Tuesday, December 16, 2014
IT'S hard to believe that another 10 years have passed, but the proof is the 11-volume stack of medical review books at my bedside. It's time for the decennial rite of cramming a thousand pages of facts for an eight-hour-long multiple choice test.
Doctors are licensed by their states to practice medicine, but they're also expected to be "board-certified" in their particular field — surgery, obstetrics, pediatrics, etc. This certification comes from the professional organization of each field. In my case, it's the American Board of Internal Medicine.
It used to be that you tackled those monstrous board exams just once after residency. Then you went into practice and never looked at a No. 2 pencil again. But in 1990, the boards decided that doctors should recertify every 10 years. This seemed reasonable, given how much medicine changes. Over time, though, the recertification process has become its own industry. The exam has been supplemented with a growing number of maintenance-of-certification, or M.O.C., requirements. Some are knowledge-based exercises, but many are "practice assessments" meant to improve care in your own practice that end up being just onerous paperwork. And the recertification process and associated materials cost doctors thousands of dollars.
PRINCETON, N.J. — Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.
And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. "Why would that be?" Mr. Charlap asked. "It really bothered me."
Tuesday, December 9, 2014
Half of Doctors Listed as Serving Medicaid Patients Are Unavailable, Investigation Finds - NYTimes.com
WASHINGTON — Large numbers of doctors who are listed as serving Medicaid patients are not available to treat them, federal investigators said in a new report.
"Half of providers could not offer appointments to enrollees," the investigators said in the report, which will be issued on Tuesday.
Many of the doctors were not accepting new Medicaid patients or could not be found at their last known addresses, according to the report from the inspector general of the Department of Health and Human Services. The study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act.
In the aftermath of what we shrinks call "August" — a euphemism for the acute clinical moments that our patients experience while we're away for the standard three to five weeks of vacation — I found myself reflecting on a series of physical accidents that befell too many of my patients during my break not to note.
If two patients fall down stairs, another is involved in a pedestrian accident, one more falls off her bike and yet another suffers severe burns, what am I to make of this? Was it coincidence? Or were their mishaps somehow a continuation of their work with me in analysis?
Thursday, December 4, 2014
These infants are born with bacterial infections that are resistant to most known antibiotics, and more than 58,000 died last year as a result, a recent study found. While that is still a fraction of the nearly 800,000 newborns who die annually in India, Indian pediatricians say that the rising toll of resistant infections could soon swamp efforts to improve India's abysmal infant death rate. Nearly a third of the world's newborn deaths occur in India.
"Reducing newborn deaths in India is one of the most important public health priorities in the world, and this will require treating an increasing number of neonates who have sepsis and pneumonia," said Dr. Vinod Paul, chief of pediatrics at the All India Institute of Medical Sciences and the leader of the study. "But if resistant infections keep growing, that progress could slow, stop or even reverse itself. And that would be a disaster for not only India but the entire world."
Deaths from chronic diseases have risen by more than 50 percent in low- and middle-income countries over the past two decades, according to the report, by the Council on Foreign Relations. The increase is part of a shift in global mortality patterns in which infectious diseases, such as malaria and tuberculosis, have declined substantially and are no longer the leading cause of death in the developing world.
The shift in poorer countries is being driven by urbanization and other major changes that have led to improvements in aspects of public health, such as hand washing, sanitation and vaccines. That has led to sharp declines in infant mortality, and in turn, to increases in life spans. The average life expectancy in Africa, for example, has increased by about eight years since 2000, according to the World Health Organization.
Tuesday, December 2, 2014
When a new patient between the ages of 18 and 25 arrives at my office, he or she generally has a specific request: a physical exam as clearance for football season, a refill of an asthma inhaler, reassurance that a sore throat isn't strep. These young men and women are healthy and don't expect to be asked very much, or little beyond the usual waiting room questionnaire.
My job, as I see it, is not only to respond to any requests or questions, but also to ask them about the things 18- to 25-year-olds do: attend college (or consider it), search for employment, separate from (or return to live with) parents, find romantic partners, shrug off one-night stands, run out of money, feel confused or depressed or anxious, experiment with drugs and alcohol.
The last topic is of special concern for me. I've seen too many people get sidetracked by drugs; I don't want to miss any signs.
Early in my career, I wasn't planning to act as a therapist — I was trained mostly to listen to hearts and lungs and feel for lymph nodes — but once I started seeing young adults I discovered the unspoken problems and hidden distress I should be looking for. Not that these young patients think of encounters with me as psychotherapy, God forbid; we're just talking.
In my experience, most young adults rarely, if ever, have a personal, 30-minute conversation with an adult. They talk mostly to people their own age. To my patients I'm a curious stranger with whom they're stuck for a while in a small room. Fortunately, most of them like talking about themselves, about their decisions and doubts. They know that after half an hour we will part company, that what they've told me goes no further. If I do my job well, they might just stumble into telling their story.
Lidia, 22, and soon to graduate college, comes in wearing jeans and a T-shirt that reads OBEY. Some minutes after we've discussed the reason for this appointment — eczema — I say: "I'm interested in how you would compare yourself today to your 18-year-old self. Do you feel like you're moving along into adulthood?"
She looks surprised by my question. But to hear about Lidia's life, I need to be broadly interested and indirect. The question defuses the pressure of asking about private things and gets her talking.
"I'm better at handling problems than I was a few years ago," she says. "I don't depend on my parents for everything. In the old days, when I had trouble with a roommate, I might have called my parents and moved home. Now I just wait for the lease to end."
I want to hear a full self-portrait, so I ask, "What things are most important to you at the moment?"
"Getting a job, completing school, putting my parents' minds at ease, making my own happiness even if it feels hard at times or I don't know what will make me happy."
By bringing up "happiness," she has given me an opening to wander into the topic of drugs.
"Does marijuana or alcohol play a part in your happiness?" I ask.
"I don't drink much because I don't like feeling hung over, but I'm smoking more weed than I was last year. I'm flipping between if I should stop and if I'm just gonna have some fun. Back and forth."
Marijuana use peaks between the ages of 19 and 22. According to surveys, 15 to 20 percent of this age group has smoked in the past month. Yet these young adults often have exaggerated perceptions about their peers' use, estimating more than half the people their age smoke pot. Sometimes I set them straight about the norms, but with Lidia I withhold this information because I don't want to break the flow of our conversation.
Rather than ask about the specifics — the amount and her frequency of use — and put her on the spot, I ask, "It's hard to think about the next week, but where do you think you'd like your marijuana use to be in a year?"
Look back to when you were 18, I'm suggesting again, and now look forward.
"I don't want to stop completely because it would weird out my friends. But I could if I had to, like if my job was going to test me, or if I had to save money."
I listen carefully for the reasons Lidia gives, trying to hear if I should be worried that her marijuana use is problematic. I'm not overly troubled when she says, "I don't think marijuana affects me like it does a lot of people." She may underestimate the effects of marijuana or perhaps marijuana does not affect her negatively at all. What's key is that she doesn't mention that she smokes to forget her troubles, or because she's sad or nervous, phrases that would suggest there's a larger problem.
With David I worry. David, 19, short-haired and big-eared, a part-time community college student, informs me that he wants to be "a great decision-maker." He reports the pride of owning a new laptop, telling me "bills create discipline." But then, as if the word "discipline" reminds him of something, he says: "My mom is going back to jail. She didn't make the right decisions in the free world." He adds: "That makes me push toward drugs. It helps me deal with it."
David isn't sure how to deal with the stress he's under. "I want to be a man of stature, but there's pressure on my shoulders," he says. "I'm not sure how to cope with what I'm going through."
As with Lidia, there is no specific amount or frequency of marijuana use that is acceptable or unacceptable; there is no magic number I'm waiting for David to announce so that I can give him a label, and offer him counsel. But if someone is smoking daily and during daylight hours, I pay special attention, so when David tells me he smokes "either before or after noon," a red flag goes up.
Here's what I'm trying to differentiate: Is this person using marijuana for fun, because it's what friends do when they're together, or to mitigate negative feelings? Using marijuana "to cope" is often a marker for other pathology — serious mental health problems, anxiety, attention deficit disorder, concurrent alcohol abuse, major depression. That's what I'll want to hear more about next time with David.
Although I'm concerned about his drug use and his admission of distress, this first visit is an orientation, an introduction. I will ask him to come see me again, and soon. Sometimes a person like David will return for more primary care, interested in himself, worried about himself, intrigued by the idiosyncrasies of an adult conversation, and I will continue to evaluate him. Sometimes people like David never reappear, perhaps embarrassed by what they've admitted or upset by my prying.
Life often changes dramatically in a matter of months at their age, sometimes physically, but more often psychically. New pleasures come along, and also new risks, new forms of distress that are deep and real and need attention. But this is not likely to be revealed unless a young adult is encouraged to find his or her way to a primary care doctor, and unless that doctor accepts that this may be the one conversation with an adult for this patient this season, and tries to understand what's happening in the full life of a David or a Lidia, a young adult who may have arrived asking simply for a refill.
Some details have been altered to protect patient privacy.
Michael Stein, a professor of medicine and of health services, policy and practice at Brown University, is the author of "The Addict: One Patient, One Doctor, One Year" and "The Lonely Patient: How We Experience Illness."
Incidents of hospital-induced harm – such as adverse drug events, infections, falls and bedsores – fell by 17 percent, or an estimated 1.3 million episodes, from 2010.
The improvements, driven by a number of public and private initiatives, saved an estimated $12 billion in health care spending, according to a new government report that found dramatic progress in the fight to curb preventable medical injuries at U.S. hospitals.
Of the estimated 50,000 fewer deaths, a decline in bedsores, or pressure ulcers, helped save roughly 20,300 lives. A drop in adverse drug events – such as overdoses or administering the wrong medication – saved another 11,500 lives.
Fewer falls by hospitalized patients saved 6,400 lives, the study found.
In a speech Tuesday in Baltimore, Health and Human Services Secretary Sylvia Mathews Burwell said the new HHS estimates represented "historic progress on health care quality."
"A 17 percent reduction in hospital-acquired conditions is a big deal, but it's only a start," Burwell said. "No American should ever lose his or her life, or spend the holidays in the hospital, because of a condition that could have been prevented."
Analysts from HHS looked at 18,000 to 33,000 medical records for each of the three years covered by the study. They estimate that nearly 10 percent of hospitalized patients in the U.S. experienced one or more of the numerous hospital-acquired conditions they were looking for.
"That rate is still too high," the report found.
Hospital-induced harm to patients has been a black cloud over the U.S. health care system for decades. The Centers for Disease Control and Prevention estimates that 2 million people each year suffer hospital-acquired infections, such as bloodstream and urinary tract infections from catheters.
In 2010, the government estimated that 27 percent of hospitalized Medicare patients sustained injuries associated with their care. Half of these patients had one or more episodes that either prolonged their hospital stays, caused permanent harm, required lifesaving interventions or resulted in death, HHS investigators found. About half the incidents were preventable.
Tuesday, November 25, 2014
Medical Mysteries: Doctors puzzled by woman’s dizziness and amplified body sounds - The Washington Post
'That's it — I'm done," Rachel Miller proclaimed, the sting of the neurologist's judgment fresh as she recounted the just-concluded appointment to her husband. Whatever was wrong with her, Miller decided after that 2009 encounter, she was not willing to risk additional humiliation by seeing another doctor who might dismiss her problems as psychosomatic.
The Baltimore marketing executive had spent the previous two years trying to figure out what was causing her bizarre symptoms, some of which she knew made her sound delusional. Her eyes felt "weird," although her vision was 20/20. Normal sounds seemed hugely amplified: at night when she lay in bed, her breathing and heartbeat were deafening. Water pounding on her back in the shower sounded like a roar. She was plagued by dizziness.
"I had started to feel like a person in one of those stories where someone has been committed to a mental hospital by mistake or malice and they desperately try to appear sane," recalled Miller, now 53. She began to wonder if she really was crazy; numerous tests had ruled out a host of possible causes, including a brain tumor. Continuing to look for answers seemed futile, since all the doctors she had seen had failed to come up with anything conclusive.
Figuring it out would take nearly three more years and was partly the result of an oddity that Miller mentioned to another neurologist, after she lifted her moratorium on seeing doctors.