Thursday, December 2, 2010

Vitamin D!... Is more better? Not really.

Vitamin D! Is more better? Not really. A committee of experts, convened by the Institute of Health, announced their Vitamin D recommendations on November 30, 2010.  Below is a summary of their findings.

Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, however, does not support other benefits for vitamin D or calcium intake. More targeted research should continue. However, the committee emphasizes that, with few exceptions, all North Americans are receiving enough calcium and vitamin D. Higher levels have not been shown to confer greater benefits, and in fact, they have been linked to other health problems, challenging the concept that that “more is better.”
The new vitamin D recommendations are bound to kick up some controversy because many researchers, led by Dr. Michael F. Holick, have argued that Americans should be consuming a lot more vitamin D than they are now, with 800 to 1,000 IU a day being the bare minimum and over 2,000 IU a day as being closer to the optimum.
Vitamin D proponents have also said the goal for blood levels should be 30 ng/mL. The IOM panel says levels that high are not associated with any health benefit and adds that levels above 50 ng/mL “may be reason for concern.”
The committee’s calcium recommendations are not likely to be nearly as controversial as its advice on vitamin D.
The summary of the panels’ report says national surveys show that most people in the United States and Canada get enough calcium, the notable exception being girls ages 9 to 18. The panel warns that postmenopausal women who take calcium supplements may be increasing their risk for kidney stones by getting too much of the mineral.

Saturday, August 7, 2010

Fix Health Care IT- Give it to Google

You may have noticed your health provider groaning behind a computer screen during a recent medical visit. No, the doctor did not have a toothache. Most likely, the doctor was being tortured by something called the electronic medical record, commonly called EMR.

This gauntlet, which cost a fortune and hours of sleepless nights, presents a multitude of problems to providers and patients alike. Suffice is to say, because there are so many software vendors, your medical data is fragmented in cyberspace. Contrary to popular belief, electronic records of different practices, hospitals and pharmacies are not connected. These expensive programs are difficult to learn and standardize. In fact there is a new government agency to facilitate our transition to an electronic medical nation.

Google please help.  Give me an EMR application that is intuitive, universal, ubiquitous, and most important open source (free). Oh and I want all those google "gadgets" to help improve the quality of care and keep me connected to my patients. The possibilities are endless. Imagine patient access with portals to medical history, appointment scheduling and lab results, email appointment reminders, electronic consultation online, telemedicine, tools to initiate and monitor lifestyle change; virtual "medical homes", doctor and patient education resources, web cam links to our patients in the ICU, online pharmacies with free generic drug offers, x-ray pics on google buzz or picasa, practice web pages / blogs, quality improvement measuring tools,  patient directed appointment scheduling, mobile device scalability, customizable interface and user preferences, embedded voice dictation and scanner services...even waiting room music, ...just to name a few.

Why Google? Why not! Google is halfway there (see Google Health). And I love those gadgets.

Wednesday, August 4, 2010

Nursing Home Care and the CNA

I have spent a large part of my professional life taking care nursing home patients. I have worked on management teams, and studied systemic approaches to improve care.  What I learned is the following. The direct care giver (CNA) is the key to the sucess or failure of a nursing home facility. So when a recent newspaper article about nursing home horrors was published, it stirred some emotions... enough to bring me our of my social media slump.

An online response to this article from a nurses aide demonstrated how unappreciated she felt.  Clearly, this response was from an individual who has the toughest job in the world.  Just think about what she must do to get through the day.  In some cases, aides are the only connection the patient has to the world. The dedication of some of these individuals is truely remarkable. I often wondered why anyone would do such a thankless job when they could earn more in Walmart and have a better quality of life.  The majority of aides care about their patients as if they were family. They infact do what most family members cannot or will not do. They get it from all ends; patients, family and management.  Ironically, they are the least paid and most undervalued members of the nursing home staff. This is evidenced by the tendency is to cut aide staffing during economic stress rather than management positions. This make no practical sense at all.  One middle management position would equal many CNA fte's.
If an investor approached me and said lets build a new nursing home, I would start with the aide. Focus your resources to ensure they are trained properly and have the proper temperment. I would pay them well and make sure they are part of key decision-making in they facility. They are an extension of the family and as such they should be involved in important aspects of the patients life. I would let them know they are enriching the lives of fellow human beings and intern enriching their own.

Wednesday, April 21, 2010

Atrophy of Clinical Skills

I read an article today written by a rheumatologist who suggested that health care dollars are wasted because primary care physicians lack physical examination skills. I agree with this notion up to a point. We don't examine patients as well as we used to. Instead, physicans are relying more on test results. Soon your exam consist of your Wii doctor (who looks a bit older than your Wii fitness coach)asking you to hold your crotch, turn your head and cough.

The article was a bit condescending. The author complained that refering docs were not performing adequate joint exams. I responded with the following comment.

"There is definitely atrophy of our clinical skills. In third world countries where there is no availability of high tech diagnostic tools, docs rely on their clinical skills. In these countries, the primary care physician is highly valued because of a broader scope of clinical skills. They perform procedures from fundoscopic evaluations to womens health. And yes, they can even do joint exams. They know how to use a stethescope; a tool that many of my specialist friends are unfamiliar with. I may be old fashion but I still listen for renal artery bruits and clicks in patients with mitral valve prolapse. But it all becomes academic when I order a echo. And that's OK too. I agree with the notion that better clinical skills add value to our healthcare system. But there will always be the spectre of time management, lack of tort reform, consumerism, and technology that drives health care dollars.

There are many reasons I refer patients to specialists. The least of which is because I lack clinical or cognitive skills. I recognize that I am only human and I appreciate the opinion of a specialist colleague. Or maybe the patient needs more focus to a problem that is unresolved. Or maybe because the HMO will not honor my request for an MRI. Whatever the case, the specialist should appreciate and be grateful to receive my patients....with or without a physical exam. This particularly applies to those specialists who rely on cognitive skills to earn a living. They are probably the first ones to be "downsized" in a corporate health care system. After all, as the article describes, examing a joint is easy. Even a primary care physician can do it."

I have great admiration for the horse-and-buggy docs. Most patients don't realize that many of our tests for common diseases are relatively new. For example, in the old days, docs would adjust thyroid medication (dessicated pork thyroid from a bacon company)by checking ankle reflexes. They were pretty good at it. It's true that the old time physicans could diagnose diabetes by tasting the patient's urine. Diabetes doctors were not likely to kiss on the first date...That is, if they could get a date. Personally I'm glad that part of the physical exam has gone. I'm happy to let the machine handle that one.

Wednesday, March 24, 2010

Colon Cancer Prevention

Colorectal cancer, cancer of the colon and rectum, is the second leading cause of cancer-related deaths in the United States after lung cancer. In honor of March, Colon Cancer Awareness Month, Horizon Family Medical Group, has initiated a campaign to encourage everyone 50 and over (45 for African Americans) to have a colonoscopy . “This is one form of cancer that can be treated and potentially cured during this diagnostic test,” remarks Gastroenterologist Dr. Alan Plummer, one of the specialists at Horizon Family Medical Group’s new Endosuite near the Orange County Fairgrounds in the Town of Walkill.
Horizon Family Medical Group’s awareness campaign will include an Open House at the Endosuite. Visitors are invited to see the offices, hear about the procedure, ask questions and hopefully make an appointment. According to Plummer, the Horizon Family Medical Group’s Endosuite was developed to make the procedure as efficient and comfortable as possible.

According to the American Cancer Society, it is estimated that approximately 150,000 new cases of colon cancer were detected in the U.S. last year and over 50,000 Americans died from the condition. Approximately one American life is lost to colon cancer every ten minutes. “These statistics are especially alarming because colorectal cancer is more than 90% preventable with early screening,” remarks Dr. Lance Siegel, another in the group of specialists performing these screenings at the Endosuite. “The key is catching it early but, unfortunately, less than 50% of the screening age population is getting screened,” he adds.
Colorectal cancer often has no symptoms until the disease has progressed beyond its earliest stages. Some potential signs and symptoms of colorectal cancer include:
• A change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days
• A feeling that you need to have a bowel movement that doesn't go away after doing so
• Rectal bleeding, dark stools, or blood in the stool
• Cramping or stomach pain
• Weakness and tiredness
Most colorectal cancers begin as a polyp, which is a tissue growth that starts in the lining of the colon or rectum. During a colonoscopy, doctors can identify and removing a polyp early in its development may prevent it from becoming cancerous.

Harry Smith Colonoscopy Results

On the lighter side - Homer's Colonoscopy

Monday, March 22, 2010

What's Wrong With Nursing Homes

Let’s face it. No one wants to spend their last days in a dreaded nursing home. Institutional care is just that. Institutional! We associate institutional care with places like prisons and hospitals. These facilities are often dehumanizing. They use assembly line techniques to achieve certain efficiencies that benefit the facility; not the patient. Our older patients dread home placement because of loss of independence and loss of dignity. Unfortunately some health care facilities are good at disguising the “institution” with superficial amenities.

It doesn’t have to be this way. The focal point should be the patient. Nursing home costs approach $12,000 per month. You can live in an upscale downtown apartment and enjoy fine dining every day for that amount. Instead patients "spend down" their life savings in facilities to be told what to do and when to do it. If you need to use the bathroom outside your toileting schedule, you are out of luck and you will probably soil yourself. Hope you’re not hungry after dinner is served. Weight loss is a common problem in nursing homes. I remember being called to evaluate a patient for weight loss. I learned the patient was frequently up all night and slept most of the day. Just by offering meals at night (against the staff's objection) the patient gained weight. A medication schedule change fixed the sleep problem. This illustrates the problem. There is no common sense. Care is schedule-based not patient-based. If a baby is crying, most caretakers would check to make sure the baby is not hungry, wet, or sick. In the elderly this common sense approach is bypassed in favor of asking the doctor to prescribe a sedative.

Many facilities subscribe to the patient-centered concept of "cultural transformation" but very few invest the required resources. Why? Because most spending decisions are short-sighted and not clinically based. Facilities are in survival mode and unwilling to venture into a highly regulated environment that discourages innovation. You see, regulators are in survival mode also and they have to justify their existence.

Here’s an example of a change that can be accomplished in one day. It’s called “bathing without a battle”. Many nursing home patients are placed in a plastic chair and rushed into a shower with the same level of compassion as a car driven through a car wash. Patient and their caretakers are quite literally battle weary after this unpleasant experience. “Bathing without a battle” is an effective cleansing technique that employs the use of warm moist towels and massage while the patient is in bed. So why is this not the standard? Short sighted bean counters are concerned about the cost of supplies. In the long run, this expense will effectively increase quality of life for both the patient and the caretaker. Processes like this will make the facility more desirable, increase census, and generate revenue.

There are many more examples that focus on quality indicators such as pressure sores, medication reduction, toileting and effective behavior management. These require an investment in nursing staff and education.

In the same way car manufactures had to re-tool their factories, health care facilities must re-think the status quo. Perhaps if administrators spent a day or two as their patients do, they would develop an enlightened perspective.

Sunday, February 28, 2010

How to "Die Healthy"

     Let's face it! Numerous advances in health technology cannot change one fact. Sooner or later we will die. We read about Mr. Rich-And-Famous being admitted to Best Hospital and then succumbing to a life-ending illness - The Great Equalizer. All the resources at our disposal will not change that fact. At first blush this premise may sound too fatalistic; especially coming from a doctor. On the contrary, life and death situations we face allow us to be more pragmatic. Let me tell you about a lesion I learned as a young doc.

     Mr. Jones was in his 90's, living at home independently, driving and managing his own business affairs. Most of his contemporaries take more than ten medications. Mr. Jones took one multivitamin a day. His weight and blood pressure were normal. And except for occasional arthritis pain, he was rarely ill. "I know when it's gonna rain", he proudly proclaimed. I asked him about exercise. He answered, I work on my lawn every day. and when I finish mine, I start on my neighbor's." I marveled at every statement he made. One day he told me what he wants out of life. The words stuck with me. "I want to die healthy."

     This contradiction in terms made more sense as I grew older and wiser. One day I received a call from the police to tell me his housekeeper found him in his bed. He died in his sleep. His story exemplifies the concept of living a healthy lifestyle and being passionate about the things you care about. Mr. Jones lived his life to its greatest potential. He did not smoke. He ate his vegetables every day. And except for an occasional glass of wine, he did not drink in excess. Never afraid of physical labor, he was proud of his muscle strength. Best of all, his attitude was always positive. These are characteristics I see in many patients that live long healthy lives.

     In contrast, there's the story of Mrs. Smith. Initially, she was overweight and smoked 2 packs a day. She had hypertension and high cholesterol which did not stop her from her self-destructive lifestyle. At first she felt well except for occasional shortness of breath and a "smokers" cough. Within a few years she was sick all the time and was on multiple medications and inhalers. Over the years, she developed diabetes, eye problems, and arthritis which caused her to gain more weight. There was always an excuse for her behavior...problems at work and a husband who was not happy being home etc. Her children where having problems of their own and unfortunately, they were following in her footsteps. Eventually she became partially blind and had multiple procedures for her circulatory problems. She was admitted to the hospital frequently and the staff knew her as "Miss Personality". One day at age 70, she came into the emergency room and was placed on a respirator. A DNR (do not rescusitate) was never signed so she remained on life support for 3 weeks until she died. While in the hospital, she developed gangrene of her foot and pressure ulcers that reached the bone. This was not a "heathy death". Many would argue that Mrs. Smith received the best care science had to offer. Technology at its finest! After all, she had everything from MRI's to angioplasties and has a hospital bill to prove it. Among other things , this case illustrates the failure of our reactive health care system. Not only did she have an "unhealthy death"; most days in her life she struggled to live with each breath.

     The choices we make on a daily basis have the highest impact on our health. The industrial complex would have you believe that fast food equals happiness. "Don't worry be happy!" "Have it you way!" The next new drug will solve all your problems. And if that doesn't happen, there's a pill that will make you think it did. We are an ailing society misguided into making the wrong choices. Our decisions are shaped by someone trying to sell something and by a health care system that discourages prevention. When Mrs Smith was younger, she was convinced that "she's come a long way baby". Bad habits are learned by our children with their first Saturday morning TV session. The result: our next generation will have a shorter life expectancy than the previous one.

     So how do you die healthy? You must go against the tendency to rely on technology to solve all your problems. Make the right choices based on old fashion common sense. Value concepts of prevention, healthy lifestyle and ideals that strengthen the human bond. And every once in a while, do your neighbors lawn.

Wednesday, February 17, 2010

What's Wrong With Our Healthcare System. One Doctors Perspective

I recently read an article about soaring health care cost. Part of the new health plan initiative is to crack down on fraud and abuse by providers. Auditors and government agencies have testified at recent congressional hearings that they will hunt down the offenders and solve medicare's financial woes. They did agree reluctantly that some of these cases are due to clerical errors rather than actual fraud. Here is an example of such a case.

In order for a patient to receive medical supplies, a physician must fill out lengthy forms (that the physician cannot bill for) . A patient needed a walker after a sustaining a fractured pelvis. The medical necessity form was returned to me several times because a change that I made on a line item was initialed but not dated. The form was returned back to me because the date that I added not re-initialed and then again because it was not re-dated. There were four sets of dates and initials because I originally wrote the wrong age for this patient. Because of my original clerical error this case was deemed to be a fraudulent claim until I corrected my clerical error. Doctors in practice see these absurdities all the time.

In my opinion, our health care system is ailing because of misguided values. It is a system that rewards reactive rather than proactive behavior. It values procedures rather than outcomes. Insurance companies don't blink an eye when they have to pay thousands to remove a lung from a cancer patient. But they will not pay for smoking cessation. Physician's cognitive skills at history-taking, physical exam prevention are undervalued. Conversely a test such as an MRI is reimbursed many times the cost of an office visit. What is the value of counseling a patient about home safety and fall prevention versus the cost hip surgery and possible permanent nursing home placement. Ridiculous policies lack any remote connection to common sense. This is not more evident than in the frequently encountered situation of the patient who needs long term IV antibiotics. Medicare will pay $10,000 or more for temporary nursing home care rather than pay for home services at a fraction of the cost.

Medicare and insurance companies are not the only culprits. Consumers want the "latest and the greatest". They object when doctors don't order a branded drug when the generic drug will work just as well. And our lawyers will always always steer us toward ordering more test and consults. Our health care environment promotes chartsmanship over a substantive encounter. Fill in the correct boxes in the medical record and spend more time with the chart than you do with the patient and you will be ok. That why EMR's are so good at spitting out pages of verbal garbage that will satisfy the auditors and lawyers alike. And self-serving government watchdogs will hide behind bureaucracy and will never work themselves out of a job.

Now that I have enumerated the failings of our health care system I have all the solutions. But that's a topic for future discussions. However, I will give you a sneak preview.
(Encourage primary care at the med school level, year of social service, higher reimbursement for cognitive skills, bonus based on outcomes, eliminate bureaucracy (less government), tort reform, incentivize the consumer to take some responsibility for health care cost, encourage prevention etc)

Saturday, February 13, 2010

Should We Put Prozac in Our Drinking Water?

Prozac in our drinking water? Why not! After all, they did it with fluoride. You can make the same argument about many other medications and supplements. Newer antidepressants have relatively few side effects; it's hard to resist giving a happy pill to all woeful patients.

So what's the downside? Well aside from the potential for up-regulation, an increase number of re-uptake receptors that may decrease the effect of neurotransmitters, there is potential for "atrophy of the coping mechanism". Each of us cope with stresses in life differently. Some better than others. If all we do is take a pill when the slightest conflict presents itself, we will not learn healthy coping skills that will help us throughout life.

Then there is a philosophical/ moral issue we must consider. By prescribing medication that blunts emotion and passion are we "anesthetizing" the psyche. An illustration of this case would be a patient in an abusive relationship. Prescribing an "emotional anesthetic" may negatively influence the proper choices that need to be made by the patient. Then there's the yin/ yang argument. Overcoming hardship may be the key to a more joyful and fulfilling life.

So how does the practitioner reconcile issues around prescribing antidepressants. First and foremost, the goal is to a relieve suffering, maintain function and improve quality of life. I like to use the broken leg analogy. We will cast the leg and relieve pain. But we will work with the physical therapist to ensure proper function restored. When we use an antidepressant, we should use therapist to restore full psychological function and prevent "atrophy of the coping mechanism".

Wednesday, February 10, 2010

Telemedicine and The Virtual Doctor

Imagine this for a moment. You sit on the toilet at home and a urinalysis is performed automatically. Once you finish your “download”, information about renal function and glucose is uploaded to your doctor. You then look into the mirror which contains a retinal scanner, step on a scale, hold onto a special grab bar and tons of medical data streams to your ubiquitous electronic medical record. A galvanic skin sensor checks your anxiety level and automatically dispenses the right amount of Xanax. Or maybe it plays the right kind of music while you shower. Sounds far fetched? Not really. This technology exists today.

The military has always been a source of scientific innovation. Remember they are the ones that invented the internet. Surgeons sitting at a computer at Walter Reed Hospital are now able to assist battlefield surgeons operate in remote areas. In the same way pilots use joysticks to fly drones over enemy territory, doctors can perform remote robotic surgery by using the "DaVinci System”. This is a device which is now available in community hospitals. Critical care specialists can monitor their patients in the ICU virtually, by watching steaming video from bedside cameras. Tele-Radiologists in Australia are reading late night X-rays in taken in NY through the Night-Hawk system. Recently, a study showed that doctors can accurately diagnose appendicitis by viewing CT scans on their iPods. The Journal of Telemedicine and Telecare is full of articles about the advancement of medical care through technology.

There is no end to our fascination with technology. ….especially for those of us who remember huddling around a neighbors TV to watch a rudimentary graphic of a peacock fill with color. Yet, I sometimes wonder when enough is enough. Do we really need things to be more complex and so remote? Since the time I saw my first TV, obesity rates have skyrocketed and for the first time our life expectancy is decreasing. We are leaving more and more garbage around for subsequent generations to clean up. Don’t get me wrong. I love technology just as much as the next guy. But I can certainly imagine scenarios where it just can’t be right.

Will technology replace me with some virtual doctor! Juxtapose the scene where your doctor walks out of the OR with sweat on his brow with the scene a robot in a Woody Allen Sleeper-like movie. The LED message scrolls across its face, “It was touch and go but we were able to save him”. I don’t want someone that looks like my Wii fitness coach telling me I have cancer. What about compassion and caring. What will happen to the human touch and the reassuring smile that only a real doctor can give!

Saturday, February 6, 2010

Compression Only CPR

This week I gave a brief presentation to middle school students. The topic was the heart and CPR. Within the hour they learned more about the heart than most adults. They also learned a skill that could potentially save a life.

Compression Only CPR is used by non-trained bystanders who is a witness to someone who colapses from cardiac arrest. The first thing to do is call 911. Depending on your location it can take 8 to 10 minutes for help to arrive. You can dramatically improve that persons chance for survival by starting chest compressions. Simply place both hands on the breast plate and start pumping. Ideally you want to perform 100 chest compressions a minute. That's it! If you want to learn mouth-to-mouth, check with your local Red Cross for classes.

It's so easy a middle school student can do it.

Wednesday, January 20, 2010

Doctors in Haiti / Tribute to Michel

I still think about Eduardo, a ten year old boy who I met in Mexico. He was malnourished and walking the steets barefoot looking for food in trash cans. You can read about it in your local paper and see it on TV but unless you experience it first hand, you will never know the meaning of "third world". I have been given the rare gift of knowing how bad it can be and how easy it is for one person to make a difference. Occasionally when one of my patients complains about having to wait an extra day to get an MRI, I think about the poverty stricken clinics where boys like Eduardo had no food or medicine. The sight of todlers begging in the streets make our NYC homeless seems lucky by comparison.

Haitian born Michel Dodard M.D. was my friend and mentor when I was a resident in training. He went on to become chairman of Family Practice at the University of Miami and started clinics in Haiti. Every year he would lead a group of medical students and residents to Haiti so they could receive the gift that I received. He is probabaly in his clinic now trying to make the most of an impossible stuation. My thoughts are prayers are with Michel and doctor all over the world who risk their lives to help those less fortunate.

Video about doctors without borders

How to donate to Doctors Without Borders

American Red Cross set up a donation system where users can text "Haiti to 90999" to make a $10 donation.

Sunday, January 10, 2010

Welcome to Medicare Visit

Did you know you may be entitled to a comprehensive preventative health visit under Medicare. To qualify you must have the visit within 12 months of medicare enrollment. Best of all, there is no deductible. You may be responsible for the standard visit copay.

The visit will include review of medical conditions, screening questions related to safety and depression, end of life care discussion and recommendations for screening test including an EKG. There may also be recommendations for bone density, gyn consult, mammogram and screening for aortic aneurysm and colon cancer.

If you want to take advantage of this service, make sure you tell your provider that you want a "Welcome to Medicare Visit" when you make an appointment. Make sure you bring a list of your medication and vaccination history.

Check the Medicare Website for more information