Summer Reading and Summer Tipping

I just finished a great read that I would like to pass on. It is called "The Help" by Kathryn Stockett. It takes place in Jackson, Mississippi during those transformative years of the 1940's through the changing 1960's. It is written from the voice of various "negro" maids who stayed with families for years and raised the kids and ran the households for their white employers.

The "Jim Crow" years of extreme segregation were not much better than slavery. Everyone had their place and these wonderful maids were constantly shown where their place was. They held the homes of the white southerners together and then went home and toiled in their own shanty houses.

The southern women could employ a maid for 20 years (below minimum wage) and never really know who she was or about her life. After all, it was a "privilege" to be welcomed into the white home to be "part" of the family. But make sure you never use the same toilet.

Change came slowly and violently to Mississippi and "The Help" is the type of book that you wish would go on and on.

Talking about "The Help" gives me a chance to encourage every blog reader to please, please remember to tip the maid when you travel. Women hotel maids, unlike the bell captain or waiter, are invisible and they work about 10 times as hard as any other hotel help. Have you ever tried to pick up wet towels, push a heavy sweeper and make huge beds all day? These women are at the bottom of the financial food chain and I bet every one has carpal tunnel syndrome and a painful back.

Leave them some money each day. Don't wait until the end of your stay when cash is short and you are rushing to the airport. I love to tip the maid daily. It is one part of keeping green than I feel good about.

Read "The Help" for a glimpse into recent history and tip your hotel housekeeper. You're welcome.

Welcome World Blog Readers

I get a kick out of my tracking software and enjoy seeing the visits to EverythingHealth from around the world. I am amazed that the internet works to connect us. In the last 24 hours I welcome: Jakarta, Guam, Australia, Nigeria, London, Anchorage, Delhi, Manila, Edinburgh, U.K., Canada, Saudi Arabia, Poland, Japan, Spain, Chile, Mexico and Costa Rica. Come back soon and I'll be humming "We are the World".

Estrogen and Progesterone for Menopause

"If you wait long enough, the pendulum will swing back", is a statement I have made to women patients who had concerns about taking estrogen and progesterone for menopause symptoms. In 2002 the Women's Health Initiative study was all over the news and it implicated hormone replacement therapy (HRT) in causing breast cancer, heart attack, and strokes. No wonder women freaked out, stopped taking hormones and decided to go "Au natural" through the aging process.

A few years later, Oprah started having hot flashes and the subject has been open for more discussion. "Natural" (and unproven) treatments have sprung up and women are more confused than ever about what is safe to deal with hot flashes, sweats, foggy thinking and aching joints that accompany menopause in many women.

The North American Menopause Society (NAMS) has published a formal consensus opinion after extensive review of the current scientific knowledge and health management. They have stated "Recent data support the initiation of menopausal hormone therapy (HT) around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both. The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause, in previously untreated women."

Let me interpret (and add more based on the published document):

• The data shows relieving the symptoms of menopause is worth the small health risk of taking hormones
• For women with osteoporosis, estrogen preserves bone
• The best time to take hormone therapy (HT) is when you are going through menopause and having symptoms. There is less evidence of its benefit in older women who have never taken it previously
• If the problem is mainly vaginal dryness, using topical estrogen is best
• HT is not recommended as the sole treatment of sexual libido decline
• HT doesn't seem to affect weight one way or the other
• Some studies show HT may slow the development of atherosclerotic plaque. The Women's Health Initiative showed women younger than age 70 who started HT had no increased risk of coronary heart disease
• Women with a uterus need to take progesterone along with estrogen, or there is an increased risk of endometrial cancer after 3 years of use
• Women who take estrogen and progesterone have a slight increased risk of breast cancer.
• HT is not a treatment for depression, but it may improve mood in some women
• HT does not prevent aging or dementia
• HT reduced total mortality by 30% when initiated in women younger than age 60
• "Bioidentical" hormones (custom-compounded) have not been tested for effectiveness or safety. There is no scientific basis for using saliva testing to adjust hormone levels.
• Lower doses of hormones are recommended to treat symptoms. Topical progesterone is NOT recommended as it does not protect the uterus.

So there you have it. The pendulum is swinging back and many women will be reassured that they can get relief from menopausal symptoms without compromising their health. If you want to read the full paper click here.

Bloggers Holiday

I'm taking a week off from EverythingHealth. Enjoy early July and click on my side links for great medical blog reading. Better yet, click on the "followers" and become a follower of EverythingHealth. I'd like to return and see lots more added. See you in a week with more health news, tidbits and opinions.

Should You Send a Bill after a Patient Dies?

I logged onto a physician forum website and came across the question; "Do you charge an uninsured man's family after he dies?" The patient was in the hospital for a month and the doctor cared for him daily. The man was not insured but the patient's finances are enough to pay cash for the entire hospitalization. The doctor questions if he should bill the family after the patient died?

My first though was "No, just absorb the losses. The situation is unfortunate and the family will have enough problems without receiving doctor bills." As I read the comments on the site however, I realized no one else thought that way, and in fact, I could see the wisdom of the replies.

Most comments were something like, "You provided service and you should be compensated". Or "We all have bills to pay and they sure seek me out when I owe them - the lawyer, the credit cards, even the grocery store." Or "If the plumbing stopped up at the man's house while he was in the hospital, would his family NOT be expected to pay it?" Or "Absolutely send a bill. You can be sure the funeral home, the car dealer, the mortgage company, the magazine subscription, the credit card companies are all sending bills every month." Or "When will physicians realize that medicine is a business? Bill the estate the entire amount due." Or "Beware of the doctor who does not charge. He knows the value of his services."

There were 116 comments and about 99% of them felt a bill should be sent. Some advised a sympathy note also and some said the bill would likely not be paid. Only 2 out of the 116 suggested he not bill the estate.

After reading the comments, I re-thought about my gut response. I think he should bill, but should not actively pursue collections if the family/estate does not pay. We all do charity work, and this may just need to be written off. Of course, that may be one reason why primary care doctors are going the way of the dinosaur.

FDA Recommends Ban on Vicodin/Percocett

I must admit my jaw dropped when I read the headline about the FDA recommending a ban on two popular painkillers...Percocet and Vicodin. Both of these drugs are combination drugs, which means they combine another ingredient with acetaminophen (AKA: Tylenol). Tylenol is available over the counter and Percocet and Vicodin both require special "secure" prescriptions, yet it is the acetaminophen component that the FDA is worried about.

In 2005, over 28 billion doses of these meds were bought by patients in the U.S. (Don't you wonder who counted?) Let me repeat...28 billion. The FDA expressed concern because of tylenol overdoses and liver damage from too much acetaminophen. They reported more than 400 people die and 42,000 are hospitalized every year from overdoses.

None of the policywonks asked, but I could tell them that pain control is a huge problem for physicians and patients. We try to use as little drug as possible but pain that does not respond to over the counter medication like ibuprofen, naprosyn (NSAIDS) or Tylenol require prescriptions. Oxycodone and hydrocodone (the ingredients in Percocet and Vicodin) are not available without combining with another pain reliever like aspirin, tylenol or ibuprofen, except as controlled release form (Oxycontin and Oxyir).

Doctors have had their hands tied by the regulations about pain relief. In California we are required to take courses in "pain management" and can have our license removed if we don't manage pain or if we manage pain too well (and over prescribe narcotics). Patients can sue us for being left in pain and they can sue for becoming addicted to pain medication. We are damned either way.

Many physicians just opt out completely and send patients to expensive "pain management clinics". I just paid $808 for renewal of my controlled substance prescribing license and the idea of opting out looks appealing if the FDA bans these drugs without offering a substitute for patient care.

Americans Hit the Web for Health Info

A new report from the PEW Internet Project shows that 61% of American adults go online for health information. These "e-patients" are seeking information about health for themselves or for friends or relatives. And 2/3 of them talk to someone else about what they find online, most often a friend or spouse.

Certainly young physicians and health administrators are aware of this sea change , but I am not sure everyone in health care really realizes how different patients (consumers) are now and how they are receiving information. Twenty-four percent of e-patients have consulted rankings or reviews online of doctors or other providers and hospitals. Another 19% have signed up to receive updates about health or medical issues.

When 60% of these patients say the information they found online affected a decision about how to treat an illness or condition, health professionals better sit up and take notice. Younger adults (ages 18-49) are the internet age and expect technology to provide information and advice.

Change it is a-comin'

Primary Care and Extra Services

Anyone who follows medical economics or medical blogs knows that primary care physicians are becoming few and far between. The number of young doctors who chose any specialty OTHER than primary care (family medicine or general internal medicine) continues to rise. So it is no surprise that I just read an article about adding "Ancillary Services in Primary Care".

It is kind of sad that taking care of the whole patient and serving as a well trained comprehensive doctor is at the bottom of the desirability food chain of medicine. Hospitals and multi-specialty medical groups see primary care physicians as "lost leaders". We have become the "oil change" of medicine, so the big ticket "engine overhaul" can be captured by the high dollar procedures.

So now there is advice being offered for how primary care physicians should add new services to the "core" practice of patient care. Believe me, the "core" is challenging and time-consuming enough but patients and payers don't seem to see it that way. Here is what is recommended:

• Diagnostic tests on site such as Holter monitor, labs, imaging, treadmill testing. (most of these require significant up front capital and the only way to justify it is to order lots and lots of tests....rising health care costs anyone?)

• Cosmetic procedures such as Botox, injectable fillers, laser hair removal, laser skin resurfacing and vein treatments. (it worked for the dermatologists. Have you tried to find one to look at a mole or a rash lately?)

• Behavioral health like weight management, nutritional counseling, smoking-cessation. (most of us do this for free. Hey maybe that's part of the problem?)

• Alternative and holistic treatments like acupuncture, massage. ( I see $$ for additional staff and space with little additional revenue)

• Products like drugs, skin care products and nutritional supplements. (lots of doctors do this already. Does it put undue pressure on patients and represent a conflict of interest?)

I find it sad that primary care doctors are advised to get into these extra services in order to survive as a specialty. I certainly understand the economics. The average fee for laser hair removal is $503. It takes about 45 minutes to do and it costs $1100 for a two day training course. It sure beats doing physical exams.

What do you readers think? Should your doctor get into these ancillary services?

Why do Celebreties Have Bad Doctors?

Michael Jackson's mysterious death that involved his personal physician at his side when he died, brings up so many questions and speculations. The 911 phone call states that the physician was there when he "collapsed" in bed and was "pumping" (presumably performing CPR) him as the call was made. Further details are impossible as the doctor has disappeared and the toxicology portion of the autopsy is pending.

Reports are coming out from family and friends, that Michael was receiving prescription medication. He was frail and underweight and family members were concerned about his health. He may have been receiving Demerol injections and there is speculation that he was given a Demerol shot before he went into respiratory arrest. The New York Times has reported about his mystery doctor:

"Dr. Conrad Murray, who public records show is a 56-year-old cardiologist with a practice in Las Vegas, has lived in numerous homes over the last decade in several states, filed for personal bankruptcy in 1992 in California and has five tax liens against him for hundreds of thousands of dollars.

According to HealthGrades, a health care ratings company, Dr. Murray is board certified in neither of his two specialties, internal medicine and cardiology. Board certification is not required to practice a specialty but is recommended and indicates a high level of training and expertise."

Whenever I see a movie star that had bad plastic surgery or recall Nicole Smith's doctor who kept her in a drug induced state until her sad death, or think about Barry Bond's infected knee surgery or any number of celebs that get bad medical advice, I wonder what the heck is going on. These folks can afford the best medical care and the best doctors. Why do they end up with doctors that are obvious quacks and deserve to have their licenses revoked?

A friend of mine is a rock musician and has traveled with many major rock groups over the years. He said those groups always had a quack doctor touring with them that would keep them supplied with drugs, B12 shots and anything else they needed.

I guess money does buy everything...even poor care.

Toxic Cleanup in Montana

With all the emphasis on the economy and health care reform, we don't hear as much about toxic clean-up anymore or the critical work of the U.S. Environmental Protection Agency (EPA).

The towns of Libby and Troy, in Northwest Montana are depending upon the EPA to clean up a vermiculite mine (opened in 1923) that was contaminated with toxic asbestos. The population of Libby was largely unaware that the hazy smoke created by the vermiculite processing plant in the town also contained tremolite asbestos which has been linked to mesothelioma, a cancer that develops in the lining of the lungs, abdomen and heart.

The EPA issued a public health emergency on June 17th for Libby and Troy and stated the conditions in the town present a significant threat. Since the closing of the mine in 1990, approximately 400 Libby residents have died from asbestos-related diseases such as malignant mesothelioma. With a population of fewer than 3,000, nearly 2,000 people in Libby have become sick with an illness related to asbestos exposure.

“This is a tragic public health situation that has not received the recognition it deserves by the federal government for far too long. We’re making a long-delayed commitment to the people of Libby and Troy. Based on a rigorous re-evaluation of the situation on the ground, we will continue to move aggressively on the cleanup efforts and protect the health of the people,” said Lisa Jackson, the new EPA administrator.

The mission of the EPA is to protect human health and the environment. Prior to 1970, when the EPA was formed, the government was not organized to protect people from pollutants that harm health and degrade the environment. The EPA was assigned the daunting task of repairing the damage already done to the natural environment and to establish new criteria to guide Americans in making a cleaner environment a reality.

Long Live the EPA and good luck to the citizens of Troy and Libby Montana.

Michael Jackson - Man In The Mirror

"If you want to make the world a better place, just look at yourself and make a change."

BILLIE JEANS BEST EVER MOONWALK

Rest In Peace, Michael. You truly are the King of Pop.

108 Days

Imagine your 44 year old husband suffers electrocution and severe burns at work. He is rushed to one of the best hospitals in the country and you anticipate a few days in the hospital while he recovers and receives compassionate care. Instead , the care is erratic, the professionals are rude and arrogant, and one complication after another spirals him into septic shock and coma. That is the account of Lisa Lindell, wife and author of "108 Days".

This book is really riveting and I found myself grimacing, denying, experiencing shock and awe, nodding and finally understanding so much about her saga and attempts to protect her dying husband from one medical error after another. Written in diary format, Lisa Lindell became a reluctant patient advocate and through sheer determination and vigilance, kept her husband alive.

She was never informed about what was going on with his care and her attempts to speak to his various treating physicians were thwarted constantly. Despite the fact that he was at high risk for infection, and almost died of septic shock, the isolation precautions and hand washing could not be counted on. With new nurses on every shift, no one saw her husband as an entire person and her efforts to inform the staff of his declining respiration ( which became ventilator associated pneumonia), oozing scratched eyes (scratched cornea which left him sight impaired), and bed sores were ignored. It seems like the medical team gave up on Curtis Lindell and certainly did not value his wife's input. By her account, the hospital administration was down right hostile to her .

This book confirms that every patient needs an advocate to watch and inform and ensure safety. The fact that the events occurred in 2003 are reassuring because I know there has been a wave of patient safety and changes in hospital quality protocols that have been instituted across the country since then. I have been in contact with the book's author, and she says the "world famous" institution where Curtis spent 108 days hasn't changed much. That is sad and scary.

If you want a good read, pick up "108 Days". It is a story that will anger you and the fact that he survived is a true miracle.

Doctors Who Don't See Patients

I wish someone would do a study on how many doctors complete medical school but never go into any type of patient care practice. I suspect the number is higher than we think.

I was at an upscale art party last weekend, filled with beautiful art and beautiful young people. I sat next to an attractive "early thirty-something" woman, confident and well dressed. She mentioned that her business partner was friends with the host and when I asked her what the business was, she said she was starting a "pharmaceutical business".

That certainly got my attention. Starting a pharmaceutical business? That is hardly what I think of as a "start-up". I made a few more inquiries, "Are you doing R&D? What types of drugs are you focused on?" She didn't answer my questions but proudly told me, "Oh, I am a physician." She trained in nephrology (kidney specialist) at UCSF...graduated...and now is starting a pharmaceutical business. She's never seen patients since her training.

The conversation didn't go much further but it did make me think about how many young physicians I know that do not see patients at all, but parlay their medical degree into some type of business venture.

It seems like a medical degree is becoming like a law degree. Very few attorneys actually see the inside of a court room or defend people against injustice. Are fewer young doctors actually seeing sick patients?

I can think of about two dozen young physicians that I know, who have left patient care completely over the past 10 years. Some started medical related business, some are in real estate, some joined pharmaceutical companies, some just retired to stay home with the kids. One teaches dance and one does a little moonlighting.

I keep up with the journals but have not seen this question addressed in any studies. Where do medical graduates go? How many stay in patient care vs. other aspects of medicine like research or teaching? How many "retire" early? How many start a "little pharmaceutical business"?

In this day of physician shortage, it is a question that needs an answer.

Health Care Run By The Post Office

My patient was admitted to the hospital with a terribly infected arm after a fall and a nasty laceration. She stayed two days and is now home and recovering well on oral antibiotics. When I examined her this morning, I chatted with her husband (a good friend of mine) about the inefficiencies of the hospital. They were thrilled with her care from the physicians and nurses, but couldn't help but notice how uncoordinated the hospital care is. She was asked her story by 10 different people. She underwent 3 arm Xrays (?) and was kept without food or water while they were deciding about surgery. No-one was able to tell them if she needed surgery and the communication between the floor and the Emergency Department was lacking.

We decided this admission would probably cost about $50,000. It will be interesting to see what the final bill is. That led us to discussion about the outrageous cost of health care. My friend said that every one $dollar out of 700 in the health care budget goes to pay the salary of the CEO of United Health. What? One dollar of every 700?

The conversation then migrated toward health care reform and the desire to GET IT DONE. Bring on that public system and do it now. If someone wants to pay for extra care through United Health Care and keep that CEO in jets and parties....so be it. There is nothing wrong with having multiple choices for the citizens of the U.S.

We talked about the fear people have about "socialized medicine", as if anyone in the UK, or Netherlands, or Canada, or France would trade places with our fragmented health system. Americans say get the government out of health care, but "I sure like my Medicare". My friend said people will say: " What do you want? Health care to be run like the post office?" He replies, "Hell yes. Run it like the post office. They come to my house and pick up a letter , take it across the country and deliver it 48 hours later for 44¢. You're damn right I would like it run like the post office."

Nestle Cookie Dough Recalled

Is nothing sacred? Are there no simple joys in life that we can count on? It turns out Nestle Toll House Cookie Dough has been recalled because...are you ready for this?...they found the bacteria E. coli in it. Yes, E. coli, that little bacteria that causes gastroenteritis with cramping and diarrhea somehow got into the cookie dough.

The health department in Washington State found the link after 28 states reported outbreaks. It's amazing that they were able to track it back to cookie dough, but sure enough when they went back to investigate other victims, they had indeed eaten the raw dough.

It turns out you should never eat the dough without cooking it and baked cookies are not infected. I used that cookie dough a week ago for a school function and, I must admit, I did sample a bit of it as I was cooking. I think I might have had some GI symptoms afterward....hmmmmmm.

Hospital Discharge - Let's Get it Right

Patients are staying fewer days in the hospital and receiving "post-op" and "post-hospital" care at home. The days of staying 10 days for an appendectomy, or hysterectomy, or pneumonia or joint replacement or just about anything are long gone. These shorter hospital stays require patients to really understand what will happen when they go home. Coordination about appropriate follow-up is essential, as well as medications, pending lab tests etc. In 2007 a study sponsored by the Agency for Healthcare Research and Quality (AHRQ) found that more than 1/3 of patients discharged from a large teaching hospital, failed to get follow up care. Yikes!!!

I was interested to read about a new program that is being piloted in Boston called Project RED (short for Re-engineered Discharge) and led by family medicine doctor Brian Jack. The program uses 11 steps to make sure patients are well cared for at discharge. I will try to give a brief description:

• Educate the patient about the diagnoses throughout the hospital stay
• Make follow up appointments and testing for the patient before they go home
• Discuss any tests or studies from the hospital and make sure there is someone responsible for follow-up
• Organize post discharge services, including making appointments and guaranteed transport
  
• Confirm the medication plan and make sure the patient understands
• Make sure the discharge plan goes with national guidelines
• Review steps to take if a problem arises..who to call, what is an emergency
• Ensure all physicians receive the discharge summary
• Ask the patients to explain the plan in their own words
• Give the patient a written discharge plan with medications listed
• Phone the patient 2-3 days after discharge to resolve problems

By following these steps, Project RED had 1/3 fewer re-admits and 30% fewer emergency visits.

Why isn't everyone doing this? There are absolutely no financial incentives to implement a discharge program such as this. Hospitals are busy, chaotic places and protocols, training and accountability need to be put into place. The rapid admit/discharge pace and obscene amount of stupid charting that is "required" to be done, leaves little time for doing things that really help patient care.

As we talk about health care reform, we also need to institute re-engineered processes that put the patient first and reward caregivers who do it right.

Zinc Supplements and Loss of Smell

The FDA has received reports of more than 130 cases of anosmia (loss of smell) in consumers who used the following zinc-containing products: Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs (kids size). There is published evidence that Zinc salts can harm olfactory (smell) function and the manufacturer has received over 800 complaints of anosmia in users.

The FDA has issued an advisory for people to stop using these products. They have never been proven to be of benefit anyway for colds or flu. The makers of Zicam sponsored a study that showed it cut cold symptoms in half. Those findings have not been confirmed or reproduced. A review of 105 studies done showed no beneficial effect of Zinc on colds.

Loss of smell is a very serious problem. As one of our main senses, smell affects our ability to taste food and many people with anosmia lose the pleasure of eating.

Colds make you pretty miserable, but permanent loss of smell is too big a price to pay for using a product that has not been proven to work.

Chronic Disease Costs Out of Control

We absolutely need health care reform and we need it now. A new study shows 3/4 ($1.7 trillion) of all U.S. health care spending in 2007 was related to treatment of the 7 most common chronic diseases. They are cancer, hypertension, mental disorders, heart disease, pulmonary conditions, diabetes, and stroke.

Forty five percent of Americans have at least one of these conditions and 26% have multiple conditions. These patients receive clinically recommended preventive care services only 56% of the time. Here is a jaw dropper...every thirty seconds a limb is amputated as the result of diabetes. That leaves a patient who is unable to work and is probably in an electric wheelchair and still has the other expensive health conditions that are associated with diabetes.

I see so many red flags here I just don't know where to begin. First of all...look at the list and then look at the rising incidence of childhood obesity. Unless we get a grip on this, those kids are going to have chronic problems by the time they are 30.

Why does anyone still smoke? Is there any value to tobacco farming (except for the farm cartel?) Cigarettes should cost $100.00/pack, since we live in the land of the free and don't want to ban them all together.

Why does Medicare pay lucrative rates to doctors who perform procedures (colonoscopy, stent placement, removing moles, passing scopes,) and doesn't even cover business cost for primary care physicians that take care of the people with multiple chronic conditions? The primary care "crisis" has been growing for the past 10 years and nothing has been done to change payments or to address the shortage.

Why is there a shortage of psychiatrists and why are mentally ill people living in homeless squalor? Our jails are filled with mentally ill people and we are happy with "out of sight, out of mind." The prison budget has bankrupted California.

There are solutions to these problems but our fragmented health delivery system will not work. The financial incentives to "pay more for doing more" episodic treatment is pushing us over the edge. We don't need one more dermatologist who does Botox, we need thousands more primary care physicians who work with care teams and are well paid to develop systems of interrelated care. Every time a patient has to go to an Emergency Department because they don't have a doctor or cannot see their doctor...we have failed.

Health care reform means "reform". The special interest groups (AMA is one of them) would like to see status quo for their interest.

The housing/banking crisis will look like a rainstorm, compared to the health care crisis flood that is looming with the baby boomers hitting Medicare age.

Way Too Busy to Blog

Just a quick note to my regular readers of EverythingHealth that I've been slammed with "busyness" and haven't had a time to blog. Look to the right of the page and click on some older posts...good info that even surprises me when I re-read it. More new info coming soon!

Rosacea Myths

Rosacea is a common skin condition that causes redness and small bumps on the face. It is chronic and progressive with flares and remissions. Sometimes it is called "adult acne" and sometimes the patient has a red, bulbous nose (rhinophyma). Rhinophyma is more common in men and develops slowly over years. Think W.C.Fields or Bill Clinton.

Patients with rosacea tend to blush easily, especially across the nose and cheeks. Small blood vessels (telangiectasia) can become visible. Unfortunately, it seldom clears up on its own and does get worse over time.

There have been a lot of myths about rosacea and who gets it. In medical school I was taught it was a sign of alcoholism. A new case controlled study from Harvard Medical School, and reported on at the American Academy of Dermatology annual meeting, found there was no relationship to alcohol use in patients with rosacea. None at all.

The people with rosacea were three times more likely than controls to have a family member with the condition and 8 times more likely to have had a blistering sunburn. There was no difference in patients with hypertension, another myth dispelled.

Most people with rosaea have fair or light skin. There are no specific tests to diagnose rosacea.

Like so many things in life, genetics play a key role in rosacea. Avoiding a severe sunburn seems to be key, but clearly we don't know who is at risk and who is not. Topical antibiotics are used to lessen the redness and we know that antihistamines are of no benefit. Eighty-five percent of people say their rosacea is affected by change of season and they flare up in very hot or very cold weather.

New Focus for Operation Rescue

Gee, I read that the abortion foes don't know what to do with their time and energy now that Dr. Tiller has been murdered and buried. After years of stalking him and his employees, blocking the clinic entrance and offering free sonograms to pregnant women so they can show them pictures of bloody fetuses, the pro-choice protesters don't know what to do next. Their "Choices Medical Clinic", which opened next door to Dr. Tiller's medical offices, may not get much business with its "free sonogram' offer and the organization is looking for new direction.

Now that Dr. Tiller is gone and his clinic is shuttered, I have some suggestions for the hundreds of pro-life advocates to make good use of their energy and dedication. Both men and women can get involved.

• Preventing child abuse. There are a number of organizations to join and they would be happy to have your energy and help

• Support foster parenting. So many children are here and need parenting.

• End domestic violence. Domestic violence includes physical and emotional abuse against women, children and even pets and it crosses all socioeconomic barriers. Lots to do here!

• Prevent animal cruelty and violence. Have you seen those puppy mills? The abused farm animals? The abuses that still go on with experimental animals? They could use your passion and volunteerism.

• Teach a child to read. Did you know our schools are in trouble across America? Many children could benefit from a volunteer to help tutor them with reading. Rather than holding signs all day, this might be a better use of your time. Try it.

• Adopt a child. There are millions, yes millions, of unwanted children who would love to have a home. It takes real skill and passion to raise a child into a happy, fulfilled adult. This is something we should all be interested in supporting.

There is much to do to make this a better world. If none of these organizations seems worthwhile to the pro-life crowd, volunteer.org can give even more choices.

Bad Bedfellows

In a new twist on the recurring story of the pharmaceutical and medical device industry climbing closely into bed with doctors, the New York Times reported about Dr. Timothy Kuklo, who allegedly forged names of co-researchers on an article he published. The journal article falsified research done at Walter Reed Army Medical Center and stated a new bone-growth product sold by Medtronic (Infuse™) performed strikingly better than the traditional bone grafting technique that was currently being used. Dr. Kuklo's research and travel was sponsored by Medtronic. The amount he was paid as a consultant has not been disclosed, nor did he disclose the relationship when he submitted his article for publication.

The unholy relationships that physicians have with pharmaceutical companies and medical devise manufacturers is having a bright light shined on it through the efforts of Senator Charles Grassley, who has been investigating these lucrative relationships.

There have been a number of shocking incidents where doctors are paid large consulting fees and they then publish results of studies that are sponsored by the company, or they speak at medical symposiums where they have the ability to influence the profession to use the drug or device. These relationships are supposed to be disclosed, but we have found out, they are often hidden, as was this bogus research.

I am particularly shocked by the relationships between orthopedic device companies and orthopedic surgeons. I saw a long list of the payments that were disclosed by multiple companies (mainly total joint replacements) to surgeons across the country. Some of these "consulting" fees were in the millions and several pages of names received upward of $300,000 to a $million. Mind you, this is on top of their every day practice. The practice is so pervasive that I am sure they all feel quite justified in taking the money. I recognized some of the names from my own medical colleagues.

Our health care system is badly broken and it will take a lot to change the paradigm and get these pigs out of the trough. It is no wonder many physicians want change...but not too much change.

How To Remember Your Dreams

I love to dream and often enjoy pondering my dreams and trying to interpret what they mean. Some people say they never dream. We know that everyone dreams but some people don't have any recall of dreaming. Here are some tips that can help you recall dreams and bring your unconscious into consciousness:

• Try to awaken naturally without the help of an alarm clock. If you do need an alarm clock, put a reminder on it so you see it first , "remember your dream".
  

• Place a pad and pen, laptop or tape recorder next to your bed and record what you remember as soon as you wake up.

• If you do remember a dream, try to make a connection between the dream and recent events. Look for themes or patterns.

• Try to change the dream by remaining in that barely awake zone before you fully wake up and "daydream" a different outcome. This is called lucid dreaming.
  

• Dream memories are often fragmented. Think about the fragments to train your mind to recall dreams in detail.

• Try to sleep without sleep aids or alcohol. Make sure you are allowing enough time for sleep.

Throughout history and in all cultures, dreams have been valued for their "messages" and ability to access other dimensions of awareness and knowledge. By consciously trying to remember dreams, we can open up those windows.

Falls as a Medicare No Pay

Hospitals receive no reimbursement from Medicare if a patient falls in the hospital. Falling is considered one of the 10 "no pay" events by Medicare. So if a patient is in the hospital for pneumonia, congestive heart failure and cellulitis of the leg and that patient climbs out of bed and falls...their care will not be reimbursed. Medicare believes falls are preventable and should "never happen."

Dr. Sharon Inouye is directer of the Aging Brain Center, Institute for Aging Research at Harvard Medical School and she has spoken out on the folly of including falls in the "no pay" list in the New England Journal of Medicine. She argues that falls cannot be completely prevented and the efforts to reduce them may actually cause more harm to patients.

Even with side rails up and the call button placed in her hand, it is not unusual for a sick elderly patient to try to crawl out of bed at night...fall. The only way to prevent this is to use restraints and tie the patient to the bed. Patients who are in restraints can become agitated or delerious. Some have died. There is a huge movement in the patient safety world to reduce the use of restraints by any means.

There are other ways to reduce the risk of falls and hospitals need to incorporate them. Certain medications should be avoided in the elderly. Beds should be lowered and there needs to be scheduled trips to the toilet. Nurses making rounds every hour is a best practice to check on the needs of the patient. Hospitals can hire sitters to ...well, just sit...with the squirreley patient at night. That increases hospital costs by $millions so it is a cost/benefit decision.

Despite the best efforts, falls will happen. AARP says one in three people over the age of 65 will fall each year. I have no problem with most of the items on the avoidable errors list, but is falling an error by the hospital? This one needs to go back to the drawing board and it is time to listen to the experts instead of the policy wonks.

Marry a Younger Woman and Live Longer

A study from Germany's Max Planck Institute found that men who marry younger women live longer. The man' s chances of dying early are cut by 20% if the woman is between 15 and 17 years younger. If she was 7-9 years younger, the risk of premature death was reduced by 11%.

The study found women do not experience the same benefits by marrying a younger or an older man.

Women with younger or older husbands increase their chances of dying early by 20%. The study was conducted in Denmark on the entire population.

There are several theories to explain "why". One is that men who are healthier (to begin with) are better able to attract younger women. Perhaps these young women are taking care of the old dude when he gets sick and that helps him live longer. Or perhaps the older men who have more money (and thus more access to healthy living and health care) are better able to attract younger women. I don't think too many old, decrepit, poor guys are able to get a young wife. Maybe the older man with a younger wife stays in better shape because he is afraid of losing her?

I couldn't find the actual study to review (as I usually do for my readers). I would ask what about men who marry women significantly younger than themselves; the 70 year old man with the 28 year old wife? What about women who never marry at all? Perhaps they live the longest?

The study could easily have been titled "Marrying an older man is bad for your health."

Save the Fetus - Kill the Doctor

Dr. George Tiller, age 67, was shot and killed today IN HIS CHURCH in Wichita. Dr. Tiller performs late term abortions and his clinic was the site of many anti-abortion protesters over the years. He was shot in both arm in 1993 and recovered. His clinic has been severely vandalized with protesters cutting through the roof and inflicting water damage. He has been sued and harassed. Now he is dead.

Dr. Tiller's website states "Women and families are intellectually, emotionally, spiritually and ethically competent to struggle with complex health inssues--including abortion--and come to decisions that are appropriate for themselves".

Will someone please explain to me why it is wrong to abort a fetus but it is OK to kill someone in cold blood? Here are some hateful comments made by those who celebrate his murder:
"Don't ask God to have mercy on this man. His soul belongs in Hell", "Sorry but it's a little hard to work up a lot of sympathy for him. Maybe a few more babies will see the light of day now." "Payback is a bitch".

I'm really scratching my head over this one. I just don't get it at all.

Cervical spine and neck pain

I saw three patients in one day with neck pain. There is a common phenomena in medicine that things come in "3s" and it certainly happened today. This cool vid shows the bony anatomy but doesn't show the muscles and ligaments, which is usually the cause of the pain. The neck, scalp and shoulders can all be affected and painful muscle spasm is pretty common, leading to headache and shoulder pain.

Best Countries for Life Expectancy

If you have a choice of where to live to live the longest...choose Japan. The World Health organization has issued stats that show a life expectancy of 83 for living in Japan. Compare that to the lowest life expectancy in Sierra Leone, which is 41 years.

The 14 countries that had life expectancies of at least 81 years were: Japan, Australia, Iceland, Italy, San Marino, Andorra (that one is sending me to google!), France, Israel, Monaco, New Zealand, Norway, Singapore, Spain and Sweden.

The mid range countries have a life expectancy of 78 years: the United States, Chile, Cuba, Denmark, Kuwait, Slovenia and the United Arab Emirates.

Avoid these countries if you want to live a long and healthy life. They are all below 50 years:
Sierra Leone, Afghanistan, Lesotho, Zimbabwe, Chad, Zambia, Central African Republic, Guinea-Bissau, Mozambique, Swaziland, Uganda, Burkina Faso (Google again!), Burundi, Male and Nigeria.

Children younger than 5 account for nearly 20% of the world's deaths and child mortality is the reason for the wide ranges in these countries. The United States ranks 29th globally for infant mortality and we are tied with Poland and Slovakia.

That doesn't sound so good to me.

Origins of H1N1 (Swine flu) Virus

The Influenza Division at the Centers for Disease Control (CDC) reported in Science that the genes found in the H1N1 (Swine flu) genome have been circulating in the environment for an extended period of time but have now combined in a new way to cause infection.

By sequencing full or partial genomes of isolates of the virus found in Mexico and the United States, the researchers found combinations of 8 influenza gene segments that had not been previously described in either human or swine viruses.

The scientists found that all segments had originated in avian (bird) hosts and then entered into the swine (pig) population sometime between 1918 and 1998. Two of the segments were derived from Eurasian swine viruses that had not been detected previously outside Eurasia. The other six segments included DNA from human, swine and avian sources that had been circulating since 1998.

Where and how these various segments came together is not clear. They do know that the event lead to the genesis of the novel H1N1 virus that has antigenic properties that are distinct from seasonal human influenza but are similar to other swine-origin influenza viruses.

The CDC reports 6764 probable and confirmed cases of H1N1 in the United States. There have been 10 fatalities to date in the U.S.

Birth as a Health Hazzard

Two different articles in the New York Times today show the vast difference between women in third world countries and western nations. One article talks about the return of the birth control sponge. The contraceptive sponge was not available for awhile due to bankruptcy of the company but it is now being distributed by Mayer Laboratories (they also make Kimono brand of condoms) and the women who like the sponge as a form of birth control will be happy to have it back.

For those women who don't want to use a sponge, no worries! There are many other choices including condoms, oral contraceptives, IUDs, diaphragms and Plan B (the morning after pill). Modern women can get pregnant when they want and avoid pregnancy with a little effort.

Contrast that to women of Africa where childbirth is the most common cause of death in young women. The World Health Organization reports pregnancy and childbirth kill more than 536,000 women a year. For every women who dies, 20 more suffer severe complications like fistulas and infection.

In Afghanistan, women experience a catastrophic death rate from pregnancy and childbirth. Most of these women have never seen a doctor, nurse or paramedic. In some areas only 4% of the women are literate. Even if clinics were available, women in repressive Muslim countries are not allowed to go out alone or even be in the company (let alone examined) by a male doctor so health care is not an option.

Millions of women around the world have no access to information about reproductive health, family planning or skilled care during pregnancy and childbirth. There are no choices for birth control and getting pregnant can be a death sentence.

How can the human experience be so wide? The contrast between many birth control options and baby showers, jog strollers and high tech, safe childbirth contrasted with women who live on less than a dollar a day and have no knowledge of how they can protect their own lives and the lives of their children.

Doctors as Good Samaritans

As a physician, I took an oath and I believe it is my duty to render aid if I can in just about any situation. I am not particularly "risk adverse" but I can understand when other physicians feel it is just not worth the risk. A malpractice suit can be a disaster.

When EMTs arrive, I give a report to them and back off as they have the tools and training to transport the victim for more advanced care. It happens all the time. A woman faints at a wedding. A child collides at a soccer game and the coaches rush the field. A man has chest pain while 20,000 feet in the air on Jet Blue. A motorcycle spins out of control and throws the rider, right in front of my car. A runner collapses at the Bay to Breakers race in San Francisco. When this happens a little bell goes off in my head before anyone even has to say "Is there a doctor in the house?" So I rush in to provide service.

I never stopped to think about the liability I was incurring by being a "good samaritan". Good Samaritan Laws are meant to protect bystanders from being prosecuted when they help a victim in distress. I was under the impression that Good Samaritan Laws protected everyone who renders aid in an emergency. Upon research, however, I found the statutes are different in every state and have loopholes big enough to drive a truck through. The laws are cumbersome and difficult to interpret and the California Supreme Court recently upheld a victims right to sue after a bystander pulled her from a wreck and she suffered a spinal cord injury from being moved. The court ruled there was not "immediate peril". Other laws only protect the first responder.

With websites like "WhoCanISue.com" and "SueEasy.com" (no I am not providing a link!), it is obvious that anyone can sue for anything. Doctors are prime targets, of course, because we carry malpractice coverage and are juicy deep pockets for trial attorneys.

Because of my training and expertise and comfort in disaster situations, I believe it is my duty to render aid no matter where there is a need. I am not particularly "risk adverse" but I can now understand when other physicians feel it is just not worth the risk to get involved. A malpractice suit can be a disaster.

What do you readers think?

What is CRP?

C-Reactive Protein (CRP) is a protein found in the blood that indicates "inflammation". It is produced in the liver and during infection, and with some forms of cancer and inflammatory diseases (rheumatoid arthritis, lupus) it can be elevated in a blood test. CRP can also be elevated when there is inflammation in the arteries of the heart and is a "marker" for coronary artery disease.

High sensitivity CRP (hsCRP) is a common test that is done to assess the risk of heart disease, stroke and diabetes. Like high cholesterol, it is not the disease in itself, but high levels (over 3.0) that indicate a higher risk. Scientists don't know if it is a marker or is a cause of heart disease, but we do know that inflammation of the heart blood vessel walls is always present in heart attack victims. Inflammation is the body's defense against injury or infection and unstable plaques in the coronary artery can rupture and the inflammatory cells rush in to repair. Even people with low cholesterol can have high CRP indicating inflammation.

There have been numerous studies of CRP in large populations of people, and it's role as a risk for heart attack is well established. Some believe it is even a better predictor than high LDL cholesterol.

What should be done for people who test high with hsCRP? Lowing other risks (smoking, diabetes control, weight, exercise, high cholesterol) is critical. Aspirin is given as an anti-inflammatory drug and to prevent clotting. Statins (Lipitor, Crestor, Zocor, Pravachol, Mevacor) are potent anti-inflammatory drugs as well as lowering cholesterol. The Jupitor Study, published in the New England Journal of Medicine, showed a reduction in heart attacks in people with high CRP and low cholesterol who were treated with the statin, Crestor.

Among cardiologists and scientists, the benefits of statin drugs in preventing heart attacks is not a controversy. The Internet is filled with blogs that "Big-Pharma" is out to addict us all but science, not emotion, should be our guide.

The First Celebrity Swine Flu Death

AND WE KNOW WHO IS RESPONSIBLE! (if you don't know - ask)

hat tip to JS

Talking with Health Plans Costs Big Bucks

Does anyone NOT think we need health care reform? A study published in Health Affairs and funded by the Commonwealth fund and the Robert Woods Johnson Foundation found that physician practices spend $31 billion annually just "interacting" with Insurance plans.

As one who as been on the "interaction" side for most of my professional life, I can tell you those numbers are probably underestimates. The time spent on prior authorizations, pharmaceutical formularies, claims, billing, contracting, collecting data and just being on hold is what has killed primary care in the United States. Doctors are bailing out by leaving patient care, going concierge (retainer) or not taking insurance at all.

This leaves more patients footing the entire bill or not able to find a primary care doctor at all.

This is a system that is entirely out of wack. By forcing physicians to deal with multiple insurance carriers, each with their own payment schedules, formularies, credentialing and claim forms, we are perpetuating waste and inefficiency and it does nothing to advance the health of Americans.

Health care reform must address insurance related administration activities. Single payer is looking better and better.