Thursday, December 22, 2011

Me and My Doctor: Congress Plays Political 'Chicken' With America's ...

Me and My Doctor: Congress Plays Political 'Chicken' With America's ...: Dan McCoy, MD   Dermatologist, Dallas, TX  Online Radio Host,   Past Chair, TMA Council on Legislation Dr. McCoy speaks ou...

Wednesday, November 30, 2011

From our friends at Baylor Health: 3 things you need to know about diabetes

Check out this very nice video post from our friends at the Baylor Health Care System on the three things you need to know about diabetes. Baylor Health Care System is a network of 25 hospitals with more than 3,400 beds in the Dallas-Forth Worth area. And, its right across the street from our Dallas studio!

Sunday, November 27, 2011

Nice msnbc Video: How patient satisfaction scores in the hospital will be tied to dollars

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So you know that survey you get in the mail after a hospital stay or an outpatient diagnostic test? The one that ask you questions like, "Were you treated politely?" and "Were snacks available without having to ask for them?" Due to requirements in the new Obamacare federal health regulations, Medicare money for hospitals will to some degree be tied to patient satisfaction scores -- most of which will come from those post-encounter surveys. Check out this nice video from msnbc.

Saturday, November 26, 2011

blogtalkradio: We're moving our audio feeds!

As part of our new website upgrade we are migrating our audio feeds to blogtalkradio! Check out this new audio player and let us know what you think. We thought we would profile one of our favorite shows. This is the audio version of an interview with Congressman Dr. Michael Burgess as he talks about his book "Doctor in the House."
Listen to internet radio with docdano on Blog Talk Radio

Tuesday, November 15, 2011

Breasts and Hearts -- What's good for one, not necessarily good for the other

The sage advice that having a glass of wine every day might be good for you now may have a foot note attached.

A recent study by Catherine Berkey of Brigham and Woman's Hospital indicates that girls who have a history of breast cancer in the family and who have two glasses of red wine every day may increase their risk of benign breast disease.

Now, I didn't say cancer, but the leap has been suggested.

The study included 7000 girls and among the heaviest drinkers (that was about 1 drink a day in a 22 year old), the risk of benign breast disease was almost three times that of abstainers.

This comes on the heals of an article in JAMA (Journal of the American Medicine Association) earlier this month that alcohol may be linked to breast cancer. In their study, 3.5% of woman who had 13 drinks a week developed breast cancer compared to about 2.8% of those who didn't drink at all.

Many experts contend, though, based on the evidence to date, that stopping drinking would have very little impact on a woman's risk of breast malignancy.

Only time will tell.

And to make matters more confusing -- having a glass or two of wine may lower your risk of heart disease.

The take home message is that data obtained from retrospective studies is always useful, but many times it lacks the clarity of a prospective, randomized study.

- Posted using BlogPress from my iPad

Location:Dallas, Texas

Monday, November 14, 2011

Do protocols and guidelines really offer safer and better medicine?

The instruments were indicating to the two co-pilots at the controls of the Airbus that they needed to pull back on the stick.

They held back on the stick for 54 seconds.

This is the position they were in when the Air France jet plunged into the cold water of the Atlantic killing everyone on board.

The fix?

Recognizing that a protocol or guideline might be giving them wrong instructions, seeing that there might be a stall occurring and the airplane was falling out of the sky -- by applying basic airmanship learned during the early hours of learning to fly -- push forward on the stick, gain airspeed, and fly the airplane out of the stall.

So does this happen in medicine? Are we putting patients in the ground by following protocols and not practicing medicine?

Certainly, protocols have revolutionized patient safety in hospital settings. From central line infections, ICU ventilator management, antibiotic use in surgery, suicide prevention with ER counseling -- there are too many to list.

And these successes have lead to a plethora of committee created guidelines for care and protocols. A physician recently spoke at the American Medical Association meeting that one of the largest and most well respected hospitals in the country now has a protocol and guideline for a Whipple procedure!

This is a complex surgical procedure relating to bowel and pancreas resection and the protocol covers the entire hospital stay. Can a committee really dictate all of the ins and outs of a hospital stay of 10 to 14 days duration?

The protocol discussion has also become a huge issue in the mid-level provider debate. When individuals are attempting to practice medicine without the complete training of a physician, nothing is better than a set of rules to follow. And for visits like well child visits and hypertension management -- these work very well.

But can you really develop protocols and guidelines for complex medical procedures or illnesses?

Or more importantly, what parts of your own healthcare would you want managed with a protocol?

I know that if I'm really sick I want a pilot at the controls that can recognize that this time the protocol doesn't apply.

Because at some point in my life my body will be in the situation of flying out of La Guardia, hitting a flock of geese, and having to be hand flown without power into the Hudson River.

They don't make protocols for patients like me.

- Posted using BlogPress from my iPad

Sunday, November 13, 2011

Patients feel "Medicare is my benefit!"

TMA President Dr. Bruce Malone tells a patient story describing that "Medicare is my benefit!" His testimony was before a reference committee at the interim meeting of the American Medical Association in New Orleans, Louisiana. Dr. Malone was speaking in favor of direct contracting -- allowing patients a choice to see any physician they want regardless if that physician participates in the Medicare plan or not.

Friday, November 11, 2011

Can "Personalized Medicine" offer the cure for cancer we've all been looking for?

You just never know when it will happen. Cancer can strike any time. But with the advent of the concept of "personalized medicine," there is a new weapon in the battle against this disease. Personalized medicine refers to tailoring or customizing a treatment to an individual patient. Check out this compelling video from Mary Crowley Cancer Research Center in Dallas, Texas about using a vaccine to treat a patient with metastatic melanoma. This disease is virtually incurable -- most patients don't survive more than 2 years...and many not more than 6 months.

Monday, June 27, 2011

The Dangers of Flying: skin cancer in the air

I got a Facebook question recently from one of my airline pilot friends about the amount of radiation that flight crews receive from being in the stratosphere during airplane flights. 

As a dermatologist I can't tell you the number of skin cancers that I have removed from pilots over the years.  I know I tend to attract pilots as patients given my own helicopter flying, but the number of individual tumors is huge.

And I'm not just talking about the typical basal cell and squamous cell carcinoma -- melanoma is not an infrequent finding. 

So how much radiation do you receive in an airplane? 

Well check out this cool website from the FAA:  Called a Galactic Radiation Calculator, it will give you the amount of radiation your body will be exposed to while in the air.

Most of the information is self explanatory, but you will need the airport identifiers of your destination and arrival airport.  For play you can use New York's JFK (KJFK) and Dallas/Fort Worth International Airport (KDFW).  But if you want to use the ones from your own travel information there are resources on Google.

Next you will need the altitude of the flight.  Now the pilot will usually tell you this during the flight briefing near the beginning of the flight (about the time he or she will tell you to keep your seat belt fastened if you're in your seat).  If you want to play, then just use 39000 feet.

One thing that you might not have is the time of your descent... just use 25 minutes as a good guide.

Then you're good to go.  Push calculate and you will get a result in a funky number of microsieverts.  What's that? Well there's a cool table on Wikipedia that will allow you to compare how much radiation you received in comparison with common things like dental x-rays and being exposed to a nuclear reactor.

Cool tool.  But the take home message is that pilots and those that spend a lot of time in airplanes are exposed to higher doses of radiation and therefore have a higher risk of skin cancer.

Wear that sunscreen! (oh...and fasten your seat belt)

Sunday, June 26, 2011

What my children will never see? Things disappearing from the doctor's office

On a recent trip to Austin I flipped through the worn copy of Spirit magazine in the seat back of a Southwest Airlines 737 and saw this nice article about babies -- and specifically what they see and understand very early in life.

I love my two young kids, and although they both aren't as young as they used to be (neither am I), I love to share with them new experiences, sights, and the general joys of life.

I think all parents must feel the same way.  There is just something about seeing the the glint of newness and understanding in the small eyes of a child.  

But today I began to wonder about things our children will never see, particularly related to health care. We have on our own list from when we were growing up, but it's certainly different now.

From polio, mumps, and small pox:  thankfully they are all distant memories.  As a dermatologist I do get to see some of the unusual but still rather rare diseases (measles, for instant) that I heard about in my childhood.

But children today will miss out on many things that are common place in our day to day lives.

Here's my list (feel free to add or subtract in the comment box below):

1) Marcus Welby:  hometown physicians in private practice that take care of families for decades will be a thing of the past.  I've written about my good friend John Keller, MD, a family physician in the small rural town of Fairfield,  Texas before here.  Practicing for over 50 years in one place, he will probably be the last "Marcus Welby" doctor that I know.  And my children will never see that.  Only on re-runs. 

2) Chicken Pox:  childhood vaccination makes this common disorder now very rare.  And, if we're lucky, shingles or herpes zoster will also be a painful encounter our kids will not have to endure.

3) Rectal thermometers:  I'm sure someone will comment that these are still around.  The last time my kids were sick it seemed like someone just shot their head with a laser thermometer -- nurses don't even have to touch the patient any more.  Novel idea.

4) White hats:  speaking of nurses -- what about those white hats?  I mention them occasionally and finally someone in my office told me that she wasn't sure it was politically correct to talk about them anymore.  I'm not sure I understand that, but I've changed my workplace banter after their expressed concern.

5) Prescription pads:  Ok, I know this is maybe a tad progressive.  But in our  paperless office we don't write prescriptions by hand any more.  We send everything electronically using an e-prescribing application.  And, frankly, everyone loves it including my staff, patients, and finally me. I know there are some slow adopters out there, but Medicare and other insurance carriers will drive that train.  Paper prescription pads? They'll be gone.

6) Drug company pens:  Yes, the pharmaceutical company give aways (not just pens: but dummy plastic models of the skin, Post It notes, stethoscope labels, you name it) are all gone.  No longer will kids see a Viagra pen or a Lipitor flashlight.  New pharma rules prohibit these types of "inducements" because some bureaucrat thinks that supplying a pen will induce the doctor to use that pen to write an expensive prescription.  Personally, I think this is stupid.  Maybe doctors shouldn't be taken on golf junkets or expensive dinners...but a pen.  Really.

7) Ties:  Though not mainstream, health care workers are quickly adopting the casual Friday look in the medical office and the hospital room.  Why?  Well those ties were shown to carry germs.  So scrubs and casual shirts are now considered appropriate dress code for health care workers.  

8) The Co-Pay:  Well, it's not gone yet, but more and more insurance products are "high deductible" health plans.  It used to be that patients could pay $20 and get all the health care they could milk out of a 15 minute visit.  Those days are disappearing as the most popular insurance product sold in our home state last year was one with a $3000 deductible.  Patients and physicians are now more cautious in their health care decisions.  That's a good thing.  The bad news is that every care component falls directly to the bottom line.  

Feel free to add or subtract from this list.  Hopefully there will be exciting improvements in our health care delivery system, new drugs to treat disease, and exciting technologies to cure our ailments that replace the items on the list.  

We can always hope.

- Posted using BlogPress from my iPad

Friday, June 17, 2011

Does Google give the wrong information on health care decisions?

Clearly using the internet to research any topic is valuable.  

Whether it's a new book you're thinking about buying on Amazon, researching the latest and greatest high definition television, or finding the value of your used car, the internet is a wealth of information.  

We all know that websites track our activity, constantly downloading cookies that both help and hinder our web experience.  They allow us to instantly be put into our "Recommendations" page on, but they also may contribute to mining our website activity and delivering us pop up ads.

But the latest use of complicated algorithms by search engines like Google resembles the ultimate over the shoulder look from big brother.  

In an effort to better put you in touch with the information you are searching, search engines have started to place context "relevant" items high in the search list.  That is, the search engine tracks both your searches and websites visited and then computes what search results would be the most relevant -- just for you.

This means that even though we might search the same topic, we might both be given a different set of results.

Now most of the time this is good.  

If you are hungry for catfish, searching for this crusty fried fatty protein would probably lead to restaurants that are near your home.  If you are a health fanatic (read: you aren't familiar with the word "fried") then you might find links to recipes for grilled fish.

Now all of this sounds really helpful. 

But instead of the results providing a broad spectrum of information, they are actually providing information that is more focused -- just for you.

Imagine for a moment that you are somewhat of a conspiracy theorist.  If you search the word set "birth certificate," you might find yourself immersed in the world of the Birther's and President Obama's long guarded secret certificate.  You could have very well been really searching for the office of your local county clerk where you could download a copy of your own vital record.

These types of results are especially concerning in health care.

Now think about this scenario:  you are somewhat of a natural and alternative medicine follower.  You just returned from visiting your primary care doctor and she gives you your mammogram results.  It looks like you might have breast cancer.

You do what most patient's do:  you search breast cancer on Google.  

Given your past search patterns on health foods, alternative medicine, herbal products, and acupuncture, an article on "prune juice as a cure for breast cancer" pops up.  Further search of this bizarre topical combination begins to reinforce your findings:  there might be a link for a cure between this fruit juice and a breast malignancy.

So instead of providing a comprehensive analysis of breast cancer treatments, the algorithms have begun to reinforce your preconceived (pre-searched) thoughts on alternative medicine.

Now this isn't an attack on alternative medicine, rather it's meant to demonstrate how the internet can focus one's mind on a solution quickly rather than providing all of the necessary information to make the best decision.  

And the scary part?  There is very little you can do about it.

These algorithms are proprietary and aren't really subject to easy manipulation.  They are meant to reflect who you are and what you generally search for;  and they do a very good job.

Yes, you can log off and then log on with another name, try a different browser, search for other types of topics for awhile, or even replace the computer, but because many use the local ip address as the pointer for determining which results to deliver, this would all be done in vain.

Probably the best advice is to cognitively realize that this is happening when you perform a search.  So don't stop with the first articles or links that are returned.

Dig deeper and go off the search engine directed path a little.  Force Google to go deeper into other topics by continuing to search different but similar keywords.  

And know that ultimately you are in charge of your search experience.  Don't believe everything you see or hear;  have a healthy respect that it's good to challenge the information you are given.

Tuesday, May 10, 2011

Doctor in the House: an interview with author Congressman Michael Burgess, M.D.

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When Dr. Michael Burgess gave up delivering babies in favor of kissing them, most physicians thought he was crazy.

After reliving the September 11th World Trade Center nightmare in his head for weeks, the successful obstetrician decided to run for Congress in his Republican district of North Texas against the well-funded and well-named son of then Majority Leader Dick Armey.

Not only did Burgess win, but he has quickly become the thought leader of American medicine in the United States Congress.

In his new best-selling book, Congressman Dr. Burgess retells the story of his first years in the House of Representatives where another nightmare unfolded: the Democratic creation of Obamacare.

His work is entitled Doctor In The House and it contains the prescription necessary to heal the ills of American health care.

In this blog we engage in a spirited discussion with Dr. Burgess. Let us know what you think.

Sunday, May 1, 2011

AUDIO VERSION: Doctor in the House

(This is the audio version of our previous video podcast. It will also be available as a download from DocDano on iTunes.)

When Dr. Michael Burgess gave up delivering babies in favor of kissing them, most physicians thought he was crazy.

After reliving the September 11th World Trade Center nightmare in his head for weeks, the successful obstetrician decided to run for Congress in his Republican district of North Texas against the well-funded and well-named son of then Majority Leader Dick Armey.

Not only did Burgess win, but he has quickly become the thought leader of American medicine in the United States Congress.

In his new best-selling book, Congressman Dr. Burgess retells the story of his first years in the House of Representatives where another nightmare unfolded: the Democratic creation of Obamacare.

His work is entitled "Doctor In The House"
and it contains the prescription necessary to heal the ills of American health care.

In this blog we engage in a spirited discussion with Dr. Burgess. Let us know what you think.

Wednesday, April 27, 2011

What should you do if you can't pay your medical bill?

Dan McCoy, MD of visits with Judy Huggins, a specialist in insurance and medical billing. They discuss the scenario that happens all to often: what happens if you can't pay your doctor bill? What should you do if you have an unpaid medical bill, and what are the pitfalls of a high deductible health plan?

Sunday, April 24, 2011

VIDEO: Pelvic Floor Physical Therapy

Dan McCoy, MD visits with Marcy Crouch, a physical therapist that specializes in pelvic floor rehabilitation. This video follows an audio podcast previously available on iTunes on the same topic. Whether its incontinence, sexual dysfunction, or bowel or bladder prolapse, pelvic floor physical therapy offers patients an opportunity for improvement.

Wednesday, April 20, 2011

Peanut Allergy and Airplanes explores the actions today by the Department of Transportation which will continue to allow peanuts to be served on airplanes. This follows concerns that peanuts may pose a significant risk to passengers that have a peanut allergy.
What should you do now if you have a peanut allergy and don't want to be caught at 30,000 feet in an emergency situation? This podcast provides you the answer.

Tuesday, April 19, 2011

Pelvic Floor Physical Therapy: rehab on the down low

Join's Dan McCoy as he visits with Marcy Crouch, a physical therapist who specializes in pelvic floor rehabilitation. This new innovative program treats both men and women for a variety of pelvic medical problems including incontinence, painful intercourse, bladder prolapse, and sexual dysfunction.

Friday, April 15, 2011

Do physicians make good employees?

There has been a clamor of legislation this past year in many states, including Texas, that would allow for the employment of physicians.

For some readers of this blog that may seem like an odd statement. Texas is one of the few states that still prohibit "corporate practice." This is where physicians work directly for a business entity rather than either working for another physician or physician group.

For Texas and the states that prohibit this practice, the reasoning has always been that this separation helps maintain the clinical autonomy of the doctor-patient relationship. And I would agree with this wholeheartedly.

Having a physician's judgement clouded in any way by the perceived need to make a bottom line is a recipe for disaster. Fortunately, most physicians understand this risk and are masters at handling the tense relationship they might have with their employers.

But the question here isn't whether physicians should be employed, but will they make good employees?

Most people would define a "good employee" as one that shows up for work on time, provides dedicated service, treats the business like their own and functions well in a team environment.

Most of the physician friends that I know all show up to work on time.

And most physicians I know treat the business like their own -- if they are the owner.

And as for team play? Well, let's just say that coed basket ball games in medical school were tense at times. Team play isn't something that is necessarily a reviewed credential in medical school applications.

As a former hospital based medical director, I've seen physician groups owned by health care systems have a turnover near 25%. And with the cost of recruiting a physician close to $250K including startup costs, first year salary guarantees and signing bonus -- that's absurd.

Physicians that are hired fall into two basic groups. They are right out of school, owe $200K in school loans and are uncomfortable in the current environment with starting a new practice from scratch. They have no experience with this model anyway -- most of their teachers are already working in an employed relationship at a medical school or hospital. Their exposure to business is only through these providers.

Or, the physicians are frustrated with private practice: the alarming increase in overhead, growth in liability risks, the long hours, lack of good call coverage and the continual decline in reimbursement. They are seeking employed relationships primarily so they can continue to do what they are called to do. They want to see patients and continue to practice medicine and let someone else worry about the business.

See the commonality here? Both groups don't want to worry about the business.

Hiring employees that "don't want to worry" about the business seems like a recipe for disaster for me.

For now hospitals and health care systems can pay a premium to hire doctors. They are funded under a payment scheme that allows them to have either profits (for profit hospitals) or margin (non profit hospitals) that can be redirected to hire doctors to refer to their hospital so they can make more profits and more margin.

But, for many systems, this doesn't work long term.

Here's an example: Dr. Welby has practiced for years in a community as a family practice doctor. He is well known, works 80 hours a week, has a nurse, two office staff, and a small office that is paid for and hasn't been updated since the 70's -- including the magazines.

Despite this frugal existence he is financially challenged because of the escalating benefit costs for his employees, higher malpractice premiums, and he can't remember the last time he received a rate increase from any payer. Most of his patients are Medicare; twice in the last year he wasn't paid at all because Congress didn't fund the health care for older Americans.

He's tired and looking for help.

In rolls Sister Daughter Felicia Hospital System -- they are a not-for-profit health care system (not-for-profit means they don't pay taxes and "System" is a word right from Modern Healthcare: makes you seem like a big health care team -- read on). They have a physician run medical group that they own, but don't directly control. Well, let's just say they do control the budget for the doctor group. And it always runs at a loss, so the hospital system is perpetually in a position of having to "bail out" the group and define budgetary goals and direction. So there is some control.

They meet with Dr. Welby, show him their electronic health record, how they achieve quality metrics in virtually every measure of health improvement, how U.S. News and World Report thinks they are a Top 100 hospital, and how they will take care of the front desk operations and provide staff. And, oh by the way, they have a new medical office building that has a gym, day care, and even a Starbuck's.

To make things better for Dr. Welby they'll even buy out his practice by purchasing his accounts receivable (there aren't that many), take all of his records, and give him a guaranteed salary for a year and a signing bonus. All he has to do is sign here and start to work.

Now Dr. Welby will have the agreement looked over by a lawyer -- the same guy who did his home refinance and his divorce. The hospital will say that "it's the same agreement that we all sign" and then will grin -- they have Fulbright and Jaworski on their side.

There is back slapping, and maybe even champagne if its a Catholic hospital system, and everyone enjoys the moment and the win.

All will be good for a few months. The staff will not like the move with all the new processes and procedures and uniformity. The patients will not like it because they have to pay to park, will get bills they may not be familiar with and there will like be some changes in health insurance coverage.

The doctor won't like it all either: certain drugs won't be on formulary, there will be an electronic medical record to learn that will "hurt my work flow," and there won't be the complete control of the practice that he's used too.

But there are benefits. It is likely that he will slow down his daily schedule by 25 to 30 percent, there will be less importance on admitting his patients to the hospital ("I'll let the hospitalist do that"), and when it comes to doing procedures it will just mean more work and more risk of weekend responsibilities.

The hospital system will overlay a whole new set of overhead for the physician ranging from new office space (read: more cost/foot), "indirect costs or overhead" that is difficult to explain (but includes many things the physician never purchased before like legal retainers, marketing, telecommunications infrastructure, bill boards, JCAHO, nurse managers, case managers, coding and compliance staff, float nurses, retreats and meetings, helicopters -- you get the picture), and staff whose benefit and salary structure is the same as that of the hospital and is richer and more expensive.

So fast forward one year later.

The hospital is not happy because the physician's practice is losing money -- actually bleeding money. Patient volume is lower and revenue is stark. They don't understand why the physician isn't working harder. They are now going to roll him into an income distribution formula where part of his compensation will be based on volume and the rest on "performance measures." The result will likely be lower pay.

He's not happy with the lower pay and pushes back. He claims its the hospital system's fault: all that higher overhead, not collecting his payments, not billing his claims right, and he can't read, understand, or have access to the right financials. "And what about that indirect costs -- what's that?!?"

So one of three things will happen. He will either leave, and the hospital will have to recruit a replacement. He will stay and conform somewhat but continue to publicly gripe about the system and be disruptive and not a team player. Or, he will conform to the hospital model and all will be well.

The hospital will be in little position to do anything about the overhead issue. But, most systems will work with the physician for awhile, supporting the practice, because they don't want to be seen as "running someone off."

What's the solution?

Certainly models that allow the physician to maintain some autonomy and responsibility for their own practice will help some. Convincing the physician of the long term benefits of some of the good things the hospital has to offer (such as quality improvement and infrastructure) and getting buy-in will be good for all involved. Convincing the hospital that the physician needs to be included under the tent and as a part of the team will also be part of the solution.

Congress could go a long way by aggressively creating gain sharing models that allow both sides of the health care team to be paid for improvement in health care value. This would promote team work and alignment.

But in the end, in the current model, do physicians really make good employees? And do hospitals really make good employers?

Monday, April 11, 2011

NAB Day 2: Roundtrip from Design, Production, and Post

This was day 3 of the National Association of Broadcasters meeting and today was all about exhibits. I thought it would be nice to give you a run down of the products we checked out today -- from pre-production, actual video capture and filming particularly with live set technology, and even post production software and equipment and streaming. This was really a great day, albeit a very busy one!

Sunday, April 10, 2011

NAB Day #1: Healthcare Social Media Future is Bright

Today was our preview day at the National Association of Broadcaster's Meeting in Las Vegas, Nevada. Where most of the day was for dealers, it offered the opportunity for our team to explore and network concerning future trends in health care information delivery.
This podcast also discusses the March study results from the National Research Corporation and the current state of patient opinion of social media in healthcare and particularly how it affects decision making. We make special mention of @melanoma_mama and provide congratulations on her 5000th tweet.
Please join us on this podcast that was recorded live onsite on the first day of the 2011 NAB. visits the National Association of Broadcasters visits the National Association of Broadcasters Meeting in Las Vegas, Nevada on April 10, 2011. This short podcast describes what were after and what we hope to deliver with our new website which focuses on interactive delivery of health care information. Our goal is to give daily updates from the meeting and describe how video technology is going to revolutionize the delivery of health information.

Saturday, March 26, 2011

Introducing Cancer Survivors New Normal with Dr. Linda

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Dr. Linda as we know her is introducing her new video blog series that focuses on cancer survivors and the "new normal" that occurs after a cancer diagnosis. No one, I repeat no one can know what it's like to have cancer more than Dr. Linda Timmerman. She is a two time cancer survivor and a life long educator. Plus, she understands the pain, terror, and crisis that people feel when cancer enters their lives. Please help me welcome Dr. Linda to

Wednesday, March 23, 2011

When health care research meets Trip Advisor

This is the time of year just after spring break when I enter the stress zone of planning the summer vacation.

I'm always on the quest of making everyone happy.

Finding some place that I can afford, where the kids will have fun and maybe get to experience something new, is always a challenge.

So, I search the internet far and wide for good deals and destinations.  One site that I always check out is Trip Advisor.

This travel website is populated with information on hotels, resorts, air fare, deals, and even food and restaurants.  But the heart of the site is the traveler reviews. These often number in the hundreds depending on the location and are many times candidly verbose.

Visitors can even give a score which is tallied at the top of the review to help you sort through the list.

So what does that have in common with health care research?

Well, frankly, if you relied completely on Trip Advisor you probably would never travel any where.

Let me show you what I mean.

Last year I thought I planned the perfect vacation (turned out, I did according to the family).  We used every (I mean, every) frequent flyer mile I had and the four of us traveled to Kona, Hawaii, one of the most beautiful and mysterious places on earth.

We stayed at the Fairmont Orchid in Kamuela which is on a  grand beach on the west side of the Big Island.  The grounds are impeccable, the staff is always at your beck and call, and virtually every room has a nice view.  I'm a member of the President's Club so the kids were able to get free internet as well as discounts on beach gear.

From the turtles that lounge on the beach to the prettiest sunset in the world, I could live there. 

Now to Trip Advisor:  here are the top reviews currently --

"I have to say that while we love the Fairmont, the level of service has become uneven, if not somewhat mundane."

"The service was average - long waits and average staff at breakfast. Room was nice, but dated. I saw three cockroaches in the hotel. The grounds were lovely but the overall experience was not worth the cost."

"For the price of this hotel, the room was a disappointment. First of all we were on the bottom floor, with people walking by constantly, so there was very little privacy. The bathroom had dust and dirt on the shelves, and the wall was filthy. There were 2 moldy pictures beside the bed..."

The take home message here is that each person has their own experience, and it is impossible to make everyone's stay perfect. 

We live in a society where expectations often exceed reality.  There is just no way to make everyone happy and provide perfection no matter how much you strive for this level. 

That brings me to health care. 

I recently had a lengthy discussion with someone regarding online treatments for a medical condition.  He had done considerable research, wanted to know the ins and outs of every perturbation of treatment, and why some people reported good results and some did not.

He finally wanted my opinion, and wanted me to weigh in on making a further review of these treatments and these patient experiences.

He just couldn't understand why some patients didn't report perfect results with at least one treatment.

I told him that unfortunately it doesn't work that way.  Every patient will have a different experience with virtually every treatment or procedure.

Sure, there is an "expected" outcome.  But we are dealing with a human body that is dissimilar from every other one on earth.  You just can't expect similarity.

But to even be more accurate, we are dealing with humans and their own expectations of what a successful outcome should be.  And that is even more challenging than the biophysics and physiology.  Humans rarely agree on anything.

So the take home message here is that research on medical procedures and treatments can be very valuable, but you should always take into context the individual nature of the reviews.

Otherwise, you would never travel anywhere, and you would never make a health care decision that could improve your life.

Sunday, March 20, 2011

The Blurry Line: When non-physicians practice medicine

It used to be that there were well defined roles.

Pharmacists dispensed medications on the order of a physician.

Nurses carried out care and healing as ordered by a physician.

Physical therapists helped patients heal their bodies on the order of a physician.

Physicians practiced medicine.

But that's all changing.  There is a hurrying pace to expand the scope of practice of non-physician providers to include elements of medical practice. The purported reason is the lack of availability of primary care physicians and access to care.

But, honestly, like almost all things in America, it's really not that altruistic.  It's about money of course.

And since it's about money, I've always been curious about the public's willingness to pay for information, time, or care from a non-physician provider at the same rate as if they were paying for a physician.

And when the stakes are high, like with your own health care, it looks like most people would only want the "best."

Now before I start getting hate mail or malicious tweets from the host of non-physician providers out there, I'm sure there are some in that group that practice good nursing, pharmacy, physical therapy, etc.  That's not what this is about.  I'm talking about medicine.

I'm sure if the airlines decide that airplanes have become sophisticated enough that flight attendants can be cross trained first as copilots and eventually as pilots, then the issue will become clear.

Someone once told me that to get hired by Southwest Airlines as a copilot in a 737 that it required 2000 hours in type and experience as pilot-in-command.  This is a hefty requirement but probably why the airline has one of the best records in the industry.

Now if you were to train a flight attendant with a fraction of that time, let's say 200 hours, would you feel as comfortable in seat 6B?  Even if your flight was on-time, everyone was friendly, and you had peanuts and a drink coupon?

But the analogy fits very well with medicine.

Let's take nursing:  its become somewhat politically incorrect to consider nursing any longer as a support role in health care.  There has been considerable growth in the industry in the role of becoming primary care givers.

Many states leave the determination of the scope of practice to the state nurse licensing boards which gives them broad latitude in defining what nurses can and can't do.

Much of this depends on the definition of the "practice of medicine" which has always been understood as the "diagnosis and treatment" of disease.

So nursing boards have morphed a term now to include the title: nurse practitioner, or NP.  These "advanced practice nurses" usually have expanded training, mostly from other advanced practice nurses  and some physicians, in the area of diagnosing and treating basic ailments.


I say supposedly because there are very few if any statutory limits on these advanced practice nurses.

Think for a minute that it might be one thing for a flight attendant to fire up the plane and taxi out to the runway, but it would be quite another to take off into the fog and rain of a messy evening.

So these APN's go into practice and begin to practice surrogate medicine.

The confusion abounds with patients who don't always know the difference from one provider to the next.  They just know their little girl has an ear infection and needs an antibiotic.

These lines even get blurrier when programs begin to offer "Ph. D." course work in nursing which then entitles the person to be referred to as "Dr. APN." Patients become confused:  just who is a "doctor" any more?

Now most of these non-physician providers are supposed to be either supervised by a physician or they are to practice under specific guidelines drafted and overseen by a physician.

But it is clearly not the same as having a physician see the patient or being immediately available for consultation.

(Think for a minute:  that flight attendant could always radio in for help....if they were to get into trouble...)

Many physicians like using non-physician providers of care because it increases through-put and therefore revenue for the practice.  These environments often deliver superb care in a team environment managing complicated patients.

Physician's assistants are one of the best examples of how the system can work well.  Usually these mid-level providers train directly with physicians, are regularly supervised, and have academic backgrounds that ground them in the basic science of medicine.

This type of preparation and apprenticeship is often lacking in other non-physician provider training programs.

But when advanced practice nurses want to open up a clinic and begin to practice primary care medicine, you really have to wonder if this is a good idea.

It's a slippery slope where most of the time no one gets hurt.

Pharmacists in many states can now give vaccinations and maybe even adjust the dose of someone's insulin to treat their diabetes.

Physical therapists may be able to diagnose a knee strain and begin corrective exercises and rehab.

Advanced practice nurses may be able to diagnose a sore throat in a 3 year old and start antibiotics.

So where does the slope end?  Despite the fact that medicine is becoming even more technical, the number of drugs is expanding at an unbelievable rate, and patients are generally sicker now than in the past (particularly with the economy challenging access to preventative health care services), there is a growing feeling that we need more non-physicians delivering health care.

And because of the purported need for access to primary care, legislatures are changing the statutes and regulations to expand the scope of practice of these non-physicians.

Physicians in the United States on average have completed a four year basic science undergraduate curriculum, four years of medical school, and typically 4 to 5 years of post graduate training in an internship and residency.

Most advanced nurse practitioners complete about 5 to 6 years of training total -- at least of three of which is spent solely in nursing.

So can a legislature obviate the need for medical school just by changing the law?  Of course not, but that is what is happening in many states around the country:  nurses, and other non-physician providers, are seeking independent practice.

This independent practice would remove even cursory physician supervision of their treatment of patients.

If lowering the standards was all that was necessary,  then one solution for the crisis in primary care access would be to shorten the requirements for physicians going to medical school.  I know, that's absurd.

With the technological advances in medicine and particularly surgical procedures and medication treatment -- the course of study cannot be condensed.

But to complete the tale of a story gone wrong, many advanced nurse practitioners never practice primary care. Instead they take up the practice of aesthetic medicine such as treating patients with cosmetic drugs like Botox or lip fillers.

To be fair, all of these non-physician providers in the proper setting offer advantages in our current health care crisis.  Working in a team under the supervision of a physician, health care delivery can be enhanced, access can be improved, and patients can get better service.

There is no better example than that of physician assistants.  This relatively new type of non-physician provider is probably the model that needs to be followed in expanding the scope of practice for medical providers.

Physician assistants usually complete a six year curriculum and even then there is typically a post graduate practicum or   on-the-job training program directly with a physician.  These professionals work hand in hand with physicians in caring for patients, have privileges to write prescriptions and perform some surgical procedures, and can help the physician in coordination of care for the patient.

In most states they are even supervised by the physician licensing board.

But as a rule, they don't have independent practice.  It is the perfect model to expand access of quality care.

Now, I'm usually a self-described progressive, and I'm always open to new ways to educate and treat patients.  But the last thing I want to do is to put patients in harm's way.

We shouldn't allow the access argument to blur the lines of right and wrong so much that we allow the training of our health care providers to be diminished.

If you want to practice in a support role working hand in hand with a physician to provide quality care, I'm all for it, and will work and lobby to make it happen.

If you want to practice medicine independently, then go to medical school.

Saturday, March 19, 2011

My skin cancer script: what I tell patients 40 times a day on how to recognize skin cancer

Moles are like stars.

And patients are like constellations.

And the number of these lesions is like the number of stars in the universe.

There is no way to see every mole, document every mole, or even have every mole examined by a dermatologist.

So patients play an important role in skin cancer diagnosis and recognition.  Teaching and educating patients on discovering these lesions is essential.

We have to make melanoma astronomers out of our patients.

So here's what I say:

1) "The most sensitive sign for a melanoma is a mole that is changing in size and color -- not specific, but sensitive.  So call me if you see a mole you are concerned about that is changing in size or color."

2) "Look for 'ugly ducklings.' That is, don't focus on your moles as individual lesions -- rather look at them as a group.  Look for moles that are ugly ducklings and don't look like their neighbors.  If you see one of these ugly ducklings, then bring it to my attention."

3) For non-melanoma skin cancer:  "You don't need to see me every time you get a pimple.  But if you get a non-healing wound or sore that lasts longer than six weeks, then we probably need to take a look."

The three steps are simple, but they represent good advice in finding skin cancer, particularly melanoma, early.

Friday, March 18, 2011

Your health records: more like a blog, or more like Twitter?

For over a decade I traveled 30 miles south to a rural clinic along I-45 in Fairfield, Texas. There I met one of those physicians that people always think of when they think the word "doctor."

Dr. John Keller is a community icon.

Born south of this small town, he practiced medicine there for over 50 years. Now he's retired, and the community is at a loss.

Though certainly not the cause, his retirement coincided with the roll out of a new electronic medical record, or EMR (sometimes AKA EHR).

This reminded me of a story from Dr. Keller that he related to me over a decade ago. He told me that when he first went into practice records were kept on 3"x 5" note cards.

As someone who has served in various administrative capacities over the years, I've always remembered Dr. Keller's initial non-electronic medical record. And I suspected that his care was super, despite the limitations of space on that card.

Today, EMRs are becoming more and more common. There is still significant resistance from some physicians because of the lack of a unified national standard of connectivity.

That is, one system still can't talk to another.

Plus there is the cost of implementation. Some estimates put this near $60,000 per physician in a practice.

In this day of declining reimbursement it's hard for many medical practices to take the plunge and invest in this new technology.

Plus there is the whole slew of resistance remarks that range from "it'll slow down my productivity," "I'm too old to learn," "there isn't one for my specialty," and on and on.

Personally (albeit I'm a self professed techno-nerd) I haven't seen any of these problems.

We use a nice cloud based system from AthenaHealth which allows us to limit our on site technical requirements and back up, is constantly up to date, and can be accessed anywhere. Patients can even log in to check their test results, pay their bill, or ask me a question.

The electronic prescribing is phenomenal. I haven't written more than a handful of paper prescriptions in a year or so.

But even with all this technology, I'm not sure that we practice medicine any better today than Dr. Keller did fifty years ago. We just document a whole lot more information.

But is it useful?

We're pretty good at not generating a ream of electronic information every time a patient comes in. Some EMR systems accomplish this task (conventional wisdom is that it might help with coding and therefore reimbursement).

But, we chart way more than Dr. Keller ever did. I hope it's still pertinent to our patients complaint.

What's amazing to me is that as we have advanced in our technology we have become more verbose in our ability to describe it.

You could say that we are "health care bloggers" in the patients' medical record.

Whereas Dr. Keller was more like Twitter. He kept his comments to probably less than 140 characters -- and he did just fine.

So Dr. Keller may have been ahead of his time. Maybe we should "follow" him.

Tuesday, March 15, 2011

How a dying child tells his parents he's ready to die

My good friend and Fort Worth pediatrician Gary Floyd relates this telling story about working with a family through the death of their child from cystic fibrosis.  Gary's story is compelling, really...downright tear jerking.  This video is part of a series from the Texas Medical Association that began as project from their creative social media guru Steve Levine.  Check out other videos from that series here.

Injections: Does hurting children now, hurt their health care decisions later

For a long time I ran a large multi-specialty group medical practice in a relatively small town. One of our most active divisions was pediatrics.

Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.

But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.

The children, though, turned, ran, and cried to their mother.

Ruby commented to me that this was a common but unfortunate occurrence for her.

She was the "shot lady."

Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."

Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.

Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."

Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.

But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.

(Just for the record, I'm opposed to corporal punishment.)

Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."

Well, it never hurts me.

Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.

Like a bee sting.

That one always makes me calm down.

"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."

You're calm now, aren't you?

Brute force is sometimes an option, particularly if it's a young child.

There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."

Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.

This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.

Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.

Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)

You see with injections there's really no "compromise." So negotiation is doomed from the beginning.

You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.

But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.

So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?

Particularly if the primal image of your first health care experience is clouded with pain.

Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.

I think many patients do.

Going to the doctor is often a painful experience. Some things just hurt.

But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.

I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.

Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.

Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.

Their fear is gone and what comes with it is a learning that water can be safe.

Health care is no different for children.

If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.

Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."

Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.

Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.

In our office it  is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.

I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.

And I don't want children to run away crying when they see me at Walmart!

- Posted using BlogPress from my iPad

Location:Dallas, Texas

Sunday, March 13, 2011

When Cancer is a Family Affair

By Linda Timmerman, Ed.D.

According to a report from the CDC, there are nearly 12 million cancer survivors in the U.S. today.

That's 12 million people seeking "new normal" in their lives. Twelve million journeys. Twelve million stories.

Every cancer survivor is an individual, and no two journeys are alike.

My family of cancer survivors is a microcosm of those 12 million courageous souls.

My 86-year-old Dad approached his diagnosis of bladder cancer some 20 years ago the way he has always approached life: philosophically and through scripture. Ask about his cancer and he'll respond: "It happens. My God is in control, and I don't worry about it."

He does, however, think deeply about his cancer.

Shortly after he had completed his three-year maintenance protocol of BCG (Bacillus Calmette-Guerin, an inactivated form of the bovine tuberculosis virus that is instilled into the bladder to elicit an immune response), he called me and asked, "now that my treatment is over -- do I tell people I HAD cancer, or do I say I HAVE cancer?"

He's deeply interested in knowing how he got bladder cancer in the first place: he was a smoker for a number of years, but hadn't smoked in over 25 years when diagnosed. He was a dairy farmer exposed to pesticides and chemicals virtually every day.

Truthfully, it was Dad who found an article about BCG in Reader's Digest in 1991, took it to his urologist, and said, "they say this is a fairly new and promising treatment for bladder cancer -- can we try it?" It worked for him -- he's been in remission almost 20 years.

Today, BCG is still the gold standard for immunotherapy for bladder cancer.

Dad spends hours pondering the fact that I, his only daughter (who is still 16 years old in his mind), has bladder cancer and that having a first degree relative with bladder cancer is a risk factor.

"How did I pass that on to you?" he'll ask. Is there some test your children can take to see if they carry the gene?

My Mom, on the other hand, approached her journey with fear and trepidation. Mom is the official family worrier. She called me one day to say that she was so worried, "things are going so well, I just know something bad's about to happen."

Mom thought her lung cancer diagnosis meant certain death.

She grew up in that era. She and I were both there when her mother, my grandmother, died -- drowning in her own fluids from breast cancer that had metastasized to the lungs.

Mom didn't know many survivors in her life.

Mom never came to see me when I was undergoing treatment for breast cancer. She just couldn't. And  I completely understood.

To this day, Mom can't believe that her cancer is gone. "All they did was remove the upper left lobe of my lung," she'll say. "The doctors say I didn't need chemo. It'll probably come back."

She has to worry. I completely understand.

My husband approaches his cancer stoically. He has had three melanomas, but rarely talks about it and doesn't want anyone to "make a big deal" of it. He has a skin condition that requires him to use ultra-violet light therapy weekly. It has to worry him that he exposes his skin to UVB light, but he does it without complaint.

He is vigilant. He visits his dermatologist regularly and uses sun screen religiously.

He and I faced our biggest fear two years ago when his daughter, my step-daughter, was diagnosed with a liposarcoma in her leg. This was different for our family: she was too young, and the mother of young children.

The biopsy was clear, but pathology on the very large tumor showed that approximately one-third of the mass was cancerous. They couldn't remove all of the tumor without removing her leg.

She is teaching us how to use humor to cope. She respects the disease, and she knows that she must be followed closely for the rest of her life. She will do what it takes to thrive and survive.

I cope by being involved.

I participate in cancer "causes," -- Relay for Life, the Koman Breast Cancer 3-Day walk, I attend a support group for bladder cancer survivors, I speak to groups, I counsel fellow survivors, I raise money for cancer research, and I blog.

I use this involvement to find my "new normal." I use it to challenge the disease that has invaded my life and the life of people I hold dear: my husband, child, mom, and dad. My prayer is that my children and grandchildren will never have to battle this disease in any form.

12 Million Survivors. 12 Million journeys. 12 Million ways to cope. It's a good thing. It gives me hope.

Linda Timmerman, Ed. D. is a two-time cancer survivor and life long educator. She blogs regularly about cancer survival and real information from real people with the disease.

- Posted using BlogPress from my iPad

Saturday, March 12, 2011

"docdano. com Live" Protesting in Wisconsin: Is Obamacare at the root of the debate?

I spoke last night to a group of young physicians at a venue across the street from the Wisconsin State Capitol at the height of the protest against the state government.

Amid the drum beats and screams of union organizers chanting how workers' rights would be eternally devastated because of the loss of collective bargaining, I lectured to a group of resident physicians on the benefits that await patients with the explosion in health care technology.

The root of the problem centers around a state, like almost all in the country, that is saddled with loss of tax revenues due to the downturn in the economy. This has resulted in massive budget deficits and hard choices.

Many states including Wisconsin have ushered in a flurry of Republicans who ran on campaigns of no new taxes, the need to cut waste and spending, and more state's rights.

So that's what the Republican Governor did from day one in office.

He first attempted to limit spending on education to trim the budget, but because of collective bargaining the negotiation of this type of decrease in the state spending was not palatable to the unions.

It didn't matter, really, because the Republicans had the votes to pass it anyway.

But instead of voting on this budgetary issue, the Democrats chose to flee to the land of Obama in Illinois to prevent the state legislature from reaching the critical number of votes to make a quorum.

For three weeks this stalled the debate and decision on the issue, until the Republicans decided to pull out the budget issues (which require the quorum) and vote instead on non-budgetary items - like collective bargaining.

So this lead to more protests.

I literally visited with hundreds of people in Wisconsin over the past week and different opinions abound from every direction.

Clearly if you are a member of the "haves" then you have no desire to give up a benefit.

That's normal.

One person told me that his daughter is a unionized teacher and she pays a whopping $23 a month for health care insurance with no deductible. Even if you factor in that there might be some requirements for her to see certain physicians in network or limitations on formulary and specialist access, this is still a bargain.

He went on tell me that the Governor's proposal would have raised this to $123 per month. I don't know if these numbers are accurate, but the change in benefit structure certainly spurred part of the protest that had national attention.

If you've read this blog before, you know that I'm not a fan of the Obamacare bill. And I think you are seeing in Wisconsin one end of the spectrum of the problems with the bill.

Let me show you why.

To pay for the extra benefits offered under the bill (like no pre-existing illness exclusion, limitations on the right of rescission of insurance if you're too sick to be in the plan, or extended coverage for children), then there will have to be either more money (read tax dollars or higher premiums) or a decline in benefits for those that are members of the "haves."

It's really that simple.

State governments who have been charged with implementing many of the provisions of the federal health care bill don't have the ability to print money or sell treasury bonds. Their only source of revenue is tax dollars.

A significant part of Obama's plan was to provide health insurance for "all Americans." And, unfortunately, a large number of the uninsured were to be covered with the under funded, limited access Medicaid system -- much of which is paid for by the states.

Finding revenue for Medicaid means that other state funded services - like education, or health benefits for teachers - have to be cut and shifted.

That is the only possible way to fund insurance for the "have nots."

I've been derided for one of my statements in the past, but I stand by it: the Obamacare health regulation was the largest transfer of wealth in American history.

So the union supported President now finds himself supporting the union backed protesters who are fighting against changes in state government that would be used to pay for the health care bill that he (and the unions) supported.

Wisconsin is only a microcosm of what is happening in every state that is now grappling with implementing the federal health legislation in a time of budget crisis.

It is an expensive bill, and now we are starting to pay the price.

I'm a big fan of expanding health care access and coverage for the "have nots." A country like the United States should be ashamed for having citizens that don't have access to quality health care. I'm just not a supporter of the big, expensive, inefficient and over-reaching federal health care bill that was passed last year.

Let's face it: the bill cost the taxpayers almost $1 trillion.

The payment for the bill is due now.

And lest you think that non-government workers will get a free ride and this is just an issue for state employees - it will filter down to every American.

As health plans shift to include the new benefits, pay the taxes and fees that are now required by the IRS, and see declining membership due to employees shifting to government subsidized insurance products there will no doubt either be an increase in your health care premiums or a reduction in your benefits.

The problem is that for many insured Americans there is no union to fight for your corporate benefits.

It will be left up to you.

One Wisconsin young man told me that maybe the Republicans should have left Congress when the health care bill was passed.

I reminded him that democracy doesn't work this way. We elect people to represent us and sometimes we win, and sometimes we lose.

I think the Obamacare bill is failure, but I believe strongly that we can keep what's good and fix what's broken. We just have to continue the debate, make compromises, and yes, probably make some sacrifices.

So it probably won't be the last protest I'll attend. Maybe next time I'll get to carry a sign...I'm not much of a drum beater.

- Posted using BlogPress from my iPad

Wednesday, March 9, 2011

Vaccinations: Is death the only motivator that works to promote immunization?

A recent conversation with my nurse and regular debating partner highlighted the passion that people have about vaccinations.

We were finishing up clinic and the topic of HPV came up.

(Now, don't be surprised. This issue is something that we deal with almost every hour of every day.)

There is a vaccination now for certain subtypes of HPV, which not only cause genital warts but also can lead to cancer in women and men.

Cervical cancer particularly is an epidemic disease among young women. And the "abnormal Pap smear" has become as frequent as many common diseases.

Women infected with the virus can develop dysplasia (atypical, precancerous cells) of the cervix which if not recognized and treated can lead to both a superficial and invasive malignancy.

The dysplasia needs to be treated with painful procedures like cryosurgery, or a cone biopsy where the affected tissue is surgically removed, to the possibility of a hysterectomy.

Aside from the fact that the vaccination is really directed to young women, it is clear that young men are also parties to the transmission of the virus. And, there is a cancer risk in men as HPV can lead to not just cometic genital warts, but also to penile cancer.

My nurse was adamant about her son not having the vaccination.

She is certainly entitled to her opinion and it's a common thought among many young parents these days.

Plus, lets face it, men serve as reservoirs of the disease for women.

So, why does she have such a strong opinion?

I mentioned this discussion to my father who in less than a month will be 91. He couldn't grasp why someone would ever turn down a vaccination.

His opinion is grounded in growing up where epidemic infections were a regular cause of death for young adults, including his family and friends.

"I can remember when my cousin died of polio. We burned all of her bed clothes and put phenol around the house," he told me.

"Then we buried her."

So what happened when the vaccine came about I asked?

"We lined up downtown at the community center. Everyone in town."

"No one felt like the government was forcing them to get vaccinated? Did anyone refuse?"

"I can't remember anyone who didn't want it. I mean, almost everyone had lost a member of their family, or a child. You didn't have to see many people in a wheel chair or an iron lung to put the fear of God in you about polio."

So that's the culture that I grew up in. My parents used every opportunity to have me punctured by a hypodermic to keep me from dying of polio, and lock jaw (tetanus), two kinds of measles, and whooping cough.

They must have also wanted to continue the blood line too because mumps was also put "at bay" and my testicles protected with a series of injections.

So maybe death is the big motivator for vaccination.

If you look at college campuses now almost all of them have been affected by meningitis. Students have died of the disease so frequently in the past few years and it is so contagious that most schools require vaccination before you can gain admittance.

I remember the first patient I ever admitted to the ICU as an intern almost 18 years ago now.

She was a 24-year old waitress at one of the Dallas cowboy bars. You know the drill: fever, chills, altered mental status, and finally collapse in the ER.

She got the finest treatment a major tertiary center could offer. But she still descended to the brink of death.

There was a ventilator, multiple consultants, loads of IV antibiotics, and plenty of hand holding from a pimple faced intern who saw someone younger than him dying.

There was no vaccination for meningitis in those days. We gowned and gloved when we took care of her. And we all took prophylactic antibiotics lest we succumb to the same fate.

And we waited, and yes, I prayed for her.

It's not that I just didn't want to strike out at my first bat with a patient in the ICU.

I met her family, her boyfriend, and friends. I got to know her.

And thankfully I witnessed her get better. It took the better part of a month, but we were able to give her the hospital equivalent of the perp-walk in a wheel chair to the front door with balloons, plants, and the to go bag containing the pink ice pitcher give-away from the hospital room.

But for the other diseases nobody dies.

Does this decrease motivation for vaccination?

It probably does. I can assure you my children will be vaccinated against meningitis.

Chicken pox maybe is an exception. Public health officials were successful in convincing parents in our state to require this for elementary school attendance.

I would like to think that it was because chicken pox can lead to devastating scars in children and to permanent pain in adults when it reappears as shingles.

More likely, the primary concern was the missed school days for the kids and missed work for the parents.

But today most parents line their kids up for chicken pox and also hepatitis B vaccinations without much consternation.

Oh, but not for the HPV vaccine.

It may be the social stigma of the disease, or the fact that their children either shouldn't be or won't be doing anything to put them at risk for the disease.

I even still the absurd argument I hear about the birth control pill: that it might promote promiscuity.

My opinion is no doubt clouded by practicing every day at a major urban metropolitan hospital. What I see is real world. But it may not be your world.

I guess I grew up with the values from my father. If modern medicine can protect children or adults from ailments or infirmities then I am easy to buy in.

Whether its small pox or HPV, I support vaccination and elimination of these diseases from the society I call home.

I no longer have to see someone die to become a cheerleader.

- Posted using BlogPress from my iPad

Location:Milwaukee, Wisconsin

Monday, March 7, 2011

Groupon: Are coupons really the right answer for health care?

I'm always fascinated by new technology and particularly ways social media works in our world.

So it was natural for me to sign up for, the internet based deal program that works with local vendors to offer special coupons and discounts for products or services.

Sometimes these deals are just incredible - from 50% off food products to half price golf to yoga for $19 per month rather than $140.

But what about using coupons for health care services?

Sounds odd, I know, but this has been a common practice for years with aesthetic services and cosmetic procedures or treatments.

It's not uncommon at all to see deals for "free Botox" or discounts on micro-dermabrasion or chemical peels.

But would you be influenced by a coupon for "free prostate exam" or "buy one get one free mammogram"?  Or would you just think that provider was weird?

It may sounds strange, but actually this happens every day.

It's hidden behind the cloak and dagger world of the pharmaceutical sample closet.

For years the drug sample has been the easiest tease to entice patients to try a different medication.  Sometimes they are very helpful -- a difficult medication to use (like an unusual dispenser for a spray on product), unusual side effects ("try it before you buy it"), or most commonly the patient has no money and they leave with a bag full of free drugs.

But these are certainly short term solutions and may or may not lead to a patient actually buying the product.

It's no surprise that most of the samples in the closet are for chronic medications -- not for something you have to take for a week or less.

But the interesting invasion into the sample closet has been the coupon.

Now not quite "groupon-like," coupons are now available for almost all name brand, non-generic medications -- particularly if they are early in their evolution of release.

This is how it usually works:  you decide you want to prescribe a new anti-hypertensive (an expensive way to say blood pressure medication).  Compared to a generic medicine which might fall under the $4 per month Walmart plan, this medication might be $300 per month.

But, there might be some advantages:  lower incidence of side effects, easier dosing regimen, or maybe its more effective.  There usually is a real medical reason despite what some Washington pundits might say.

Newer drugs usually work better.

But, nevertheless it costs $300. That's roughly half of some people's Social Security check.

Now with insurance this medication would be a lot cheaper (for the patient) but it is very likely that it would not fall under the "preferred plan" of their prescription drug coverage.

That means that it would likely cause a higher co-pay such as $50 as opposed to $5.

This is where the pharmaceutical coupons come into play.  Now, instead of advertisement laden boxes of pills, the sample closet is full of boxes full of coupons or discount cards.

Patients are asked to call a 1-800 number to activate the card, "register" (which means the company collects information on the patient, disease, and provider), and then the card can be used to off set part of the extra cost related to use of the expensive medication.

These cards usually function as "discount cards."  That is, they will provide either a certain reduction in your copay amount, or they will fix the total cost of medication at a certain point.

Most of the cards require you have insurance to use them.  There is no free lunch here, and the drug companies themselves don't want to be out the total cost of the drug, only part of their margin.

Sometimes there are limits on the amount of benefit you can receive.  The card may only be good for three refills, or it may be unlimited.  You want to make sure you check this carefully before you continue to refill your medication.

Pharmacies as rule don't like to deal with these cards.  Much like grocery stores don't like to deal with coupons.

There is an extra step for them, possibly some activation required on their part and certainly they have to carry additional float, in addition to your insurance, before they will get paid.

What's fascinating to me is that these provide a direct incentive to use a more expensive medication.

Now, as I've outlined here, there are some benefits of these cards.  But let's face it, these are expensive medications -- there is no free lunch.

It's the incentive that seems bizarre.  Physicians and hospitals are forbidden from discounting co-pays, not collecting deductibles, or for offering covered services for less than the contracted amount in most insurance contracts.

There have been several lawsuits already between rival health care systems in communities where one hospital might write off co-pays or deductibles to entice patients to choose their facility over the competitor.

This might be like a patient knowing that regardless if he has Blue Cross Blue Shield insurance, for example, they could choose either emergency room -- because the cost would be the same to them.

Patients with high deductible insurance plans are particularly susceptible to this type of gaming.  The catch is that the hospital is able to collect enough money on the subsequent procedure or test to offset the loss of the deductible.

The problem is for the insurance company and the other insured patients that are on the policy.

It removes the incentive to stay within network and comply with the contract that makes indemnity insurance work in the first place.

Everyone has to play by the same rules.

So why do pharmaceutical companies get to use these discount cards?

I'm not sure I can answer that question, but I hope I've been able to shed some light on these type of cards and discounts.

In some situations they may be very helpful.  If you require an expensive medication, particularly one that is new, be sure to ask your physician if the company offers any type of discount card.

If not, then asked them for a lower priced, generic alternative.

Otherwise, just be aware that these cards can get you established on an expensive medicine for you only to find out that the benefits were temporary.

Also be careful if the company is going to send you a rebate.  This puts the risk on you for collecting the money.

So although not quite type coupons, there are some discounts available for expensive medications.

You just may have to shop around and be an educated consumer-patient.

Study finds unnecessary breast biopsies: maybe needles should stick to being lost in haystacks

By Linda Timmerman, Ed.D.

So who do you listen to?

I get frustrated when I hear about research studies that say women don’t need mammograms every year or before a certain age, not all lymph node dissections are necessary, and now many breast biopsies are done just to line the pockets of physicians and hospitals.

A recent article in the American Journal of Surgery suggested that physicians are doing too many biopsies and should favor doing fine needle aspirations or biopsies (the "FNA").

The FNA is a procedure where a needle is inserted into the tumor either based on palpation of the lump or by the use of a sonogram to guide it to the proper location.

Then using suction, some of the cells are removed and examined under the microscope.

I thought about my friend, Robbie, when I read the findings of the research study.

Robbie found a lump under her arm. She was still young, so the doc thought it was probably just a cyst or infected lymph node. They did a fine needle aspiration (FNA). Results: all clear.

We celebrated with margaritas and Mexican food at Don Jose’s!

Three months later, the “lump” was growing – another FNA – good results – more margaritas!

Six months passed and Robbie went for her well woman checkup. Her OB/Gyn just didn’t like the feel of the lump – so a third FNA followed by the celebratory margaritas!

Fast forward a few weeks. Robbie dropped by to say she was going back to the surgeon. “I know it’s nothing, “ she said, “but it just bothers me knowing it’s there. I’m asking him to take it out.”

“Lump” removed – positive for cancer – invasive ductal carcinoma with lymph node involvement. A modified mastectomy, 8 rounds of chemo, and 35 radiation treatments followed – and Robbie’s been cancer free for 15 years.

Now to be fair, biopsies in general are samples.

Think of a loaf of bread.

You decide you want to serve it for Thanksgiving but you're not sure its fresh. So you pull out several slices and examine them. All ok. No green stuff here.

You put it on the table and then one guest pulls out a different piece, and guess what? A Pasteur prize addition to your holiday meal.

But FNA's are even more of a sample: small fragments of cells pulled through a hypodermic needle. Analysis requires special training and certainly has a margin of error that is bigger than examining a larger piece of tissue.

Robbie is alive today because she listened to her body and followed her “gut feeling” that the lump needed to come out.

So what’s the takeaway message?

If you find a lump, go to a center that specializes in breast cancer.

Find a surgeon and radiologist you can trust.

And most of all follow your gut feelings.

Listen to your body.

Maybe you’ll be one of the fortunate ones whose breast biopsy was unnecessary.

Linda Timmerman, Ed. D. is a two-time cancer survivor and life long educator. She blogs regularly about cancer survival and real information from real people with the disease.