ACP Internist

Vitamins in a Nutshell

noreply@blogger.com (the Better Health network) — Tue, 09 Feb 2010 14:00:00 +0000

This post by Davis Liu, MD, originally appeared at Better Health.

Some patients love their vitamins, spending hundreds to thousands of dollars annually. At times, they will even forgo proven medical therapy. As more Americans go without health insurance coverage while others face higher office visits and copays, increasing numbers of patients are seeking alternative, natural therapies instead of medical care. Are vitamins really the scientific breakthrough and secret that doctors refuse to recommend, or are they simply marketing hype? As any medical school student will tell you, the correct answer to any question is: it depends.

For certain groups, pregnant women, patients with macular degeneration and vegetarians, vitamins and minerals may be recommended as research finds them helpful. Prenatal vitamins have more folic acid, which has been found to decrease the risk of neural tube defects in the fetus. Vegetarians may need to supplement their diet with vitamin B12, iron, and vitamin D, which are absent in their food choices.

Patients with a history of gastric bypass should be on a multivitamin that contains iron and vitamin B12. The surgery, which is used to cause weight loss in morbidly obese patients, can bypass part of the digestive tract responsible for absorbing these nutrients.

Women of all ages should take calcium and vitamin D to improve bone density to decrease their future risk of osteoporosis. This means at least 1,000 mg of calcium daily and vitamin D 800 to 1,000 international units (IU) per day. Women over 50 should be taking 1,500 mg of calcium/day. A common misconception is that a multivitamin has enough calcium. It doesn't! A typical multivitamin has about 45 mg of calcium (a glass of milk is about 300 mg).

Aside from these individuals, the result of us with a balanced diet should get the right amount of vitamins and minerals. You don't need the large mega-dose vitamin packs found at your local warehouse store or nutritional shop. Not only are they expensive, but also unproven.

If you still feel like you can't get through life without taking vitamins, then at least be aware of the following:

Limit the amount of fat soluable vitamins that you ingest, specifically vitamins A, D, E and K. Unlike water soluable vitamins, of which excess amounts are excreted by the kidneys, fat soluable vitamins can build up levels in the body.

For vitamin A, toxic levels begin after ingesting more than 50,000 IU daily. Upper limit of tolerable intake (what is considered the upper limit of normal but still safe) is 10,000 IU. Recommended daily allowance is 3,000 IU.

For vitamin D, the upper limit is 2,000 IU. The current daily allowance is 600 IU. A new recommendation is expected in May 2010 by the Food and Nutrition Board. Vitamin D is obtained by the skin via sunlight exposure. With people indoors more often than generations ago and possibly the increased use of sunscreen, doctors are seeing more cases of vitamin D deficiency. Your doctor may prescribe a weekly dosage of 50,000 IU weekly for three months to replace. Low levels of vitamin D can cause muscle pains, so if a constant problem, ask your doctor to check your levels. (Cod liver oil, incidentally, is rich in vitamin D and is probably why growing up in Canada I had a lot of it during the winter. Ick.)

For vitamin E, the recommended dosage is 22.4 IU with the upper limit of tolerable intake no more than 1,500 IU. Some research suggested that there was increased mortality for those individuals taking more than 400 IU per day. Because of its antioxidant properties, researchers thought taking more was better. It wasn't.

For vitamin K, found in green leafy vegetables, it is the only fat soluable vitamin where there is no defined upper limit for toxicity. Overdose of vitamin K is rare.

Am I against vitamins? Of course not. For some patients, in fact, they are recommended. What I am against is, however, having individuals spend their hard-earned money for therapies that aren't proven. Note that the FDA, under current legislation since 1994, has no oversight over nutritional supplements.

This is why all vitamin package inserts have the following statement:
* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Want to live well? A better insurance policy than vitamins is to not smoke, perform regular physical activity, take in five servings of fruits and vegetables, and possibly drinking alcohol in moderation (as a doctor I can't recommend that, but if you drink already, it might be ok). Researchers found individuals who did all four behaviors added 14 years to their lives. Why don't more of us these activities? They all take some effort. Swallowing vitamins are quicker and easier.

If I still haven't convinced you not to take unnecessary vitamins, then at least check with your doctor before stopping your medical therapies or adding supplements that can interfere with your treatment.

Finally, please avoid colon or total body cleanses. Sounds natural and healthy, but again aren't required. A product found at a large nutritional chain's special "anti-oxidant" formulation basically consists of fruits, vegetables and fiber. You can do that yourself for a lot less, and it probably tastes better too.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

You can date your patients after all.

noreply@blogger.com (Stacey Butterfield) — Mon, 08 Feb 2010 17:59:00 +0000

What with all those pesky ethics rules, it's not often that the line between romance and medicine gets blurred. But a new article (in the business section of AMedNews, of all places) brings the topics closer together than usual.

The story even begins like a romance novel. "The young woman wondered: Could Dr. Emmet be the right physician to perform her first pelvic exam?" Thankfully, before the situation deteriorated into any heaving bosoms, the article explains the woman and the doctor were participating in a physician-patient speed date. That's right, speed dating, an activity formerly confined to dark singles bars, could be headed to a hospital cafeteria near you.

At this Texan event, a group of physicians in need of patients and patients in need of physicians met and chatted to see if they were compatible. If they hit off, the pairs made appointments rather than second dates. But it's amusing to consider what kinds of icebreaker questions would have worked in both types of speed dating: "Are you looking to have children soon?" is probably OK, but "When was your last full-body exam?" might take some daters aback.

QD: News Every Day--Obama calls for a health reform summit

noreply@blogger.com (Ryan DuBosar) — Mon, 08 Feb 2010 15:11:00 +0000

Health care reform
In a bid of showmanship, President Barack Obama invited Republicans to the White House for a televised half-day summit to lay out ideas for health care reform. During the president's State of the Union address, he asked if anyone had better ideas to bring to the table, and a chippy House Minority Leader, John Boehner, raised his hand. Here's his chance to speak. (Wall Street Journal, TIME)

H1N1 influenza
The H1N1 epidemic has "one foot in the grave," William Schaffner, MACP, told TIME magazine. Anne Schuchat, FACP, updated reporters about the issue last week. (transcript and audio)

With that good news, the Roman Catholic Archdiocese of Boston plans to restart offering the Communion cup and sharing the Sign of Peace, which were stopped because of its spread. Meanwhile, professional hockey's New York Islanders will host free flu shots to all fans at tomorrow's game. (Leave your own punch line in the comments field.) (WHDH-TV, NHL.com)

In case you missed it ...
A Dallas-Fort Worth area hospital used the speed-dating model to match patients to primary care physicians. In case you're not familiar with the concept, speed dating involves quickly rotating people for chats of a few minutes at a time. At the end of the event, people decide who they'd like to see again. (American Medical News)

Medical News of the Obvious

noreply@blogger.com (Stacey Butterfield) — Mon, 08 Feb 2010 13:00:00 +0000

Again this week, the mainstream reporters are doing our job for us. Newswise brings us reports of "an unmet need to study what might seem obvious: Gay kids will be pushed around." Researchers, published in the Journal of Adolescent Health, attempted to fill that need by surveying thousands of kids to learn that the very few who identified themselves as homosexual (less than 2%) or bisexual (0.5%) were also more likely to be bullied than the blend-in-with-the-crowd heteros.

In other news of those mysterious little miniature humans, it turns out that kids don't take themselves to the dentist. "About 86 percent of children whose parents had a dental visit during the preceding year had a dental exam, compared to about 63 percent of the children whose parents hadn't," HealthDay reports. What, that other 23% couldn't get it together to call a cab or hitchike to the dentist's office?

Airplane Medicine: What Happens When You Answer The Flight Attendant's Call For A Doctor

noreply@blogger.com (the Better Health network) — Fri, 05 Feb 2010 19:20:00 +0000

This post by Liam Yore, MD, originally appeared at Better Health.

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

But gee, I can hear you think, Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory? Well, yes. But, first of all, there is the performance anxiety thing. I'm used to working with a very small audience. In economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room--and I know they are very interested in what's going on.

Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

Click on the "More" link to read the full post.

So, on Olympic Air, somewhere over the mid-Atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back.

Great, I thought to myself, It's an aortic aneurysm. (See? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again ... there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking someone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that.

The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell. As I stood up, I saw an elderly man about 10 rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in.

Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain. I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane. So I sat up in first class with him to keep an eye on him (The wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be--probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better. And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--The government's rising stake in health care costs

noreply@blogger.com (Ryan DuBosar) — Fri, 05 Feb 2010 16:51:00 +0000

The federal government may be stalled on health care reform legislation, but the executive branch has been expanding its stake in paying for care.

Yesterday, QD reported that federal and state governments will pay for more than half of the health care purchased in the U.S. by 2012, and likely even sooner. Today, Medicare's actuaries announced that growth in national health expenditures (NHE) outpaced growth in the Gross Domestic Product (GDP) last year. The recession, H1N1 programs and federal subsidies for COBRA benefits all contributed to the largest one-year increase in history, from 16.2% of GDP in 2008 to 17.3% of GDP last year.

In 2010, NHE growth will decelerate to 3.9% while GDP is anticipated to rebound to 4% growth. But, and this is a big caveat, much of the projected slowdown in NHE growth is attributed to the 21.3% slashing of Medicare physician payment rates called for under current law’s Sustainable Growth Rate provisions.

We here at QD love a good chart to explain all this, and there's plenty to peruse.

Also released today is a report that, one year after expanding Children’s Health Insurance Programs, 2.6 million more children gained Medicaid or CHIP coverage. As a result of the extra federal spending, all but two states cover children in families earning at least 200% of the federal poverty level, ($48,100 for a family of four in 2009.)

Health care reform
Speaking to a friendly audience, President Barack Obama broadly outlined his goals for moving forward on health care reform. He called for a "methodical, open process" and a public airing of ideas from partisan legislators and non-partisan experts. Vice President Joe Biden backed up those statements, but U.S. House leaders dodged the topic following a meeting with the President. (New York Times, The Hill, Politico)

Invest in Primary Care to Bring Costs Under Control

almom2@comcast.net (Toni Brayer, MD) — Fri, 05 Feb 2010 14:00:00 +0000

I went to my physical therapist yesterday for knee treatment and we talked about the fact that Blue Cross is cutting their reimbursement to the point that the cost of providing care will not even be covered. All I could do was lament with him and listen. One insurer even told him (the owner of the business) to just "make the sessions shorter and don't give as much care." As if that is how it works: "You get little money, so just do a little".

Clearly the insurance intermediaries, who never actually see a patient or deliver any care, haven't got a clue how this whole health thing works. They are happy with mediocre doctors that cut time and care. Those doctors (and physical therapists) run mills, but the insurance companies are happy with them. Quality and quantity of time are not rewarded, and in fact are punished in the health care environment we have.

He asked me if primary care had any problems like that. (I felt like screaming "Aren't you reading my blog?") More the point, why doesn't the entire population know that access to a primary care physician will become as rare as swimming with dolphins? It will depend upon how much money you have to buy concierge/retainer medicine. Where you live will play a role. If your community has a large multispecialty clinic, like Kaiser or Sutter Palo Alto Medical Group, you may have access.

Doctors in training are flooding away from general internal medicine, pediatrics and family medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lerher report discussed the reasons. We've been talking, talking, talking about it for years but things have only gotten worse, not better.

The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation--primary care that is valued by the government, the payers, the population and even by the physicians.

We have it all backward. It is time to revamp the system from the bottom up. Frankly, I don't care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new " next generation" imaging scanner until we can rationalize how we pay for care.

We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers (you know who you are, Ed) said "You can't clear the swamp until you get the pigs out of the way."

We have a lot of pigs to move aside so more people can get to the water.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Reflexive Doubt: The Psychology Of Misguided Scientific Beliefs

noreply@blogger.com (the Better Health network) — Thu, 04 Feb 2010 20:00:00 +0000

This post by Amy Tuteur, MD, originally appeared at Better Health.

Those of us who study, practice and write about medicine cherish the hope that explaining the science behind medicine (or the lack of science behind "alternative" treatments) will promote a better understanding of medicine. Certainly, I would not bother to write about medical topics if I did not believe that promoting science-based medicine would lead to increased understanding of medical recommendations and decreased gullibility in regard to "alternative" remedies. Nonetheless, lack of scientific knowledge is not the only reason for the current popularity of "alternative health. Indeed, many advocates and purveyors of "alternative" health are impervious to the scientific evidence. What else might be going on?

Belief in "alternative" medicine is a complex social phenomenon. Like any complex social phenomenon, the explanation cannot be reduced to a simple answer. But I would argue that there is an important philosophical component, developed by and promoted by advocates of "alternative" health. That philosophical component is the rise of reflexive doubt. Simply put, among a significant segment of society, it has become a badge of honor to question authority.

As an obstetrician, I am most familiar with its expression among childbirth activists. They recognize that many people hold the common sense belief that modern obstetrical practice has made birth safer, and have worked ceaseless at undermining this common sense view.
To continue this post, click on the "More" link below.

Craig Thompson, a professor of marketing, has examined this tactic in his paper What Happens to Health Risk Perceptions When Consumers Really Do Question Authority?:

... [U]sing the natural childbirth community as a context ... helps us understand how groups of people come to deeply believe in anti-establishment risk norms ... Natural childbirth activists believe that low-tech midwifery ... provides the best labor outcomes, except for in a small percentage of high risk cases. They also believe that the medical practices of childbirth pose a host of unnecessary and avoidable risks ...

...Childbirth reformers interpret ... innovations ... as unnecessary intrusions whose primary function was enabling physicians to display technical skill ...

... During the past 50 years, many obstetric interventions that were once deemed to enhance the safety of birth or to improve postpartum outcomes--shaving of the women's pubic region; mandatory intravenous drips ... enemas--have all been discarded as ineffective, unnecessary, and in some cases, potentially harmful. The natural childbirth community invokes this historical legacy to argue that many contemporary obstetric interventions are likely to meet a similar fate.

In other words, the apparent success of modern obstetrics is illusory. Innovations were unneeded and developed simply to enrich physicians. Moreover, obstetrics has been mistaken in the past so no one should trust it in the present. Therefore, questioning the claims of physicians, and reflexively doubting explanations is not merely necessary, but is the mark of and "educated" and "empowered" consumer of health care.

Such tactics may have originated with the "natural" childbirth movement, but they have arguably reached their apogee with the vaccine rejectionists. That's why millions of parents consider former Playboy playmate Jenny McCarthy a reliable source on vaccination. No one argues that she has any formal training in immunology or even that she understands the science behind vaccination. That's not necessary. She is admired by a community that has come to believe that reflexive doubt is a sign of sophistication and education.

As Hobson-West explains in Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK, vaccine rejectionists generally ignore the actual scientific data, focusing instead on whether parents agree with health professionals or refuse to trust them. Agreement with doctors is viewed as a negative and refusal to trust is viewed as a positive cultural attribute:

Clear dichotomies are constructed between blind faith and active resistance and uncritical following and critical thinking. Non-vaccinators or those who question aspects of vaccination policy are not described in terms of class, gender, location or politics, but are 'free thinkers' who have escaped from the disempowerment that is seen to characterise vaccination...

This characterization of vaccine rejectionists can be unpacked even further; not surprisingly, vaccine rejectionists are portrayed as laudatory and other parents are denigrated.

... instead of good and bad parent categories being a function of compliance or non-compliance with vaccination advice ... the good parent becomes one who spends the time to become informed and educated about vaccination...

... [vaccine rejectionists] construct trust in others as passive and the easy option. Rather than trust in experts, the alternative scenario is of a parent who becomes the expert themselves, through a difficult process of personal education and empowerment...

The ultimate goal is to become "empowered":

Finally, the moral imperative to become informed is part of a broader shift, evident in the new public health, for which some kind of empowerment, personal responsibility and participation are expressed in highly positive terms.

So vaccine rejectionism, like most forms of "alternative" health is about the believers and how they would like to see themselves, not about vaccines and not about children. In the socially constructed world of vaccine rejectionists, risks can never be quantified and are always "unknown". Parents are divided into those (inferior) people who are passive and blindly trust authority figures and (superior) rejectionists who are "educated" and "empowered" by taking "personal responsibility".

As Prof. Thompson notes in regard to believers in "natural" childbirth:

Importantly, their beliefs are far more than an abstract system of thoughts. The natural childbirth model shapes childbirth choices by being accepted as a structure of feeling ...

...The risks singled out by the natural birth model express cultural anxieties over the unintended and dehumanizing consequences of technology; the loss of individual independence through the workings of complex 'expert' systems; and a political project of supporting midwifery over the socially-accepted knowledge of the medical establishment.

Similarly, the purported "risks" of vaccination express cultural anxieties over unintended or dehumanizing consequences of technology, expert systems, and supporting self "education" over the accepted knowledge of the medical community.

In counseling patients about the claims and remedies of "alternative" health, we may need to do more than simply explain the underlying science (or lack thereof). We may need to address the philosophical beliefs about the value of reflexive doubt. Reflexive doubt is not laudatory in and of itself and it certainly is not a sign of being "educated." It is just a mindless rejection of authority, with potentially devastating consequences.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--A new milestone for government-paid health care

noreply@blogger.com (Ryan DuBosar) — Thu, 04 Feb 2010 18:55:00 +0000

ACP Internist's wrap-up of current events notes that the government is paying more for people's health care, while the FDA seeks a record-setting allocation.

Health care reform
Those objecting to health care reform over fears of having government run their health care should note this report. Medicare's actuaries report that federal and state governments will pay for more than half of the health care purchased in the United States by 2012, and likely even sooner. The recession and aging baby boomers triggered this tipping point. (AP)

Howard R. Engel, ACP Member, has an eight-point wish list for internist-friendly health care reform. (South Bend Tribune)

Primary care shortage
Indiana University responded to state budget cuts by reducing medical school enrollment. The state is already short on physicians, and the school had been increasing its enrollment by 30% to fill the gap. (Courier-Journal)

In case you missed it ...
The FDA's budget request for 2011 tops $4 billion, or nearly $750 million more than what the agency received for 2010. FDA Commissioner Margaret A. Hamburg, FACP, cites as justification new tobacco regulation oversight, as well as initiatives for better food safety, patient protection and core science to translate advances into practice.

Clorox got a first fiscal quarter boost from sales of cleaning products generated by H1N1 fears, but they aren't expected to continue, analysts said. (Los Angeles Times)

Because 90% of the population has a cell phone, and they indispensible for reaching low-income people government and industry sponsors are collaborating on the text4baby campaign. Expectant parents who text "BABY" to 511411 will receive expert-vetted messages timed to their due date through to the first birthday dealing with nutrition, immunization and birth defects. (AP)

Patients Value Personal Recommendations Over Online Doctor Ratings

noreply@blogger.com (the Better Health network) — Thu, 04 Feb 2010 14:00:00 +0000

This post by ACP Internist editorial board member Toni Brayer, FACP, originally appeared at Better Health.

The organizations that rate hospitals and doctors have proliferated as the Internet has become mainstream over the past five years. I'm sure you have seen some of these: U.S. News & World Report, Consumer Reports Health, Health Grades, Leapfrog, Hospital Compare, America's Best Doctors and 100 Best Hospitals. My local magazine lists the "top doctors" along with full-page paid ads and promos that are very compelling. The questions is, do consumers care? Are these rating agencies really steering people toward top quality in health care?

Each of these agencies and organizations that "rate" have different measurements and criteria for their choices. The top rankings do not necessarily relate to quality outcomes. The Medicare data are two years old. Different treatments and conditions are judged, so a "top" hospital in one area may be a loser in another.

Even the mortality rates for acute myocardial infarction (heart attack) that were in the top 50 hospitals in U.S. News & World Report were misleading. One third of the ranked hospitals were outside the best performing quartile based on mortality and four of them were within the worst performing quartile.

Where can a patient go to find out the outcomes of a hip replacement? What if I want to know the infection rate and the number of hips that require "re-do"? How can I find out information about my surgeon? How many has he/she done? Do they track outcomes one year after surgery?

Believe me, you cannot get this information. Period.

Patients are becoming more savvy about health care choices, but research suggests that rankings have little influence over those choices. "The primary care physician is still the leading source for patients seeing specialist physicians and the opinions of referring physicians remain the leading factor for an individual patient choosing a hospital," according to a JAMA perspective article.

For that reason it is important that patients have a choice and have transparent information on their primary care physician. Selecting a physician is done mainly by word-of-mouth and availability. The consumer Web sites where patients can rate doctors are imperfect, but without better ways to get information, more patients are looking there as they select a doctor.

We still don't know if the 5-star doctors are just nicer or if they are clinically better.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Internists still seeing yet-untreated Haitians

noreply@blogger.com (Ryan DuBosar) — Wed, 03 Feb 2010 16:43:00 +0000

ACP Internist's wrap-up of current events turns its attention back toward Hati, where 22 days after the earthquake, patients are still being seen for the first time for injuries. Peter Melchert, ACP Member, a hospitalist from Abbott Northwestern Hospital and Children's Hospital in Minneapolis, reports via internist and writer Craig Bowron, FACP. (MinnPost.com)

Health care reform
Amid a near-abandonment of broad sweeping reform, Congress members hope to salvage small victories. They are looking now at repealing the federal antitrust exemption for insurance companies to drive down prices in regions dominated by one company. Even this one small component faces Senate opposition, and the odds are even longer for the procedural maneuver of reconciliation, which is still being mulled in some pockets of Congress. Republicans want to start from scratch, while others have started drafting a compromise bill. And the clock is ticking as elected officials look to turn their attention toward other issues, such as employment, and as states assert their rights by drafting legislation that would bar individual insurance mandates. (Wall Street Journal, Politico, AP, AP/San Francisco Chronicle, AP/Boston Globe)

In case you missed it ...
Internists are discussing the pros and cons of e-mail diagnoses. Some see time savings, others see a time drag, or fear liability issues and the practice of "garbage" medicine (registration required). About 5% of patients used e-mail last year to talk to their doctors, but 51% looked up health information on the Internet. (Medscape, Reuters)

QD: News Every Day--Vaccine shortages become surpluses

noreply@blogger.com (Jennifer Kearney-Strouse) — Tue, 02 Feb 2010 20:40:00 +0000

ACP Internist's daily digest continues with an update on H1N1 influenza and other vaccine news.

H1N1 influenza
Many wealthier countries now have a surplus of H1N1 influenza vaccine, while poorer countries continue to struggle. The obvious solution seems to be sending vaccine from countries with too much to those without enough, but the reality is much more complex. (The New York Times)

Vaccines and autism
The Lancet today retracted a study from 1998 linking the measles-mumps-rubella vaccine to autism, after the U.K. General Medical Counsel's Fitness to Practice Panel concluded last week that the research had been conducted unethically. (The Lancet, L.A. Times)

In case you missed it ...
Baptist Princeton Hospital in Birmingham, Ala. uses employee badges to track whether staff wash their hands when entering and leaving a patient's room. Hospital officials, including the CEO, get the details on habitually noncompliant staff, who in turn could get a private text or e-mail to prod them. (NPR)

The ups and downs of Vitamin D

noreply@blogger.com (Stacey Butterfield) — Tue, 02 Feb 2010 16:59:00 +0000

There's probably some way to write this blog post without appearing to make a shameless plug for our own coverage, but why bother? Look, today's New York Times is saying the same things about Vitamin D that we wrote last November!

Mammography--just like 1997

noreply@blogger.com (Ryan DuBosar) — Mon, 01 Feb 2010 20:00:00 +0000

It's not easy to translate health care policy into health care practice. The February cover story for ACP Internist addresses the continuing fallout from the release of new mammography guidelines. Internists can still enter into a reasonable discourse with patients who might be confused by the politics and conflicting statements released in recent months. Reporter Kathy Holliman addresses the issue here, but her research also uncovered some lessons that the past could have taught us, but didn't. She writes ...

When the U.S. Preventive Services Task Force (USPSTF) was called to explain its recent recommendations for breast cancer screening at a U.S. House hearing in early December, panel members said the published statement could have been phrased a bit more clearly. In its testimony before Congress, they reiterated a statement that USPSTF committee chair Ned Calonge, MD, MPH, had issued a few weeks earlier: "The USPSTF recommends that all women 40 to 50 talk to their doctor to get information about the benefits and risks of getting a mammogram. ... A woman's decision about an age to begin screening should be an informed decision."

Prevailing political winds also compelled the panel to reiterate what was obvious to most health professionals: "The USPSTF values the lives of women of all ages equally. The USPSTF wants all women of all ages to be able to have the tests that they and their doctors decide have benefit."

For some, the uproar and statement before Congress was a disturbing deja vu, a repeat of events that took place in 1997. That year, the NIH Consensus Development Conference on Breast Cancer Screening for Women Ages 40 to 49 concluded that current data did not warrant a universal recommendation for mammography for all women in their 40s. "Each woman should decide for herself whether to undergo mammography," the NIH panel said.

Accused of possibly condemning women to death, the NIH panel was called before the Senate in 1997 to justify its recommendations. In a New England Journal of Medicine column in 1997, Suzanne Fletcher, MACP, of Harvard Medical School, described the outcry against the NIH panel's recommendations as much like the Queen's order in Alice's Adventures in Wonderland: "Off with her head!"

And just like in 1997 when the Senate voted 98-0 in favor of a nonbinding resolution supporting mammography for women in their 40s, the Senate last fall supported a provision that would require insurance companies to provide free mammogram screening for women aged 40 and older.

Dr. Fletcher, professor emerita of population medicine at Harvard and editor emerita of Annals of Internal Medicine, recently reflected on the continuing controversy that has enveloped breast cancer screening recommendations since the early 1970s. "It remains a very important and emotional issue among women."

QD: News Every Day--Congress was close to passing health care reform

noreply@blogger.com (Ryan DuBosar) — Mon, 01 Feb 2010 16:41:00 +0000

ACP Internist's wrap-up of current events looks at how close health care reform came to passage. Meanwhile, two other "reforms" that passed years ago--national mental health parity and one city's requirement that eateries disclose their calorie counts--are soon to become reality.

Health care reform
A final deal for health care reform had been agreed to just before Scott Brown won Massachusetts' senatorial seat. His election and opposition to the legislation brought the near-deal to an end. He suggested starting the whole process over. (The Hill, Politico)

Mental health care
Mental health parity regulations released by the federal government will take effect July 1. Insurers will have to apply the same standards for mental health care that they do for other types of health coverage. Co-pays can't be higher for mental health than other coverage, and there can't be separate deductibles. One mental health advocate told the Winston-Salem Journal, "You would never tell a diabetic you can only see your doctor 20 times a year even though your diabetes is totally out of control. Both are biologically-based illnesses. But health plans enforced these limits on people with bipolar illness even if the illness was out of control." (Reuters, AP/ABC News, Winston-Salem Journal)

Primary care shortage
Quinnipiac University (the ubiquitous political pollsters) is founding a medical school dedicated to primary care and global health and plan their first classes for 2013 or 2014. Next, they need to find a university or hospital as their clinical partner.

In case you missed it ...
Philadelphia is phasing in its requirement that food chains post calorie information on their menus and ordering boards. But will thicker menus lead to thinner people? (Philadelphia Inquirer)

Medical News of the Obvious

noreply@blogger.com (Stacey Butterfield) — Mon, 01 Feb 2010 13:00:00 +0000

You know a study's obvious when the news article covering it begins "Just in case the world needed more evidence on the matter..." We totally second the HealthDay reporter's opinion, and welcome her to our subspecialty of journalism. The link between exercise and good health--most recently and most frequently uncovered by the Archives of Internal Medicine--has become such a MNO staple that we're considering banning it from our coverage. If even HealthDay knows it's a given, perhaps we need to devote our energies to highlighting some less-obvious obvious news.

QD: News Every Day--Liability risk leads to reduced physician hours, study says

noreply@blogger.com (Jennifer Kearney-Strouse) — Fri, 29 Jan 2010 18:16:00 +0000

ACP Internist's wrap-up of current events looks at medical liability risk and news on H1N1 influenza.

Health care reform
Medical malpractice caps have been one area of contention in health care reform. Now economists (the dismal science, indeed) say that a jump of 10% in expected medical liability risk makes doctors reduce their workload by 1.7 hours per week. That's like having one in 35 physicians quit entirely, or a loss of 21,800 physicians overall. (NPR)

H1N1 influenza
Although some hospitals have lifted their visitation restrictions enacted to curb the spread of H1N1, officials in Virginia have kept theirs in place at 18 area hospitals because the state is still reporting regional virus activity. Meanwhile, WHO announced today that H1N1 continues to spread in some areas of the world but that "activity in general is decreasing." (Daily Press of Newport News, Va., Reuters)

In case you missed it ...
President Obama's State of the Union address talked about jobs much more than health care reform. He may have overlooked that the issues can overlap. Doctors' offices hired 8,900 staff and hospitals added 1,400 in December 2009, according to preliminary data from the Bureau of Labor Statistics. Outpatient medical centers added 2,500 positions and home health care agencies added 8,000. (American Medical News)

...and I Feel Fine

rob.lamberts@gmail.com (Dr. Rob) — Fri, 29 Jan 2010 18:00:00 +0000

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.

Primary care is dead. Long live primary care.

Wait a minute, I am in primary care. I am not dead. Not yet, at least.

Which reminds me of this Monty Python skit:

CART MASTER:
Bring out your dead!
[clang]
Bring out your dead!
[clang]
Bring out your dead!
[clang]

CUSTOMER:
Here's one.

CART MASTER:
Ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
What?

CUSTOMER:
Nothing. Here's your ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
'Ere. He says he's not dead!

CUSTOMER:
Yes, he is.

DEAD PERSON:
I'm not!

CART MASTER:
He isn't?

CUSTOMER:
Well, he will be soon. He's very ill.

DEAD PERSON:
I'm getting better!

CUSTOMER:
No, you're not. You'll be stone dead in a moment.

CART MASTER:
Oh, I can't take him like that. It's against regulations.

DEAD PERSON:
I don't want to go on the cart!

CUSTOMER:
Oh, don't be such a baby.

CART MASTER:
I can't take him.

DEAD PERSON:
I feel fine!

CUSTOMER:
Well, do us a favour.

CART MASTER:
I can't.

CUSTOMER:
Well, can you hang around a couple of minutes? He won't be long.

CART MASTER:
No, I've got to go to the Robinsons'. They've lost nine today.

CUSTOMER:
Well, when's your next round?

CART MASTER:
Thursday.

DEAD PERSON:
I think I'll go for a walk.

CUSTOMER:
You're not fooling anyone, you know. Look. Isn't there something you can do?

DEAD PERSON: [singing]
I feel happy. I feel happy.
[whop]

CUSTOMER:
Ah, thanks very much.

CART MASTER:
Not at all. See you on Thursday.

Now I would never suggest that the cart master who clubs the dead person represents, say, Medicare. It would not be in my nature to make such a suggestion.

But that is not the point of this post. While many complain of the death of primary care and declining reimbursement, some practices are experiencing quite the reverse: growth in income. I should know, because I am in such a practice.

We are not business geniuses in any stretch of the imagination, but we have been quite successful and raising our incomes substantially. Since I started 13 years ago, my income has doubled, and most of that increase has happened over the past five years, just the time that the death of primary care has been announced.

Our practice is almost totally outpatient (we still see inpatient pediatrics), and we earn very little at this point from labs and procedures. The vast majority of our income comes from regular office visits.

Here are some of the ways we have accomplished this:

We have focused on process. Using our electonic medical record, we try and find the most efficient ways to perform tasks in the office, involving the lowest possible number of staff. This has been a passion (see also: obsession) of mine.

We have focused on our patients. Our patients are our business, and so trying meet their needs (instead of the needs of the doctors) has resulted in a booming business. Here are some ways we have done this:
1. We have extended office hours. with a walk-in clinic (for acute problems only) every morning from 7:30-9:00 a.m. and every evening from 5:30-7:00 p.m. People don't get sick on a schedule and so we allow them to come in when they are sick. To do this, we had to drop most of our inpatient care (or have no life). This accounts for about 25% of our revenue that we would have otherwise lost to prompt cares or ERs.
2. We allow work-in visits. The patient likes to be able to see their doctor when they are sick (they get whoever is in clinic if they use our walk-in clinic). So even with a full schedule, I allow one "quick sick" visit every hour.
3. We do not tolerate patients being treated poorly. Doing so is considered a fireable offense. If a physician does so, they talk to the senior partner (which is me, but this really has not happened).
4. We strive for timeliness. Although we can never guarantee being on-time, we have done our best to have patients out the door within an hour of their arrival. This goal was modest enough to be possible, while allowing for the obvious emergencies.
5. We have a modified "open access" schedule. While I have too many chronic disease patients and scheduled follow-up visits to want to go completely open access, we do leave an hour of each afternoon open until the day of, so even complex patients can possibly be seen on the day they call.

We understand what is most important. While many practices focus on the complex higher-priced visits, we have understood from the start that the money we can earn per hour is much higher for ear infections and urinary infections. Plus, the majority of our patients are only going to use us episodically, so we want our office to cater to the larger population rather than the minority who are sick all of the time.

We are growing. My income went up when my share of the overhead went down. While our system worked fine for three physicians, it requires very few additional staff and space to run it with six. Adding new physicians and/or mid-levels has cut our overall overhead per provider dramatically.

We are planning. We know that pay-for-performance (P4P) and the "medical home" concept are probably going to happen. We have tried hard to keep our data good enough to be able to pounce on this once it is offered. So far, I have personally collected over $5,000 from P4P programs already, and their penetration is minimal. We know that once that wave starts, we will be in the front of it.

Quality is not compromised. We have done what we can to run the business well, but have tried not to forget that we are offering healthcare. The physicians in our practice agree to certain care standards and common practices. If we can all agree to what good quality care is, then we are far more likely to achieve it and we can engineer our process to accomplish it. For example, when National Committee on Quality Assurance certification became a means to increasing income, we were already exceeding the standards to become certified in diabetes care within a matter of weeks.

Admittedly, it has not been a smooth road to where we are now, and we are not without our problems (there is always a crisis somewhere), but from what I can tell, we have remained one of the less dysfunctional practices around. Given the unstable ground of U.S. health care, we certainly have no guarantees that this trend will continue, but I am doing my best to anticipate any trends in the system and set us up for capitalizing on this, rather than being caught off-guard.

Hopefully we are not facing any bridge of death in the near future. If we are, then perhaps we can start collecting shrubbery. I already have my electronic medical record programmed to say "Ni!"

Bonus points if you know the significance of the title. The answer is here.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Patient-Driven Primary Care, A Cornerstone Of The Health & Wellness Movement?

noreply@blogger.com (the Better Health network) — Fri, 29 Jan 2010 13:00:00 +0000

This post by Alan Dappen, MD, originally appeared at Better Health.

Health and wellness go hand in hand; there is little question of this. I therefore ask why isn't primary care at the heart of the health and wellness movement? This, I feel, would make outstanding economic sense for all involved.

In an effort to survive these sour economic times, more and more companies are trying to stave off the escalating cost of healthcare by pushing for wellness. There is good reason for this. According to Buck Consultant's third annual global wellness survey which was cited on the Society of Human Resources Management web site those U.S. companies who measured financial outcomes of their wellness programs reported a 43% reduction in health care costs or about two to five percentage points per year.

At first 2% doesn't sound like that impressive a cost savings. Consider, however, the skyrocketing costs of healthcare and the fact that businesses often foot up to 80% of these costs, and 2% doesn't seem like such small peanuts anymore.

How would primary care and wellness programs partner to ensure the healthier wellbeing of people? Central to the concept are the delivery of services and affordability. First of all, all involved participants would have access to a primary care practitioner, round the clock, for any issue ranging run-of-the-mill primary care issues, to urgent care problems and to the management of ongoing chronic conditions, including smoking cessation, weight management, and the monitoring of diabetes.

A service like this costs our patients and corporate partners $25/month (or $300 per year) per employee, and guarantees our patients a face-to-face check and medical history and then 24/7 access to the a practitioner however the patient wants: by phone, e-mail, videoconferencing, same-day office visits and even house calls.

Imagine how much healthier corporate America would be if employers could guarantee their employees access to a doctor without the employees ever having to leave the office or waiting hours in a waiting room packed with sick people? If, when someone called her doctor, the doctor picked up the phone and talked to her directly, often times solving her problem within 10 minutes after the phone call started? Since we establish a patient-doctor relationship with a face-to-face visit first, our patients can be treated by telemedicine, and done so quickly that our malpractice insurance rates have actually gone down.

A benefit like this could easily be paid for by a company in numerous ways: by the employer either as an add-on benefit or by funding it from a health savings account. Employees, too, can pay for the benefit from their health savings account, if they have one, or from a flexible savings account as services are rendered.

If $300 per year per employee could save 5% of a company's health care costs, plus saving employees and the company hours of lost productivity and hassle--not to mention employee loyalty--isn't it worth it?

I now come full circle: Shouldn't convenient access to a primary practitioner be a core component of any health and wellness program? Wouldn't this save businesses--and all of us--millions of dollars, not to mention help to ensure our health and wellness?

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Health care reform scarce in presidential address

noreply@blogger.com (Ryan DuBosar) — Thu, 28 Jan 2010 17:28:00 +0000

ACP Internist's wrap-up of current events looks at a lack of attention to health care reform in the State of the Union address. For those keeping track, President Barack Obama didn't mention health care until a half-hour into his nearly 70-minute speech. When he did, it was nine paragraphs out of 112. He vowed to keep pushing for reform, but didn't lay out any specifics. (New York Times, White House transcript, The Hill, Politico)

Primary care shortage
Dentists want to screen their patients for cardiovascular disease and other chronic conditions. More than three-quarters of nearly 2,000 dentists surveyed thought it was important for them to screen for hypertension, cardiovascular disease, diabetes, hepatitis and HIV. Two-thirds would tell the patients the results right away and nearly all would refer for primary care treatment. (And of course, four out of five dentists still recommend a certain brand of gum.)

Why Physicians Are Going To Stop Accepting Medicare

noreply@blogger.com (the Better Health network) — Wed, 27 Jan 2010 20:00:00 +0000

This post by Stanley Feld, MD, originally appeared at Better Health.

President Obama's health care reform bill will not work. It is based on decreases in physician reimbursement while forcing physicians to increase overhead with unaffordable electronic medical records. More and more physician groups and practices are starting to realize that they cannot make a living from the reimbursement from Medicare. They are quitting taking new Medicare patients and trying to get rid of the old ones by not taking assignment.

President Obama's idea is to force physicians to be more efficient producers. It is very difficult to force anyone to do anything they cannot afford.

Click on the "More" link to continue reading this post.

President Obama also believes that physicians over-test patients in order to make money. Wrong! Much of the over testing comes from the practice of defensive medicine. Many physicians have been sued for under testing. No one is sued for doing a test. Yet there is not a word about malpractice reform in either version of the healthcare reform bill to decrease testing by eliminating defensive medicine.

President Obama's solution is to prohibit physicians from testing in their office even though it is more convenient and efficient for patients. Ancillary services can help with overhead and does increase physicians' efficiency of care.

In fact, the fees for the ancillary services in a physicians' office are generally much less expensive than the fees for ancillary services in hospitals. President Obama ignores this fact. He believes physicians over test for profit. This might be true in some cases. However, this abuse can be discovered with the information technology system we have at present. He believes he can force physicians to tests less if it is outsourced to the hospital.

Physicians on average earn 20% to 30% less from Medicare than they do from private patients, and many are dropping out of the program.

The administration is beginning to feel the kick-back from the physician community. I think this kick-back will escalate in the coming months. It will worsen the delivery of medical care.

"President Obama last year praised the Mayo Clinic as a "classic example" of how a health-care provider can offer "better outcomes" at lower cost."

How were better outcomes determined? The question is unanswered.

"Mayo said last week it will no longer accept Medicare patients at one of its primary care clinics in Arizona. Mayo said the decision is part of a two-year pilot program to determine if it should also drop Medicare patients at other facilities in Arizona, Florida and Minnesota, which serve more than 500,000 seniors."

Mayo says it lost $840 million last year treating Medicare patients, the result of the program's low reimbursement rates.

In Arizona alone it lost $120 million dollars. The losses are usually made up by cost shifting to the private insurers and private patients. These losses are getting harder and harder to make up by cost shifting.

"Mayo Clinic loses a substantial amount of money every year due to the reimbursement schedule under Medicare," the institution said. "Decades of underfunding and paying for volume rather than value in Medicare have led us to this decision."

The media has reported that Mayo Clinic has only dropped accepting Medicare in a small clinic in Glendale, Ariz. It has been reported as an insignificant event by the traditional media. Mayo Clinic is being very civilized by not eliminating participation in Medicare in all the clinics at once. The Mayo Clinic is sending a message to President Obama and his future plans. It will also be a signal to physicians throughout the country.

Ninety-two percent of family physicians accept Medicare. Only about 73% of those are now accepting new patients. This reduction in participating physicians comes on top of a shortage of primary care physicians.

Patients struggle to find any specialist who will accept Medicare. This experience is greatest in the specialties of neurology, oncology and gynecology. Cardiology is next.

Last week cardiologists filed a lawsuit in U.S. District Court for the Southern District of Florida, charging that the government's planned cutbacks will deal a major blow to medical care in the USA.

"It will force thousands of cardiologists to shutter their offices, sell diagnostic equipment and work for hospitals, which charge more for the same procedures."

The lawsuit is an attempt by a group of medical specialists to stave off steep Medicare fee cuts for routine office-based procedures such as nuclear stress tests and echocardiograms.

"What they've done is basically killed the private practice of cardiology," says Jack Lewin, CEO of the American College of Cardiology (ACC), which represents 90% of the roughly 40,000 heart specialists in the USA."

The government's response was politeness. It will hide behind regulations made as a result of congressional mandates. The result is typical bureaucratic gobbledygook.

"Jonathan Blum, director of the government's Center for Medicare Management, says the agency is bound by law not to increase spending when making reimbursement decisions each year."

"Lewin and other heart specialists met with Sebelius on Dec. 8 and explained their concerns. "I thought she was very empathic," he says, but Sebelius has yet to take action."

Kathryn Sebelius will not take action. Neither she nor President Obama really understands the problem, much less the solutions. One cardiologist said it is an efficient way of getting rid of cardiologists and ration access to care.

"It's so absurd, it's kind of funny," he says. "I know ACC doesn't think it's funny, but I do."

It isn't funny. It is an unintended consequence of government control of healthcare. Healthcare should be consumer driven not government controlled. Government should make appropriate rules to level the playing field for all stakeholders and then get out of the way.

A cardiologist in Silver City, N.M., not far from the Mexican border, said,

"The closest cardiologist to me is 150 miles away. With all these cuts coming, it will make it impossible for me to break even seeing 40 patients a day."

Does anyone want the government and its 118 new bureaucracies to take over medical care?

What is the problem?
1. The government is broke.
2. They have to reduce expenditures.
3. Physicians are the weakest link, politically, in the healthcare system because they are ineffectively represented.
4. The government will not fight the healthcare insurance industry's lobbying.
5. The government will not fight the Plaintiff attorney's lobbying.
6. The government will continue to waste taxpayers dollars on stakeholders who add little value to the treatment of sick patients.

It is about time groups of physicians started to make some noise.

Congratulations goes to the Mayo Clinic and the American College of Cardiology.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--health care reform pauses for a gut-check

noreply@blogger.com (Ryan DuBosar) — Wed, 27 Jan 2010 16:42:00 +0000

ACP Internist's wrap-up of current events looks at health care reform, and the slow process state legislators encounter when trying to solve health policy issues such as the shortage of primary care physicians.

Health care reform
Congress will pause on health care reform, at least until tonight's State of the Union address, while they search for a clear direction to proceed. Legislators say their constituents are telling them (and pollsters) that they want more focus on jobs and the economy, and less on health care. (AP/San Francisco Chronicle, AP, Wall Street Journal)

Primary care shortage
Regulatory overhaul is one way to solve the primary care shortage, but it moves sloooowly. A New Jersey task force is looking at the particulars in the Garden State--a projected 12% deficit by 2020. For primary care, that's 1,000 too few doctors. A state legislator asked the state's Board of Medical Examiners to add questions to one of its surveys to collect data that could be used to attract federal funds. No word back yet. The president of the association for teaching hospitals asked legislators to prove their interest in retaining physicians. (Courier News)

Michigan is facing a retention problem, as well. Thousands of doctors leave the state after their residencies, and an 8% cut in Medicare reimbursement may drive more away, says the state's medical society. That group is looking to drive physicians into the state's universities, where they may get better reimbursement. (South Bend Tribune)

In case you missed it ...
An internist undergoes recertification and mulls the relevance of standardized exams to her real-life practice, and to her work-life balance. (JAMA, subscription required)

QD: News Every Day--Health reform reconciliation (for Democrats, anyway)

noreply@blogger.com (Ryan DuBosar) — Tue, 26 Jan 2010 16:37:00 +0000

ACP Internist's wrap-up of current events looks at an agreement to try to salvage health care reform legislation.

Health care reform
Democrats will use a legislative maneuver called reconciliation to pass health care reform legislation. The procedure bypasses the Democrat's lost filibuster-proof majority in the Senate. In short, the House will modify the Senate's legislation with enough changes to try to pass it in both Chambers. Reconciliation hadn't been a popular option before today's announcement. (San Diego Union-Tribune, Politico, Boston Globe)

The White House continues to mull over what's achievable. To avoid being perceived as trying to push through health care policy, it had sought cooperation with Republicans on the low-hanging fruit--capping medical malpractice, buying insurance across state lines and tax credits for those buy their own insurance. But Republicans aren't necessarily in agreement on those very issues, which couldn't pass a Republican-controlled Senate in the 90s and 00s. (New York Daily News, NPR)

Patient-centered medical home
Carilion Clinic Family Medicine's Parkway Vinton practice describes how it implemented the patient-centered medical home. Care coordinators, a new role in the practice, track patients with chronic illnesses, ensure screening tests are up to date, answer questions and locate community support. The National Committee for Quality Assurance certified the practice its first Level-3 Patient-Centered Medical Home in the state. (Roanoke Times)

In case you missed it ...
Joseph Kim, MD, who hosts a blog on non-clinical physician careers, mulls over the options for doctors who want to pursue an MBA.

Med students unfamiliar with electronic health records

noreply@blogger.com (Ryan DuBosar) — Tue, 26 Jan 2010 14:00:00 +0000

Generation Y medical students are supposed to be the tech-savvy ones. As it turns out, they may be more familiar with Facebook than with the electronic health records they'll likely use in their medical practice. (Modern Physician, free-registration required)

Educators at the University of Illinois at Chicago College of Medicine assessed nearly 190 fourth-year medical students on their use of EHRs during a mock encounter simulating a cancer patient hospitalized with complications from chemotherapy.

Students were scored on their ability to find information crucial to the patient's case within the EHR and their ability to analyze the EHR without alienating the patient. While most couldn't access the information, they did interact with the patients face-to-face and even explained when they looked away to the computer.

Following more research, the school may incorporate class work on using EHRs.

QD: News Every Day--Health politics becomes health policy

noreply@blogger.com (Ryan DuBosar) — Mon, 25 Jan 2010 15:10:00 +0000

ACP Internist's wrap-up of current events turns its attention toward health care reform, and how health care policy translates into health care delivery.

Health care reform
Congressional legislation will move forward with the least controversial elements of health care reform: solving Medicare's pending insolvency and closing a gap in Medicare Part D coverage. But Democrats and Republicans differ on how to accomplish such goals. (Wall Street Journal)

Medicare's reimbursement system has long stuck in the craw of primary care physicians. As a result, they don't always accept such patients, so one in three Medicare enrollees had trouble finding a primary care doctor when entering the Medicare population, according to a June 2008 report by the Medicare Payment Advisory Commission. The impact is shortening an already pressed primary care system. In Arizona, only three of that state's 15 counties have the appropriate ratio of primary care doctors to the general population. (The Arizona Republic)

Physicians aren't waiting for health care reform that may never come. They continue to leave community practice and delve into concierge care, which they say allows them to practice the thorough, hands-on medicine they'd envisioned when they graduated medical school. ACP Fellow David Grulke, MD, of Norfolk, Va., converted his practice to a concierge model in 2002. He charges $660 to $1,080 annually (unlike some practices that charge thousands or more) and describes it as a service for ordinary people who want a relationship with their doctor. In the same article, Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, tells the Virginian-Pilot such arrangements are the symptom of a broken care system. (Virginian-Pilot)

Haitian relief efforts
ACP Member Myriame Casimir, MD, was raised in Haiti. Today, she returns there on a medical mission comprised of her and 20 other providers from Rush University Medical Center in Chicago. (Chicago Tribune)

Also, an aid worker used a first-aid app on his cell phone to survive 60 hours trapped in the rubble of a building. (CNN)

In case you missed it ...
ACP Fellow Turi McNamee, MD, blogs about the "weekend effect" and concludes that, on Satursdays and Sunday, it's better to be shot than have a heart attack. She covers her local hospital's shifts on weekends and wonders what the impact will be on her facility's relaxed atmosphere if more research leads to an increase in weekend staffing. (True/Slant)