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Latest Posts

Book Review: The First Step To Improve Health Care Is A Close Examination Of How It’s Delivered

My friend and former Chair of the CFAH Board of Trustees, Doug Kamerow, has written a book that I think you will like.

Besides being a mensch and witty as heck, Doug is a family doctor and a preventive medicine specialist.  In his new book, Dissecting American Health Care: Commentaries on Health Policy and Politics, these four characteristics constitute the lens through which he comments on scores of events, controversies and changes in public health and health policy that have taken place over the past four years. For example, Doug writes about last year’s debate over the H1N1 vaccine, the papal position on condoms and HIV, how prevention fared in the health care reform act (ACA) and his attempt to Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Waiting For Medical News That Could Change Your Life

That old Tom Petty song, “The Waiting is the Hardest Part,” keeps running through my mind. Four of my friends are waiting to hear the results of medical tests taken last week.

  • Lucas has exhausted all of the standard cancer therapies for rectal cancer and is waiting to hear if he is a candidate for any experimental treatments.
  • Sam, who has lived through aggressive treatment for multiple cancers, is waiting to hear results from a test that will tell him if the fact that he is so very, very sick is due to one of them recurring.
  • Lucy just had major abdominal surgery and is waiting to hear the results of the pathology report that will determine whether or not her cancer can be treated at all.
  • Phil, who has been in remission from two different leukemias, had Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Telehealth Services May Support Mass Exodus From Nursing Homes

Did you know that every nursing home resident in the U.S. must be asked every quarter whether she wants to go home, regardless of her health or mental status? And if she says yes, there is a local agency that must spring into action to make that happen.

This is the result of a 2010 Center for Medicaid/Medicare Services regulation aimed at helping keep older people in their (less expensive) homes rather than institutional settings. A New York Times article notes that the nursing home exodus, while modest to date, is building. This means the number of people with serious chronic conditions like congestive heart failure, diabetes and chronic obstructive pulmonary disease who draw heavily on community-based primary care services will grow.

These returnees are joining their peers and the blossoming crowd of us Baby Boomers who intend to resist living in nursing homes with as much spirit as our parents did, while the consequences of our plump and sedentary lifestyles arrange themselves into a constellation of diabetes, congestive heart failure and COPD similar to the one that plagues our elders.

Much has been written about Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Efforts To Improve Health Care Must Involve Patients

Here’s the bad news: We will not benefit from the health care services, drugs, tests and procedures available to us unless we pay attention, learn about our choices, interact with our clinicians and follow through on the plans we make together. And that “following through”part?  We have to work at doing that every day, whether we feel sick or well, energetic or tired out. And if we can’t do it, we’d best find a spouse or parent or friend or social service agency who can step in to do the things we can’t manage.

OK.  For some people, this is not bad news.  This is how we think it should be: “Nothing about me without me.” For others, our personal encounters with tests and treatments and illness have taught us that this is just the way it is.

But for many of us, this news – should we have reason to attend to it – is inconsistent with our idealized vision of health care that, tattered as its image might be, will step in, take over and fix what ails us. Most of us, after all, are mostly well most of the time and our exposure to health care is minimal.

Efforts to improve the effectiveness of health care and contain its cost have produced Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

The Rising Price Of Health Care: How Are People Dealing With The Expense?

A couple of weeks ago, I was asked to speak as a patient about “consumers and cost information” while being videotaped for use in the annual meeting of the Aligning Forces for Quality initiative funded by the Robert Wood Johnson Foundation.

RWJF Video - This Costs How Much?

I admire the aims of this initiative – “to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform” – and I think it has taught us some valuable lessons about what it takes to make even slight course corrections in the trajectory of the huge aircraft carrier that is health care.

Plus, I have listened to hundreds of people talk about their experiences with the rising price of health care: who thinks about it when and why, what individuals do to cut back on the expense, where they have been successful and where not. I’ve heard lots of stories, most of them involving Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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