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Archive for the ‘Medical topics’ Category

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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A Special Delivery on Madison Avenue.

Posted in Medical topics, tagged , on December 2, 2021| 2 Comments »

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:

https://blogfinger.net/?s=losing+sleep+in+the

(reprinted from the Ocean Grove Record, 2004)

 

LESLIE ODOM, JR.  From the Broadway show Hamilton.

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MEDICAL: The Case of the Hypokalemic High Jumper.

Posted in Blogfinger Medical Reports, Medical topics, tagged on October 23, 2021| 6 Comments »

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 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 I would have to lower the talking bar for this high jumper. So I tried another detailed history.   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 at “Sinai” which lasted about two days.  It was the first time a published medical report contained a serum insulin level.

History taking is becoming a lost art. Electronic medical records encourage doctors to use checklists and computers, 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.

 

LITTLE WILLIE JOHN:

 

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Is sex good for the heart? A new doctor meets the press.

Posted in Medical topics, tagged on July 9, 2021| 2 Comments »

 

 

The new Dr. Goldfinger talking to myself at Dover General Medical Center in Morris County, NJ. c.1975

Talking to myself at Dover General Medical Center in Morris County, NJ. c.1975

 

When I opened my new office for the practice of cardiology, I was hoping for some publicity in order to get known in the community.  Then I got a call from the Daily Advance, a small town newspaper in Dover, New Jersey.  They wanted to send a reporter to interview me about something.

She was an attractive young woman who sat down in my consultation room with a pad and pen in hand. Then she said, “There is a new medical research study which says that sex is good for the heart.  What do you think?”

I immediately realized that this was a mine field that I had to carefully navigate. So I said, “Well, uh, um, hmmm.”

But finally, I said,”You know, sex can be a good source of exercise, and we know that exercise is good for the heart.”

“OK…,” she said.

“And so, you know, um, it all depends on how you do it….I mean that the amount of exercise determines how good it is for your heart. Um, I don’t mean your heart, I mean hearts in general. So you have to get the heart rate up in order to get that aerobic benefit.”

“So,” she said, “I guess then that you agree that sex is good for the heart and you would recommend that for your patients.”

“Well,” said I, “Heart patients have to be careful to not get too excited…er, I mean they should be gradual and not so vigorous…uh..are there more questions?”

She said, “I was just wondering if someone  could die during sex.”

At that point my mind was getting ahead of itself. It occurred to me that it might be worth dying for, but I said to myself, “Self….don’t be a wise guy.”   I was recalling a medical report that suggested that the risk of sudden death during sex was greatest if a man were doing it with someone who wasn’t his wife.  But I wasn’t going to share that with her.  Then she stood up, and the interview was over.

The next day, on the front page of the Advance, was the article about me, and the headline was, “Sex—You Knew It Was Good for Something.”  Thankfully, she managed to get my remarks straight.

The Hit Crew with some medical advice:

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MEDICAL: Antibiotic may not be best treatment for sinus infections.

Posted in Medical topics, tagged on December 2, 2020|

Sinusitis: You can get a print of this, suitable for framing, by writing the Mayo Clinic.

 

The Washington Post (2/15, Huget) “The Checkup” blog reports, “A study released Tuesday adds to the growing body of science suggesting that with some infections, including those of the sinuses, antibiotics aren’t the best course of treatment.” Investigators found “that in their study of 166 adults with sinus infections, those who were given the antibiotic amoxicillin didn’t feel better any faster than those who received a placebo. People in both groups experienced about the same amount of relief after three days.” The study is published in the Journal of the American Medical Association.

Bloomberg News (2/15, Ostrow) adds, “One in five antibiotic prescriptions in the US are given to adults for sinus infections, the authors wrote. The findings suggest doctors avoid routine antibiotic treatment for patients with an uncomplicated sinus infection, they said in the study.”

Medscape (2/15, Brown) reports, “‘Considering the public health threat posed by increasing antibiotic resistance, strong evidence of symptom relief is needed to justify prescribing of antibiotics for this usually self-limiting disease,’ the authors write.”

“CDC guidelines for the evaluation and treatment of adults with sinusitis…suggested that doctors only prescribe antibiotic treatment for the condition when patients have moderately severe or severe symptoms,” WebMD (2/15, Broder) notes.

Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC.  This post is from 2013, but is still valid.

It has been known for over fifty years that most upper respiratory infections  (URI’s) are due to viruses and not bacteria.  Why is that important?  Because viruses do not respond to antibiotics, while bacteria do.  When I went to med school they taught us to rule out Strep throat (the cause of rheumatic heart disease) with a throat culture and treat with penicillin if positive.

If the  culture was negative, and since most URI’s are viral, we were encouraged to withhold antibiotics and treat with decongestants, humidifiers and analgesics.  Then, if signs of bacterial overgrowth were to develop later (e.g. a bronchitic cough, discolored sputum, fever, signs of pneumonia, etc.) then an antibiotic could be added.  The main reason why everyone with a URI should not get antibiotics is because of concern about a major public health problem—antibiotic resistance.

Many patients with URI’s involving the nose and throat also have sinusitis, which is one of the most common conditions that doctors treat. It is very uncomfortable, and patients expect doctors to give antibiotics—most do.  The study above shows that for patients with uncomplicated rhinosinusitis (rhino refers to your nose), antibiotics do not reduce symptoms better than placebo.  About 70% of cases will subside spontaneously.  The study was done using a special questionnaire called SNOT-16. Who says doctors have no sense of humor?

Even if bacteria are present in the sinuses, antibiotics may not work, because the sinuses are closed spaces with limited drainage; good drainage is an essential aspect of curing infections. Complicated and/or recurrent sinus infections can be difficult to treat, and ENT docs have a variety of approaches to such cases.

But if you have a “common cold” with or without an element of sinus infection, the problem usually will resolve without antibiotics. If you are sick, let your doctor decide.

ADELAIDE’S  LAMENT..from Guys and Dolls:

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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|

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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|

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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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CDC says flu activity has reached epidemic threshold.

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, tagged on January 3, 2015|

 

 

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“Following earlier warnings from the CDC that this year’s flu season could be more aggressive than other years, the agency announced that flu incidence has crossed the epidemic threshold. An emailed statement from the CDC’s flu division said that influenza “reaches an epidemic level when the proportion of deaths attributed to pneumonia and influenza reaches a certain threshold: 6.8 percent.” Most major national outlets covered the story, focusing on both the characteristics of this year’s strain and the efficacy of the vaccines currently available. Local media have focused on the flu as it has affected local hospitals and school systems.

“The Washington Post (12/30, Ohlheiser) reports that the CDC’s announcement that this year’s flu activity has reached “epidemic levels” comes as “the number of states reporting a ‘high’ level of influenza activity jumped from 13 to 22 in one week.” The dominant strain of the flu this year is H3N2, and in early December CDC Director Tom Frieden warned that “H3N2 predominant seasons tend to have more hospitalizations and more deaths.”

“Similarly, ABC News (12/31) chief health and medical editor Dr. Richard Besser said that “while this year’s strain of the virus is especially severe,” the flu “can always be deadly for children, the elderly and anyone with a compromised immune system.”

“USA Today (12/31, Grisham) reports that according to Michael Smith, a doctor and chief medical editor for WebMD, the H3N2 strain of the flu “isn’t uncommon; it’s just not what was predicted when the flu vaccine was created.” What ultimately gets included in the vaccine is decided each year by the FDA “based on recommendations from the World Health Organization” and “takes about six months to produce.”

“Reporting on the available treatments, Bloomberg News (12/31, Cortez, Edney) adds that some areas of the US “are experiencing spot shortages of Tamiflu (oseltamivir),” one of the mainline flu treatments for this year.”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

Influenza can result in a “superinfection” with pneumonia.   Such lung infections can cause death in about 8% of cases, and the combination can cause a patient to get very ill and wind up in the hospital.    

If you are over 50, ask your doctor about a new vaccine to prevent pneumonia called Prevnar13.  It is not 100% protective, but it can offer good results in some people. It is a single shot treatment, and it doesn’t matter if you had a pneumovax shot in the past  (except less than one year ago.)

If you haven’t had a flu vaccine, you can still get one.   This new pneumonia vaccine can cost about $135.00, but Medicare may pay for it.

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Preventing Stroke by Extended Heart Monitoring Looking for Atrial Fibrillation (AF)

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, tagged on July 22, 2014| 2 Comments »

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The New York Times (6/26, O’Connor) “Well” blog reports that “two major studies suggest that many strokes of unknown origin (i.e. cryptogenic strokes) — up to a third — may stem from atrial fibrillation.”   Atrial fibrillation  (AF) is a cardiac rhythm disturbance which causes the heart to beat erratically.   “These findings are likely to encourage physicians to look more aggressively for signs of atrial fibrillation in patients who suffer strokes of unknown cause.”

Hooman Kamel, MD, Weill Cornell Medical College, New York, says that most patients with cryptogenic stroke or transient ischemic attack should undergo at least several weeks of rhythm monitoring.

 

Blogfinger Medical  Commentary.  By Paul Goldfinger, MD, FACC

When considering the cause of stroke, the heart is usually not directly involved.   But if that occurs,  it is usually due to a clot  (an embolism,)  originating in the heart,  traveling  to the brain . This condition  is called an “embolic stroke”  and may be due to atrial fibrillation.  Atrial fibrillation  (AF) can be chronic  (i.e. present all the time) or intermittent (paroxysmal—-  PAF)

Stroke patients receive a workup in the hospital to look for a specific cause of the stroke.   After that  initial evaluation, including heart monitoring,  up to 1/3 of stroke cases are found to  have no obvious cause—i.e. they are “cryptogenic strokes.”   But the absence of AF in the hospital does not rule out PAF as the cause of the stroke.

In the past, if we found AF in the hospital, we would soon start anticoagulation (blood thinners) to prevent clot formation. If there was no AF in the hospital,  many doctors would also get an outpatient  24 hour Holter monitor recording done.   But thanks to new extended heart monitoring technology, we now know that AF may  commonly occur intermittently, including very infrequent episodes,  last for short periods of time, produce no warning symptoms, and  can cause embolic  strokes.  So now we have the challenge of finding out if a stroke victim has undetected paroxysmal AF  (PAF,)  and that involves extended ECG monitoring of the heart’s rhythm.  Just a few days of monitoring is not enough.

This fairly new observation about PAF has awakened the cardiology community, and on June 26, 2014, two new clinical trials, one from Canada and the other from Italy, appearing in the New England Journal of Medicine, have confirmed that embolic strokes due to PAF are more common than ever thought before, and that finding those patients  with new monitoring methods may save lives by getting those individuals on anticoagulation treatment and possibly treatment aimed directly at the AF itself.

That is why the American Heart Association now  suggests that doctors order heart monitors for up to 30 days to look for evidence of “silent” PAF  (i.e. the arrhythmia occurs, but there are no symptoms such as palpitations.)  

And now, thanks to long term monitoring (for months or years) using small implantable devices that are on constant alert (Medtronic “Reveal XT”), one of those new studies  reveals that up to one third of those cryptogenic strokes are, in fact, due to parosysmal atrial fibrillation.

Medtronic implantable heart rhythm monitor. Medtronic graphic.

Medtronic implantable heart rhythm monitor. It is placed under the skin on the chest . Medtronic graphic.

The NY Times article  linked above speaks in lay terms  about these amazing monitors, and as a cardiologist interested in heart rhythm problems, this is very exciting.  As with all new medical discoveries, new answers generate new questions, and  related issues need to be investigated to identify how to best use the new technologies while keeping costs down.

Some insurance companies may not pay for the expensive implantable monitor.  In my opinion, anybody who is found to have a stroke or TIA due to AF,  should undergo an evaluation by an electrophysiologist—-a cardiologist who specializes in heart rhythm disturbances.

 

 

 

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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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AMA: “Little evidence multivitamins prevent heart disease, cancer.”

Posted in Medical opinions by a physician, Medical topics, tagged on February 25, 2014| 6 Comments »

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According to USA Today (2/25, Painter), “Most vitamin and mineral supplements, alone or in combination, have not been proved to help or hurt when it comes to preventing cancer or heart disease, says a new report from the…US Preventive Services Task Force.” In the majority of “cases, more research is needed, but there are two exceptions, the panel says: Consumers should not take beta-carotene or vitamin E to prevent heart disease or cancer because vitamin E doesn’t work and beta-carotene increases the risk for lung cancer in people at high risk for the disease.”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

In 2011 when we finalized the current edition of our book “Prevention Does Work–A Guide to a Healthy Heart” we reviewed all the current data on vitamins and came up with this summary, “Vitamins used to be recommended as preventive therapy due to their anti-oxidant actions. In recent years, however, large trials have shown no benefit with vitamins, so these supplements can no longer be considered part of a prevention regimen. This conclusion does not apply to vitamins found in fruits and vegetables “

The AMA summary above brings us to 2014 on the subject of vitamin supplements.  There was a 2012 trial of Centrum Silver which suggested that daily multivitamin use in men might reduce the risk of cancer, but the proof was iffy.  The article below from Forbes is a brief and excellent review of the whole topic.

A huge number of people take vitamins regularly, but unless they have a vitamin deficiency, they are just engaging in wishful thinking.  As a practicing doctor, some patients did confess that they took vitamin supplements.   My reaction was to say that there was no good evidence as to benefit, and I reminded them that supplements are not always safe.

Do I take daily vitamins?  No.  But after the 2012 study, I hopefully bought a bottle of Centrum Silver, however,  it still is sitting in a closet, with about 14 tabs missing—my personal two week trial.

Good vitamin review at Forbes

EDITOR’S NOTE:  I call your attention to the comment below where David Seres, MD, a genuine expert in nutrition and Associate Professor of Medicine at NY Presbyterian Hospital in NYC, has offered us a superb and erudite discussion of the roll of vitamin supplements in preventing disease.

David is also a Grover, one of many highly accomplished individuals who call Ocean Grove home. So, you see, you never know who might be in line with you at Days.   —PG

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Concerns about HHS rule allowing consumer access to lab results.

Posted in Blogfinger Presents, Medical topics, tagged , on February 12, 2014| 5 Comments »

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CBS News (2/11, Castillo) reports on its website about concerns with the new HHS rule allowing medical labs to provide test results directly to patients. Some medical providers are worried that unexplained test results may cause concerns among patients who are not trained to understand them.

Blogfinger Medical Commentary    by Paul Goldfinger, MD, FACC

Even though patients are generally not equipped to interpret their lab results, they should make sure to obtain copies of their labs for their records. The same is true of their latest ECG, their CT scan report, biopsy results, XRAY reports, etc.  Even consultation notes should be requested. I actually believe that inquisitive patients can learn a lot from their own test results.

Patients are entitled to their records.  In the future, and even now in some places,  patients can access their results online, but one way or another, get your reports.  This HHS ruling is good for patients, and I have no sympathy for doctors who might be opposed.

Patients need to empower themselves and learn about their medical problems in an act of self defense based on the current deterioration in how medicine is practiced, especially in the outpatient setting.

Physicians sometimes forget to report the results of lab tests to patients, and one should never assume that everything is OK just because the doctor hasn’t called with results.  Sometimes test results get overlooked. Lab tests are done to obtain certain information about a person’s health, but the results are worthless unless the doctor reviews them, interprets them and then reacts to them.

What's her name and what's her title, and can I talk to the doctor?

What’s her name and what’s her title, and can I talk to the doctor?   Internet photo

In many offices, you will not hear from the doctor—- only from a nurse or some other medical helper whose credentials and name are often a mystery .  Sometimes they are abrupt, ill informed and confusing, leaving you with opacity instead of clarity. Sometimes you don’t even know if the advice you are being given is from the doctor or just the end result of some time-saving office procedure for dealing with patients without “bothering” the doctor.    If needed, ask to speak to the doctor.

Having obtained your results,  you may find it frustrating to try to obtain explanations.  I have discovered, now that I am a patient,  that there is a new communications tyranny in doctors’ offices that compromises access for inquisitive patients.  It’s as if a wall of resistance has been built between the physician and his patients.   If I figure out how to deal with it, I’ll let you know.

Meanwhile, I am still putting my MD to good use, even though I would prefer to simply leave it all up to my doctors. I can navigate around some issues,  but the average patient must learn to swim or find themselves adrift in a sea of medical confusion.  And don’t forget to get second opinions if there are doubts and find an “advocate” to help you if you are feeling muddled.

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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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“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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