable states, and I wondered what kind of lasting psychological damage that this woman had inflicted upon them, especially poor Mrs. Johnson. I also felt frustrated and vulnerable – unable to really protect my hospital from future assaults. What could I do, stand in the Emergency Department each night to identify her if she chose to return? I can only imagine that this woman is still up to her old tricks at a neighboring inner city hospital near you…

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Medical fraud – what to look out for

I was reading a news story about how medical fraud is becoming more frequent in Australia. They attribute this to the recent transition to electronic record keeping, which makes it easier to file fraudulent claims. Although these tactics are old news in the US, I think it’s worth a little summary (from the article) here – stay on the lookout for overcharges and fraud! The best way to protect yourself is to review your bills with vigilance. It’s sad that it has come to this…

Fraudulent tactics

Supply companies:

* Upcoding of items and services where, for example, a medical supplier may deliver to the patient a manually propelled wheelchair but bill the patient’s health fund for a more expensive, motorized wheelchair, or where a routine follow-up doctor’s office visit might be billed as an initial or comprehensive visit.

* Billing for medical services or items that are in excess of the patient’s actual needs. These might include a medical supply company delivering and billing for 30 wound care kits per week for a nursing home patient who only requires one change of dressings per day, or conducting daily medical office visits when monthly office visits are adequate.

Providers:

* Duplicate claims, where a certain item or service is claimed twice. In this scheme, an exact copy of the claim need not be filed a second time. Rather, the provider usually changes part of the claim so the health insurer does not realize it is a duplicate.

* Unbundling, where bills are submitted in a fragmented fashion so as to maximize reimbursement for tests or procedures that are required to be billed together at a reduced cost.

* Kickbacks, when a healthcare provider or other person engages in an illegal kickback for the referral of a patient for healthcare services that may be paid for by Medicare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Why are people so angry about doctor salaries?

In a really engaging recent post, ER doc Edwin Leap (via GruntDoc) discusses why it seems that the general public is outraged at reports of the occasional specialist who makes $500,000 and yet do not flinch at the much larger salaries of football players, musicians, or media tycoons.

I posted a response to Dr. Leap’s blog post, explaining my take on why people are so angry. Let me know if you agree:

You are right that there is a lot of anger towards physicians – it is the collateral damage of the broken physician-patient relationship. When third parties (insurers) got between us, and reimbursement dwindled with drastic cuts in Medicare/Medicaid, physicians had to make up the difference in volume. When you see 30+ patients/day none of them feels as if they’ve had a valuable interaction with you. And the physician’s memory of each individual patient (and their psycho-social context) becomes dim.

When we lose the sacred, personal, physician patient relationship – we lose the best of what compassionate individualized medical care has to offer. This is why patients believe that a government sponsored system can give them the same level of care that they currently receive. I shudder at the idea of handing over medical decision making to a distant bureaucracy that only knows what’s right for a population, not for the individual. But if doctors continue to treat patients like a commodity, the patients are actually receiving nothing more than population-based care anyway. Quality care is personal, and the physician-patient relationship is a trusted bond that cannot be easily broken. We need to know our patients well so that we help them to make the best possible decisions for their personal situation. I believe that the IMP movement (see Gordon Moore’s work) – where PCPs use IT to drastically reduce overhead costs so they can afford to see fewer patients – is one of the best ways to improve healthcare quality.

As far as Emergency Medicine is concerned – we need to get the non-sick patients out of the ER and back to the PCPs. Easier said than done – but if the patients have a real relationship with their PCPs they’re less likely to substitute an ER doc inappropriately.

My 2 cents! 🙂

Patients are angry about physician salaries because they know instinctively that they are not getting the quality care that they are paying so much for… Moreover, the major cost causers (hospitals that cost shift unpaid bills to the uninsured and take large cuts for hospital administrator salaries, and for-profit insurance companies) don’t have a name and a face to the patient.  So docs take a double dose of anger on the nose, further damaging the already strained relationship.  We must go back to our roots – and support the personal doctor patient relationship that has been a pillar of American medicine.  Revolution Health can be our meeting place… the new digital medical home, supporting the old physician-patient team decision-making approach!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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…

Read more »

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…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

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…

Read more »

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…

Read more »

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…

Read more »

See all book reviews »

Commented - Most Popular Articles