KevinMD.com

May 8, 2017May 8, 2017

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore. I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see…

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore.

I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see my rationale for ordering that CT scan or MRI my patient needed.

Now I am getting more and more requests to initiate a “peer-to-peer” call instead. My heart sinks every time; each …

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The evolution of prior authorizations

Physician

What’s the difference between health care in the U.S. and Haiti? Not much.

Vincent DeGennaro, Jr., MD, MPH

May 8, 2017May 8, 2017

“How long have you had the bleeding?” “About seven years,” my patient replies stoically. Ange’s angular face no longer retains the beauty of her youth. The sharp lines around her mouth speak of a long life packed into a brief…

“How long have you had the bleeding?”

“About seven years,” my patient replies stoically.

Ange’s angular face no longer retains the beauty of her youth. The sharp lines around her mouth speak of a long life packed into a brief 42 years. She is well dressed, but her manner of speaking betrays the poverty in which she exists.

Ange has advanced cervical cancer — a completely preventable disease. In fact, cervical cancer can …

Conditions and Diseases

Give your body a real immune boost

Roy Benaroch, MD

May 8, 2017May 8, 2017

The human immune system is an amazing thing. There are thousands of microorganisms -- millions, maybe -- that are lurking out there, eager to make you sick. You breathe them in. They’re in every bite of food, and all over…

The human immune system is an amazing thing. There are thousands of microorganisms — millions, maybe — that are lurking out there, eager to make you sick. You breathe them in. They’re in every bite of food, and all over your hands when you rub your nose. We live in constant bombardment.

And they’re sneaky, too — with changing DNA and proteins to fool us. We’ve got soap and water and …

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Give your body a real immune boost

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Health Policy

Are nonprofit hospitals a fairy tale?

Niran S. Al-Agba, MD

May 8, 2017May 8, 2017

Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations. 3900 (62 percent) of U.S. Hospitals are nonprofit and therefore tax-exempt — they pay no property tax, no federal or state income tax and no sales tax. An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the nonprofit variety, each earning …

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Are nonprofit hospitals a fairy tale?

Physician

To be an oncologist today is to be a part of a revolution in medicine

Don S. Dizon, MD

May 8, 2017May 8, 2017

When I was a resident, my colleagues chided me for wanting to be an oncologist. Back then (and it pains me to be old enough to use that phrase, by the way), oncology was thought of as a field of…

When I was a resident, my colleagues chided me for wanting to be an oncologist. Back then (and it pains me to be old enough to use that phrase, by the way), oncology was thought of as a field of futility. We administered toxic drugs to patients with cancer, and far more often than not, they …

Health Policy

After 100 days: 5 things we learned about health reform

Robert Pearl, MD

May 7, 2017May 7, 2017

For much of the first 100 days of the new Congress and administration, the news has featured health care and the frequently rancorous debate on its future. Will the Affordable Care Act (ACA) be repealed, replaced, revised or remain essentially intact? Will funding be cut or will subsides and cost-sharing reduction payments stay the same in order to encourage insurers to stay on the health care exchanges?

At this point, we’re …

Physician

The vaccine study you’ll never see

Chad Hayes, MD

May 7, 2017May 7, 2017

I’ve seen a lot of social media posts or comment threads that say we don’t have any studies to prove that the CDC’s vaccine schedule is safe or effective.| As a pediatrician, the first time I read that, I was…

I’ve seen a lot of social media posts or comment threads that say we don’t have any studies to prove that the CDC’s vaccine schedule is safe or effective.|

As a pediatrician, the first time I read that, I was surprised. But now, I think I know what they mean.

I think they mean that we haven’t done the best study. Those of us in the scientific and medical fields frequently demand …

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The vaccine study you’ll never see

Medications

If pharmaceutical companies don’t restrain themselves, someone else will

Peter Ubel, MD

May 7, 2017May 7, 2017

Imagine that you are gasping for breath, literally on the verge of death. Then someone injects you with a medicine and -- miracle! -- you are perfectly healthy again. Would you pay $300 for that injection? The treatment is epinephrine;…

Imagine that you are gasping for breath, literally on the verge of death. Then someone injects you with a medicine and — miracle! — you are perfectly healthy again.

Would you pay $300 for that injection?

The treatment is epinephrine; your illness was a life-threatening allergy. And that $300 price? That reflects a six-fold increase from a couple of years ago. It’s one thing for medications to be …

Physician

MACRA penalized this doctor for going the extra mile for his patients

Matthew Hahn, MD

May 7, 2017May 7, 2017

We’ve taken care of Jane and her son, Sam, for a long time (the names are fictitious, but the rest of the story is true, and the real patient approved this story, in case you were wondering). At first, the…

Sam also had a very significant learning disability. At one point I asked …

Physician

Never forget the patients we do not see

Dave A. Chokshi, MD, MSc

May 6, 2017May 6, 2017

In medicine, we speak of “seeing patients” when we are rounding in the hospital or caring for those who come to our clinics. But what about those people who may be sick but do not seek care? What is our…

This question takes on greater urgency in the current political climate, as patients face the threat …

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Never forget the patients we do not see

Physician

The sad reality that medical consultants face

Michael Kirsch, MD

May 6, 2017May 6, 2017

What should a medical consultant do when the referring physician wants a procedure that the consultant does not favor? Of course, this sounds like a layup. The consultant, readers would surmise, should have a conversation with the referring colleague to…

What should a medical consultant do when the referring physician wants a procedure that the consultant does not favor?

Of course, this sounds like a layup. The consultant, readers would surmise, should have a conversation with the referring colleague to explain why the procedure is not in the patient’s interest. The colleague then thanks the consultant for his thoughtful input, and for sparing the patient from the risks and expense of …

Conditions and Diseases

MKSAP: 57-year-old man is seen after results of a carotid ultrasound

mksap

May 6, 2017May 6, 2017

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 57-year-old man is seen for follow-up evaluation after results of a carotid ultrasound obtained to investigate a left neck bruit show a mixed…

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

A 57-year-old man is seen for follow-up evaluation after results of a carotid ultrasound obtained to investigate a left neck bruit show a mixed density plaque at the origin of the left internal carotid artery. Stenosis is estimated to be 60% to 80%. He has had no focal neurologic symptoms or visual …

Medications

How should opioids be prescribed?

Linda Girgis, MD

May 5, 2017May 5, 2017

According to the U.S. Department of Health and Human Services (HHS), the U.S. in the midst of a major public health crisis regarding the misuse of opioid medications.| Today, more people die of overdoses related to the use of opioids…

According to the U.S. Department of Health and Human Services (HHS), the U.S. in the midst of a major public health crisis regarding the misuse of opioid medications.|

Today, more people die of overdoses related to the use of opioids than any other drug or medication. In fact, opioid deaths (including the use of heroin) have quadrupled since 1999. Approximately 650,000 prescriptions are written for opioid medications every day in the …

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How should opioids be prescribed?

Physician

5 things doctors should know about compassion fatigue

Jennifer Lycette, MD

May 5, 2017May 5, 2017

For many physicians, the term “compassion fatigue” may imply, as the words describe, that fatigue leads to the loss of ability to feel compassion for others. After all, what physician doesn’t have a day when s/he is too tired, running…

For many physicians, the term “compassion fatigue” may imply, as the words describe, that fatigue leads to the loss of ability to feel compassion for others.

After all, what physician doesn’t have a day when s/he is too tired, running on too little reserve, and feeling some degree of emotional numbness?

Many physicians may not realize, however, that compassion fatigue can go much deeper. According to the Compassion …

Physician

Focus on the outcome, not what’s negative

Shabbir Hossain, MD

May 5, 2017May 5, 2017

A free moment to read my favorite health care blog is hard to find. The days are packed with complex and time-intensive patients. In between them, I struggle to complete documentation and take care of a myriad of tasks, making phone calls and plodding through cumbersome electronic medical records. Then, there’s still actual paperwork to review and complete. I still have to make time to read clinical literature in addition …

Conditions and Diseases

It’s time for psychodynamically informed clinical thinking

Steven Reidbord, MD

May 5, 2017May 5, 2017

In a world of diverse mental health treatments and treatment settings, psychoanalysis and psychodynamic psychotherapy have lost their former prominence. Only a small fraction of patients have the time, money, and interest to engage in long-term, open-ended mental exploration --…

More commonly, emotional distress is dealt with in emergency departments, in crisis clinics, on the medical and surgical floors of hospitals, in …

Patient

At this skilled nursing facility, the staff was skilled but not compassionate

Susan Ely, CRNP

May 5, 2017May 5, 2017

SNF is the acronym we use in health care for “skilled nursing facility.” Fittingly, it is pronounced “sniff,” a fact that became fitting as I watched my father die in one this past week. My parents, 86 and 89, bought…

SNF is the acronym we use in health care for “skilled nursing facility.” Fittingly, it is pronounced “sniff,” a fact that became fitting as I watched my father die in one this past week.

My parents, 86 and 89, bought into a beautiful retirement community 10 years ago. Included was a lovely apartment, full-service dining facility, gym and health center, the last of which included an SNF.

In the past three months, …

Physician

I want to quit medicine, and it has nothing to do with patients

Rosalind Kaplan, MD

May 5, 2017May 5, 2017

I think a lot about quitting medicine lately. A lot. Then I have a morning like yesterday morning: I see a patient I've known for more than twenty years, caring for him through an adrenal tumor, a major gastrointestinal surgery…

I think a lot about quitting medicine lately. A lot.

Then I have a morning like yesterday morning:

I see a patient I’ve known for more than twenty years, caring for him through an adrenal tumor, a major gastrointestinal surgery and now renal failure, for which he needs a kidney transplant. As we review his last set of labs (stable, thank goodness), he is sanguine, hopeful. He may have found a donor, …

Conditions and Diseases

This gynecological issue is misdiagnosed over 50 percent of the time

Roger Reichert, MD, PhD

May 4, 2017May 4, 2017

As a consultant in gynecologic pathology, I receive requests for second opinions from patients who have been diagnosed with endometrial hyperplasia. My opinion is based upon correlating the relevant clinical history with a review of the patient’s pathology slides and report. In my experience, there is a difference of opinion that leads to a change in treatment in about half of the cases. 75 percent of cases with changed diagnoses …

Medical Education

Should we standardize clerkship grades?

Anonymous

May 4, 2017May 4, 2017

I’ll be honest, when I first matriculated into medical school, I didn’t even know what a USMLE Step exam or clinical clerkship was. In fact, the first time I ever heard of them was from another applicant on the interview trail. I have always been a take-it-one-step-at-a-time type of person, but eventually, I would have to succumb to the pressure and ask upperclassmen about the exam. And what did they …

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Should we standardize clerkship grades?

Real physician voices, twice a week

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