Dr. Ian Gawler, a veterinarian, suffered from osteogenic sarcoma (a form of bone cancer) of the right leg when he was 24 in 1975. Treatment of the cancer required amputation of the right leg. After completing treatment he was found to have lumps in his groin. His oncologist at the time was confident this was local spread from the original cancer, which is highly aggressive. Gawler later developed lung and other lesions as well, and was given 6 months to live due to his metastatic disease.

Gawler decided to embark on an alternative treatment regimen, involving coffee enemas, a vegetarian diet, and meditation. Eventually he was completely cured of his terminal metastatic cancer. He has since become Australia’s most famous cancer survivor, promoting his alternative approach to cancer treatment, has published five books, and now runs the Gawler Foundation.

At least, that is the story he believes. There is one major problem with this medical tale, however – while the original cancer was confirmed by biopsy, the subsequent lesions were not. His oncologist at the time, Dr. John Doyle, assumed the new lesions were metastatic disease and never performed a biopsy. It was highly probable (more…)

*This blog post was originally published at Science-Based Medicine*

There are at least two conversations going on in the health care marketplace today, each focused on one of two key questions. One is: How can we achieve the Triple Aim? The other is: Why do they get to do that?  (It’s not fair! I want more!)

Until we stop asking the second question, we can’t answer the first question. Why? Because all too often the answer to the second question is the equivalent of: It’s OK, Timmy, I’ll buy you TWO lollipops; pick whichever ones you want.

It’s the tragedy of the commons, transposed to the health care marketplace.

Recent cases in point:

• Avastin
• Tufts Medical Center – Blue Cross Blue Shield of Massachusetts grudge match
• Mammography and PSA guidelines

1.    Avastin.  Late last year, (more…)

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

High blood sugars come in three different tiers for me:  No Big Deal (NBD), Tricky Little Sucker (TLS), and What The Eff (WTE).

No Big Deal (NBD) highs are the ones I see when I first hear the Dexcom BEEEEEEEP!ing.  They are the 180 – 240 mg/dL highs, where I’m cruising out of range, but not so far outside that it takes hours to correct.  The NBD highs are usually mild in their symptoms (kind of thirsty, sort of tired, maybe wouldn’t have noticed if the Dex hadn’t hollered) are thankfully short in their duration, so long as I’m on the ball about keeping tabs on my blood sugars.

Tricky Little Sucker (TLS) highs are obnoxious pieces of garbage that hang on for hours.  These highs are the ones where you hit anything over 200 mg/dL and just ride there for hours.  HOURS.  Like you can undecorate the Christmas tree and pack up all the holiday nonsense back into the attic and STILL find yourself rolling outside the threshold.  They’re the ones that (more…)

*This blog post was originally published at Six Until Me.*

The call never should have been made.

It broke every proscribed rule.

After all, I was not on call. Thanks to the wonders of computer technology, it was very clear that I was being covered by my colleague. And yet, despite this, it came.

“Dr. Fisher, I’m so sorry for calling you at home, but I received a call from Ms. X, the wife of your patient Mr. Y. who said she really needed to speak to you about her husband… she seemed quite concerned and insisted I call you…. I told her I’d see if I could reach you at home… I’m so sorry, but it sounded urgent… I have her number, could I connect you?” (more…)

*This blog post was originally published at Dr. Wes*

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, (more…)

*This blog post was originally published at Musings of a Dinosaur*

I’ve been using my iPad in the ED, with my white coat’s sewn-in iPad-sized pocket, for some time now — mostly for patient and resident education, and to look up dosages or rashes. Hitting up my Evernote database or Dropbox documents is also useful. Occasionally I’ll use my iPhone, for its LED light (when the otoscope can’t reach to where I need to see) or rarely, its camera (in compliance with my hospital and department photo policy, naturally).

Our ED’s EHR isn’t quite accessible enough via iPad for me to quickly check results or place orders at the bedside — right now it’s just too cumbersome. But there’s been progress — enough so that I start to wonder about the flip side: instead of reviewing iOS medical apps and pining for an optimized EHR experience on the iPad, what if there are features of the iPad that could limit the utility of medical apps?

Well, there are some product design issues, like impact resistance and bacterial colonization, that have been discussed. But the operating system, iOS 5, has some quirks, too. Some have received a lot of attention. Some are maddening in their capriciousness. (more…)

*This blog post was originally published at Blogborygmi*

“We’re Listed With the Plumbers Now”

Angie’s List can help you locate a reputable handyman. Yelp can push you in the direction of the perfect restaurant for your anniversary dinner. Amazon’s consumer reviews can even help you choose the TV that will fit in the corner of your den. So why wouldn’t you turn to the Internet to find your next doctor?

39-year-old Jennifer Stevens did just that when she needed an obstetrician for her first child. Not wanting to reveal her pregnancy too soon by asking friends for suggestions for a good OB, she turned to the Web for more information on potential physicians. She soon found that a lot of the information she needed to make this important decision was missing. “A lot of sites gave stars, but I didn’t really know what those stars meant. I just wasn’t comfortable picking an OB based on that kind of vague information,” she said.

Lindsay Luthe, a 30-year old Washington, D.C. resident, consulted the popular ratings website Yelp after asking her friends to recommend a physician. “I perused the reviews for this particular doctor and saw how positive they were. Those reviews, combined with my friend’s personal recommendation, led me to make an appointment with the doctor. I think I even used the contact info on the Yelp page to call the office,” she said.

The success of physician ratings websites—such as HealthGrades, or RateMyMD, among many others—has been mixed. (more…)

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

How Did My 2011 Predictions Turn Out?

Pretty well, actually.

As predicted last December, there was no big change to health care reform, doctors still didn’t have enough time with their patients, Microsoft (disclosure: Microsoft is a Best Doctors client) made moves to create a “Windows” for electronic health records, and “ACO” became the hot buzzword in health care.  Some state governments started major redesigns of their benefits programs, saving money in the same ways private sector employers do.  Meanwhile, more than ever, private sector employers are penalizing employees who don’t take care of themselves.

Misdiagnosis finally started to be recognized as a public health problem.  At Best Doctors we got a great deal of press coverage in 2011 on this (for a few examples, go here, here, here, here and here).  I will sneak in a 2012 prediction and tell you that you will hear a lot more about this this year, and not just from us.

What did I get wrong? (more…)

*This blog post was originally published at BestDoctors.com: See First Blog*

A hundred bucks doesn’t buy much these days. A crisp Ben Franklin can be exchanged for

• 50 Big Macs
• A Broadway show ticket
• A night in a New York City hotel (just joking)
• A college textbook (paperback)
• Your life

Your life? Yes, 5 crumpled Andy Jacksons can save your life, as was reported earlier this year in a front page article in The Plain Dealer, Cleveland’s only daily newspaper. University Hospital is now offering a $99 spiral computed tomography (CT scans) of the chest in individuals who are at increased risk of developing lung cancer. The rationale is that if cancers can be detected early, then the cure rate for surgical removal is very high.

Gary Schwitzer, medical blogger and press watchdog, tries to bring some balance to the distorted media coverage of CT lung cancer reportage.

The test is (more…)

*This blog post was originally published at MD Whistleblower*

Online resources for tummy tuck information suffer with a great deal of misconception. Even surgeons may disagree regarding choosing between different tummy tuck operations for a given patient. Reduced cost, pain and extent of surgery tend to push patients toward lesser surgery. These days “less invasive” is a popular selling point. As my practice has progressed, however, I have found the satisfaction rate of mini tummy tuck to be too low to support doing many of them. I do “minis” only in rare circumstances these days.

Mini tummy tuck surgery corrects much less than more involved full versions of the operation. If there is any significant looseness above the belly button, the mini will not address it much. If there is any more than a tiny bit of excess skin, the mini will not touch it much at all. The feeling of having been “under corrected” is common after mini tummy tuck surgery. If patients are unhappy with the results of a mini tummy tuck it is not always possible to (more…)

*This blog post was originally published at Truth in Cosmetic Surgery*