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Archive for the ‘Medical topics by Paul Goldfinger’ Category

Blue, but not broken hearted: A medical mystery

Posted in Medical topics, Medical topics by Paul Goldfinger, tagged on February 4, 2023| 4 Comments »

 

“Blue Angel. ”  Still image by Paul Goldfinger from the movie Marco Polo.

 

By Paul Goldfinger, MD, FACC

 

Cyanosis: a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

 

The patient was a middle aged woman who worked in the bank on Blackwell Street in Dover,  New Jersey, where I had recently opened my practice.   People began to notice a change in her appearance: she had developed a bluish discoloration of her skin. Each day it became worse and worse until her friends and family became alarmed. Everyone was amazed that she had no symptoms other than the striking blue face which was looking at her in the mirror. Finally she called her family physician.

I got a call about the case from her doctor, a kindly older man who smoked cigarettes in his office and dropped ashes on his vest. “Paul” he said, “I want you to see this lady who’s turning blue.”

I was shocked by the call. Middle aged females don’t just turn blue out of the blue. I could see why he might want a cardiologist, but how could his patient have a heart condition when she felt fine?

She came to the ER at Dover General Hospital where I met her. She was indeed cyanotic, but the cause was not obvious. I admitted her to the hospital where it became clear that she had neither heart disease or lung disease—the two leading causes of cyanosis. Those were the days when you could admit a patient to the hospital “for tests.”

All the tests were negative, so I decided to go back to basics—an old fashioned approach: a meticulous detailed history was required.

As I was going over all the particulars again, she mentioned something that she hadn’t disclosed when I first met her: she was being treated for a urinary tract infection. When I looked up her medication, I discovered that her pyridium could cause a change in her blood hemoglobin to produce a compound called methemoglobin. So instead of red blood, her blood was turning blue.

Eureka! The lab ran a methemoglobin level on her blood , and we had the diagnosis: methemoglobinemia—the first and last case I ever saw.

We stopped that medication and we kept her in the hospital, and each day, when I made rounds, I became more and more relieved—she was turning light blue: lighter and lighter each day.

Finally I became confident enough to tell her that she was cured; and I sang her a few bars of the chorus to this song: (performed here by Ethel Waters in 1929)

 

ETHEL WATERS.  “Am I Blue?”

 

 

 

 

 

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When Doctors Are No Longer in Charge of Healthcare…

Posted in Blogfinger Presents, Healthcare Topics @Blogfinger, Medical topics, Medical topics by Paul Goldfinger, tagged , , on September 17, 2022| 12 Comments »

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This letter appeared in the New York Times on February 5, 2014  from a physician who is concerned about the loss of traditional medical practice ethics:

To the Editor:  2014 

Recent accusations against the for-profit hospital chain Health Management Associates (“Hospital Chain Said to Scheme to Inflate Bills,” front page, Jan. 24), including that it put pressure on doctors to admit patients to increase profits, demonstrate the destructive power of the corporatization of medicine on the practice of medicine. The ethical base is lost when businesspeople take over and destroy the traditions of medical practice. Hospital Corporation of America, the nation’s largest for-profit hospital chain, is under investigation for similar practices.

Leaders of corporate America care little about the credo that established medicine as a noble profession, operated not for profitability but for the good of the patients. Sadly, doctors within the corporate system who have opposed fraudulent and illegal practices designed to maximize profitability are punished and terminated. Meanwhile, the white-collar criminal behavior of corporate executives is not adequately punished.

Such practices have a corrosive effect on independent doctors as well. This leads many to game the system and find loopholes to maximize profits. Costs soar. Hospitals and medical schools are often complicit.

Many decent doctors deplore the changes in health care delivery systems that foster such abuses. But I find it hard to be heard when I speak of accountability. I call on our current and next generation of medical school graduates to have the vision and courage to take back the leadership of medicine and restore its right to be considered a noble profession.

HOWARD A. CORWIN

Naples, Fla., Feb. 3, 2014

The writer was a clinical professor of psychiatry at Tufts University School of Medicine.

 

Medical Commentary by Paul Goldfinger, MD,  FACC,  in reply to Dr. Corwin’s letter above:

I think we must agree that medicine, a “noble profession,” has not been totally squeaky-clean when it comes to putting financial gain ahead of the best interests of patients. But Dr Corwin is certainly correct when he claims that the medical profession, for the most part, has lived up to its credo to always put the best interests of patients first.

Of course there are exceptions, but somehow, without an actual ruling body, doctors have usually done what’s right, and it is a source of pride to those of us who are physicians that we adhere to long-standing traditions regarding ethics, and most doctors can be trusted to honor their traditional priorities.

But, in my experience, financial conflicts of interest due to the fee-for-service system cause an ethical tug of war for some doctors, and such ethical failings have been going on for a long time including fee splitting which I saw when I first entered private practice.

Insurance companies are part of the problem in the other direction because they make more money by trying to withhold care. And  patients are also sometimes complicit because they don’t worry about such “abuses” as long as they are not paying directly.

Dr. Corwin is correct when he puts his finger on recent corporate practices that attempt to require doctors to churn services such as when employee-physicians are pressured to admit more patients just to increase the numbers. If healthcare allocation decisions are put into the hands of bureaucrats or corporate managers, the financial bottom line will be the guiding touchstone for practice policies.

Whatever ethical shortcomings might exist among doctors, they can be dealt with in a new healthcare system, but, as I have repeatedly said, doctors need to be in charge of patient-care decisions.

 

September 2023.  At Blogfinger we were all over this topic when it first appeared on the scene nearly 10 years ago.  We raised warning flags regarding  quality issues under Obamacare.

And we revisited these topics in our Sept. 2, 2023 article:

Are doctors disappearing from healthcare by Paul Goldfinger

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New York Times: “How Medical Care is Being Corrupted”

Posted in Blogfinger Medical Reports, Blogfinger Presents, Blogfinger's Opinions, Medical topics by Paul Goldfinger, tagged on January 11, 2019| 9 Comments »

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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National public awareness campaign launches for prediabetes

Posted in Blogfinger Medical Reports, Blogfinger Presents, FACC, Medical topics by Paul Goldfinger, Medical topics by Paul Goldfinger MD on Blogfinger, tagged on January 25, 2016| 2 Comments »

Good Morning Dr. Paul Goldfinger. Here are today's top stories.Friday, January 22, 2016

Good Morning Dr. Paul Goldfinger. Here are today’s top stories. Friday, January 22, 2016

Fasting blood sugar chart

Fasting blood sugar chart

CBS News reports on a public service ad campaign to encourage people to be checked for prediabetes launched by the American Medical Association, the American Diabetes Association, the Centers for Disease Control and Prevention, and the Ad Council.

HealthDay (1/21,)  reports the message of the campaign is “no one is excused from diabetes.” It also includes “a short online test at DoIHavePrediabetes.org.” that “can also be taken through texts and interactive TV and radio announcements.” The CDC issued a news release announcing the campaign, in which AMA President-Elect Dr. Andrew W. Gurman, MD, said, “As soon as someone discovers they may be at risk of prediabetes, they should talk with their physician about further testing to confirm their diagnosis and discuss the necessary lifestyle changes needed to help prevent type 2 diabetes.”

MedPage Today (1/21, ) reports that Dr. Gurman explained the reason for the campaign: “There are 86 million people in this country who have prediabetes, and 90% don’t know it,” adding, “we need to do something to make people aware of this condition and its risk.” The AMA is also seeking to raise awareness among physicians, “because they may have lots of people coming into their office and saying, ‘I just took the prediabetes test and I think I have it,’” said Gurman.

Blogfinger medical commentary:  By Paul Goldfinger, MD, FACC.

This public service ad campaign is about “prediabetes,” the latest medical issue to strike fear into the hearts of the public. Above, a doctor calls this a “diagnosis.”  Another calls it a “condition.”  But they are all careful not to call prediabetes a “disease.”  It actually is a state of awareness where early detection can result in a prevention program to reduce the risk of  type II diabetes.     In fact, 15-30% of prediabetics eventually get type II diabetes.

Prediabetes  is a name given to a borderline abnormal blood test coupled with the threat that the abnormality will give rise to overt diabetes and to heart disease.Those who are at highest risk of having prediabetes are obese, sedentary, hypertensive males, age 40-60, with a positive family history of diabetes.   The PR buildup will include a massive barrage of ads on TV, internet, doctors offices and elsewhere which will scare people with what amounts to a real concern, but it is not actually a disease, making this PR campaign somewhat unusual.   Maybe it is like the campaign to take BP readings in dental offices or shoe stores.  That way you can identify those with borderline high blood pressure readings who are not quite hypertensive—-ie prehypertensive.

In fact prediabetes has no symptoms, no physical findings, no medicines to take,  and no clear endpoint for therapeutic success except for a normalization of blood sugar levels.  It is really an idea about preventing a disease, diabetes, which can cause death and disability.  Prediabetes, a circumstance that can be found in millions of people,  is certainly a situation worth your attention.  So let’s put it into perspective.

There is type I  diabetes (insulin dependent) and the much more common, but less serious,  type II  (non-insulin dependent or “maturity onset” diabetes.)    The main worry with diabetes is generally not the elevated blood sugar levels (although that could become a problem; ) it is the risk of vascular complications including heart attack, kidney failure, stroke, blindness or amputation. Treating prediabetes is supposed to reduce the risk of clinical diabetes–type II.

The diagnosis of prediabetes is made with blood tests that measure blood sugar levels in a few different ways.  The best test is the A1C  (aka glycohemoglobin test) which averages blood sugar levels over time instead of in a snapshot as occurs with the fasting blood sugar test.  Normal A1C is less than 5.7%; prediabetes is 5.7-6.4% and diabetes is over 6.5%.

If you are said to have “prediabetes,” the usual recommendations include preventive measures which you  would want to do anyhow.  Number one is weight reduction.   Then comes exercise and specific dietary advice.  Control of all cardiac risk factors would be advisable also including BP control, stop smoking, cholesterol treatment, stress reduction, etc.

The Joslin Diabetes Center ( www.joslin.org/info/what_is_pre_diabetes.html  )   at Harvard Med. School says that weight reduction is the most important preventive measure.  They say that calorie reduction is more important than sugar intake. Below is their simple dietary advice if you have prediabetes, but it is good advice for anyone:

—-eating more foods that are broiled and fewer foods that are fried.

—-cutting back on the amount of butter you use in cooking.

—-eating fish and chicken more, and only lean cuts of beef.

—-eating more meatless meals, or re-orienting your meals so that your dinner plate has more vegetables, fruit and starches on it, and less meat.

This is what they say at Joslin, “The solution isn’t “avoid foods with sugar in them.” Rather, you need to lose weight if you are overweight, cut back on portion sizes, and plan for those occasions when you eat a small piece of cake or pie.”

So the latest celebrity disease is upon us, and the treatment is the same as what prevention minded docs have been advocating right along, but another dose of awareness and education could wake up a lot of future diabetics.

 

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Eating out or eating in? Blogfinger medical report:

Posted in Blogfinger Medical Reports, Medical topics by Paul Goldfinger, tagged on December 13, 2015| Leave a Comment »

Cravebits.com

Cravebits.com

 

Click to read the small print.

Click to read the small print.

From MarketWatch.com:

“Down to your last belt loop and your last penny? These seemingly unrelated phenomena may have more in common than you think, a new survey shows.

“Dining out is the No. 1 thing that Americans blow their budgets on, according to the Principal Financial Group’s annual Financial Well Being Index, which will be released Wednesday (Market Watch got an early look at the data). The company surveyed more than 1,100 employed American adults.

‘Those restaurant meals are also adding to our growing waistlines: On days when people dine out, they tend to consume 200 more calories than when they eat at home, according to a study of more than 12,500 people published by Public Health Nutrition last year, and government research shows that “when eating out, people either eat more or eat higher calorie foods — or both — and that this tendency appears to be increasing.” Other studies show that eating out more frequently is associated with obesity and higher body fat.”

And the problem is getting worse. While 22% of Americans blew their budgets on dining out in 2014, this year, 24% did so.

In the Huffington Post a few years ago, Mark Hyman, MD wrote a fascinating piece which is very important.  Here is an excerpt and a link:

“Research shows that children who have regular meals with their parents do better in every way, from better grades, to healthier relationships, to staying out of trouble. They are 42 percent less likely to drink, 50 percent less likely to smoke and 66 percent less like to smoke marijuana. Regular family dinners protect girls from bulimia, anorexia, and diet pills. Family dinners also reduce the incidence of childhood obesity. In a study on household routines and obesity in U.S. preschool-aged children, it was shown that kids as young as four have a lower risk of obesity if they eat regular family dinners, have enough sleep, and don’t watch TV on weekdays.”

http://www.huffingtonpost.com/dr-mark-hyman/family-dinner-how_b_806114.html

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

For the first time, data reveals that Americans spend more money on eating out than they do at  grocery stores.  Processed foods and restaurant foods tend to contain more salt, fat, and sugar than you might think.  The food industry plays up the addictive properties of certain ingredients including sugar, salt and fat.     Eating at home brings more fresh fruits and vegetables as well as low fat proteins and less calories to the table.

The issue is not only calories, which goes to the obesity issue, but it also involves prevention from cardiovascular disease, strokes, high blood pressure, cancer and diabetes.  In our book Prevention Does Work: A Guide to a Healthy Heart, we go over every nutrition issue that we could think of including good/bad fats, coffee, chocolate, nuts, salt, statins and many others.

In addition, for you modern men and women who don’t know how to cook, Eileen provides 36 easy-to-prepare evidence- based original recipes with an emphasis on seafood, and it’s all about home cooking.  You young families should try to eat most  of your meals at home, for a variety of reasons.

Our book is an inexpensive way to get on a better nutritional road. Don’t rely on unsubstantiated Internet claims.  We provide the scientific evidence  in a way that you can understand.

Go to Barnes and Noble and type Paul Goldfinger, MD.  They have it for $12.95 in paperback.  It is also on Amazon.com.

Good diets, exercise, good music, low stress, and a good lifestyle will help keep you young.  Here is Frank Sinatra who would have been 100 yesterday, joining Charles Aznavour with another way to feel young:

 

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Documenting a deteriorating healthcare system.

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics by Paul Goldfinger, tagged on October 6, 2015| 3 Comments »

Internet graphic

Internet graphic

Paul Goldfinger, MD, FACC.   Editor @Blogfinger.

Some of you have berated me for having a negative attitude regarding Obamacare. The truth is that many good things will come out of our new healthcare, but I am alarmed by the negatives which continue to slowly drip out the cracks and insinuate themselves seemingly overnight and unannounced into our experiences with doctors, hospitals, drug companies, etc.   I am concerned that the negatives will outweigh the positives and cause damage to our loved ones as they seek care.

So I will have an ongoing project to report on pluses and minuses as they occur. Here are two that appeared on my radar screen this week. Since I am no longer practicing medicine, I go by the experiences of family, friends and myself. Yes it is anecdotal but I also keep watch on the media, especially when clinical trials look at these matters, when doctors speak about the situation, and by watching the AMA reports which I receive regularly.  Hopefully some of you will share your observations.

Here are my recent findings.   It may not seem like much, but cumulatively, there may  be substance, and I do believe that smoke might indicate a fire.

#1. A man approached the front desk at a surgeon’s office. He asked that the surgeon’s report be sent to his doctor. He was told that he would have to pay $15.00 for that service.

Whenever a specialist sees a patient, it is his obligation to send a consultation report to the primary doctor. Ideally he should also call the referring physician. I believe that communication of this type is deteriorating because of the expectation that electronic medical records will fill that void, but they won’t because they are lacking in specificity, and when our society allows time-honored individualized medical practices to fall by the wayside in the interest of time and money, quality will suffer.

Patients should request copies of their consultation notes and they should read those notes carefully.   They should find a history, physical exam, test results, a diagnosis and a narrative discussion/analysis, with an individualized plan, regarding the problem;  and no one should be charged for those reports.

#2. A doctor orders a blood test for a patient. He orders it, not on a whim, but because it is needed for proper patient care. The patient goes to the lab and is informed that the insurance company may not pay for the test. He is required to sign a form to indicate that he may have to pay personally.

Subsequently he receives a bill for $115.00 from LabCorps for that routine test. Evidently the diagnostic codes supplied by the doctor did not justify the test.   The patient complained to the doctor’s office and asked that the bill be resubmitted by the doctor for consideration, using “better” codes. The office tells the patient that this is not the doctor’s problem. Ouch!

Sorry, but this is the doctor’s problem, and he should help so the patient doesn’t get stuck with the bill. This is an example of interference in the practice of medicine by insurance companies  and indifference on the part of the doctor.

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“Small dose of exercise” may be sufficient to improve many aspects of thinking in seniors

Posted in Blogfinger Presents, Medical topics by Paul Goldfinger, tagged on September 1, 2015| 1 Comment »

newest ama

Internet illustration

Internet illustration

The New York Times (8/12, Reynolds) “Well” blog reported that a study published last month in PLoS One suggests that “overall, ‘a small dose of exercise’ may be sufficient to improve many aspects of thinking, and more sweat may not provide noticeably more cognitive benefit,” although it will improve aerobic fitness. The study of “101 sedentary older adults, at least 65 years of age,” revealed that “briskly walking for 20 or 25 minutes several times a week” appeared to be enough to help keep “brains sharp as the years pass.”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

There have been so many studies about the value of excercise, that I have come to the conclusion that this therapeutic modality exceeds every other that is advocated to prevent all sorts of medical problems.

Whenever exercise is used for prevention, such as in cardiology, the mechanisms are never clearly elucidated. But all doctors and most people in general believe in the benefits of exercise.   At a basic common sense level, it makes sense. Our bodies are so complex and with so many moving parts that it seems logical that “use it or lose it” is a reasonable mantra.

I recall other studies in the past that I raised my eyebrows over when they said that even small doses of exercise can be helpful, but I see now that it is  likely to be true. You can benefit even if all you do is take a walk. Exercise makes the heart work harder and increases blood flow throughout the body, and from an evolutionary point of view, it makes sense that more blood is good for survival of the fittest, even if the fittest only get up from their computers and walk around the block.

The effects on the brain, as noted in this trial, are fascinating and believable although I don’t know why.  Here  is what we said about exercise in our book  (2011):   front cover

Exercise: Physical inactivity is associated with increased risk for coronary disease (CHD) and is considered a major risk factor. Increased physical activity results in  a reduced risk for CHD.  Advantages of exercise include a lower risk of diabetes, less tendency for blood to clot, improved lipids including higher HDL levels, improved sleep patterns, and reduced anxiety and depression. Other benefits reported include reduced colon cancer, reduced gallstones, reduced arthritis symptoms, lower blood pressure, less prostate enlargement and less osteoporosis (weak bones in the elderly).

A regular aerobic exercise program is a necessary adjunct to a good diet. It is very difficult to lose weight without exercise, but don’t be discouraged if the weight loss is slow. Exercise does not burn a lot of calories. Walking or running a mile will burn only about 100 calories, but exercise improves fitness and thus allows you to do more exercise and burn more calories. Also, the calories that are burned are more likely to be from fat than from carbohydrates, and the ability to keep weight off after losing is easier with regular exercise.

The amount of exercise necessary is controversial; however, a brisk walk 4-5 times per week can offer some protection. In the Nurses Health Study from Harvard, women who regularly engage in brisk walking reduced their risk of heart disease to the same degree as women who engaged in vigorous exercise. Some studies suggest that strenuous efforts are probably better.

An exercise prescription based on your heart rate is a good technique for judging how hard to exercise and your doctor can give you advice about this. Pulse monitors, (e.g. by Polar at polarusa.com or FitBit) are available in sporting goods stores. If you are healthy, you can get a fitness evaluation at the local YMCA and receive advice regarding an exercise program, or, if there were concerns about coronary risk, then a formal exercise stress test ordered by your physician would be appropriate. The Centers for Disease Control suggests that people should get at least 30 minutes of moderate activity on most, or preferably all, days of the week.

If someone has underlying heart disease, vigorous physical exercise can be risky, especially if the patient is not accustomed to regular exercise. Sometimes people who have no awareness that they have heart trouble can be at risk for complications during exercise. Individuals with heart disease or who are at risk for heart disease should speak to their doctors before engaging in strenuous forms of exercise. According to Barry Maron, MD, an expert on the subject of cardiac events during exercise, “The balance of the evidence supports the value and importance of participation in regular exercise regimens (NEJM.11/9/2000).”

THE SOLITAIRES:

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Blogfinger Medical Report: Walk-in health clinics growing in popularity. Where the medical profession is failing, alternate providers rush into the vacuum.

Posted in Blogfinger Presents, Medical topics, Medical topics by Paul Goldfinger, tagged on May 8, 2015| Leave a Comment »

AMA new banner

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McClatchy (5/8, Pugh) reports that a growing number of “walk-in health clinics, with late-night and weekend hours, on-site prescription drugs and cheaper prices, are proving a hit with busy patients who’ve grown tired of getting medical treatment when it’s most convenient for doctors.”

Walk-in clinics include the more than 1,900 retail health clinics and 6,400 urgent care centers nationwide. McClatchy adds that with “a national shortage of doctors, higher rates of chronic illness and more people with health insurance under the Affordable Care Act, it’s no surprise that walk-in clinics are booming.”:

Blogfinger report from May, 2014:   Blogfinger report on urgent care centers

Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC

During my earlier reporting on the Affordable Care Act, I pointed out that there will be a shortage of primary care doctors as well as other healthcare providers such as nurses. Now that many people have health insurance that didn’t have it before, doctors’ offices as well as other providers such as ER’s are having trouble stemming the tide.

Patients are finding that quality is sometimes being compromised because of these shortages..  In addition, many patients still don’t have a doctor.  They are called “the medically homeless.”

If you try to reach your doctor, you often find that barriers have been erected to discourage your contact with the physician.  Poorly trained individuals often screen your calls into the office, and you may not even get a call back. If you are sick, you may be told that there are no openings—period!   Sometimes you are greeted with a recording that tells you to go to an ER if you are having a genuine medical emergency.   Many physicians are becoming salaried employees of big hospital corporations, and that causes a myriad of changes and issues regarding availabity and quality.

Patients crave the way that they used to be the top priority at the doctor’s office whereas now, efficiency, cost cutting,  and electronic records are at the top of the priority list.  Patients  want “patient first consumerism.”

At first I was unsure how things would evolve regarding shortages, but now it is obvious  that a flood of urgent care centers and “retail clinics” are moving into the vacuum, and patents are happy with the results. I’ve become frustrated myself with access and quality issues in physician offices, and I don’t hesitate to go to an urgent care center.

But urgent care centers are not well suited to following patients with chronic conditions or serious medical matters.  For that you need a regular doctor who is the “quarterback” of your care.    But the urgent care centers are great for so many health issues that are common and not life threatening.  Also, I would suggest that patients be sure that an actual physician will see them when they seek help at such a facility.

What remains to be seen in the future is how these facilities  rate when quality parameters are assessed.  Initial reports are hopeful.

Carol Rizzo of OG, an expert on healthcare, often helps us out with our discussions on new health care models, and she provides us with the link below where the CEO of Kaiser Permanente lists 5 concepts regarding the future of US healthcare. I suggest you all read it.

link to future of US healthcare

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Advisory panel considers changing recommendations on cholesterol

Posted in Blogfinger Medical Reports, Blogfinger Presents, Medical opinions by a physician, Medical topics, Medical topics by Paul Goldfinger, tagged on February 16, 2015| Leave a Comment »

AMA new bannerACC

The Blond Pharmacist

The Blond Pharmacist

Scott Pelley reported in the CBS Evening News (2/10) that according to the Dietary Guidelines Advisory Committee, a government advisory panel, “we don’t have to worry so much after all about cholesterol in our diets.”

 

Dr. Jon Lapook noted that while “the amount of cholesterol in your blood is still important,” the panel found that “the amount of cholesterol in your food doesn’t necessarily translate to a higher level of cholesterol in your blood.”

 

While the current recommendations “say people should have less than 300 milligrams of cholesterol in their diet a day,” that number is “likely to change when the recommendations come out later this year.” Linsey Davis noted on ABC World News (2/10, ) that while the panel said that “eating some foods that are high in cholesterol like eggs and seafood may not be so bad after all,” foods like “meats and cheeses, because they contain saturated fats, are still on the list.”

 

The Washington Post (2/11)  reported in its “Wonkblog” blog that this “does not reverse warnings about high levels of ‘bad’ cholesterol in the blood, which have been linked to heart disease,” adding that “some experts warned that people with particular health problems, such as diabetes, should continue to avoid cholesterol-rich diets.”

 

The blog stated that “a group from the American Heart Association and the American College of Cardiology who looked at the issue in 2013 said there is simply not enough evidence of danger to call for limiting cholesterol in diets.”
USA Today (2/11, ) reports that “the committee will send its final recommendations to the Department of Health and Human Services and the U.S. Department of Agriculture, which issue the dietary advice.” HHS and the USDA “are expected to issue Dietary Guidelines for Americans, 2015 later this year.”

 

The AP (2/11, Jalonick) reports, however, that “it’s unclear if the recommendation will make it into the final guidelines.”

 

Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC

The cholesterol story began in the 1960’s when it was found that high blood cholesterol levels were associated with heart disease. But we also found out that dietary cholesterol does not increase blood levels of “bad” cholesterol, unlike lab models where heavy intake of cholesterol leads to plaque formation.

When it came to dietary advice, early on in the cholesterol era, most experts favored diets low in saturated fats without stressing cholesterol so much.  In our book, in the chapter called “Concepts: Cholesterol Risks and Treatment,” we did not even mention dietary cholesterol. As it turns out, many foods that are high in fats, such as red meats, are also high in cholesterol. But eggs, rich in yolk cholesterol, contain no fats and do not raise blood cholesterol.

What hasn’t changed is the fact that lowering bad blood cholesterol levels does save lives, but restricting dietary cholesterol is not the way to do it.

As time went by, we learned that even severe dietary fat restriction often doesn’t lower bad cholesterol levels enough to produce a clinical benefit, and that has led the prevention community to stress Mediterranean style diets which we discuss in depth in Prevention Does Work: A Guide to a Healthy Heart by Eileen and myself.

If the guidelines change, as described above, I don’t think it will make much of a difference in what people do or doctors advise. Maybe there will be a loosening of restrictions on eggs, lobsters or shrimp, but otherwise, not much change.

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Aging population raises issues for outpatient procedures.

Posted in Blogfinger Medical Reports, Medical topics by Paul Goldfinger, tagged , on September 12, 2014| 1 Comment »

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Bloomberg News (9/12, Langreth, Gilblom) reports that the death of Joan Rivers during an undisclosed procedure has centered attention on aging population seeking care at ambulatory care facilities. Anesthesiology experts say such “centers generally need to go out of their way to identify pre-existing conditions in patients because some facilities may not have all of the emergency equipment a hospital would.” Beverly Philip, professor at Harvard Medical School said that since older people are generally more frail and there is a need to re-evaluate “the suitability” of these individuals “for minor outpatient procedures at centers” that lack full array of equipment for responding to medical emergencies

BLOGFINGER MEDICAL COMMENTARY:  Paul Goldfinger, MD, FACC

There is not enough information out there about the Joan Rivers case to draw any specific conclusions now, but a death during an outpatient”minor” procedure is very rare.  The Rivers case is being investigated—not because it is she, but because any such incident would be investigated.

We don’t know if there were any unusual  specific problems in this one case.  We do know that this particular outpatient center had anesthesiologists present. The Bloomberg News article  (link above)  is quite good, but it emphasizes the importance of having certain “equipment” on hand for emergencies. Surely any facility that would give anesthesia to a person over 80, especially with a history of medical issues, must have had appropriate emergency equipment.

So the investigation would have to look at the check list results for this patient during the pre-op assessment. Were there any warning signs in her history or physical exam and/or were any corners cut or mistakes made during  her assessment and during the procedure?

If she had laryngospasm, (larynx spasm)  then an anesthesiologist should be able to solve that problem.

I think that anyone with a cardiac history should be carefully considered for having their procedure done at the hospital, even if it is a more annoying preop. assessment.  To say that the equipment is the same at both kinds of facilities  does not mean that the safety is the same.  If someone has a cardiac arrest in the hospital, the cavalry  arrives in less than one minute including cardiologists.  That won’t happen at an outpatient center where only the EMT unit arrives.

Also, the article says that there is a 4 minute window without oxygen before brain damage occurs, but that window is actually much smaller in an elderly person.

 

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Do you care about urgent care? You should.

Posted in Medical topics, Medical topics by Paul Goldfinger, tagged , on May 2, 2014| 7 Comments »

Central Jersey Urgent Care

Central Jersey Urgent Care

By Paul Goldfinger, MD, FACC  (Editor @Blogfinger)

You may have noticed urgent care centers in strip malls around the state. These facilities, which specialize in treating non-life- threatening ailments such as minor accidents, flu, rashes etc., are increasing in numbers around the country and will play a significant roll in the new healthcare system. They already are an important cog in healthcare in countries like England, Israel, New Zealand and Canada.

The idea first developed in the 1970’s in the U.S.. We had one in Morris County (Budd Lake) which was run by ER doctors and ER RNs. At first they didn’t do so well because their roll in the delivery of healthcare was unclear, and some insurance companies wouldn’t reimburse their care. But the prospects for urgent care facilities have brightened in recent years, with over 10,000 across the country, and 64 in New Jersey.   There is now a specialty of Urgent Care Medicine, and many new centers open each year.

With an impending shortage of family doctors and increased numbers of insured patients, the urgent care centers are looking good as a practical  offering on the medical buffet table. Did you ever get sick, such as with a pain in the abdomen, and wonder where you should go to be evaluated?  Most of us would rather walk on fire than go to an ER where you are guaranteed a long and even dangerous wait.

You could call your family doctor, if you have one, but you might be told that you can be seen next week. And you can’t find a doctor who will see you on weekends, evenings or holidays.  Well, a good solution is to go to an urgent care center where you can be seen that day, by just walking in, and you can be evaluated by a board certified physician. Clearly, this is looking more and more attractive each day.

The economics are changing in a way that makes it feasible for good doctors to choose urgent care medicine for a career. The cost of care in such a facility is much less than that in an ER, and without the risks, time lost, discomfort and psychologic side effects.

Yesterday I visited the Central Jersey Urgent Care which is in the new strip mall  (732 Rt 35, Unit G) on the Asbury Circle  (right before you get onto Rt. 66)   There I met with Markintosh Berthelemy, MD, Chirag Patel, MD and Larry Desrochers, MD. These doctors are all American university trained,  board certified ER physicians who are highly qualified for the kind of work  they do at the Urgent Care Center. Their facility is modern, gleaming and spacious. It includes a lab and X-Ray. They opened one year ago. Phone 732 455 8444.

Dr. Barthelemy explained that there is rarely a wait at their facility. They are open 365 days per year, and you can find details at their web site ( CJUC link).   He said that they are “an alternative to the ER.” They see adults and children. But he pointed out that significant acute conditions such as heart attacks should go to an ER, and if such a patient comes into their center, they will stabilize the situation and call 911.

Dr. Patel, who also works part time in a hospital ER, agreed that the future of urgicenters seems bright, but that there is considerable uncertainty regarding how it will work out under Obamacare and if mega-corporations such as Barnabas Health might try to undercut them.

For the patients that they do see, they can save a lot of time by setting bones, suturing wounds and running some labs. There are about six urgent care centers around here, but they are not all the same. For example some use nurse practitioners or primary care doctors instead of board certified ER docs, of which there are 4 at CJUC.

This urgi center does not also function as a primary care facility, so they don’t follow patients with chronic issues, but they will fill in if your regular doctor cannot see you, even if the problem is not so acute, such as you are about to run out of blood pressure medication and need a prescription. The Center calls all their patients back two days later, and once a patient leaves, he can call the Center if things aren’t going well or if there are questions. These doctors communicate routinely with primary docs, and they can be a huge help to patients by arranging referrals, if needed,  to the best specialists in the community.

I enjoyed meeting these doctors and their staff. They are personable, knowledgable and caring. Don’t hesitate to go there if you are having a problem, and it is about 10 minutes away. If you research urgi-centers in the area, make sure that you will be seen by board certified doctors.  Nurses and PA’s are not the same. Similarly, don’t confuse the advantages of urgent care centers with the “doc-in-a box” services provided by a growing number of pharmacies.

 

 

 

 

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The Mammography Mess: A controversy with conflicting information

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, Medical topics by Paul Goldfinger, tagged on February 2, 2014| 7 Comments »

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Mammogram

Mammogram

“A 25 year Canadian study just published in the British Medical Journal  questions the value of mammography. Research suggesting that mammography may not be beneficial was covered by some of the nation’s most widely-read newspapers as well as on several medical websites.  

“In a  front-page story, the New York Times (2/12, Kolata) reports that research published in the BMJ, “one of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age.”

“The findings may “lead to an even deeper polarization between those who believe that regular mammography saves lives, including many breast cancer patients and advocates for them, and a growing number of researchers who say the evidence is lacking or, at the very least, murky.”

“The  Los Angeles Times (2/12, Morin) reports that investigators “examined the medical records of 89,835 women in six Canadian provinces between the ages of 40 and 59. All of the trial participants received annual physical breast examinations, while half of them also had yearly mammogram screenings for five years, beginning in 1980.” During “the next 25 years, 3,250 of the 44,925 women in the mammography arm of the study were diagnosed with breast cancer, along with 3,133 of the 44,910 women in the control group.” Meanwhile, a nearly identical number of patients from each group died of breast cancer.

“In a separate story, the New York Times (2/12, Rabin) reports that the new findings will add to the controversy surrounding the value of mammograms. Further complicating the issue is the fact that different medical groups have different recommendations regarding mammography.

“USA Today (2/11, Szabo) reports that ‘Barbara Monsees, a radiologist with the American College of Radiology, says the…study is fundamentally flawed and useless for drawing conclusions.’ “

Blogfinger Medical Commentary by Paul Goldfinger MD, FACC:

If you walk on Main Avenue in Ocean Grove, if the snow has been cleared, you will see remnants of a pink stripe that was put down during a one month breast cancer fundraiser in October. The pink symbols were everywhere, and the theme was to promote mammograms for women who hadn’t had them.  I thought that the pervasive drumbeat was overdone, given that it was all about pushing mammograms. I couldn’t recall another comparable  fundraiser that focused on a diagnostic test rather than basic  or clinical research into prevention and cures, so this month- long effort seemed to me to be out of proportion.

In 2009, the US Preventive Services Task Force recommended cutting back on mammograms for all women, and especially avoiding them altogether for those in their 40’s.  They suggested that women age 50-74 have the test every other year.  The American Cancer Society disagreed and suggested mammograms yearly from age 40 and up.

A controversy ensued which is still simmering and has now been exacerbated by this massive Canadian trial on nearly 90,000 women over 25 years.  The study concluded that annual screening mammograms do not reduce death rates when compared to skilled manual examinations by specially trained nurses.  They say that too many mammograms are being done and that mammograms can cause “harm.”

Last week, on NPR.org  radio, there was a one hour discussion with Diane Rehm interviewing  two of the world’s experts in mammography as they debated the results of the Canadian trial. They had practically opposite opinions and they were attacking each other over facts and even  issues such as conflicts of interest and flawed conclusions.

So there is no way that I can do this subject justice except to summarize the facts and the  issues, especially as put forth by the Canadian trial.  I suggest that women do some reading on their own to avoid being swayed by experts with agendas:

1. Mammography is an imperfect test for the diagnosis of breast cancer and is over-rated as a life-saving procedure. The idea that early detection saves lives is being seriously questioned.

It is true that in recent years, the survival rates of breast cancer have improved significantly, especially in the 40-49 year old group, but the benefit seems to be due to newer treatment options, such as the drug tamoxifen, and not due to screening mammograms.

2. This huge Canadian trial is being criticized by some, such as a leading professor of radiology from Harvard, on the grounds that the study design was flawed, the quality of the mammograms was awful, and too many small tumors were missed due to antiquated  machines.  He also had other highly technical criticisms as well.

3. Even current mammography machines sometimes miss small cancers. The test also often raises questions about abnormalities that are not cancer  (i.e. false positive results.)  30% of the time patients are brought back for more films causing great stress and extra radiation.    In addition, the test may detect cancers that either are too small and slow growing to cause harm or are pre-cancerous conditions which will not endanger lives.  One in five cancers found by mammography are the kind that pose no lethal threat, so those patients currently get unnecessary treatment.

4. The problem with such “over diagnosis” is that some women get subjected to  harmful aggressive approaches including biopsies, drugs and mastectomies which are not necessary. The harms include drug toxicity, surgical mutilation and risks, and mental distress.  The researchers in Canada say that sometimes mammograms cause more harm than good.

The clinical challenge is to decide which cancers can be left alone or just treated medically. The ability of oncologists to make these differentiations are currently inadequate.

5.  Some fund raising organizations have been accused of over stressing the importance of mammography and distorting the statistics of success attributed to the test.   (see the Time article below).

6. This new trial of 90,000 will cause all doctors who treat breast cancer to re-evaluate their use of mammography and will result in a new assessment of the criteria for ordering screening mammograms. These new guidelines should be available in 2015, but as with the PSA controversy, different expert panels will offer different recommendations.

7. At this time, most women will probably plan to continue with the same yearly regimen from age 40-59  (which is the age range of the new study,)  but they may be surprised to find a more nuanced individualized approach when they see their doctors. And they may discover that their doctor offers them an option of skipping mammography altogether.

One potential concern is whether the new Obamacare insurance policies will cover all mammograms that are requested. This Canadian study will likely provoke women’s advocacy groups to object strenuously because most American women have been sold on the life-saving benefits of early diagnosis with mammography.

8.   There will be many women who have not had mammography  or who have been skeptical of the test.  They will use the controversy as a reason not to have mammograms.  But if a woman makes that choice, she must do self examinations and have a manual exam by an expert examiner yearly.  (The same is true also for women who do have mammograms.)  She also should discuss her decision with a doctor, because some individuals have higher risks than others.

9.  New imaging methods are in the works including 3-D mammography.

Time magazine article on Komen ad

10.  Here’s a link to a  NY Times article on self examination of breasts:

self exam link

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