Archive for the ‘Blogfinger Medical Reports’ Category

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.”


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.


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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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CJUC on the Asbury Circle. All photos by Paul Goldfinger.©


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

Four years ago I wrote a piece about the increasing successes of urgent care centers, and, specifically, the Central Jersey Urgent Care at the Asbury Circle  (731 Rt. 35, Ocean Twp).  I was impressed with their focus on convenience and quality care and their determination to improve the possibilities for patients who are acutely ill. No one likes to go to an ER, and this is an excellent option for many kinds of situations.

Here two links to articles we have posted on this subject


Urgent care assessment 2014


Blogfinger 2015 post on walk-in health clinics


In 2014,  I spoke enthusiastically about the urgicenter concept and about the CJUC.    Now, the CJUC doctors are operating a total of six centers in this area.  Recently the Ocean unit expanded by 1,700 square feet and they have modernized that spacious location and have updated their procedures. Their main goals remain convenience and quality, and I continue to be impressed by the success of their operation.  As for convenience, they are about 10-15 minutes from Ocean Grove, and their records indicate that many Grovers go there.  You just walk-in; no appointment is needed.   All members of my immediate family including myself have received fine care at the CJUC.

Part of the waiting area at CJUC. 7/13/18 ©


Vikram Varma, MD,  collaborates with one of his advanced practice colleagues. He is the Medical Director of the Ocean facility.    Paul Goldfinger, MD photo. 7/13/18 © Blogfinger.net

Today I interviewed their Practice Manager Anthony Orzo and two of their physicians  and I learned of the progress they have made in the last 4 years.

The main theme for the physician directors of the CJUC  is to address many of the problems that patients now face in accessing healthcare, particularly urgent care, and then finding solutions to make the experience as excellent as possible. Here is a summary of what I learned:

a.  All their doctors are board certified ER physicians who work part time in hospital ER’s to maintain their acute care skills.  Today I met Chiraq Patel, MD and Vikram Varma MD. We spoke doctor to doctor, and  I was impressed with their desire to operate the finest urgicenter in the area and with their intense emphasis on quality. I found that they have examined their operation top to bottom to insure the best results.

b. The doctors now work with physician extenders, ie nurse practitioners and/or physician assistants.   When a patient enters their facility, a triage decision based on the complaint determines whether he will be initially evaluated by an “advanced practitioner” or by an MD. This team of two is always present and often collaborate on patient care. Generally the most worrisome cases go right to the doctor, but their advanced practitioners are instructed to consult with the physician if there is any concern.  If you wish, you can request an MD regardless of your complaint.

c. The facility is open from 8-8 every day of the year. Parking is easy. Leaving can be a bit of a challenge on the circle.   The staff is welcoming. The waiting area is divided so that potentially infectious patients are placed in one location. They will offer a mask if it is desired. If someone looks worrisome in the waiting area, they will bring them inside immediately. They try to expedite waiting times.

The recent renovation has produced 5 new examining rooms including one where they can offer treatments such as IV’s.  There is a welcoming pediatrics area with a colorful hand painted seashore scene on the wall  and a very efficient central operations station for personnel to interact and monitor care. It looks like one that you might find in a hospital.

d. The doctor enters a patient’s room with a “scribe” which enables him to focus totally on the patient instead of on a computer. The scribe deals with the computer and the written documentation of the visit.

e.  The staff is able to perform a variety of blood tests and other diagnostics such as a Strep throat and  HIV testing. They give vaccinations such as flu shots and they  do Xrays and ECG’s. The Xrays  are over-read within 2 hours by outside radiologists. You can get a physical exam, travel medical counseling, and pediatric care for 6 months and up.

f.  Although the CJUC doctors will not function as  your primary physician, you can go there for followup of issues that they initially saw you for.

g. The experience is much better than going to an ER, but if necessary, they will arrange to have a patient transported to the hospital. If you need a referral to a specialist, they will help you make that contact.

h.  The CJUC offers a phone app which lets you check on waiting times.  They also have a brilliant “membership plan” which offers a number of guaranteed visits outside of your insurance. As for the latter, they accept most insurance plans including Medicaid.  Their goal is to turn no one away.

On Sunday July 15, they will have an open house from noon to 4 pm, and the public is invited. There will be tours, food, face painting and giveaways. You can see the facility and meet the staff.  You will be impressed.

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Note the increased number of cases of hypertension if the 2017 cut-offs are used.


Paul Goldfinger, MD, FACC.  Editor @Blogfinger

Here is a link to our post last year about the new 2017 guidelines. This is the most recent information available in terms of guidelines for diagnosis and treatment.

2017 blood pressure guideline update on Blogfinger


In 2015 the SPRINT Trial appeared, but it provided more aggressive treatment than many doctors would accept.

And below is a link to the JNC 8 guidelines of 2013.

2013 JNC 8 blood pressure guidelines. Review in Blogfinger


For those of you with an active interest in the topic of hypertension, you would do well reviewing the BF posts linked above to appreciate that doctors may disagree about guidelines.

All these guidelines come together now in 2018 as doctors try to figure out what method is best and  how to resolve discrepant results.

Currently physicians are trying to come up with a lucid and uniform approach to diagnosing and treating hypertension. Below are some of our conclusions at the Blogfinger Off-Shore Medical School in Ocean Grove, NJ.

a. The 2017 guidelines found that following that cutoff (130/80) reduces risk of stroke  and cardiovascular complications if the target readings are achieved, but that can be difficult. We think that the 2017 guidelines, applied carefully to patient care, would be best.

But some major physician groups  (American College of Cardiology and the American Association of Family Practice) say that for those over age 60, this cutoff is too dangerous and for that group, the cutoff should be 150 mm Hg systolic.  But if the patient is high risk  (eg someone who has had a heart attack) a cutoff of 140 would be best.  They are using the 2013 JNC 8 recommendations.

b. Most medical groups have embraced the 2017 guidelines.

c. This is not a trivial issue because with the 2017 guidelines for diagnosis, 45% of the US population would be considered to be hypertensive.  But the more people who are placed on drug therapy, the more people will show up with complications such as hypotension (excessively low BP) which can result in falling  (with injuries,) dizzy spells, fainting, and kidney problems.

d. It seems to me that the 2017 guidelines make sense and will produce better outcomes than the less aggressive cutoffs that existed for many years.  Unless all the doctors get it together and agree, there will be a sort of free for-all with individual physicians deciding on their own. Hopefully the smoke will clear and most physicians will be on board.

But what is clear, and I suspect most doctors will agree, we do need to lower BP readings more than in the past, and we do need to diagnose hypertension at lower cutoffs than the past.

e.  Finally, patients should follow medical advice which should include preventive measures  (diet, weight, exercise, etc.) and usually medication.  Regarding the latter, oftentimes combination therapy of 2-4 different drugs may be required to achieve the desired cutoff. Such combinations allow individual drugs to be used at safer lower doses.

Hypertension is the “silent killer,” so follow good medical advice and participate in your care with home BP monitoring and adherence to medical regimens even if you feel fine.  That is the essence of prevention.

f.  Ask your doctor about his targeted plan for you.  Make sure that you are not a therapeutic failure.   Know your target reading and keep a written record.

And, to cheer you up, here is Jerry Seinfeld in the drugstore:

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Internet cartoon.


Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups. But some relief appears to be coming, as the AMA and joins forces with some payers to fix this broken process. Read more at AMA Wire®.

This quote is from the AMA Morning Rounds:  “Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,”

Blogfinger Medical Commentary:  Paul Goldfinger, MD, FACC

Some of you may have experienced rejection of a particular prescription drug by your drug plan. But such rejections typically get reversed by enlisting your doctor’s help, and that would require his time and that of his staff to deal with the insurance company.  The process is called “prior-authorization.”

In the article above, from the AMA, they discuss the problem from the perspective of the physician, but I have experienced it myself, from the perspective of the patient.

And, without a doubt, the episodes of prior authorization have increased noticeably for patients, but, as discussed above, also for the prescribing physician and his staff.

And now we see insurance companies questioning even cheap generics or chronically used stable medications,  and the issue isn’t always the drug choice itself.

For example, I recently ran into this situation related to my use of a high blood pressure medication that is perhaps the number one or number two choice prescribed by doctors for their patients with hypertension.

In my case, I was doing very nicely with two 5 mg. tablets each morning of that drug   (10 mg per day)—lisinopril, an ACE inhibitor. However recently my doctor wanted me to increase the dose from two tabs each day to two tabs twice per day  (20 mg per day), ie 4 tabs per day instead of 2.

So I would need 360 tabs per 90 days instead of 180 tabs per 90 days—-a perfectly reasonable dose change.    I was notified that they would not send me my medication because it required the prior authorization process.     Meanwhile I was running out of medications while the plan would try to get my doctor to respond.  And the drug plan was contacting me by mail and phone messages to raise the PA alarm.

I couldn’t understand why this innocuous dose change was a problem—it’s a cheap drug with a zero  copay.  I was baffled, so I called the company, but the customer service representative couldn’t figure out why prior authorization was being applied to my prescription.  She advised me to wait for the process to play out.  This was unacceptable.

I  thought about the problem, and it dawned on me that maybe the number of pills was the issue, and not the medication itself.

Maybe the problem was the 360 tablet requirement, every 90 days.   Being a physician I was able to call and  speak to a pharmacist at the mail order plan. He verified that the number of pills was the problem, not the dose.

So I asked if we could change the tablet size from 5 mg. to 10 mg, making the daily dose two tabs each day.  He said “fine” and a few days later I received 180 of the 10 mg tabs.

But the warning letters and phone messages continued.  Finally I called the “prior authorization” department and told her that I fixed the problem myself. And she said, “Oh, when you get the letters and phone calls just ignore them until the matter is fully resolved.”

The best resolution available for most patients is to make sure that your doctor’s office staff has done their job with the paper work. It might  be easier to resolve if you buy your meds from a local pharmacy.  If you have a mail order pharmacy, as I do, and you are running out of pills, one of the local pharmacies will help you get a temporary supply, assuming that the left hand and the right hand at your drug company can resolve the problem.




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cow s(2)

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

In a NY Times piece recently a young physician argued that experience in medicine is overrated and that smart young physicians, armed with technology, can do a better job in diagnosis and treatment than silver haired professors steeped in Hippocratic values.

In 2016, I posted a piece called “The Case of the Hypokalemic High Jumper.”  (link below)  It was a difficult situation where all the technology available could not produce a diagnosis, but a careful history taken at the bedside by a physician was all that was necessary.

The case of the hypokalemic high jumper

In the New Yorker cartoon above, an alert doctor took a good look and made the diagnosis.

In medical school, in the second year, we all took a course called “Physical Diagnosis.”  It taught us how to take a proper history—very detailed, but customized to suit the needs of an individual patient.  We also learned how to conduct a sensitive physical examination—how to feel a spleen, palpate a liver and listen to the heart and lungs—in fact how to accurately assess the whole body.  We were taught that such skills  have been used by physicians going  back to the Greeks  and that we could learn so much using those basic tools.

During my cardiology residency, we were trained to be meticulous in auscultating the heart  (ie listening with a stethoscope.) We used stethoscopes with 3 heads to help sort it all out.  We made recordings of heart sounds where we could measure intervals down to fractions of a second in order to figure out how narrow a heart valve might be.  It was a source of great pride to be able to use just our ears and minds to determine if someone needed heart surgery or not and then to help a medical student who couldn’t appreciate the subtleties of the cardiac examination.

But now, I am afraid that doctors are becoming too complacent in using technology to replace the traditional tools. These skills are still helpful in assembling all the pieces of a puzzle and then following the progress of the patient at the bedside or long term in the office.  I see doctors doing a poor job in taking a history, a process which has been replaced in large part by computer check lists.  Garbage in, garbage out.  And the same concern exists for the physical examination.

I was present when a patient went to a local ER with a painful, swollen knee. The Physician Assistant took a cursory history  (he had no idea that a real doctor was observing) and ordered an X Ray.  He did not properly examine the knee.   And he never bothered to review the patient’s medication list. He was functioning like a robot via an algorithm.  If he had done a proper history, he would have learned that the patient was on a blood thinner and might have a hemarthrosis  (bleeding into the knee.)  The problem was diagnosed with a proper history and physical exam by a careful physician and corrected by aspirating the joint with a needle and adjusting the medication.

Yes, the new technologies are remarkable, but each patient is different, and the physician must use all the tools available at his disposal including his eyes, head, ears and hands.  And, experience is perhaps the best tool of all.

RUFUS WAINWRIGHT   “Heartburn.”   This is a peculiar song, but it makes the point that doctors need to remember that psychological factors can mimic heart burn or something much more serious—like a derailed roller coaster.  A doctor must take a good history to pick up on this situation.

“Is this heartbreak or is this heartburn?
Can I be spared from being so dramatic?
Gotta learn the difference when I love ya
The difference when I love ya and that derailed roller-coaster”



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