Thursday, July 31, 2008
Wednesday, July 30, 2008
Effective Jan 1, 2008, there are two codes that doctors can use for "Smoking and tobacco use cessation counseling visit: intermediate, up to ten minutes (99406)" and "greater than 10 minutes (99407)". The reimbursement for 99406 is $11.96 and for 99407 it is $23.55.
(Yes, you saw those numbers correctly. I can't wait to get my check for $11.96)
Welcome to the world of Primary Care.
Smoking is one of the most detrimental of bad health habits and it costs each American $630 a year in federal and state taxes for the public health of smoking related problems. A pack of cigarettes costs $4.49 and a 40-year-old who quits smoking and puts the savings into a 401(k) earning 9% a year would have nearly $250,000 by age 70. So how much is primary care counseling really worth to society?
Why is something that should be valued...helping patients quit smoking...reimbursed pennies, yet a CT of the lung to check for cancer can be reimbursed over $2,000.00. Add on pulmonary consults, PET scans, follow up CTs, and Chest X-rays to evaluate a lung nodule and you can be up to $25,000 in no time at all. That is all just "screening"...not even a diagnosis or treatment.
What does this tell us? Primary care is dead in the United States and our health system is imploding with misaligned incentives and payments. The $11.96 that Medicare pays a primary care physician will buy 2 packs of cigarettes with change left over for a donut.
Sunday, July 27, 2008
In one week we heard of two new ways that Viagra is being used for more than male erectile dysfunction (ED).
First the story came from the Journal of American Medical Association (JAMA). Researchers looked at women who had sexual dysfunction from taking antidepressants. Up to 70% of women who take antidepressants loose interest in sex or have difficulty having an orgasm. The average age in this study was 37 and they found that 72% of women who were given Viagra before sexual activity said they had improvement in sexual function compared with 27% in the placebo group.
It should be noted that Viagra doesn't do anything for womens sexual desire or libido. And it doesn't work for everyone , but for the subset of women whose sexuality changed after being on antidepressants, it might be worth a try.
The 2nd new use for Viagra is to treat babies who are born with pulmonary hypertension. Because Viagra allows more blood to flow to lung vessels, it improved symptoms for these babies and allowed one to be weaned from ventilator.
Isn't modern science wonderful?
Friday, July 25, 2008
This tongue shows atrophic glossitis. Notice that the taste buds (papillae) in the center of the tongue are gone. This is most often associated with vitamin deficiency like folic acid and vitamin B. Celiac Disease causes inability to absorb certain vitamins in the gut and pernicious anemia is often the result.
In third-world countries where protein calorie malnutrition is present, atrophic glossitis is very common.
Thursday, July 24, 2008
Wednesday, July 23, 2008
"I smoke ten cigars a day,' she said. ' Before I go to bed I smoke a few cigarettes, and I like to drink a whole bottle of Jack Daniels each week. I eat lots of fast food and on weekends I pop pills. I never exercise."
"That's absolutely amazing! How old are you?"
"Twenty-four", she replied.
(Hat tip to Ray B)
Tuesday, July 22, 2008
Monday, July 21, 2008
The news buzz of the day concerns the conservative radio talk show jock, Michael Savage, and the outraged parents who are petitioning for his firing. This "shock jock" personality used his show to rant about something he has zero knowledge.
Michael Savage said autism is a "fraud and a racket" and that "in 99 percent of the cases, it's a brat who hasn't been told to cut the act out. That's what autism is. What do you mean they scream and they're silent? They don't have a father around to tell them, 'Don't act like a moron. You'll get nowhere in life. Stop acting like a putz. Straighten up. Act like a man. Don't sit there crying and screaming, idiot.'" In defending his comments he went on to say, "It's an over diagnosed medical condition. In my readings, there is no definitive medical diagnosis for autism."
When challenged further, he defended his comments by lashing out at the medical community and lambasted "greedy doctors who use children as profit centers by a greedy, corrupt medical/pharmaceutical establishment...."
Sorry, Michael Savage. You've really gone too far this time with your hateful "Savage Nation". You may know nothing about autism, but as a physician I know far too much. It is a spectrum of brain dysfunction that can be truly heartbreaking for parents and families. It has nothing to do with spoiled children or neglectful parents and your ignorance would be laughable if millions of people didn't hear you on the radio.
Michael Savage is first a showman. He is so proud of his comments that he is keeping the debate going by continuing the accusations against the medical establishment. And why not? His name is in the news and controversy is like money in the bank for him.
Michael Savage, you owe millions of parents, children and doctors an apology and if I were your boss, I WOULD fire you for just being plain stupid.
Thursday, July 17, 2008
The confusion about which diet is best for health and weight maintenance has plagued us for decades. The New England Journal of Medicine reported today that the Mediterranean and low carbohydrate diets are the way to go. Here were the parameters:
Low Fat Diet - based on the American Heart Association with no more than 35% of calories from fat. The participants were counseled to consume low fat grains, vegies, fruits and legumes and to limit additional fats, sweets and high-fat snacks. Calorie restriction of 1500/day for women and 1800/day for men.
Mediterranean Diet- Rich in vegies and low in red meat with poultry and fish replacing beef and lamb. No more than 35% of calories from fat and the main sources of added fat were olive oil and 5-7 nuts a day. Calorie restriction of 1500/day for women and 1800/day for men.
Low-Carbohydrate Diet- 20g of carbs/day for 2 months with a gradual increase to a max of 120g a day. The intakes of total calories, protein and fat were not limited but the participants were counseled to choose vegetarian sources of fat and protein with no trans fat. (Based on Atkins diet)
All the groups lost weight but the low carb and Mediterranean diet groups lost the most. All groups decreased their waist circumference and blood pressure.
The low-carb group had the best lipid profiles (cholesterol and triglycerides) and the largest decrease in these levels.
C-reactive protein decreased the most in the Mediterranean diet and low carb groups.
The Mediterranean diet group had the best improvement with diabetes. The low fat group increased their fasting glucose levels. The low carbohydrate group had the best improvement in glycated hemoglobin (a marker for blood sugar control).
The liver tests were the same in all groups.
So the take home message is that calorie restriction works for weight loss (surprise) but the low carb and Mediterranean diets had beneficial metabolic effects beyond weight loss. Weight loss was the same with the low carb group without restricting calories!
It looks like the "Atkins Diet" might be making a comeback based on this well controlled trial.
Tuesday, July 15, 2008
Yes, the practice of medicine is a joy. But your doctor does get irritated at times. We know what irritates patients...waiting too long, being put on hold, doctors rushing you out the door. Do you ever wonder what yanks your doctors chain? I'm willing to bet these are universal:
- Calling for a drug refill on weekends or nights and not knowing the pharmacy phone number. "Oh it's the pharmacy I always use". Let me tell you...I don't want to search information for your pharmacy number. Be prepared. Better yet, call during office hours.
- When we call you to report your test results it is usually at the end of a long day. It's not the time for you to bring up brand new health issues. We want you to have your results but those phone calls are keeping us from getting home. Please just say thanks. We dread those calls because what should take a minute can drag on and on.
- Please don't call and cancel your appointment at the same time you are supposed to be there. Would your hairdresser stand for that?
- I want to concentrate on you when you have an appointment. Please don't ask medical questions about your friend, relative, acquaintance. That is not a good use of our time and it is irritating as hell.
- Please don't call me to get the test results that another doctor ordered. It is time consuming to pull your chart, call you back and try to interpret tests that someone else thought was necessary. We hate it when you say "Oh, Dr. Jones is so busy...I couldn't get through to him so I called you." Guess what, I'm busy too and now I'm irritated and busy.
- Please don't ask for handicapped placards if you aren't really handicapped. The same goes for jury duty excuses. I serve on jury duty and so do my employees. Enough said.
Monday, July 14, 2008
This shocking vid has made the rounds over the past few weeks. At EverythingHealth I don't like to rant and rave but I do appreciate the ranting of other medical bloggers. Check out this great post by White Coat Rants about this woman dying on the floor of a hospital without anyone noticing. There are lots of pointing fingers and blame to go around, but perhaps cutting the funding to psych hospitals might play a role? His blog is worth a read.
Sunday, July 13, 2008
I wrote about the cozy relationship between pharmaceutical companies and academics last month but now the subject is heating up in the New York Times.
Here's how it works. Drug and device makers (think: joint replacements, pacemakers, heart stents) pay doctors and academic programs millions of dollars to collaborate in research, write scientific articles that always show the drug or device to be better, and go on speaking tours around the world, convincing doctors to use the product.
Conflict of interest? Of course it is. The defenders will say that they always "disclose" the conflicts. But here is what they mean by "rigorous disclosure policies and federal guidelines".
The speaker or writer simply reports they are a speaker for a certain company: "I have been a consultant for Pfizer, Lilly and Astra-Zenica." End of story. Every educational program I attend has this disclaimer and every speaker has some type of relationship or another. It's like the do not remove tag on your mattress or the small print in a TV ad. It is so ubiquitous, no one cares.
We don't get told what Senator Grassley, who is investigating these relationships, found out. That Dr Alan Schatzberg, the president elect of the American Psychiatric Association, holds $4.8 million stock in a drug development company that he is promoting. That many physicians handsomely supplement their income with speaker fees and these physicians prescribe three times as many prescriptions of the new powerful drugs to children.
Dr. Melissa DelBello, of the University of Cincinnati, received $238,000 to promote the antipsychotic, Seroquel. Dr. Thomas Spencer, Harvard professor, reported earning at least $1 million after being pressed by Mr. Grassley's investigators. The list goes on and on and we all know that this is just the tip of the iceberg.
I saw a multi page report that showed the names and fees paid to orthopedic physicians to research and speak about replacement joints. This multi billion dollar industry can throw a few hundred thousand at each influential orthopedic surgeon and hire a ready made sales force. Hundreds of surgeons from large and small hospitals across the U.S. have been part of this payola. Many were influential surgeons I know.
There are many who defend this corruption and say it is a way to bring "needed drugs to the marketplace." Who better to test and analyze expensive devices than the doctors? What is wrong with paying doctors for their consulting expertise?
When this much money changes hands, when we see that it does affect prescribing and when so much of it is hidden and under the table, it is hard to make a case that it is ethical. The doctors and institutions on the receiving end will scream loud and hard that they have the "interests of patients" in mind. Don't believe it.
Saturday, July 12, 2008
Estrogen mimics are a group of different molecules that attach themselves to estrogen receptors in cells and mimic the action of natural estrogen. DDT is an estrogen mimic, as are other estrogen-like chemicals (DEHP) that show up in plastic bottles and even nail polish. There has been suspicion that they can endanger animals by feminizing the sex organs of male frogs and fish living downstream from sewage treatment plants.
Now researchers in Wales have compared starlings raised in aviaries with those living near sewage treatment plants and they found that during mating season, the male who ate the "estrogen cocktail" (worms and bugs from rocky filter beds), sang 5 times as long and louder and composed more complex songs. To a female starling it was like a blue box from Tiffanys ...they were more attracted to those "estrogenized males."
OK, so what's the big deal? What is so wrong with having a little mating advantage? After all, human males have Viagra, right?
Blood tests showed that the doped male starlings were less fit. They had compromised immune systems and should not have been the first choice of the female bird. They fooled the female and were really the rejects.
Starling population in Britain have dropped by half in the last four decades. No one knows for sure why, but perhaps the gals are fooled into picking duds.
When I look a some of the bad choices human women make...I wonder if other pollutants are in play too. It ain't nice to fool mother nature.
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Thursday, July 10, 2008
One of the reasons we are getting fatter and diabetes is becoming epidemic is our intake of concentrated fructose (High Fructose Corn Syrup). A new study shows intake of fructose has increased in the typical US diets to more than 10% of energy intake with negative effects on the health of children and adults.
We are supposed to get our fructose (sugar) in the natural form from fruits and vegetables. But less than 20% is consumed this way. Fruits and vegies contain fiber and help us maintain healthy body weight. Fructose added to soft drinks and processed foods is highly concentrated and contains no other nutrients.
High fructose intake causes increased plasma triglyceride levels, insulin resistance and obesity. OUR BODIES AREN'T SUPPOSED TO BE EATING IT.
Start looking at the labels of foods and you will see huge amounts of high fructose corn syrup which is about 50% concentrated fructose. Not only does it add empty calories but it is added to foods that already have high calorie counts. Adolescents age 12-18 had the highest intake and sugar-sweetened beverages accounted for the largest source of fructose.
These researchers say if all sources of fructose were eliminated other than whole fruit and vegetables, children and adults would eliminate 82% and 75% of fructose from their diets, respectively.
My advise is to swear off soft drinks and other sweetened beverages. Load up on summer fruits and vegies. If you are thirsty drink cold water or iced coffee or tea.
Wednesday, July 9, 2008
There is an old saying I repeat when a problem is so big it is overwhelming. It goes: "How do you eat an elephant?" Answer is "One bite at a time."
So how do we deal with the 500 billion to a trillion plastic bags that are used each year by consumers? We know they are bad for the environment. We know they end up as litter in streams and oceans and landfills where they do not biodegrade and the toxic chemicals leak into groundwater. About 100,000 whales, seals, turtles and other marine animals are killed by plastic bags each year, according to Planet Ark, an international environmental group.
Before the 1980s we didn't have these plastic bags but now we can't do without them. In South Africa, the bags are so prominent in the countryside that they are called the "national flower". Some Countries like Australia, Bangladesh, Ireland, Italy, South Africa, Taiwan and India have banned or discourage the use of plastic bags. But with a trillion new bags in use each year, we have to do more.
We each need to do our part. If you don't have reusable cloth shopping bags, get them today. I keep mine in the back of my car because it is so easy to forget them.
Stop the checker from grabbing a plastic bag to hold that carton of ice cream. They do it automatically and it is not necessary. Even fruit and vegies do not need plastic at the grocery store. Just place it in the basket and load it into your reusable bag at the check counter.
You can reuse those handy zip lock bags. They can be used over an over and rinse out nicely. Less than 2% of plastic bags get reused. If you have a plastic bag, reuse it as much as you can.
Will these small changes make a difference? I have no idea but the elephant is pretty big and one bite at a time sounds reasonable to me.
Tuesday, July 8, 2008
Ever since Tim Russert died of an acute myocardial infarction at age 50, men all over the country are wondering about their own ticking hearts. This brilliant article by Michael Bicks in the New York Times describing his own experience with a heart attack is sure to send a chill up your spine.
I have always said we are really at the infancy of understanding heart disease and the factors that cause a heart attack. That damn unstable plaque! At the very least, remember to take your baby aspirin once a day!
Monday, July 7, 2008
I had a little time over the weekend to cruise some other websites and see what is on the blogosphere. Here are a few links that will make you laugh, ponder, angry or wish "Why didn't I think of that".
An ER doctor rants about drug seekers on Craigslist (guess he doesn't have a blog...too bad) Years ago I was an ER doc and I totally get it. Don't read this at work or if you hate the "F" word.
Ever get annoyed at parkers who take up two spaces? Don't get angry, get even on this site.
Dr Paul Levy, the blogging CEO at Boston's Deaconess Hospital owns up to the most serious of medial errors: Wrong Site Surgery. Going public is a good thing and it just points to the need for standard protocols that are followed EVERY TIME without fail as I wrote about on Surgical Checklists.
The post about the 77 year old who gave birth to twins made me crazy. Just because we have the technology to do something, doesn't mean we should do it.
If you want to really understand what is happening with Medicare and the 10% cut in physician reimbursement, read what The Happy Hospitalist has to say. It's long and wordy but chuck full of information you won't find anywhere else. It will show you why primary care is gasping its last breath. He says "Let the cuts stand" and that will completely unravel primary care in this Country and force true health care reform.
Gee that was fun.
Sunday, July 6, 2008
Nothing is better than a good book on a hot summer day. Or making sure you have a good read while you are waiting in the airport. "Better (A surgeon's Notes on Performance)" by Atul Gawande is a great book if you enjoy non-fiction.
Gawande uses medicine as the platform to write about high performance in what ever we do. From the updated MASH units operating in Iraq to looking at modern childbirth and how it has changed over decades, he shows how ingenuity and persistence reap benefits for millions of people.
He has a chapter on treatment programs for Cystic Fibrosis that shows the difference between being 99.5% successful and being 99.95% successful means years of life to the patient. What makes the difference? He writes that "Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously."
Dr. Gawande, a Surgeon at Brigham and Women's Hospital in Boston, is a terrific writer and he knits together each topic in a very readable and thought provoking manner. Check it out!!
Thursday, July 3, 2008
Wednesday, July 2, 2008
Tuesday, July 1, 2008
I guess research money is easier to to get now. I saw an advance copy of a study to be reported in Circulation in July that has the astonishing finding "that eating fruits, fiber and vegetables is better for women's health than eating saturated fats and sugar."
Yes, these courageous researchers from Harvard School of Public Health recommend a diet that limits saturated fats, cholesterol and sodium. They advise lowering sugar consumption and eating more fruits, vegetables, whole-grain and high fiber foods.
Well, there you have it! In 2008 we now know that we should eat a healthy diet to promote health.
Maybe next they will study the effects of rubbing glass into eyeballs and how it affects vision.
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