Archive for the ‘Medical topics’ Category

By Paul Goldfinger, MD, FACC. (Re-post from 2012, but still valid.)

In the N.Y. Times Sunday Review on June, 3, 2012, a physician presents an article entitled: “Let’s (Not)  Get Physicals.” The subtitle is: “We cling to the ritual of the annual exam, despite evidence that it isn’t needed.”   She is talking about the traditional yearly exam that many doctors recommend for people who seem to be healthy .  We are, of course, not talking about office visits for patients who actually have medical conditions.

Dr Elisabeth Rosenthal says, “…annual physical exams—and many of the screening tests that routinely accompany them—are in many ways pointless or (worse) dangerous, because they can lead to unneeded procedures.” She begins by slamming PSA blood tests for prostate cancer detection.

She goes on to blame “economic impetus for American medicine’s ‘more is better’ mode.” In other words, doctors do it for the money.

Then she presents a list of  “tasks to jettison.” These are “a sampling of routine screening tests and medical procedures that research has suggested are not necessary: annual physical, annual ECG, annual routine blood work, annual cholesterol test, annual Pap smear, and PSA test.”

In general, I am sympathetic with Dr. Rosenthal’s message because I have been a long-time critic of waste and greed in the medical profession. But I think her glib article about “physicals” is off the mark and might discourage patients from getting needed healthcare.

The problem here is that the premise is wrong. She equates the annual “physical” to performing unnecessary screening tests. Although it may be true that such tests may be done during an annual exam  (such as the yearly ECG, for example), she fails to mention that those “physicals” also include important healthcare services other than the  tests which she condemns.

To begin with, everyone should see their doctor once in a while (we can debate the frequency) for no other reason than to assess and counsel patients regarding disease prevention: weight, diet, exercise/fitness, smoking, flu shots, blood pressure, mental health, and adherence to recommended tests, such as colonoscopies, which are proven to save lives. So while she denounces  yearly health maintenance visits to a doctor, she has made no provisions in her negative analysis for prevention—the number one health challenge, by far, in the U.S.

There is also a valid concern in medicine regarding early detection of diseases which may be manifested by unimpressive symptoms or by physical findings, before the person actually gets sick. It’s not unusual for doctors to actually find something during a yearly “physical.” That’s one reason why med students study history taking and physical examination. I also believe that a yearly visit with a dermatologist is a good idea, especially as one gets older–they sometimes find things like curable melanomas.

In addition, if a physician is prescribing some preventive medication, such as a cholesterol drug or a birth control pill, he is not only justified to ask for a periodic office visit, but it will be malpractice not to do so since he is accountable for the efficacy and safety of those prescribed drugs.

Similarly, if a doctor is to take on the responsibility of accepting you as his patient, making his office available to refill prescriptions, responding to your phone calls, seeing you if you get sick, providing coverage at night, and being your personal advisor regarding consultants and other medical inquiries, then he should make sure that he sees you at least once per year so as to maintain the time-honored “doctor-patient relationship.” This is good medicine.  All sorts of health maintenance  services can be accomplished during a yearly “physical.” And the visit brings the doctor up-to-date and provides a new baseline in case the patient should call on him subsequently.

As for her list of unnecessary tests, you will notice that it is mostly the yearly timing rather than the test itself that is criticized.  All the tests on her list, such as blood work and Pap smears, are essential when used properly. The only one which is truly controversial is the PSA blood test to screen for prostate cancer. At a yearly physical exam, the doctor can use his judgement about ordering certain tests, and no practice guidelines can replace the art of medicine.

Unless Obamacare, or whatever system we get, provides some mechanism for healthcare maintenance, then I believe the annual physical exam still has a purpose—it just needs to be redefined and renamed. Let’s call it the “see your doctor once-in-a-while to go over your health status visit.” It makes sense. Somebody needs to be in charge, and the NY Times doctor won’t be there for you.

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Disease was once thought to be due to sin. We now know more,  but not enough.

Edited and reprinted from a prior edition of Blogfinger.

By Paul Goldfinger, MD, FACC

Most people have high hopes when they go to a doctor with a problem.  They want to believe that their physician will do some tests, find out what’s wrong, and then fix the situation. That is usually what happens. However, doctors sometimes do not recognize their own limitations. They may not  like to admit to themselves or to  patients that they do not know what’s wrong and what to do. The fact is that there is much that doctors do not know and there is much that they do which is unproven.

Sometimes a physician will suggest a second opinion. That is always a good idea, but the patient should go to someone who is a known authority in the field, even if it means a trip into New York or Philadelphia. Seeing a real expert may help put a halt to the doctor-shopping.  But what happens when no doctor knows the answer no matter how many you consult?  What happens when a situation hits the wall of the unknown?

There is a parallel universe where people reside with persistent symptoms despite the best efforts of doctors.  I know someone who has chronic vertigo. He has seen multiple specialists in New York City and has had every possible test for this condition. No diagnosis or effective  treatment has been found. The patient is still dizzy; he has been seen by professors without answers as well as charlatans who waste his time and money. He makes the best of it, but he keeps looking for another doctor who might help. He scours the internet for solutions.

Most everybody has something physical that bothers them, and if there is no definite diagnosis,  they try to get by, one way or another.   Some get conventional care from their doctors, while others resort to alternative therapies and OTC medications.  Many simply accept their fate and lead their lives without further tinkering by the medical establishment. But the ones who keep bouncing around from doctor to doctor, without diagnostic or therapeutic success,  are the ones who need the most guidance from the medical profession.

Physicians sometimes need to stop the snowballing of tests and opinions. Stopping means to admit that the patient’s problem cannot be solved, so the doctor needs to shift gears and focus on attentive and supportive symptom relief. It’s difficult to judge when that time has come. It has to be a decision made by the doctor and his patient. But once the decision is made, the physician  should continue to follow the patient, because you never know when an answer might appear.

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May 21. Ocean Grove. By Ted Aanensen, Blogfinger photographer

May 21. Ocean Grove. By Ted Aanensen, Blogfinger photographer.  Re-post.

Pollen counts have been exploding around the Jersey Shore.  The pollen is mostly due to trees in Ocean Grove, but elsewhere grass pollen is also an issue.

As the Gershwin song goes, “Summertime and the livin’ is easy. Fish are jumpin’ and the pollen is high”

My car had a green hue this morning, so I went to the car wash.  A few hours later, it was coated again, but at least the bird poop was off the Blogmobile and did not fall on my head, like it once did in France.  Those French birds pack quite a wallop, but at least they didn’t hit my croissant.

One thing you can do is to shut your windows at home and turn on the ac if you have it.  Take off your shoes when you come home.  Take a shower before you go to bed.   Antihistamines can help, but you might want to ask your physician for prescription grade medication. Avoidance is the best preventive medicine.  Lock yourselves in your houses and  don’t breathe if possible.   Soon it will all blow over.

—Paul  Goldfinger, MD

CIBELLE.  From her Las Venus Resort Palace Hotel  album

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Normal electrocardiogram. Dreamstime.com

Normal electrocardiogram. Dreamstime.com.   Re-posted 2014.


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.


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)






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East Side, West Side, all around the town.

By Paul Goldfinger, MD  (Reposted from Blogfinger.net, 2011)

We recently posted a photograph of Central Park after the 1969 Blizzard.  I took that photo from the top of The Mt. Sinai Hospital where I was a resident physician in internal medicine.  An Ocean Grover emailed to say that he was born there in the spring of 1969.  That took me back to something that happened there around that time:

Mt. Sinai Hospital is a large medical center  on the Upper East Side; one entrance faces Fifth Avenue while the other is on Madison Avenue.  Back then, the hospital consisted of a group of buildings that were connected by tunnels underground. One morning, at about 3 a.m., when I was on call in the ER, I received a page to come quickly  to the Klingenstein Clinical Center on Madison Ave.  The fastest route was to go outside and walk a half block to the KCC.  I was dressed in my house staff uniform: all white with a stethoscope and loose papers sticking out the jacket pocket.

As I stepped outside, a yellow cab screeched to a halt at the curb.  The driver jumped out, looked at me and said, “Are you a doctor?”  Lots of things pop into one’s mind at times such as that.  I thought, “No–I’m Batman” and then, “Why is this cabbie asking for my credentials?”

Anyhow, I said, “Yes. What’s the problem?”

“A lady is having a baby in the back seat!” he exclaimed.

“Sorry, I gotta go” is what first came to mind, but I opened the door to the cab, and there they were: Mom flat on her back, and the baby’s head crowning.  “Hello, I must be going” is what I next thought (to borrow a line from Groucho).  “But I can’t go; I have to stay.”

I had delivered 30 babies in medical school (but who’s counting?  I kept score in my ob. text).  However, I did not go to Mt. Sinai to deliver babies. Oh well— I reassured the mom and then caught the baby: PLOP!!!  It was as easy as that. Blood all over. A gooey crying baby in my arms.

Just then the intern from the ER stuck his head in the door. “Can I help?” he asked.

“Here” I said, handing him the baby….”I gotta go.”

Editor’s note:  If you want to read more about Paul’s adventures as a resident physician  in New York, go to this link:


(reprinted from the Ocean Grove Record, 2004)


LESLIE ODOM, JR.  From the Broadway show Hamilton.

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Snow shoveler faces a couple of thousand pounds of white stuff. Monday.   Blogfinger photo in Ocean Grove.

Ominous truck appears on Main Avenue: maybe a sign to stop shoveling

By Paul Goldfinger, MD, FACC

When I was working as a cardiologist, we were wary of snow storms because we knew that we would have to go to the ER to see shovelers who developed chest pains, dizziness, fainting, palpitations and other worrisome symptoms.  But we also knew that the fatalities were usually among those who simply died without any warning—due to a major cardiac rhythm disturbance.

The early signs of a heart attack are well known, although sometimes they can be misleading.  For example, chest pains may be harmless, due to muscle strain from shoveling. On the other side of the coin, the early signs of a heart problem might be ignored, such as when jaw or arm pain occur without chest discomfort or if you become short of breath.

If you are having symptoms but are unsure, the best bet is to go to the ER.  I could tell you how to analyze your symptoms, but for a lay person: “Better to be safe than sorry.”

If you are thinking about shoveling, there is an important principle that you should know:  silent coronary heart disease  (ie without any warnings) is common, and you might be at risk of dying during shoveling even though your doctor says you are healthy and even though you feel fine. This is true even if you had a negative stress test.

Cardiologists refer to “hearts too good to die.” That means that heart disease, where arteries on the surface of the heart develop blockages severe enough to cause sudden death, may be associated with a strong heart, and that the narrowed arteries could have been fixed if diagnosed.

The risk of sudden death during shoveling is particularly relevant for those who have risk factors:  over age 50—especially males, smokers, high cholesterol, family history of early heart disease, high blood pressure, diabetes, sedentary, obese, and known heart disease. Even those under age 50 might be at risk from shoveling if they have major risk factors such as family history.

The best advice: don’t shovel snow.  Let some kid do it. It’s cheaper than having your family pay for a funeral.

This may sound harsh, but I have seen it.   I personally know someone who died suddenly in his 50’s while snow shoveling and without a cardiac history. He was a heavy smoker with very high cholesterol.    I know two doctors without known heart disease who died suddenly while cross country skiing.   So don’t be foolish.

If you do shovel, do not do so after a meal or after having caffeine or nicotine. Pace yourself and rest frequently.  Remember that the stress on your cardiovascular system during strenuous exercise will be especially extreme in cold weather, even if you dress warmly and think that you are protected . The cold air causes your arteries to constrict and your blood pressure and heart rate to shoot up abruptly.  Cover your face.

Please click on “email” below and share this with some of your friends.

This article re-posted as needed. —-PG


CLARENCE “FROGMAN” HENRY  says take  care of yourself—it’s a gift to your loved ones.

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Get internal temperature to 160 degrees F.   Consumerist.com

Well-done burgers are 160  safe and tasty degrees.   Consumerist.com.


By Paul Goldfinger, MD  (This article has been updated from our 2011 post)

Sal commented regarding our article about hamburgers.  He said, “Be careful mentioning that your burger was medium- rare… isn’t it now against the law to serve a burger in New Jersey that’s not well done?  No pink at all from what I know.”

Regarding Sal’s question,  I could not find an actual health department ordinance for restaurants about this, so if any readers know more, please comment below. I have checked the USDA recommendations (US Dept. of Agriculture. See link below)  They monitor meat processing plants routinely.

When you buy hamburger from the store, leave it in the original packaging and keep in the refrigerator at less than 40 degrees F.  for no more than 1-2 days before cooking or freezing.  Below 40 degrees will keep the bacteria from multiplying but will not kill the pathogens..

If the meet is frozen, thaw it in the refrigerator; never at room temperature. Do not leave the meat out at room temperature for more than 2 hours. But the best practice is never to leave it out of the fridge. Bring a cooler to the grocery store for the trip home.

Get a good food thermometer to check the burger while cooking it.

Here is a USDA link on this subject:



Hamburgers from fast food restaurants are OK because they are cooked safely to 160°F. In other restaurants, ALWAYS order your child’s hamburgers well done. Also, older people, pregnant women, or people with a serious illness should order hamburgers well done. But it is best for everyone to order “well done” burgers or ask the waiter to have the burger cooked to 160 degrees F.

At home, cook burgers to 160°F and keep cooking for at least  15 seconds. Looking  at the interior color is not a good way to know if hamburgers are cooked enough. Check the temperature with a good quality food thermometer.

The concern is about E. Coli or other worrisome bacteria such as Salmonella—- These are dangerous organisms that may grow on the surface of meat and which can be stirred into the mix when meat is ground.   It is also recommended that you do not grind meat at home. A person could get violently ill from such an infection; in fact, it could be fatal.

The pathogens may survive within the burger even if the burger is in the fridge.  You kill the bacteria when you cook the meat to 160 degrees.  When you use a thermometer, insert it into the interior center of the  burger.  If it is a thin burger, insert the thermometer from the side.

I saw a video of the famous chef  Daniel Boulud making a hamburger. He grilled it on a cast iron pan, stove top, for 3 minutes on each side. He then proudly cut a piece off and exclaimed success;  it was rare. But, of course, he is confident of where his meat is coming from and what the condition of his kitchen is.

To tell the truth, when I ordered my burger medium-rare at Asbury’s Ivan and Andy’s steakhouse (now closed,)  I didn’t worry about it because it was a fine restaurant where the owner was a butcher, and I suspected they cut and grind their own meat.

But, when I am in a diner or most other restaurants, I always ask for it to be medium.   (Experts say that we should order burgers “well done” in restaurants.)  Sometimes the restaurant will refuse to serve it rare or medium rare.  And some people will not order a burger in a restaurant at all.

On occasion, the health risks surrounding food are especially high, and so we must change our habits. About 15 years ago I stopped eating something that I loved: raw clams and oysters. One of my colleagues, an infectious disease specialist, had just returned from a medical meeting in New Orleans. He said that he did not eat any raw shellfish down there because of the substantial risk of hepatitis. If he could turn his back on those New Orleans oysters, then it was time for me to bite the bullet.

But as for hamburgers, I think the risk varies with circumstances. My official advice is to always order or cook your burgers well done  (160 degrees F.)    But if Daniel Boulud were making my burger in his kitchen,  I probably would still ask for it medium rare, which is the most delicious end point.

There is an adage: “Physician—heal thyself.”    So if we physicians do order our burgers medium-rare, we probably shouldn’t admit it on Blogfinger if we didn’t want Sal to give us the business.


DUKE ELLINGTON AND HIS ORCHESTRA like to stop at Dixie Roadside Diners:


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Getting back to basics…Medicine 101

By Paul Goldfinger, MD, FACC.  Dean of the Blogfinger Off-Shore School of Medicine in Ocean Grove, NJ.

She was a tall, thin blond, 22 years old, from East Germany.  She had long graceful legs and she was a good looker.  But she was more than just that; she was an international elite high jumper and she was exhausted.  Beside muscle weakness, she had leg cramps and she had passed out a few times.

I admitted her to the internal medicine teaching service at Mt. Sinai Hospital, located on the upper east side of Manhattan, facing Central Park. The year was 1967 and I, a first year medical resident, was struggling to come up with a diagnosis.

She seemed perfectly healthy. Her history was unrevealing, and her physical examination was unremarkable. Doctors like to say “unremarkable” for normal,  but she was anything but unremarkable. She denied taking any drugs, being on a crazy diet  or vomiting to lose weight.  We ran tests on her, and there was only one salient abnormality:  her blood potassium level was very low.  In other words, she was hypokalemic.

The second year resident,  the chief resident, and the attending physician could not figure out the cause of her electrolyte disorder.  “Electrolyte” refers to the minerals in the blood such as sodium, potassium, chloride and calcium.  We ruled out kidney disease and metabolic problems.

Dr. Solomon Berson, the Chief of the Department of Medicine, said that he would order an experimental serum insulin level from his lab—a test that would eventually win the Nobel Prize in Medicine.  But that didn’t help either.

Finally I decided to go back to basics and take another history.  It’s like those cop shows when they keep interrogating the suspect until something squeaks out to solve the case. In the 1960’s, a great deal of emphasis was placed on talking to patients, because our testing methods were so primitive compared to today’s.

It seemed that we would have to lower the talking bar for this high jumper. We discussed her life and her habits.  Finally the truth popped out:  she was a secret user of thiazide diuretics.  It wasn’t clear why she was doing that. She didn’t know that diuretics cause your body to be depleted of potassium.  We took away the diuretics, and she was cured.

Next stop was the psychiatry department.  Meanwhile I got a case report out of it in the Mt. Sinai Journal of Medicine plus a bit of notoriety there which lasted about two days.

History taking is becoming a lost art. Electronic medical records encourage doctors to use checklists, and often the history is obtained by a medical assistant or “physician extender.”  There is an old saying in the profession: “Listen to the patient; he is telling you the diagnosis.”  The great Sir William Osler, one of the founders of the Johns Hopkins Hospital, is credited with those words of wisdom.

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Small portions can help you lose weight. Reposted from 2012.  Calories still count.

On its website, ABC News (7/11, Tackett) reports that for the study, presented at the international conference for the Society for the Study of Ingestive Behavior, investigators “gave 301 hungry college students either a whole bagel or the same bagel cut into four separate pieces.”ABC World News (7/10, story 6, 0:35, Sawyer) reported on a new study suggesting that people may eat less when their food is cut into smaller pieces.

WebMD (7/11, DeNoon) reports, “The group that got the whole bagel ate a little more of it than those who got the cut-up bagel. But the real difference came 20 minutes later, when all of the students were offered a free meal.” The researchers found that “those who’d eaten the cut-up bagel — even though they’d eaten a little less — ate less of the free meal.”

Blogfinger Medical Commentary.   By Paul Goldfinger, MD, FACC

This is a funny little study which includes observations on college kids and rats.   The results are a little confusing, but cutting your food into small pieces, as with the college kids in the study, somehow promotes a feeling of satiety that has nothing to do with how full your stomach is.  In other words, mind games can  help you feel less hungry.

But this is nothing new.  When Eileen was a coed at the George Washington University in DC, she was trying to cut down on calories and on spending (so she could buy more clothes.)  She skipped breakfast, and after morning classes, would go to the campus hang-out: Quigley’s.   It was like a luncheonette.

Quigley’s on the GWU campus, Foggy Bottom, c. mid-1960’s

Eileen called it “brunch.”  She would sit at the counter and order a coffee and a small slice of pound cake.  She would then cut the cake into about ten pieces and then eat the pieces very slowly. The trick worked then,  and even now she is a very slow, methodical eater.  I, on the other hand, try to lose weight by shoveling large amounts of food into my mouth as quickly as possible.    Eileen  is more successful than I in controlling weight and  she also knows more about nutrition these days than when she was eating tiny pieces of cake at Quigley’s.

Our friend Carol from Randolph liked to take a tiny scoop of ice cream which she would eat slowly with a demitasse spoon.  This game caused her to feel  satisfied without eating a lot of that sinful stuff.

There are many elements that go into how many calories we consume.  Certainly the types of foods we eat are important;  for example a gram of fat contains more calories than a gram of carbs.  Also the amount of food we eat is critical, and that is where portion control is one method to promote weight loss.

Surgical procedures that reduce the size of the stomach also work by promoting satiety. Then you have methods that reduce one’s appetite, such as the old diet pills with amphetamines.  And don’t forget the other side of the equation:  burning calories through exercise.

As for the rats, they were pretty smart in the maze, and they don’t even go to college.

The bottom line is that weight control is difficult, and if you are motivated, there are many tools, methods and games at your disposal.  And, soon there will be a new diet pill available.

Soundtrack:  The Andrew Sisters with a depression era song about portion control:

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AMA new banner


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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