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Archive for the ‘Medical topics’ Category

The dangers of snow shoveling….

Posted in Medical topics, tagged on January 27, 2026| 5 Comments »

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. 2016.

 

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 shovelers who simply died while shoveling without any warning symptoms—ie a cardiac arrest due to a major heart  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.”  Even a physician or a nurse should not attempt a diagnosis on themselves.

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  has said that  you are healthy and even though you feel fine. This is true even if you had a negative stress test and a normal ECG.

Cardiologists refer to “hearts too good to die.” That means that heart disease, where coronary 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 coronary  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.

The best advice: Don’t shovel snow.  Let some kid do it.

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 knew two doctors without known heart disease who died suddenly while cross country skiing.   Any strenuous exercise can trigger an event, not only shoveling.

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.

Here is a true story:    I was making rounds at the hospital  (Dover General in NJ) when I heard the alarm “CODE  18” which indicated someone has had a cardiac arrest or some other life threatening situation.  The code was across the street at a medical facility.  I was in shape and had a negative cardiac history, but I was 54.

I raced out of the building and ran as fast as I could go, and when I reached the scene, others were already initiating care.  But I couldn’t breath, and it wasn’t like my asthma due to cats and pollen.  I quickly recovered, but I told one of my partners who did a stress test that day.  It was positive, and I was sent to NYU where a cardiac catheterization revealed several narrowed arteries.  Frank Spencer MD, the eminent chief of heart surgery there, came down to see me.  He knew me from  surgery referrals which I often sent there.

He came to my bedside, and in his deep southern accent, he said, “Paul,  you need bypass surgery now.”  There were no stents at that time.

As a physician I knew every complication of my situation, so I feared the worst.

But  I survived the operation and spent 3 weeks in the hospital in a room overlooking the East River.   Eileen slept in my room in a recliner chair.  The lengthy stay was because of complications.  My emotions ran the gamut, but I did find out how my patients might feel under similar circumstances.  It also reinforced an old saying:  “Any doctor who tries to be his own physician has an idiot for a doctor.”

20 years after my surgery I got to meet my grand son Noah.

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

I hope this article will save someone’s life.  I am retired now, and timely  care gave me many more years.

 

Noah visits us in Ocean Grove.  Thank you NYU.

 

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

 

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Chief White Nose reports on sunscreens.

Posted in Blogfinger News, Medical topics, tagged on December 3, 2025| 1 Comment »

From MD Anderson Cancer Center. (aka MD Anderson Center).   “SPF means “sun protection factor”

 

By Paul Goldfinger, MD,  Dean of the Blogfinger Off-shore School of Medicine in Ocean Grove, NJ. author of the famous medical article: “The Parking Derangement Syndrome.”

In my late teens I worked summers at a resort hotel in the Catskill Mountains. (“The Borscht Belt.).     My job was to run around all day in shorts,  Hotel Nemerson T- shirts and sunglasses  as a  member of the athletic staff, organizing  volleybal, basketball, hand ball,  and softball games, being sociable with the new guests  (Wowee!) and suffering  sun exposure as a side effect.  My nose was always peeling, so I would put thick schmeers of white zinc oxide on,  and the guests called me “Chief White Nose.”

Anyhow, we didn’t know anything about the sun risks, and I don’t think they had invented sunscreens back then. They barely had just invented the wheel.  I think they may have had Coppertone—the emphasis was on getting a tan and not avoiding skin damage.  I remember the women lying all day by the pool “working on”  their tans, and if they were really dark, they were much admired.

So then I became a doctor and learned about skin cancer, but very little about prevention.   Of course now we all know about  using sunblocks, hats, clothes, etc. to reduce exposure to the sun.  But the sunscreen thing has been a bit of a mystery—even now.   We don’t  really know how protective they are and how to use them properly. The SPF  numbers remain  somewhat of a mystery.  And how long do they last and how heavy should they be applied?

Have you gone shopping lately for a sunscreen?  You could spend an hour and a half reading labels and still not be sure what to get.  So you choose a product with an SPF of 1,000.  But, it turns out that over SPF  30 is of dubious usefulness.  If you are at a the beach, reapply sun screen every two hours.

Did you know that melanoma cancers are on the rise ?

Attention must be paid!

In today’s New York Times (5/29/13)  there is an excellent discussion of this subject  called, “New Rules For Sunscreen” by Roni Caryn Rabin. The piece includes  a review of the latest FDA labeling rules , so below is a link. I recommend that you read it and then smear your entire body with large globs of sunscreen and don’t go into the midday sun, because only mad dogs and Englishmen do that.

LINK :      “New Rules for Sunscreen” NY Times May 29, 2013

 

LINK.  2025 update from the MD Anderson Center.  (Cancer specialists.  aka MD ANDERSON CANCER CENTER.   in Texas.

MD Anderson discussion of spf—-“sun protection factor.”

 

BILLIE HOLIDAY:    Life may not be so sweet on the sunny side of the street.

 

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MEDICAL: Are Annual Physical Exams Out-of-Date? The NY Times says, “Yes.” Blogfinger says, “No.”

Posted in Medical topics, tagged on October 15, 2025| 2 Comments »

By Paul Goldfinger, MD, FACC.  2020. (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. The decision about the PSA test is important because it might save someone’s life–ie to identify the risk of dying of metastatic prostate cancer.   Your doctor must individualize your need for that test.

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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“Medicine’s Parallel Universe”

Posted in Healthcare Topics @Blogfinger, Medical topics, tagged on September 26, 2025|

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

 

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

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  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 live 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, and that can lead him into a morass of expensive unproven snake oil or nutritional remedies.  Some are drawn  to a world of ancient remedies such as my friend found in Chinatown.  (NYC).

Most everybody has some physical complaint that bothers them, and if there is no definite diagnosis, then usually there is no specific treatment.  So they try to get by, one way or another,  often accompanied by arbitrary diagnoses  and therapies.

Some get conventional care from their doctors which might  be tried on a trial basis, while others resort to alternative therapies and OTC medications.  The FDA has no control over OTC medicines.

Before giving up, the patient and his doctor must review what he is taking:  side effects of all therapies must be reviewed along with monitoring for drug interactions.

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 snowballing tests, opinions, and treatments.  A primary physician who is doing his job properly will monitor what his patient is doing on his own.

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.

A friend of mine was suffering from recurrent  hives.  (itchy skin bumps). His doctor couldn’t figure it out, so my friend  was resigned to the situation.

I asked him about his diet and his meds , because allergic reactions can cause hives.  He was taking a drug to help him urinate. I suggested he stop it on a trial basis, but he said, “No. It can’t be that because I have been taking it for 5 years without any problems.”

I said, “Sometimes an allergic side effect to meds  can appear after a long time without hives.”  So he stopped the drug and he was cured.”  Doctors should never give up.

 

“High Hopes:’

 

 

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Delivering Babies: What a Thrill!

Posted in Medical topics, tagged on September 14, 2025| 3 Comments »

Photo by one of my fellow med students. Washington, DC. c. 1966

Photo by one of my fellow med students. Washington, DC. c. 1966. Goldfinger family album

 

By Paul Goldfinger, M.D.

Four of us rotated together through the clinical years of medical school. Bill was from Utah,  Bob from New Jersey, Dennis from Pennsylvania and myself from New Jersey.  We were in Washington, D.C. at the George Washington University School of Medicine.   The med school was in a crummy part of town with strip joints around the corner—an excellent environment to study anatomy.  The school was a brick structure from the 19th century where we had lectures in a big amphitheatre like in Rembrandt’s “The Anatomy Lesson.”   There were 94 guys and 6 women.

GWU Medical School at 1335 H Street. It was replaced in 1970 by a new school at Foggy Bottom

GWU Medical School at 1335 H Street. It was replaced in 1970 by a new school at Foggy Bottom.

The Dean, John Parks, was a big man—a former football player for the University of Wisconsin.  He was a well known Ob-Gyn specialist.  The students called him  “The Patriarch of the Pelvis.”   So Ob-gyn was a big deal at our school.  Our Ob-gyn rotation was at a large city hospital–D.C. General, which was also ancient and which no longer exists.  That was a rough old place with big public wards and students coming from the three med schools in Washington:  G.W., Georgetown and Howard universities.

We got to deliver babies there. We would be assigned to a woman as she came through the door in labor.  We would stick with her during labor and then we would deliver the baby. What a thrill!   Then we had two postpartum patients and we wore two hats:  obstetrician and pediatrician.

One time Dennis called me. He delivered a baby, but he couldn’t deliver the placenta.  I gave a gentle tug and nothing happened, so my contribution was to call the intern. He came and then called the resident. He came and found out that there was another baby in there.  In those days the diagnosis of twins was sometimes difficult.

At  GWU hospital, it was a more genteel experience in Ob because the patients were private. But I delivered babies there also, although the supervision was a bit tighter than at DC General.  They allowed me to do a minor surgical procedure called an episiotomy where a small incision is made to allow the baby’s head to emerge more easily. That was satisfying for me, the mother and the baby.  Then I got to sew it all up —nice and neat. We also learned to use forceps for difficult deliveries—that procedure I disliked intensely.  I kept score in my OB book :  30 babies delivered; 20 were little girls. I couldn’t account for that distribution.

I loved Ob, but, in the end, I chose cardiology. Two years later, as a medical resident at Mt. Sinai Hospital in NYC,  I was walking in front, on Madison Avenue, on  a summer morning, at about 2 am.   I was on call;  they had asked me to see a patient in the next building.  Just then a taxi screeched to a halt at the curb. The cabbie, seeing my white uniform with a stethoscope around my neck, urged me to look into the back seat.

There was a woman about to give birth—the baby’s head was crowning.  So I jumped in and delivered a boy—that was the last time I would ever have the privilege to deliver a baby;  and  was I  grateful for that rotation in Washington, D.C.

 

ANNETTE HANSHAW

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Blue, but not broken hearted: A medical mystery…

Posted in Medical topics, tagged on July 3, 2025| 1 Comment »

 

By Paul Goldfinger MD, FACC

 

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. Although she had no symptoms, the time had come to contact her family physician.

I got a call about her 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 stunned.  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 such a heart condition when she felt fine?

She came to the E.R. 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— there had to  be a clue in her history.   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 the pyridium and kept her in the hospital.   Each day  when I made rounds, I became more and more relieved—she was turning lighter and lighter blue each day. As her hue returned toward normal, I became confident that she would be cured.

After that we could relax, so on rounds  I would sing her a few bars of the chorus to this song:  (performed here by Ethel Waters in 1929).  She eventually went home–a normal white woman, and I had a story to tell : over and over.

(*Cyanosis is a bluish discoloration of the skin)

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Study: Pharmacist-guided home blood pressure monitoring may help hypertensive patients.

Posted in Medical topics, tagged , on April 4, 2025| 5 Comments »

AMA_masthead_728

Omron 711dlx Blood Pressure Monitor

Reuters (7/3, Pittman) reports that a study that appeared Tuesday in the Journal of the American Medical Association found that patients with hypertension  who were involved in a telemonitoring program were able to keep their systolic and diastolic blood pressure readings down compared to others who received “usual treatment.”  Dr. Karen Margolis from HealthPartners Institute for Education and Research in Minneapolis and her colleagues followed a group of people with uncontrolled blood pressure and had them utilize home pressure monitors to measure readings at home and then call in the readings to the pharmacist.

At the end of the program, researchers found 71% of participants involved in the telemonitoring program had their blood pressure in the recommended range, compared to only 53% of participants in the control group.

BLOGFINGER MEDICAL COMMENTARY:          By Paul Goldfinger, MD, FACC.    This article was originally posted here in 2013, but it is still valid.

In this small study of 450 adult patients with poorly controlled high blood pressure  reported on July 3 in the Journal of the American Medical Association, it is suggested that home blood pressure readings coupled with pharmacists’ monitoring the results and adjusting medications could produce better blood pressure control  in hypertensive  patients whose target readings were not achieved under the care of primary doctors  (i.e. “usual treatment.”)

Large trials have  shown that there are millions of  patients with poorly controlled hypertension in the US, but only half have achieved the goal of BP under 140/90.  The reason for the unacceptable stats is not that we need pharmacists to take over care;  it’s because the usual and customary care in the hands of primary physicians has not worked well.

This particular study gave no long term results and no evidence that pharmacists are better for the job than real doctors doing the job correctly.  The main lesson of this trial has been known for some time:  Home BP measurements are an excellent tool to achieve better control.  Home  readings are superior to office readings in managing hypertension.

Doctors can produce excellent results in their office practices if they organize their procedures better.  The idea that hypertension care should be “pharmed out”  to pharmacists is nonsense and potentially risky to patients.  There are too many potential problems  in these cases to allow the care to slide downhill to the corner Rite-Aid.  It is not enough to simply focus on the BP reading. The care of such patients is complicated, and fragmenting that care is not conducive to therapeutic success.

The hazards inherent  in caring for hypertensives include  failure to identify complications such as drug reactions/interactions and side effects that affect other body systems.  For example, drug therapy for hypertension can promote kidney malfunction, worrisome low blood pressure, and metabolic disturbances. Hypertension is a major risk factor for stroke and heart attacks, so turning over the job to pharmacists is just a political gimmick to further disrupt the doctor-patient relationship.  Physicians are not doing the job well now, but that can be fixed by a new healthcare system.

In my own practice, I achieved nearly perfect BP control for my patients by using home BP devices, education and careful/detailed record keeping by patients, and supervision by our cardiac trained RN’s who helped me with the process.  We encouraged necessary life style changes including weight control, diet, salt advice, exercise, and paying attention to emotional factors such as stress.  Controlling high blood pressure  is usually not difficult, but it can be expensive   (as with all good medical care) and it requires commitment on the part of the doctors and their office management personnel.  It does not require yet another category of pseudo-doctors.

I say that physicians are the best choice to do the job and they can do it with a team approach in their practices, better technology (especially, tele-transmission of results and  accurate and easy to use home monitors),   practice guidelines created by doctors,  success- based reimbursements for physicians, and insurance coverage of qualified office staff and necessary equipment including the home BP machines and transmission devices.

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Blue, but not broken hearted: A medical mystery

Posted in Medical topics, Medical topics by Paul Goldfinger, tagged on January 6, 2025| 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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Modern BF history 2012: The ACA (Affordable Care Act) What about the role of the physician?

Posted in Medical topics, tagged on November 7, 2024| 36 Comments »

By Paul Goldfinger, MD, FACC  2012.        2024 update.

2012:       Now that the ACA has become a certain reality, the two areas that interest me most should begin to come into focus out of the mist.  One has to do with how the quality and availability of healthcare will be affected, while the second is about how the practice of medicine by physicians will change.

The evolution of all this will start out slowly and then become an avalanche over the next five years as new regulations come into play. At this time, there is no way to be certain about much of the details, because the ACA is, in large part, largely a skeletal plan waiting for the blanks to be filled in. There are many complicated aspects to all this, so let’s get specific: What will happen to physicians and the doctor-patient relationship?

It is clear that there will not be enough doctors to meet the needs of all the patients who will have health insurance. Care will be given by teams of providers, supervised by doctors who will delegate tasks to all sorts of physician extenders like nurses, technicians and PA’s. Doctors will no longer have a personal relationship with patients. Care will be largely governed by practice guidelines, and physicians will become cogs in industrial-size health systems. Most doctors will eventually become employees on salary; fee for service reimbursements will disappear as will the private practice of medicine by solo or small group practices.

Here are examples of the unsettling current climate that I have observed recently by talking to three physicians.

Doctor A is a solo internist who has been in practice for about 10 years. He is 42 years old and he is loved by his patients and highly regarded by his colleagues. He has just announced that he will soon close his practice and seek work in some type of large-scale setting like the VA, the military, or within a  hospital-run mega-organization. The reason is economic: declining reimbursements and rising costs have caused his “business” to fail.

Doctor B is a 52-year-old cardiologist who is a superb and caring clinician who is consistently mentioned in the “best doctor” rankings. His current practice hours are long and exhausting. He and his colleagues have formed a defensive alliance — a large group practice with other cardiologists — but he cannot keep up with the rising demand for his services accompanied by sharp declines in reimbursements (especially from Medicare) and by rising costs. Recently he stopped taking new patients, and his group had to fire some excellent employees.

Doctor B says that morale is low among his colleagues because they see no way to pedal faster while maintaining quality and income. He tells me that I “got out just in time,” and he is glad to be in the final phase of his practice.

Doctor C is a 3rd year internal medicine resident at a city medical center. He tells me that half of his fellow residents will go on to become specialists. Another quarter are seeking salaried hospital jobs. Those “hospitalists” work 7 days on and 7 days off.  The final 25% are seeking jobs in outpatient settings, but almost none of them are planning to open their own practice. He and his fellow residents expect decent pay in exchange for a better life style. Doctor C is satisfied with that conclusion. The new doctors coming out will learn to be comfortable with all the changes that the ACA will bring. They won’t miss a style of medicine that they will never experience.

Most practicing doctors today are feeling discouraged about the prospects for their profession. They see the ACA as destroying a system that could be improved but should not be changed wholesale, as will occur under the ACA. About 55% of physicians said that they would vote for Romney, vs. 36% for Obama.  (2012).

Stay tuned.

2024 update.  I have begun to pay attention to these topics  from the inside as my view has been sharpened by being a senior citizen and a patient.  I almost always find issues to complain about each time I interact with the healthcare system.

There are many moving parts, and many of those relate to incredible technologic advances, and that of course is marvelous .

But the parts that alarm me have mostly to do with doctor-patient relationships and especially with communication failures.  Doctors don’t seem to enjoy close interactions  with their patients, and the patients wind up being ill informed about their conditions.

If a doctor is willing to call you back, you are fortunate. A small army of physician assistants together with front desk triage dopes create roadblocks to being able to speak to your doctor, unless the interaction involves a fee.  This system is a failure, but everyone involved believes it to be just fine.

There are times where the lack of such relationships can be dangerous.Where is the inevitable army of malpractice attorneys.

Tele office visits are convenient, but they are suboptimal  without the physical exam and close conversations.

And now we are dealing with  a plexus of corporate mechanisms which control how the entire playing field of healthcare is being dramatically changed, seemingly with new processes almost daily.

The new “Epic” system of documentation and communication  appeals to me in many ways , but I don’t see how patients can enjoy such systems which are designed to replace the doctor patient relationships of old.  Confusion and mistakes can occur.  Data seems to replace the essential human component.

I had a serious specialized test done at a New York hospital a few days ago  and I was surprised to find the result posted on My Chart under the heading of the Hackensack Meridian system.  Privacy??  Who gave them permission to post my report?

Patients  and their advocates will have to make a greater effort to navigate the latest system dated now 2024.  Practice defensive medical care.

Paul Goldfinger, MD, Blogfinger Editor and CIC. (Complainer-In-Chief.)

And take care to practice equanimity:

Choir of Kings College:

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What your doctor won’t tell you: How much salt should a healthy person consume? Now Blogfinger brings you the latest word from the FDA.

Posted in Medical topics, tagged on August 17, 2024| 3 Comments »

Blogfinger.net  photo

 

See the August, 2024 AMA/FDA  update  at the end of this  4/24  post:

 

By Paul Goldfinger, MD, FACC. Co-author of “Prevention Does Work: A Guide to a Healthy Heart.”   4/24.

 

Here is a link to a 2013 Blogfinger post which explains the definitions of salt and sodium;

Dr. G discusses dietary salt

 

This small 15-ounce can of cooked peas in water contains 3 1/2 servings. Most of us can easily eat the whole can because it seems healthy to do so and it goes down easy. One portion has 380 mg (milligrams) of sodium (salt). The whole can contains 1,330 mg. sodium. That’s a huge amount, but not unusual for many processed foods such as canned soups.

On the other hand, a 16-ounce package of frozen raw mixed vegetables (Wegman’s “Just Picked and Quickly Frozen” Japanese Stir Fry) has 5 servings, but each serving has only 10 mg. of sodium. If you eat the whole package, you get only 50 mg. of sodium.  If you buy the Wegman’s shelled green peas in a microwave bag, the sodium content is zero and the nutritional value is probably better if you enjoy them raw than if you eat the cooked peas in a can.

Salt contains sodium and chloride, but the sodium is the important component. The American Heart Association recommends that we all consume less than one teaspoon of salt per day. A teaspoon of salt has 2,300 mg. of sodium.

We all should try to keep our sodium intake under 2,000 mg. This includes what’s in your food and what you add to food. Learn to wean yourself off added salt. Fresh corn on the cob seems to beg for salt, but you can get used to enjoying it without the sodium chloride. Avoid processed foods because they often contain extra salt, unless you find a product like our frozen vegetables.

When you read labels, ignore everything on the package except the ingredients. Look for the mg.  of sodium. Also look for portion size, because sodium content (along with all other ingredients) is given according to a portion size which may be surprisingly small.

Fresh foods are always best. Processed foods often have added sodium for taste and/or preservation. Please read labels and make good choices for you and your families.  Latest update below.

 

FDA lays out goals to reduce sodium levels in packaged, processed foods by 20%. 8/17/24

Reuters (8/15, Vanaik) reports the FDA “on Thursday laid out fresh goals to cut sodium levels in packaged and processed foods by about 20%, after its prior efforts to address a growing epidemic of diet-related chronic diseases showed early signs of success.” In October 2021, the FDA “had set guidelines to trim sodium levels in foods ranging from potato chips to hamburgers in a bid to prevent excessive intake of salt that can trigger high blood pressure.” The FDA “is now seeking voluntary curbs from packaged-food makers such as PepsiCo, Kraft Heinz and Campbell Soup.” The agency “wants to cut sodium intake over the next three years to an average of 2,750 milligrams per day – 20% lower than the levels prior to 2021.

 

Now you can’t say that a doctor never told you this stuff.

Cheer  up—-here’s Leon Redbone:

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Regular brisk walking may confer health benefits.

Posted in Medical topics, tagged on July 29, 2023|

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USA Today (10/20, Hellmich, 5.82M) reported that research shows that brisk walking on a regular basis may confer health benefits. Regular activity, including a walking program, may lower the risk for premature death, help people keep their weight under control, “and reduce the risk of heart disease, stroke, type 2 diabetes, depression, some types of cancer and a host of other conditions.” For walking to be its most effective, people should be walking briskly enough that they cannot sing but still can talk.

BLOGFINGER MEDICAL COMMENTARY  by Paul Goldfinger, MD, FACC

It is my professional opinion that some people cannot sing even if they are standing still. However, this is what we said in the exercise section of our book “Prevention Does Work: A Guide to a Healthy Heart:”

“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. “

One time we went to France, and within one day of arriving and having visited a bistro, a cafe and a patisserie, we decided to forget our diets.  So we ate croissants, foie gras  ( a delicious but very scary food), and all sorts of French cuisine. But we also did a great deal of walking.

When we got home, neither of us had gained any weight.  That impressed me regarding the value of walking as exercise.  I also know some Ocean Grovers who lost substantial amounts of weight simply by acquiring a dog. I don’t mean that they ate dog food, only that walking a dog is good exercise.

You also have to bend down a lot, and that too is good exercise.  In addition, carrying around a full poop bag can reduce your appetite.  Wegman’s bags are good for that purpose, and it’s pretty funny when yours says “asparagus.”

Another good exercise technique is dancing. If you are in the living room, try dancing around the room to “La Cachimba de San Juan” by the Havana Casino Orchestra:

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Medical update: Should we be eating rare hamburgers in restaurants?

Posted in Medical topics, tagged on July 17, 2023| 4 Comments »

 

Get internal temperature to 160 degrees F.  Go to 165 for turkey burgers. Consumerist.com

 

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

 

By Paul Goldfinger, MD, Dean.  (This article has been updated from our original 2017  post).   It is from the Blogfinger Off-Shore School of Medicine in Ocean Grove, NJ.

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..

Store butchers say that the tastiest burgers come from  80/20 ground beef:  80% beef and 20% fat (aka “chuck.”)

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:

www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/meat-preparation/ground-beef-and-food-safety/CT_Index

HAMBURGER. (beef)  MEAT (160°F)

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.   After handling raw beef, wash hands with soap and water.

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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Medical: Birth control on Route 95, heading south.

Posted in Medical topics, tagged on March 23, 2023| 2 Comments »

Georgia on Route75 heading south, stopping for gas and looking around. PG photo Georgia on Route 95 heading south, stopping for gas and looking around. It seems we reached a crossroads.   PG photo.  Left click for full view.

By Paul Goldfinger, MD, FACC.  2013 on Rt. 95  Re-post 2020.

Sometimes in life you reach a crossroads, and in this case you can choose between a drink or a no-needle, no-scalpel vasectomy.  If you are in the market for a permanent pregnancy preventer, then maybe you would consider doing both.

When I saw that billboard, however, my interest as a physician was raised significantly  (perhaps “raised” is not the ideal verb) because I couldn’t figure out how that promise could be kept.

For those of you unfamiliar with this procedure, the vasectomy is a surgical intervention performed on the male to prevent any of his sperm from ever reaching the promised land.  It is the most commonly performed urological procedure.  About 500,000 are done each year in this country.    The operation is minor and safe in the hands of an experienced surgeon. It rarely fails to work, and it frees up the female from using contraceptives or having surgery herself.

So, when I got to a Wi-Fi zone, I had a Starbucks and checked out the new method.  In the traditional form of the technique, a local anesthetic is administered by a thin 1 1/2 inch needle which is gently used to numb the scrotum skin and then penetrates further to reach the vas deferens (ie the spermatic cord) a long tube whose job is to transmit sperm from the testicles to the penis.  An incision is then made, and the vas deferens is cut and tied off. There are two vas deferenses, so usually two incisions are used. vas

The new technique was developed in China where a lot of men are fearful of the needle/scalpel method.   The numbing is accomplished using a high pressure spray device  (“a jet injector” made in New Jersey) which numbs the skin and the deeper tissues—thus, no needle.   Then, the scalpel incision is avoided by creating a self sealing puncture hole which allows the surgeon to do the job.  As you might imagine, this procedure requires a lot of experience, but it attracts many men who fear the needle and the scalpel more than their wives.  Side effects including bleeding and infection are less with this new method. It also feels like you are dragging your scrotum around for two weeks.

The bottom line is that the surgeon still has to anesthetize the area and he still has to cut the vas deferens. But this new technique gets the job done with less discomfort, less psychologic distress, and reduced risk of side effects. If you consider this procedure, make sure that the surgeon has had a lot of experience. If you are a married woman  who has had all the children she wants, you might suggest this to your spouse, and then go with him to the doctor and don’t let go of his hand.

Note that they do it at NYPresbyterian Hospital. It is an outpatient procedure  and it takes about 30 minutes or less. Dr. Stein  (the urologist on the billboard) charges $490.00, but, if you want it reversed, the charge is $4,900.00.  However, reversal surgery doesn’t always work.

BRUCE SPRINGSTEEN with DARLENE LOVE:   “A Fine Fine Boy”

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