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Paul Goldfinger, MD, FACC.  Editor@Blogfinger.net

In the 2011 edition of our book* on preventing heart disease, we have a section on particular foods such as nuts, chocolate, red wine, tea, coffee, salt, and eggs. Regarding the latter, this what we said then:

“The egg industry says that eating eggs is healthy, because eggs contain no fat and do not raise cholesterol blood levels. The American Heart Association disagrees, pointing out that each egg yolk contains 185 mg of cholesterol, and research trials have shown that eating cholesterol promotes heart disease, even if the cholesterol levels do not rise (Nutrition Action Healthletter, July 1997.)

“According to Jeremiah Stamler, a world expert on prevention, eggs do raise total and bad (LDL) cholesterol levels.”

“The AHA recommends that individuals eat no more than four egg yolks per week.  They also say that we should eat no more than 300 mg. of cholesterol from all sources each day.  Other experts advocate reducing egg intake to only one or two eggs per week (JAMA 4/21/99)”

In the 1990’s, at Dover General Medical Center (NJ) where I worked, one of our gastroenterologists, who was a gentleman egg farmer, loudly asserted that eggs posed no risks despite their cholesterol content. He stressed that eggs have no fats in them, so he brought eggs to the hospital frequently, peddling them in the coronary care unit.

Then in 2013, the British Medical Journal came up with a study that found no risk with one egg per day.  So the pendulum was swinging.

Now, in the Journal of the American Medical Association, an impressive study appears looking at 30,000 individuals over 17 years.  They found that there was an increased risk of death, stroke and cardiovascular diseases associated with eating eggs.  They suggested that eating even 3-4 eggs per week is bad.  But the study is subject to criticism of its methodology.

I can conclude that our egg intake should be limited to some extent, perhaps no more than 4 per week, but the verdict is still not in despite this JAMA article which looked at a large number of people and their dietary habits and heart disease risks.

Here is a link to a prior  (2016)related post on Blogfinger, and in that post is another link.

eggs and health 2016

And here is an excellent short video from a physician at McGill University.  This doctor is brilliant in his assessment of the situation:

CAST OF OLIVER:

 

* prevention-does-work

 

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American sponsors of the 2017 hypertension guidelines.

 

By Paul Goldfinger, MD, FACC  and Editor  @Blogfinger.net

Part III: Who Cares?

Almost all doctors believe in treating hypertension, but how many will be enthused about following the new guidelines?  We’re talking about the American Heart Association/ American College of Cardiology 2017 guidelines for the diagnosis and treatment of high blood pressure.

If you were a doctor, would you spend hours going through piles of hypertension guidelines, looking at all the intricate details, and trying to resolve the controversies? Or would you just do whatever it is that you normally do to treat the most common cause of death in the US ?

And even if a physician were trying to wade into the weeds and trying to figure all this out, he might emerge confused, because in the end, he will have to use his best judgement. Guidelines are supposed to provide consistency not controversy.  But when it comes to hypertension, knowledge has been evolving since the 19th century when a device to measure blood pressure was invented.

I have hypertension and I keep my finger on the pulse of advances in cardiology. My own cardiologist is an eminent and respected doctor in this area. But he is fairly conservative, and when I press him about the new guidelines, he usually falls back on his own judgement which doesn’t try to push too hard on drugs. Last time I saw him, it appeared that he was beginning to adopt the new American guidelines, yet he didn’t change my treatment, although he might have. He was going to take his time figuring out how to use the new guidelines.

But my biggest concern is that not only will physicians pay little attention to the guidelines, but probably half of their patients with high blood pressure are not under good control.

However, in the new world of medical practice in America, we have new ways to practice, and that involves mid-level practitioners such as physician assistants and nurse practitioners. Also we have electronic medical records and fabulous new technologies to help accomplish our goals. And there is a welcomed trend to use home BP measurements to guide diagnosis and treatment.

The new corporate style of practice involves a team approach to try and improve the track record in hypertension. And when a patient is put into the hands of such “teams,” those teams will be forced to use the latest guidelines, taking it out of the hands of doctors.

And we know that perhaps up to 800 entities such as the Mayo Clinic, the Cleveland Clinic, Summit Medical Group, Monmouth Cardiology, etc. across the country have already established this new approach, and more will jump on the bandwagon.

Then, it is hoped that the success rates of hypertension care will become much better. But I am also suspicious of corporate motives in such circumstances. Insurance companies, healthcare entities, and Big Pharma are interested in this topic.

I am skeptical of turning over the care of our patients to corporate managers, mid-level teams, and one-size-fits-all algorithms. It is a recipe for reduced quality of care, failure to properly evaluate patients, and higher risk of complications.

I would be more enthused if the system were returned to the control of physicians.

So, having expressed that concern, we will proceed with the nitty-gritty of providing successful care for the millions of hypertensives in America. Watch for Part IV.

 

DIANA KRALL  from her album Turn Up the Quiet

 

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Reuters reports that a study suggests “more babies could be born with heart defects in the future as global warming puts pregnant women at greater risk of exposure to dangerously high temperatures.”   Currently, “congenital heart defects affect about 40,000 births per year.” The research was published in the Journal of the American Heart Association.

From the authors of the study:   “The burden of congenital heart defects (CHD) across the United States may increase as a result of climate change.” 

“As global temperatures continue to rise, more intense, frequent, and longer‐lasting heat events are expected.12 Significant gaps remain in understanding the potential impact of climate change on maternal heat exposures and the associated CHD burden.”

“In conclusion, our findings reveal a potential nationwide increase in future maternal heat exposure in the United States.”

 

Dr. Dianne Atkins, Professor of Pediatrics at the University of Iowa in Iowa City, cautions that “the data from the study is preliminary and is based only on estimates.”

“We cannot be certain that heat exposure will increase the risk of congenital heart disease, but it would be prudent for women to avoid becoming overheated during the early weeks of pregnancy,” Atkins, who was not involved in the study, told Reuters Health by email.

 

The author of this paper, not an MD, is a Professor of Public Health at the University of Albany, and he concluded by saying, “Although this study is preliminary, it would be prudent for women in the early weeks of pregnancy to avoid heat extremes similar to the advice given to persons with cardiovascular and pulmonary disease during heat spells.”

Blogfinger medical commentary:   Paul Goldfinger, MD, FACC

This “research” is mostly speculation, not science.  The American Heart Association published this study in their Journal of the American Heart Association.  Nothing here is certain including the projections due to global warming. I’m surprised they accepted this paper without an editorial explaining their decision. 

A medical journal like this one should be a holy temple of medical science and not a place to camouflage speculation and political correctness as health science.  This paper belongs in a journal of public health or environmental science where torturing statistics and speculation might be more at home.

There is no doubt that excessively high temperatures should be avoided by pregnant women, but the same is true for patients with heart disease, lung disease, and any  elderly person.  As for global warming, that topic should have been barely mentioned and not emphasized.

The AHA should keep its focus on clinical medicine and what can be done to help physicians keep our people safe through evidence based research.

Allowing political correctness to creep into their work is a mistake and will erode the confidence of physicians and patients.

 

CRAIG OGDEN   “Cavatina”   from the Deer Hunter

 

 

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This topic is currently caught up in a tangle of controversies and guideline wars.

 

British Medical Journal. 2012.

 

By Paul Goldfinger, M.D., F.A.C.C. Board Certified cardiologist/internist, Editor of Blogfinger.net, and Dean of the Blogfinger Offshore School of Medicine in Ocean Grove, NJ.  Closed on Sunday mornings until noon.  



PART I: WHAT ARE THE ISSUES?

 

We wrote a series of this type before, but there are some important issues to discuss now based on changes of guidelines for the diagnosis and treatment of high blood pressure, i.e. hypertension.

Hypertension is a condition which threatens huge numbers of people around the world. The prevalence among adults in the U.S. used to be quoted as 32%, but since the new guidelines came out with new definitions, the number is now estimated to be 46%. And that number goes up with age, so that 76% is the prevalence in adults ages 65-74; and rises to 82% in ages 75 and older.

The measurement of BP is obtained using an electronic device—a sphygmomanometer. 120/80 is the classic normal, but even that is controversial. The top number is called the systolic, while the bottom is diastolic. If either number or both is consistently elevated, then a diagnosis of hypertension is obtained. But there are different degrees of severity, and the risks of the disease go up as the numbers go up.

What is clear is that bringing the blood pressure to normal will reduce the risk of devastating vascular problems such as heart attack, heart failure and stroke.

Where the guidelines differ is in the cutoffs for making the diagnosis of hypertension, cutoffs for choosing various therapeutic approaches, and cutoffs having to with target readings when therapy is established.

But the world-wide healthcare establishment has yet to agree about how to correctly diagnose and treat hypertension. And the matter has other ramifications:

a. Many people with the disease have no idea that they have a problem

b. Of those who have been diagnosed and treated, a large percent have failed to reach desirable BP goals. And many who know that they have a problem are in a state of denial and do not go for evaluation or they receive inadequate followup, or they do not reliably and correctly take their medication.

In addition, physicians often fail to deal with hypertension properly, as defined by guidelines.  In fact, some doctors ignore guidelines altogether, deciding their approach based on instinct and ignorance.

I have always thought that guidelines were a great idea since most doctors don’t have time to read all the research, so why not take the advice of experts?   But there is a caveat: The doctor-patient relationship must be preserved, and the physician must be allowed flexibility in his decisions.  However, if guidelines become inviolable laws, then doctors will rebel, and quality care will decline. In medicine, one size does not fit all.

c. There currently is a war of sorts, between the Americans and the Europeans regarding guidelines which determine how to diagnose and treat this important disease. No, it’s not like the D-Day invasion, but it is bad enough that both sides have published their own guidelines: the Americans in 2017 and the Europeans (let’s include Australia in this group) in 2018.

For years, the National Institutes of Health took on the task of issuing hypertension guidelines in the form of the Joint National Commission reports. The last time they did so  (JNC8) was in 2014, but then, probably for political reasons, they retreated to their Bethesda headquarters, turning the job over to a combined committee from the American Heart Association and the American College of Cardiology (disclosure: I am a “Fellow” of both organizations.)  And the Europeans have the European Society of Cardiology and the European Society of Hypertension.

To tell the truth, I not only prefer their croissants, their wine, and their beachwear, but I also prefer their hypertension guidelines. However we will get into that later.

d . And why can’t they totally agree? It’s because there have been hundreds of credible research trials on the subject done around the world, many recently, and because there are some philosophical differences between the two sides.  And because medicine is a mixture of art and science, and no matter how much doctors try to practice “evidence based” medicine, there always is room for good judgement, style, and experience. 

And don’t forget the incursions into medical practice by the bottom-line oriented health corporations, government, “Big  Pharm,”  and insurance companies;  and by many physicians themselves who have been coerced into leaving private practice to become puppets of their employers—large hospital “health” systems.  

Along the way, some of these doctors have compromised their standards in exchange for less stress, less administrative duties, more time off, and more cookbook medicine that can torture and break the traditional doctor- patient relationship.  And the growing use of physician extenders to replace doctors introduces perhaps more efficiency and more money,  but, in my opinion, greater chances for mistakes in patient care.  As the hypertension guidelines become more complex, the involvement of physicians gets less.

I’m going to try to penetrate the layers of complexity of all this for you . You would be surprised if you knew how deep those layers go. 

 Feel free to comment by looking down and finding the comments button.

See you soon for Part II (I hope I can remember my Roman numerals.)

 

THE MARVELOUS WONDERETTES.   And if you think that medicine and music don’t mix, just walk into an OR sometime during major surgery.

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The Blogfinger cow says, “Eat more chicken.”

Blogfinger team of investigative reporters and fact checkers says that reports of methane gas from American cows poisoning the environment are fake news. Blame the Chinese cows.   Blogfinger photograph. ©

The AP (1/17, Choi) says a new report from nutrition, agriculture and environmental experts “recommends a plant-based diet, based on previously published studies that have linked red meat to increased risk of health problems.” The recommendation also “comes amid recent studies of how eating habits affect the environment,” as the production of red meat “takes up land and feed to raise cattle, which also emit the greenhouse gas methane.” The diet, organized by Stockholm-based nonprofit EAT, “says red meat consumption on average needs to be slashed by half globally” and “encourages whole grains, beans, fruits and most vegetables.”

Reuters (1/16, Kelland) reports that if the world followed the recommended diet, researchers said “more than 11 million premature deaths could be prevented each year, while greenhouse gas emissions would be cut and more land, water and biodiversity would be preserved.” Tim Lang, a professor at Britain’s University of London who co-led the research, said, “The food we eat and how we produce it determines the health of people and the planet, and we are currently getting this seriously wrong.”

Blogfinger medical report by Paul Goldfinger, MD, FACC, Dean of the Blogfinger Off-shore Medical School based in Ocean Grove, New Jersey.

Overall, this recommended diet encourages whole grains, beans, fruits and most vegetables, and says to limit added sugars, refined grains such as white rice and starches like potatoes and cassava.  Click on links above for more details.

This article is just another in a long series of medical dietary news going back over 60 years advocating reducing red meats in our diets and increasing fruits and veggies.  A more recent, but also not very new, component is to reduce carbs and lose weight.

And, as for the food-fashion vocabulary, the following words are not found in these articles: “fiber, kale, gluten-free, or quinoa.”

Now we find “plant-based,” “food systems,” “whole grain,” “greenhouse gas methane,” “production of red meat,” and “legumes.”

Overall, the American public has already reduced its intake of saturated fats.

Eileen and I wrote about nutrition/prevention in our book which is actually still available on Amazon:  Prevention Does Work.

This book, like its authors, has aged a bit, but most of it still applies.  The science of prevention evolves slowly.  Eileen’s 36 recipes are still delicious, easy to prepare, and healthy.  Just go to Amazon and type “Paul Goldfinger, MD.’

This current AMA report basically says the same things, quoting from the Lancet,  except it is much stricter with its dietary recommendations.  But the science behind this latest “news” is rather mushy.    The best bet is not to become a vegan, because then your diet becomes impossible to maintain as well as very boring.  Instead, the Mediterranean diet still seems the best choice.

The other “hook” in the current pronouncement is to link healthy diets to concerns about the environment.  It reminds me of the NY Times which, these days, finds it necessary to politicize everything including sports, sex, health, and food.

Here’s a related link from Blogfinger:

Diet resolve for New Year on Blogfinger

And don’t forget exercise as we try to prevent heart disease:

SHE AND HIM:  Take a walk; something good will come from that:

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By Alex Merto, NY Times, to illustrate this article below.

By Alex Merto, NY Times, to illustrate this article below.

By Paul Goldfinger, MD, FACC.    (I wrote this piece in 2014 but it could have been written yesterday.)

Since 2014, the damage being done to quality care is becoming much more clear.  By now most of you have gotten a taste of what the ACA has wrought. Yet there has been no discernible public outcry, but just speak privately to nurses, doctors and patients.

I do realize that as long as patients have insurance, they will put up with almost anything.

When someone I know was recently (2018)  in a horrible car crash and wound up at Jersey Shore hospital with serious injuries, he was tended to by a “trauma team” but no physician saw him until the next day;  and mistakes were made.

Here is the 2014 post:

In our Blogfinger series about the Affordable Care Act, I said that practice guidelines without flexibility for physicians to make individual decisions for patients would compromise quality. But since the details of how medicine would be practiced under the ACA was not available, I predicted that once care was actually provided under the new system, we would begin to see the worrisome truth.

Now, in an opinion piece published yesterday  (2014) in the New York Times*, and written by two doctors from the Harvard Medical School faculty, we find out that “financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks, and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctors decisions.”

This quote (above) is from the article written by Drs. Pamela Hartzband and Jerome Groopman, both well known authors on the subject of what’s right in the care of patients.

When I was learning to become a competent practicing physician, I was taught that patients should be viewed as individuals. In fact, it is those individual differences that make the practice of medicine so fascinating and demanding. For example, consider hypertension (high blood pressure.) Between the different causes, complicating factors, various manifestations, and the myriad of drug combinations and interactions, each patient poses a unique challenge.

High blood pressure, a extremely common condition, cannot possibly be reduced to guidelines that are suitable for the group as a whole. Doctors must be able to treat each case individually, and, their professionalism must be trusted to make the right decisions. What is the point of spending about 10 years of one’s life becoming a doctor if bureaucrats turn the profession into a mindless field governed by mandatory robotic rules, financial priorities, and staffed by unsupervised non-physicians?

It is now becoming apparent that the new health plan is providing regulations and incentives that compromise the doctor-patient relationship. Physicians have a moral imperative to place the patient’s best interests first. That is one of the prime values for the practice of medicine. But to adhere to that imperative is becoming more difficult.

The cat is now out of the bag.  The public must pay heed  to what their doctors are saying about this situation.  My own doctors, almost uniformly, say to me, “You got out just in time.”  Many have become employees of large corporations.

According to Drs. Groopman and Hartzband, “The power now belongs, not to physicians, but to insurers and regulators that control payment”   In other words, the bottom line is becoming the top line.

To help patients understand what conflicts of interest may be occurring in their care, the authors say, “We propose a …..public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.”

The Times opinion piece concludes by saying, “Medical care is not just another marketplace commodity.  Physicians should never have an incentive to override  the best interest of their patients.”

NYTimes article    *

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Lollypops can do it. Amazon music photo.
Lollypops can do it. Amazon music photo.

By Paul Goldfinger, MD, FACC.   Editor@Blogfinger.net and Dean of the Blogfinger Off-Shore School of Medicine in Ocean Grove, NJ.
There is a song called “My Heart Goes Pitter Patter” recorded by Simone and Girlfunkle. There is another (below) by Bia, a young singer from Brazil whose song is “My Heart Goes La La La.”

BIA:

Rod Stewart has a tune called “Rhythm of My Heart”, while Etta Jones sings “There Goes my Heart” (below)

I know a cardiologist whose heart goes pitter patter every time he drinks coffee.   The symptom is due to extra heart beats (premature contractions) which give that sensation.

If the heart is stimulated, it might react with a fast beat or an erratic beat. The stimulation can be due to intense emotions including love.  Brain related causes result in adrenaline release and activation of the sympathetic nervous system—ie the “flight or fight” reaction; or the stimulation might be due to certain substances such as caffeine, prescription drugs, cocaine, or alcohol.   The effects on the heart may be perceived by the patient or may be “silent.”

A violinist came to see me because, before she would go on stage, she would experience tremors in her hands, sweaty palms,  and palpitations due to “stage-fright.” a typical emotions-based cause of such symptoms.   Other brain related causes of adrenalin release symptoms include fear, anger, severe stress, sudden surprise, threats, and battle.  As for love,–if would have to be pretty intense.

The violinist was successfully treated by blocking the effects of adrenaline using a drug called a “beta blocker” which the musician could take as needed, prior to a concert. The drug would not adversely affect the performance as might a tranquilizer, but would enhance it by removing the fear factor.

The cardiac responses to stimulation do not necessarily indicate heart disease.    It can happen to healthy individuals. But if you have palpitations, a visit to a cardiologist would be wise. He can order a take-home monitor which can record your electrocardiogram (ECG) when your heart goes pitter patter and it will also make a recording if you have a rhythm disturbance (arrhythmia) without symptoms. In either case, the doctor will be able to see what kind of arrhythmia is causing the symptoms, and then a decision can be made regarding what to do about it.

But no doctor will advise giving up love.

ETTTA JONES:

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Hollywood, Ca. Resistant gonorrhea antibiotic bacteria represent the biggest current threat. There is now only one antibiotic left which is toxic to gonorrhea  (“GC”) bacteria.

 

 

New cases of chlamydia, gonorrhea and syphilis rose sharply for the fourth consecutive year in 2017, to a record high of nearly 2.3 million, according to new data from the Centers for Disease Control and Prevention.

The United States “continues to have the highest STD rates in the industrialized world,” said David Harvey, executive director of the National Coalition of STD Directors.

Bloomberg News (8/28, Edney) reports there was “a record number of cases of sexually transmitted diseases in 2017, marking the fourth straight year of sharp increases in gonorrhea, syphilis and chlamydia, according to preliminary data from the Centers for Disease Control and Prevention.” The CDC also warned that the growing prevalence of antibiotic-resistant gonorrhea is a contributing factor to the increase.

NBC News (8/28, Carroll) reports on its website that according to the CDC, there were “nearly 2.3 million cases of chlamydia, gonorrhea and syphilis were diagnosed in the U.S. in 2017, surpassing the record set in 2016 by more than 200,000.” The article adds that “less frequent condom use” may be the greatest contributing factor.

The New York Times (8/28, Zraick) reports that there is no “single reason for the increase in sexually transmitted diseases.” Public health officials point to “deteriorating public health services, like S.T.D. testing clinics,” in addition to the opioid epidemic, “as users engage in unsafe practices.”

 

Blogfinger Medical Opinion.  Paul Goldfinger, MD, FACC

One important factor in this issue is that condoms are being used less often.  That is partially because of the advent of HIV prevention drugs.

Another problem is that the infrastructure for preventing STD’s is declining across the country.  These three articles lay out all the facts.  Note that most of these infections are in men, but the numbers are on the rise in women as well.  Dating services have also been blamed, but there is no data on this.

Gonorrhea used to be the scourge of soldiers and sailors.  They called it “the clap,” but one shot of penicillin would cure it but not so now.  There now is an urgent need to develop new antibiotics for that STD.

From the NYT:     “Many cases go undiagnosed, and the diseases can cause serious problems down the line, including infertility and increased H.I.V. risk.

“Most people with these S.T.D.s do not know they are infected,” said Dr. Gail Bolan, director of the C.D.C.’s division of sexually transmitted disease prevention. “They don’t realize that these diseases are spreading silently through the country.”

Syphilis could kill people, but after penicillin was developed in the 1940’s, doctors became unfamiliar with the condition.  I saw some cases in the 1960’s.  Primary syphilis caused a lesion on the genitalia or the lips,  but secondary and tertiary forms could cause sterility, abortion, blindness, rash, brain damage and mother to child transmission.  And the advanced form may be difficult to diagnose.

All of these conditions can be present without any symptoms, so prevention methods and testing can help with diagnosis.  There are tests available to make the diagnosis of STD’s using blood, urine and some other methods.

If you have young people in your family who may be sexually active, have a talk about this or give them our link.

 

 

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Dissecting aneurysm of the aorta. Internet image.

Dissecting aneurysm of the aorta. Internet image.

By Paul Goldfinger, MD, FACC  (Re-post from 2014 on Blogfinger.net)

The simple answer is yes, and it often has to do with fear of harming a patient either through what we do to treat a disease or through missing a diagnosis.

A basic tenet of medical practice is, “First do no harm.”   During my career I thought of that warning many times, because a physician is often tempted to do something that might be risky. Oftentimes that concern is more than balanced by the potential to help a patient—-even to save their lives.

I think that certain diagnoses also strike fear into the hearts of doctors.  In my years as a cardiologist, the condition which worried me the most was dissecting aneurysm of the aorta. This is a life threatening emergency which usually affects men, ages 60-70, but anyone could be a victim. The aorta is the large blood vessel that leaves the heart to carry oxygen-rich blood all over the body and especially to vital organs such as the brain and heart.  A tear develops in the aorta, for a variety of reasons, and the wall of this large artery begins to split apart lengthwise and may even rupture. The condition usually develops suddenly and evolves quickly,  resulting in high mortality rates.

Aside from the obvious risk of such a catastrophe, one of the fearful  elements of it for the physician is that the signs and symptoms can be varied and difficult to figure out, and the chance of survival improves when treatment is initiated as soon as possible.   For example it can mimic a heart attack or a stroke.   Very often it produces excruciating mid or upper back pain, and whenever I would get a call from the ER about someone with such pain, a knot in my stomach would quickly develop. Oftentimes the varied presentation of a dissecting aneurysm would fool the doctor and send him down the wrong path.  My greatest fear was to miss the diagnosis.

Occasionally this dangerous condition would present with no pain at all—-just other symptoms like nausea or sweating or shock. I recall one patient whose sole initial symptom was fainting accompanied by a very slow pulse, initially causing us to misunderstand the situation.

If a doctor experiences fear, it is often alleviated by the certainty of  experience, knowledge, a correct diagnosis, and a hopeful treatment plan.

Another source of fear is when the doctor is involved in a surgical procedure which goes wrong. But experienced  surgeons often don’t have fear during such situations because they are trained professionals who react reflexly to correct a problem. I worked with a surgeon at Dover  (NJ) General Hospital  and Medical Center who had been in a front line surgical unit in Viet Nam. There was nothing that would scare him.

The best defense against fear is competence  and character,  and that is why a solid education during medical school and during post-graduate training at quality institutions is so important and why patients need to look at their doctors’ credentials.

Gen. George Patton said, “All men are afraid in battle. The coward is the one who lets his fear overcome his sense of duty. Duty is the essence of manhood .”  

And so it is for physicians who must put aside their fear and go ahead and protect their patients.

As for dissecting aneurysm, new diagnostic imaging methods and new treatments now available, including non-surgical approaches, provide reassurance for the doctor and the patient during this dangerous problem.

 

CARTER BURWELL   “The Deer”  from the movie “3 Billboards Outside Ebbing, Missouri.”

 

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Keep an eye on that “team” connection between doctor and patient. Don’t assume that it is working.

 

By Paul Goldfinger, MD, FACC.   Editor @Blogfinger

Several years ago I  predicted on Blogfinger  that the doctor-patient relationship and quality care would be compromised by the new medical system.  I turned out to be right, but I never imagined what is happening now, and the public is totally clueless.

Corporate entities such as Hackensack-Meridian have introduced a new way to practice medicine, and one of the core strategies is to carve out physicians from the dynamics of patient care.  This divide and conquer approach, called “team based medical care”  has succeeded in changing everything, and you, if you haven’t  noticed it, will get a shock when you do.

Here is an true example.  A man  (let’s call him X) is in a terrible car crash and is taken to the Emergency area at (Hackensack-Meridian) Jersey Shore University Medical Center.  He is sent to the Trauma ER where his care is turned over to the Trauma Team.  But that team has no physician in a hands-on role.  During this patient’s hours spent in the trauma area of the ER and later in the Trauma ICU, no physician came in to see him.

A variety of members of the team came around including medical assistants and  physician assistants but no doctor.  As a result the diagnosis of pelvic damage was delayed by hours, and that is a serious mistake.    It was simply missed by the team, each of which had certain tasks, but no one actually took charge and explained anything of substance to the patient or the family.   There was no physician involved.

About 7 hours after arrival, a man in a white coat arrives in the ICU and says that he is the “physician assistant” for the orthopedic trauma surgeon  on the team.  He tells the patient/family that the lower body CT scan reveals a broken pelvis.   Why was that CT result not mentioned hours before?  Which team member missed it?   The P.A. tells the family that surgery is scheduled for the next morning.  He explains the diagnosis and the surgery; it’s a scary problem.    But why doesn’t the doctor show up to discuss the diagnosis and treatment of such a serious problem?

The next morning the surgeon shows up just before wheeling X to the OR.  He speaks to the family and the patient. The surgery takes 3 hours and involves screws and steel plates.

A similar pattern of fragmented care is evident post-op.   The surgeon doesn’t make rounds—only “the team.”      There are no serious complications, and a few days later, X is transferred to a sub-acute rehabilitation center where similar communication issues develop, and physicians are missing  in a team approach.    As a result, a significant problem is missed.  Eventually the surgeon gets involved, and only then is the correct diagnosis made.

According to the AMA, “Team-based care is a strategic redistribution of work among members of a practice team. In the model, all members of the physician-led team play an integral role in providing patient care. The physician (or in some circumstances a nurse practitioner or physician assistant) and a team of nurses and/or medical assistants (MAs) share responsibilities for better patient care.”   But in our sample case, the “physician led” element was AWOL.

Healthcare planners associated with large corporations  like H-M love to talk like this, because they save money while providing, they say, more efficient, higher quality  and less expensive care,  but they don’t understand how medicine is traditionally  practiced:  tried and true methods with the patient at the center of a medical situation and with a physician engaged with the patient and  integrating all aspects of the case—just the opposite of what these team members did.  I do not trust those corporate types to place the patient first, and that is central to Hippocrates’ and Maimonides’ values for doctors.

Many doctors like this approach because it takes considerable pressure off them, reducing burnout, but I fear that it will allow all sorts of errors to fall between the cracks, as occurred in our sample case above. Physicians need to insist that they not be replaced by “mid-level” practitioners who think that they are as good as physicians. Such physician helpers need to be just that, and their name tags should say so.

Such examples of a broken system in a  hospital, at an inpatient sub-acute rehab center, and in an office-based setting must be identified and fixed.

When you are interacting with medical environments that use the “team based care” approach, keep your eyes peeled for mistakes, missed details, absent physicians, and over-emphasis on physician extenders who do not receive appropriate oversight.  Be skeptical and ask questions to be sure that all details are covered.  You may not be a doctor, but you may have enough common sense to actually identify a real problem.   I know that some institutions such as the Mayo Clinic have achieved success with this approach, but don’t assume anything at your local provider.

Below is a quote from an AMA article about physician led team based care:

“Physicians should maintain authority for patient care in any team care arrangement to assure patient safety and quality of care, since the ultimate responsibility for each individual patient’s medical care rests with the physician. In addition, physicians must be responsible and have authority for initiating and implementing quality-control programs for non-physicians delivering medical care in team-based practices.”

 

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