Being with the wrong doctor can have grave consequences - literally. As a practicing physician, I’m the first to admit that no doctor is perfect, especially me. I’m in a field that is eternally humbling, with my next mistake potentially hiding just around the corner. The stakes are enormous and the number of tasks I must juggle often daunting. From my point of view, I’m trying my best. But from the patient’s point of view, that may not be enough. So how do you know when it’s time to call it quits with your doctor? Here are ten reasons to make you think twice about continuing with the status quo:

1) You feel your doctor isn’t listening to you.
Listening isn’t waiting to speak. One of my favorite and most beloved teachers, Dr. Alfred Markowitz, once told me, “If you let patients talk long enough, they’ll actually tell you what’s the matter.” Studies show that, on average, doctors let patients talk for 18-23 seconds before interrupting. Patients are allowed to finish their opening statement of concerns about 25 percent of the time.

You want a physician who not only is willing to hear what you’re saying but who’s intrigued by interpreting nuances of words and body language, who notices when you hesitate a millisecond before answering a question that’s hit a hidden sore spot. Don’t be shy about confronting a doctor who isn’t listening. And leave if your concerns aren’t addressed.

2) Your doctor can’t communicate effectively with you.
Your doctor not only needs to be a great listener but has to be able to explain things to you in a way that you can understand. You’ll know it when you don’t hear it.

3) The doctor isn’t taking you seriously.
This is a deal breaker. It may happen if your doctor jumps to a conclusion about the cause of your symptoms before considering other possibilities. Even if you’re a hypochondriac, your hypochondria needs to be seriously addressed. And even hypochondriacs get real illnesses.

4) You have a problem with the office staff.
Office personnel represent the doctor. If they’re unfriendly or unkind then you’re starting off on the wrong foot. And it gets worse if they’re inefficient. Messages must be given to the doctor, insurance forms filed, tests properly scheduled and results reported. Last week, a survey of primary care practices found that patients were not told of abnormal results an average of 7 percent of the time.

5) You’re kept waiting too long.
Doctors can be delayed by unpredictable medical emergencies. But if it happens consistently then the doctor is probably scheduling inefficiently. A clue you’ve been in the waiting room too long: if you pass completely through menopause while waiting to discuss your hot flashes.

6) It takes too long to get an appointment.
Routine annual visits can be scheduled months in advance but new problems and ongoing medical complaints need to be addressed in a timely fashion.

7) The doctor’s too busy.
This may develop over time, as the practice grows. If messages are going unreturned, insist on talking to the doctor. If the problem continues or the doctor always seems to be in a hurry then you may need to find somebody else.

Your doctor gets annoyed by questions.
This may be a reflection of other problems listed above such as the doctor being too busy or not taking you seriously. Whatever the cause, it’s unacceptable. Not only are patients entitled to careful consideration of questions, those questions may provide doctors with important clues. “Why do I get a stomach ache every time I eat a slice of toast?” may lead to the diagnosis of celiac disease, a condition in which gluten - a component of wheat, rye, and barley - is toxic to the body. If a doctor doesn’t immediately know the answer, a perfectly good response is, “I don’t know but I’ll research it and get back to you.”

9) Your doctor is too arrogant.
God save us from the brilliant doctors. You probably need to be a B+ student to be smart enough to learn everything you need to be a great doctor. But you also need to be A+ in empathy, listening, carefulness, keeping an open mind, logic, and common sense. Doctors who think they are brilliant scare the heck out of me. I’ve seen them make huge mistakes as they take short cuts or rely on their instincts without seeking help from others or adequately listening to their patients.

10) It just doesn’t feel right.
As with any relationship, sometimes you can’t put it into words but you just know it’s wrong. Don’t fight your instincts.

For this week’s episode of CBS Doc Dot Com, I visit the Mount Sinai School of Medicine in New York City and speak to Erica Friedman, the director of the Morchand Center, where budding doctors are schooled on bedside manner by treating actors pretending to be patients.

Watch CBS Videos Online

I went to a great grand rounds the other day about osteoporosis and learned that all teenage girls should be taking about 1,500 mg of calcium with Vitamin D a day in addition to a multivitamin. Three glasses of milk provide about 1,200 mgs, but most teens are not drinking that much milk. Dark green vegetables are another good source of calcium. Exercise and weight-bearing activity is also important in the prevention of osteoporosis.

Calcium is a mineral that gives strength to your bones. Calcium is also necessary for many of your body’s functions, such as blood clotting and nerve and muscle function. During the teenage years (particularly ages 11-15), your bones are developing quickly and are storing calcium so that your skeleton will be strong later in life. Nearly half of all bone is formed during these years.

Women develop most of their bone strength before they are between 25 and 35. After that, bone is broken down faster than it is created, leading to a small loss of bone mass every year. For women, bone loss accelerates during menopause, but slows again around age 60.

There are specific risk factors for osteoporosis that teens should know:

• Being white;
• Having irregular periods;
• Doing little or no exercise;
• Not getting enough calcium in your diet; Being below a normal weight;
• Having a family history of osteoporosis;
• Smoking; and
• Drinking large amounts of alcohol.

Osteoporosis can be prevented, but teens need to start early.

Being the first group of parents to have to have to parent an all digital generation of kids, it’s no wonder our brains go on overload trying to sort out not only how to use all things digital but keep our developing kids safe and thriving in their ever digital lives.

I talked about these issues today on Fox25 Boston and highlighted the new social media and sexting tips out from the American Academy of Pediatrics in honor of Internet safety month. Here’s the clip of the segment with all the details:

To remember the key points of the new AAP tips, I came up with the mnemonic “TECH”:

T: talk to your kids about their technology use and what they think of technology and the issues they hear about online.

E: educate yourself about the technology your kids are using, your kids about the issues, and your community about the need for youth education programs in schools as support for the issues

C: check your kids online profiles and logs often, and sometimes without warning

H: have a family tech use plan and follow-through when violations occur.

We know how to parent off line. We know how to create consequences when curfews are broken and expectations for social rules and proper behavior are not met. What we have to do now is modify our already great parenting skills to the online world. These tips are the first step!

Plus, keep in mind, you are not alone. Not only are all the parents around you in the same boat but you have experts like me here to help answer your questions about the high tech lives of kids.

I had a great chat after the segment with many FoxNews25 viewers and will post what we talked about soon so everyone can benefit. In the meantime, if you have questions about your own “Networked Family” or a story to share from your own “Networked Family” archives, email me at ideas@pediatricsnow.com.

When patients ask me if a chiropractor can help them with their problem, I often think to myself, “OK, do I give them the short answer or the long answer?” The difficulty is often in the fact that chiropractic is a diverse profession and it is difficult to even characterize what a “typical” chiropractor is likely to do. As a chiropractor once admitted to me - there are a great many things that happen under the umbrella of “chiropractic.”

In this article I will summarize some of the history and practice of chiropractic, highlighting what I consider to be many of the enduring problems with this profession.

History

Chiropractic was founded in 1895 by Daniel David Palmer, a grocer with an intense interest in metaphysics. Prior to his “discovery” of chiropractic, D.D. Palmer was a magnetic healer. He also had interests in phrenology (diagnosing disease based on the bumps of the skull) and spiritualism. Palmer reported to have discovered the principle of chiropractic when he allegedly cured a janitor of his deafness by manipulating his neck. The fact that the nerve which conveys sound information from the ears to the brain does not pass through the neck did not seem to bother Palmer, if he was even aware of this fact.

Palmer created the term “chiropractic,” which literally means “done by hand,” to refer to his new therapy. He argued that all disease is caused by subluxated bones, which 95% of the time are spinal bones, and which disrupt the flow of innate intelligence. He did not subject his ideas to any form of research, but rather went directly to treating patients and to teaching his principles to the first generation of chiropractors.

Subluxation Theory

Palmer believed in the pre-scientific vitalistic notion that health stems from the flow of a spiritual life force. Although vitalism was rapidly declining within scientific thought by the end of the 19th century, it was the centerpiece of early philosophies of health in most cultures. Palmer borrowed this ancient belief and renamed it “innate intelligence” which he claimed flowed from the brain to the rest of the body through the spinal cord and peripheral nerves. All disease, he argued, results from disruption in the flow of innate intelligence. Disruption in flow is caused by spinal subluxations, which are small misalignments in the spine that compress the spinal nerves.

Therefore, liver disease is caused by a subluxation which compresses the spinal nerve which supplies the liver with life force, depriving it of its vital innate intelligence. Palmer therefore believed he could cure by fixing these misalignments with manipulation.

This idea has remained the cornerstone of chiropractic despite advances in neurobiology and anatomy which have failed to show any evidence for innate intelligence or chiropractic subluxations. Many continue to ascribe all disease to the blockage of innate intelligence despite scientific advances in medicine which have discovered infectious, genetic, autoimmune, degenerative, nutritional, and other causes for many of the diseases which plague mankind.

Chiropractic was also not the only tradition based upon manipulating the bones. Of note, osteopathic doctors also developed an art of bone manipulation in order to heal, but they believed they were unblocking blood flow through arteries. Osteopathy and chiropractic had similar roots, but took very different paths, as we will see.

D.D. Palmer’s son, B.J. Palmer, became involved in the chiropractic movement early on, during the formative years. B.J shared his father’s metaphysical bent (prior to chiropractic, he worked with a mesmerist and worked in the circus), his tendency to make sweeping statements about health without justification, and his ignorance of contemporary scientific knowledge. He was reported to state, for example, “When I saw there was no use for a sympathetic nervous system, I threw it out, and then just had to put something better in its place, so I discovered Direct Mental Impulse.” B.J. also “discovered” a non-existent “Duct of Palmer” connecting the spleen to the stomach. In 1907 B.J. engineered a hostile take over of his father’s school of chiropractic.

B.J. Palmer set the tone that would later dominate the field of chiropractic. He emphasized salesmanship, advertising, and practice building. He was highly critical of medicine, stating that M.D. stands for “more death.” He continuously sought new methods for increasing revenues, such as his neurocalometer, which would pinpoint subluxations by measuring skin temperature and he decreed must be rented from him by other practitioners at exorbitant fees.

From the beginning chiropractors were also politically aggressive. They sought licensure as a protection from the growing scientific medicine with which they were completely at odds. Many legislators were reluctant to license chiropractors for this reason, but as more and more states voted in licensure, it became increasingly difficult to fight. Additionally, many legislators looked upon licensure as way of controlling the scope of chiropractic. By 1925, 32 states had instituted licenses for chiropractors. The struggle ended in 1974 when Louisiana instituted licensing.

Many states then began to pass basic science board requirements for licensure, making chiropractors pass the same tests of basic science knowledge as medical and osteopathic students. This was justified by the fact that chiropractors were presenting themselves as primary practitioners. However, where roughly 86 percent of medical students passed their basic science boards between 1927 and 1953, only 23 percent of chiropractors did. Chiropractors who could not pass the boards either moved to another state without the requirement, or practiced without a license. Between 1967 and 1979 all of the basic science laws for chiropractors were repealed.

Over the years chiropractic has never ceased its tireless struggle for growth and acceptance. Despite the fact that scientific medicine has continued to progress and chiropractic has never shed its pseudoscientific origins, they have been quite successful. After licensure, they gained coverage under Medicare. They have also successfully sued the AMA to stop their antichiropractic campaign. Today they continue to lobby hard for increased coverage and access under health insurance and HMO policies.

Straights, Mixers, and Reformers

Almost since the beginning, chiropractic has been fraught with many internal schisms. Today there is a wide range of differences between individual chiropractors, but most can be placed within one of three basic types.

Straight chiropractors consider themselves the only true or pure chiropractors because they limit their practice to the identification and treatment of spinal subluxations. They adhere strictly to Palmer’s concept of disease and believe that all ailments can be treated through manipulation to restore the flow of innate intelligence. Once freely flowing, they believe innate intelligence has unlimited power to naturally heal the body.

Straight chiropractors are the most extreme in their anti-scientific views. They openly advocate a philosophical rather than a scientific basis for health care, calling mainstream medicine “mechanistic” and “allopathic.” They call physicians “drug pushers” and disparage the use of surgery. They are careful not to give diseases names, but none-the-less they claim to cure disease with their adjustments. They oppose vaccinations. They also openly advocate the replacement of scientific medicine with chiropractic as primary health care. The statements of Dr. Wilson A. Morgan (who just passed away earlier this month), previous Executive Officer of Life College School of Chiropractic, are typical:

“Chiropractic: The health care system whose time as the official guardian of the public’s health is fast approaching!”
“On the other hand, it is equally appropriate for chiropractors to be viewed as generalists in that the far-reaching effects of their highly specific spinal adjustments usually are followed by the decrease and often disappearance of a very broad array of symptoms, disabilities and pathological conditions.”
“Unlike the medical profession, chiropractic has a very strong philosophical basis, which no doubt has contributed to its having been labeled ‘unscientific’ by the more mechanistically-oriented scientific community.”
“It appears that education will prove to be the best strategy in the ‘war on drugs,’ including education about the dangers of drugs available on the street and also those available from the physician as prescriptions.”

Mixers, comprising the largest segment of chiropractors, may at first seem more rational. They accept that some disease is caused by infection or other causes and they do not limit their practice to fixing subluxations. Most chiropractors in this group, however, do not supplement subluxation theory with scientific medicine, but rather with an eclectic array of pseudoscientific alternative practices. Mixers commonly prescribe homeopathic and herbal remedies, practice acupuncture and therapeutic touch, diagnose with iridology, contour analysis, and applied kinesiology, and adhere to the philosophy of naturopathy. This broad use of unproven, unscientific, and fanciful so-called “alternative” practices clearly indicates an antiscience attitude, as well as a lack of scientific knowledge, on the part of those chiropractors who employ them.

The rhetoric of Mixers indicates that they are attempting to become accepted into the scientific mainstream, rather than replace scientifically based medicine with a philosophy based approach. They no longer openly oppose immunization, like straights do, but they do advocate the freedom to choose whether or not to be immunized. Their appeal to freedom is emotionally effective, especially in the United States, but it fails to recognize that immunization is far less effective in eliminating or containing infectious diseases when it is not given to everyone. They also advocate a role for chiropractors as a primary care portal of entry system within HealthCare, despite the fact that they lack adequate training as generalists skilled in medical diagnosis.

A small minority of chiropractors, numbering only about 1,000, or 2% of all chiropractors (these are rough estimates because accurate figures are lacking), have been openly critical of their own field. They have called for absolute rejection of the subluxation theory of illness, disposing of pseudoscientific and unethical practices by chiropractors, and the restriction of chiropractic to treating acute musculoskeletal symptoms. They are attempting to bring their field into the scientific mainstream.

Occasionally chiropractic reformers have attempted to forge a new profession, entirely shedding the pseudoscience attached to the chiropractic brand. About ten years ago one group in Canada renamed themselves “Orthopractors,” and considered the new discipline of orthopractic as distinct from chiropractic. Orthopractic is the use of manipulation to provide symptomatic relief from uncomplicated acute back strain. They do not believe in maintenance therapy, treating medical ailments, or the use of pseudoscientific alternative practices.

Unfortunately, this reform effort died because “orthopractic” did not exist as a legal entity. This also partly explains why the “chiropractic” label persists and covers such a wide range of philosophy and practice - because it exists as a recognized licensed profession. It has a regulatory inertia that is hard to combat.

To further complicate things, spinal manipulation exists outside of the chiropractic profession, and not all manipulation is chiropractic manipulation. Some physiatrists, sports medicine doctors, and osteopaths legitimately employ manipulative therapy to relieve muscle strain, mobilize joints, and improve function. Chiropractors do this as well. But some chiropractors also do chiropractic manipulation designed to realign the spine and reduce imaginary chiropractic subluxations.

The Evidence - Subluxations

In the past 100 years, there has been very little research conducted into the basic principles of straight chiropractic. There is no research that indicates the existence of innate intelligence or that such a force plays any role in health and disease. Further, the evidence strongly suggests that chiropractic subluxations are a figment of the chiropractic imagination. And it also seems that spinal manipulation is not capable of realigning the vertebra of the spine.

A study carried out by Edmund Crelin, Ph.D. investigated the amount of force necessary to displace vertebral bones of the spine in order to cause impingement of a spinal nerve. The study was carried out on six corpses within 8 hours after death. His conclusion was that the amount of force necessary to actually displace the vertebra was great enough to break the spine, arguing strongly that chiropractic manipulation cannot significantly affect spinal alignment, and that misaligned spines do not caused pinched nerves (Crelin, 1973).

Pinched or impinged spinal nerves do occur, but they are caused by herniated discs, fractures, tumors, or overgrowth of the vertebral bones. When spinal nerves are impinged they cause pain, numbness, and tingling and may cause a decrease or loss of deep tendon reflexes and weakness of the muscles supplied by the affected nerve. Impinged nerves are not caused by subluxations nor do they result in diseases of the organs. Believers in subluxation theory must claim, implausibly, that nerve impingement causes only a blockage of innate intelligence without causing any of the known signs and symptoms of such impingement.

Ironically, spinal manipulation is contraindicated in cases of actual nerve impingement and should not be performed. In medical studies of manipulation, such as the RAND study, often cited by chiropractors as evidence for manipulation, spinal nerve impingement was considered a reason not to have manipulation and therefore was a criteria for exclusion from the study.

Another source of evidence that the chiropractic theory of subluxations and innate intelligence is completely false comes from the unfortunate victims of spinal trauma. There are many victims of complete transection, or disruption, of the cervical spinal cord in the neck. Such a complete injury leaves its victim quadraplegic, unable to move the arms or legs. If the injury is high enough in the spinal cord the victim may not even be able to breath on their own. In such victims no impulses from the brain are able to travel below the spinal cord in the neck, and therefore most of the communication between the brain and the body is interrupted. Certainly, this is a much more dramatic and complete interference of nerve flow than that of an impinged spinal nerve.

Yet, in these patients, the organs continue to work without difficulty and diseases do not develop at any higher rate than those without such an injury. Of course, there are some effects from the disruption of the autonomic nervous system, that part of the nervous system which regulates the bladder, the degree of bowel motility, and other functions. But all effects of spinal cord damage are caused by known neurological injury. If subluxation theory were correct, then patients with high spinal cord injuries would be ravaged by every conceivable disease.

So chiropractors cannot realign the spine to fix imaginary subluxations and restore the flow of nonexistent innate intelligence. Subluxation theory is pure pseudoscience, like homeopathy or therapeutic touch, and has no place in a 21st century scientific health care system.

Despite the extreme scientific implausibility of subluxation theory, specific applications have been tested with clinical research - with predictable results. For example, many chiropractors will use manipulation to treat asthma is children. The results of this research are soundly negative - chiropractic does not work on asthma.

Despite this many chiropractors persist in treating asthma. This led Simon Singh to write in the Guardian in 2008 that the British Chiropractic Association, which does advocate chiropractic for childhood asthma, “promotes bogus therapies.” In response to this statement the BCA notably did not provide the evidence that Singh claimed was missing. Rather, they sued him for libel (the case is ongoing).

Next week I will cover the evidence for musculoskeletal uses of chiropractic.

[Dr. Jim Herndon is a past president of the American Academy of Orthopaedic Surgeons, and chair emeritus of the department of orthopaedic surgery at Partners Healthcare]

***

The challenges of health care reform are enormous. To expect that the vast array of problems that exist today will be corrected or solved in a couple of months is totally unrealistic. Witness the moving target of announced changes and options occurring daily in the press and media in general. And add to the confusion…these changes are being developed at the top (Congress and the White House)…not from the bottom up (from doctors, nurses and other health care providers, and importantly, patients). In their place are the powerful lobbyists…the health insurance industry, the hospital industry, the drug industry and even organized medicine (AMA)…who wield their influence over our policy makers by all sorts of tangible (financial donations) and intangible (spouses of leaders on corporate boards) pressures.

I must admit, although occasionally said without real meaning…I don’t hear an outburst of support for the essential mission/purpose of health care…the health of our citizens…”the patient comes first”. Where is the patient…who is supposed to come first…in this national debate?

Everyone knows that health care is expensive. In 1970 health care spending consumed 7% of the Gross Domestic Product. In 2009 health care spending is consuming 16% or more of our Gross Domestic Product. It is increasing more rapidly than inflation. Yet, as a nation, we have not…in all these years…had a serious conversation about Americans’ health. Where is it in our list of priorities? I don’t think we know. From recent events we do know it is lower than the need to remove Saddam Hussein from power…it is lower than bailing out investment companies and banks…it is lower than stabilizing the mortgage market…and it is lower than bailing out two automobile manufacturers. I am not knowledgeable enough to question the priority of the bailouts of banks and financial institutions or the mortgage companies…but I do question the priority of removing another country’s dictator or bailing out two automobile manufacturers instead of allowing them to proceed through bankruptcy in our court system…over health care reform.

Too often in my lifetime I have seen the importance of health care reform pushed down the list of priorities over other needed programs…to wait for another day. How important is the patient, the health of Americans today? How far are we going to push the profession of medicine from “a calling”…a profession, as President Obama states to “a business”. It is known that patients trust their doctors, but not our health care system. When will patients begin to trust their own doctors less? It will happen if and when they believe doctors are more “concerned with the pulse of commerce” rather than the “pulse of their patients”. I submit we are getting very close to this tipping point…in losing the trust of our patients and society in general.

There is no unanimity of opinion regarding the health care reform debate…amongst Democrats, amongst Republication…amongst the public…amongst physicians in general…and orthopaedic surgeons specifically. I asked a few young physicians in an orthopaedic residency program their opinions about the health care reform debate. All believed that every American should have basic health care insurance coverage. Obvious to them, it would include coverage for care of patients with acute fractures or patients with severe pain or loss of function. They admit not knowing much about the “public option” and the swirling politics going on. They also were not comfortable with defining what situations or problems would not be covered by insurance…although they agreed that some restrictions above “basic care” would have to be implemented.

Their responses reminded me that in 1990, when I was in graduate school for an MBA…we had a class debate about whether health care was a right or not of all citizens? Although the discussion was lively and some felt health care was a privilege, the class conceded that health care was a right of all citizens…admitting historically it was considered a privilege for the few who could afford it, but then (1990 or earlier?) health care had become a right for all in the US. I then asked a few of my colleagues who enjoy leadership positions in the field of orthopaedic surgery their opinions regarding health care reform. They also could not agree on the issues of this debate.

One area where they did agree was that academic medical centers are not well positioned for the future…especially those that depend on state funding. We have already witnessed this in Massachusetts where apparently the state has decreased funding to some teaching hospitals that traditionally have cared for a large number of uninsured. Now that most citizens have insurance, they are seeking their care in other hospital emergency departments. My colleagues also agree that physicians will receive lower payments for specific treatments or participate in “bundled” payments to the entire healthcare team/facility for comprehensive care of the patient.

Otherwise my colleagues disagreed. On the one side some support the public option and universal coverage…although “the devil is in the details”. For this group they have become tired…like so many American physicians…with the convoluted way we finance health care and the associated paper trail/documentation overload. The system has made some patient conditions profitable and others not profitable…described by one as “perverted incentives”. These physicians (me included) are angry at the loss of our professionalism as hospitals and physicians chase dollars and not the health needs of each patient and the public. On the other side (against public option), my colleagues have some agreements…most orthopaedic surgeons are supportive of care of the uninsured and underinsured, especially for patients presenting with acute problems to hospitals’ emergency departments. Most also agree that there needs to be a serious realignment of incentives and improved collaboration of hospitals and doctors.

But they have many disagreements…including the provision of elective care. They argue…with good reasons…that with continued rising costs to practice medicine (rent, electronic records, employee wages and benefits, malpractice insurance, increased personnel requirements for the administration/paperwork overload) and continued reductions in reimbursement (Medicare, for example, pays an orthopaedic surgeon today approximately 50% of the reimbursement it paid for a total hip replacement in 1990)…it is becoming increasingly problematic to provide elective care for the underinsured and uninsured. They commonly ask…”How can you provide care that costs more than any receipts”?

Other disagreements include: the single payor system…they don’t believe it will work; although well-intended, they believe these reforms will result in overall lower quality of care for patients; that emergency departments will still be used by those with insurance because patients can see a physician at the patients’ convenience and avoid long delays to see a doctor in his/her office…for example there is a 40-day wait to see an orthopaedist in his/her office in Boston; the continued tremendous demands by American patients to have the latest technology, the latest treatment…even if evidence for its use is unknown; skepticism about the prevention of disorders that have a genetic basis, i.e. osteoarthritis…in the foreseeable future; the simple fact that to reduce errors and overuse/misuse of tests by an electronic medical record and computer physician-order system will cost enormous amounts of increased spending in the short term…before cost savings are eventually realized… and to draw attention to one specific unsolved problem area…Workers’ Compensation…where orthopaedists, daily, see ineffective treatments being used and large numbers of patients on disability.

Briefly, the follow are factors that have led to increased and inefficient health care in the US: high administrative costs; overuse of services and new technology; an increased prevalence of chronic disease; tremendous geographic variations in care; increased payments not resulting in improved quality; a continually high number of medical errors and complications; a broken professional liability system; a shift in costs from the uninsured to the insured; a predominant third-party payer system; overuse and misuse of care; focus changing from the patient to the pocketbook; insurance company abuses (cherry-picking healthy patients, denying care of patients with chronic disease, deliberately lowering the normal of “usual and customary” fees…to name a few); and continued issues of fraud and abuse, especially in the Medicare and Medicaid programs.

Finally I would like to close with the official position of the American Academy of Orthopaedic Surgeons (AAOS) on health care reform: “Any changes to the health care financing and delivery system…the well-being of the patient must be the highest priority. The AAOS strongly supports reform measures…that provide individuals with patient-centered, timely, unencumbered, affordable and appropriate health care and universal coverage while maintaining physicians as an integral component to providing the highest quality treatment”.

The AAOS is opposed to a single-payer health system or even a federal health care authority. The AAOS suggests “a number of tax initiatives…that will level the playing field and make health care coverage more affordable”. There should be “adoption of policies that restore equity and enhance market competition”. The AAOS also “strongly believes that patient empowerment and individual responsibility are necessary components of health care reform. Health choices should be recognized and preventive care should be promoted”.

“Community acquired” (that is, not acquired in the hospital, which would be “hospital acquired”) methicillin-resistant Staphylococcus aureus (MRSA) infections have not likely come about because germs that have evolved bacterial resistance by residing within hospitals have spread into the community. Rather, this bacterial resistance to methicillin appears to have arisen independently. The “community” now absolutely needs to be considered to include the outdoor community. Hikers, kayakers, divers, climbers and all other outdoors persons who share equipment or mingle with the general population are susceptible. From a reference entitled “Diagnosis MRSA - The Clinical Challenge of Multidrug-Resistant Infections,” authored by Peter DeBlieux and colleagues and published as a supplement to ACEP NEWS, comes some useful observations.

Skin and soft tissue infections are among the most common infections caused by bacteria that can develop resistance to bacteria. Persons at particular risk for such infections include males, certain geographies, time of year (during warmer months), and affliction with diabetes. Many of the infections are abscesses, in which there is a pus pocket that can be drained by making an incision. Such treatment is in fact important to help control the spread of MRSA infections, presumably by helping to cure the abscess(es).

The current thinking is that in the setting of an “uncomplicated” skin and soft tissue infection (e.g., no involvement of deep tissues, minor clinically: simple abscess, impetigo, pimple, or superficial cellulitis), incision and drainage of small, localized abscesses can be curative. However, this is not an absolute, so many physicians are of the opinion that adding an effective antibiotic is useful. Until we have more information, it remains the clinical judgment of the treating physician about whether or not to prescribe an effective antibiotic, such as trimethoprim-sulfamethoxazole.

In complicated infections, which involve deeper skin structures (such as infected tissue ulcers, rapidly progressive infections, diabetic foot infections involving MRSA), antibiotics are deemed to be essential. The oral antibiotics that are felt to be effective against MRSA are clindamycin, trimethoprim-sulfamethoxazole, doxycycline, minocycline, linezolid, and rifampin. The injectable antibiotics that are felt to be effective against MRSA are vancomycin, clindamycin, daptomycin, tigecycline, linezolid, and quinupristin-dalfopristin. Notably, the fluroquinolone category of drugs, which includes ciprofloxacin, is not recommended as an effective treatment for community acquired MRSA infection. The same holds true for the macrolide category, which includes erythromycin, as well as cephalexin, penicillin, and dicloxacillin.

To prevent the spread of MRSA, wounds should be kept covered with clean, dry bandages; hands washed with soap and water or an effective hand sanitizer after each dressing change; close contacts instructed to bathe regularly; no sharing be allowed of bedding, towels, washcloths, bar soap, razors, and so forth.

image courtesy of www.mrsatreatments.com

Canadians and their fans celebrated a great Canada Day (Fête Du Canada) at the Washington, DC embassy, July 1, 2009. Canada Day is America’s Fourth of July equivalent.

I enjoyed the barbeque, air puppets, kiddie tattoos, and a photo op with the RCMP (aka the “Mounties”).

God bless Canada… but please don’t bring their healthcare system here.

If you’re a Canadian (or someone who loves ‘em) check out the Canada Day party finder here.

Addendum: just added a bonus photo taken with a Blackberry - me horsing around.

Apparently, there are some legitimate reasons why a patient may lie to their physicians.

A recent article in the Los Angeles Times discusses the phenomenon, which as Dr. Gregory House would aptly summarize as, “Everyone lies.”

In fact, a recent survey suggests that “38% of respondents said they lied about following doctors’ orders and 32% about diet or exercise.”

One interesting reason is that patients are wary disclosing potentially damaging information to health insurance companies. Indeed, when patients apply for individual health insurance, their medical record is pulled up. And since trivial details can cause insurance companies to deny health coverage, patients certainly may have second thoughts about giving an accurate history.

Furthermore, “when processing a claim, the insurance company finds something in a patient’s records that contradicts something the patient said when purchasing the policy, the company can retroactively cancel the policy.”

That’s pretty harsh.

But making medical decisions on inaccurate information has consequences as well, including providing poor patient care.

One suggested option would be to maintain two sets of medical records, one that is shared with the insurance companies, and a private one that is not released to third parties. Some patient advocacy groups even go as far as saying, “If your physician won’t do that, it’s reason enough to leave the physician.”

I currently don’t offer such an option. I wonder how many other practices do.

When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.”  Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.

I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred.  Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.”  Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.”  The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine.  “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”

I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes.  Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement.  I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.

I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court.  Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion.  In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy.  This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.

In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change.   Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise.  Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births.  Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.

On the other hand, tort reform has resulted in major shifts in the physician workforce.  In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff.  The limit for a wrongful death case was set at 1.6 million dollars.  Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.

In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today.  I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with.  The time for reform is here, action appears inevitable, and the moment to speak out is now.

Until next week, I remain yours in primary care,

Steve Simmons, MD