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Observation status: When you’re not a hospital inpatient

Physician

February 8, 2014

Two decades ago, a decision was made by Medicare policymakers that carotid endarterectomies would not be allowed. Their claim was too many were being done costing Medicare money. The following year, data revealed a sharp rise in debilitating strokes, so wisely, surgical criteria was developed recommencing the use of this quality-of-life saving operation.

For years, there have been other misjudgments against Medicare patients that are only now becoming apparent. Let me clarify …

Approach patients as one human caring for another

Shoa L. Clarke, MD, PhD

Medical Education

February 8, 2014

Remember your humanity, and forget the rest.
-The Russell-Einstein Manifesto

The American healthcare system is a paradox of triumph and failure. We lead the world in medical innovation, yet we lag behind in cost, quality, and equity. During my last month of medical school, I sat with a group of graduating students to discuss this challenge. As students, we had directly confronted the shortcomings of modern healthcare. As the next generation of …

MKSAP: 33-year-old woman with amenorrhea and galactorrhea

mksap

Conditions and Diseases

February 8, 2014

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 33-year-old woman is evaluated for a 5-month history of amenorrhea and a 3-month history of galactorrhea. The patient says her menstrual cycles were normal before onset of amenorrhea. She takes no medication.

On physical examination, vital signs are normal. Visual field findings are normal. Bilateral galactorrhea is noted.

Results of laboratory studies show …

Options for the injured older adult in the emergency room

Eric Widera, MD

Conditions and Diseases

February 7, 2014

A 92-year-old woman with a history of stroke comes to an emergency department and is found to have fractures of her cervical spine. Neurosurgery sees her but doesn’t think she needs surgery. The emergency department physician tries to admit her to the hospital as she has a new functional disability due to the fall but the hospitalist refuses as the patient doesn’t meet criteria for inpatient admission.

And there she sits …

6 tips for talking to your kids about sex

Claire McCarthy, MD

Conditions and Diseases

February 7, 2014

When it comes to the parts of parenthood that people dread, well, there’s so much to choose from. There are poopy diapers. Vomit. Tantrums. Nasty teenagers. But all of that pales in comparison with … The Talk.

The talk about sex, that is.

Nobody wants to talk to their kids about sex. Nobody wants to think about their kids having sex — the same way nobody likes to think about their parents …

After hospice takes over, what happens to the physician?

James C. Salwitz, MD

Physician

February 7, 2014

Today, I hesitated to refer a patient to hospice. The patient is perfect for that model of care. She has strong family and friend supports, multiple opportunities to maintain quality, independence and dignity, and while she has a disease we cannot fix, she will do very well with personal palliation. Nonetheless, I almost did not recommend hospice, because I realize that hospice is going to completely fail to take care of a …

After a cancer diagnosis: Giving a patient time

Jim deMaine, MD

Physician

February 7, 2014

Ben’s first symptom was coughing up blood. The cancer had been silently growing for months, if not a few years. He had no pain or shortness of breath. The chest x-ray showed a “5cm L hilar mass” and the subsequent CT scan showed enlarged lymph nodes and likely spread to the liver.

“So Doc, what is it? A cancer? How much time do you give me?” All these questions on a …

Test overuse: Why does it happen and what can we do about it?

Kevin R. Campbell, MD

Physician

February 7, 2014

In medicine today diagnostic testing and advanced imaging is readily available and widely utilized in most every clinical setting. Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan. Fear of missing something pervades every emergency department and has resulted in hundreds of thousands of unnecessary testing costing billions of dollars in healthcare expenditures.

Of course, the driving causes of increased testing …

An interview with Team USA’s chief medical officer

Val Jones, MD

Physician

February 7, 2014

I am a huge fan of the winter Olympics, partly because I grew up in Canada (where most kids can ski and skate before they can run) and partly because I used to participate in Downhill ski racing. Now that I’m a rehab physician (with a reconstructed knee) I’m thrilled to have the opportunity to interview Team USA’s chief medical officer, Dr. Gloria Beim. As we enjoy the Sochi Olympic …

Why doctors and hospitals shouldn’t advertise

Skeptical Scalpel, MD

Physician

February 6, 2014

The decline of medicine as a profession began when it became legal for doctors and hospitals to advertise.

Apparently it all started when an Arizona lawyer sued for his first amendment right to advertise his services. In 1977, the US Supreme Court ruled that states could not prohibit advertising by lawyers.

This opened the floodgates for all professionals. Soon advertising by doctors and hospitals became common.

I don’t know what it’s like where …

Did a New York Times column unfairly attack ER doctors?

WhiteCoat, MD

Physician

February 6, 2014

Cardiologists are causing patients to get cancer.

It’s true.

Cardiologists routinely perform angiograms on patients who have no heart disease whatsoever.

As shown in this Harvard newsletter, each angiogram exposes the patients to about 7 mSv of radiation. Add in the myocardial perfusion imaging at another 25 mSv of radiation and you have enough radiation to cause cancer in an otherwise healthy individual.

And cardiologists routinely subject patients with normal …

Thank an EMT for their courage, their dedication and their spirit

Julian Orenstein, MD

Physician

February 6, 2014

When, a couple times each year, dozens of our county teenagers train to become EMTs, they know they are taking on a challenging, heavy responsibility. But probably none of them are ready for the kind of horrible death our community experienced a week ago, when a 15-year-old-girl walking home from school in Rockville was struck and killed in a crash involving two cars that news reports say may have been …

Removing a suture: What the future may bring

Bruce Campbell, MD

Physician

February 6, 2014

The future of robotic surgery can be determined only by probing the possibilities. To ignore the potential for extending the boundaries and safety of surgical care with robotic technology seems unwise.
-“The Future of Robotics,” Bulletin of the American College of Surgeons (July) 2013; 98:9-15.

It is a spring morning in July 2047. Jenny, a nursing assistant, emerges from an exam room and gently closes the door. She is wearing scrubs tastefully covered with …

Is the medical home really worth it?

Jan Gurley, MD

Health Policy

February 6, 2014

Patient-centered primary care medical homes (PCMHs) are all the rage. A frequently-touted part of the Affordable Care Act (ACA), they have received literally hundreds of millions of dollars in federal incentive and demonstration-project funding. They’ve been around for decades. In fact, the more you know about the intention behind the creation of a primary care patient-centered medical home (PCMH), the more you want to ask, “Well, of course – how …

Read more…

Is the medical home really worth it?

Applying the new cholesterol guidelines to real life patients

Juliet K. Mavromatis, MD

Conditions and Diseases

February 5, 2014

Cardiovascular disease — including coronary atherosclerosis and cerebrovascular disease — remains the number one cause of mortality in the United States. One out of three people in this country will die of cardiovascular causes. Although I can’t say that the other top causes of mortality are particularly attractive — cancer, chronic lung disease, accidents and dementia — premature cardiovascular death can certainly be very devastating and it makes sense to do …

Shotgun medicine: An arrow is often better

Jennifer Adaeze Anyaegbunam

Medical Education

February 5, 2014

During my internal medicine rotation, the medical students had the opportunity to attend intern morning report, an interactive teaching session where attending physicians walk the interns through a patient’s story, starting from the moment they hit the door of the emergency room to the final stages of diagnosis and treatment.

After discussing the patient’s symptoms, complaints and past medical history, the attendings always ask the group to think carefully about the …

Accountable care organizations: Everything old is new again

John Schumann, MD

Health Policy

February 5, 2014

In addition to providing coverage to millions of uninsured Americans, one of the key attributes of the Affordable Care Act (aka Obamacare) is reforming the way that we finance health care in the U.S.

Since the rise of the health insurance industry (as a job benefit or under Medicare), we have operated under a system known as “fee-for-service,” in which every little nugget of health care provided (from an operation to …

When a home visit invigorates

Jordan Grumet, MD

Physician

February 5, 2014

Home visits are hard, there is no doubt about it.

I felt like I had been driving for hours. The thirty minute travel time showing on my GPS was woefully understated due to the arctic temperatures and colossal snowfall. My jacket and clothes felt caked with dried salt rubbed off from the car or somehow accumulated from the ether. I pulled the key out of the ignition and braced for the …

Read more…

When a home visit invigorates

Grateful for the pennies from heaven

Starla Fitch, MD

Physician

February 5, 2014

A few short years ago, my wonderful father-in-law Bill was diagnosed with an inoperable cancer.

My husband and I traveled to the Midwest to visit Bill and my mother-in-law Betty. We were happy to be able to spend a little time with him, and he knew we were there.

Sadly, he passed away the night before we left.

We believe he held on until my husband arrived; all his other children lived nearby.

Later, …

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Grateful for the pennies from heaven

How I feel after chemotherapy

Elana Miller, MD

Physician

February 4, 2014

I feel …

Much better than I did after my last chemo cycle.

I feel tired, but not bad.

I feel really glad that using a smaller needle for the lumbar punctures spared me the headache.

I feel thrilled to have a port and have that PICC line out. There’s nothing like having medical tubes dangling out of your arm to make you feel extremely cancery. Plus, with the port buried under my skin, water …

Read more…

How I feel after chemotherapy

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