Thursday, October 16, 2008

New Mexico Residents Struggle to Navigate Health Care System in Crisis | PBS

Once a month, badly needed food and health care come to the small rural towns that dot the country roads of Chaves County.

In this part of the state, one-quarter of the people live below the federal government's poverty line. They've been hit hard by rising food and gas prices. So when the Roadrunner food pantry hands out 50 pounds of groceries for $2, that's an offer locals can't refuse.

JANE BATSON, dean of health, Eastern New Mexico University: Did you go get your blood pressure checked?

BETTY ANN BOWSER: While people wait for food, Jane Batson works the line, looking for those with health care problems.

JANE BATSON: Have you got one?

NEW MEXICO RESIDENT: Oh, a doctor? No.

BETTY ANN BOWSER: As dean of health at Eastern New Mexico University Roswell, Batson is keenly aware that nearly one quarter of the people in New Mexico have no health insurance. That's the second-highest percentage of any state in the nation.

Many of these people work for the small businesses that drive much of the economy of the state and whose owners can't afford to offer health insurance.

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Wednesday, October 15, 2008

Deformed child cannot sue doctor, court rules - Globe and Mail

Physician who prescribed acne drug to woman did not owe duty of care to unborn baby, Ontario Court of Appeal says

A Toronto doctor cannot be sued by a child born with serious deformities caused by a drug that was prescribed to its mother, the Ontario Court of Appeal ruled yesterday.

In an important 3-0 ruling, the court said that doctors cannot owe a duty of care to unborn children because their primary obligation is to their female patients.

"Because the woman and her fetus are one - both physically and legally - it is the woman whom the doctor advises and who makes the treatment decisions affecting herself and her future child," Madam Justice Kathryn Feldman wrote on behalf of Mr. Justice Michael Moldaver and Mr. Justice Russell Juriansz.

The court also said that granting a child the right to sue doctors for damage caused before birth would also interfere with a woman's right to an abortion. The ruling closed the door on a lawsuit launched by Jaime Paxton, her parents - Dawn and Paul - and her three siblings.

The family alleged that Shaffiq Ramji negligently prescribed Ms. Paxton, 36, the acne drug Accutane, which is known to cause severe defects in fetuses.

Jaime was born without a right ear, and with portions of her face paralyzed.

At trial, family lawyers Paul Pape and Susan Chapman won the battle, but lost the war.

They managed to persuade a judge to buck jurisprudential odds and find that Dr. Ramji owed Jaime a duty of care. However, the judge went on to conclude that Dr. Ramji had met the standard of care expected.

In defence of Dr. Ramji, lawyer Darryl Cruz and Sarit Batner argued that the prescription was given because Mr. Paxton had undergone a vasectomy several years earlier, making it virtually impossible for his wife to conceive.

Yesterday, the appeal judges reasoned that the position of a doctor relative to an unborn child is remote. They said that doctors cannot "advise or take instructions from a future child."

If children disabled by medical damage caused in the womb are to be compensated, it will be up to politicians to find a way, the court said.

Doctors are with you at the beginning and at the end - Dr. Yoel Abells - National Post

A few years ago, I was sitting in the labour and delivery room of Mount Sinai Hospital in Toronto, waiting for a patient of mine to deliver. One of the nurses poked her head out of a delivery suite asking for help. A patient who had been pushing was not feeling well. As I walked in, the patient suddenly lost consciousness. Her heart stopped beating. I began resuscitative efforts while the patient’s obstetrician delivered the baby. By the time the arrest team arrived, the baby was born and the mother’s heartbeat was restored. At this point, her care was transferred to the team and I returned to my patient. I thought that this was the end of the story.

Three weeks after this event, an elderly patient of mine came to the 
office complaining of lower back pain. She was an apparent breast 
cancer survivor, having recently celebrated her fifth year of 
remission. After a careful examination, I concluded that she most 
likely had mechanical back pain. However, because of her past medical 
history of cancer, I ordered an X-ray of her back in order to ensure 
that the tumour had not invaded her bones. She never went for the X- 
ray. A few days later, I was notified that she had gone to Mount 
Sinai because the pain had become unbearable. Radiographs showed that 
the cancer was everywhere. Because it was compressing on her spinal 
cord, she could not walk and was admitted. It was clear that she was 
not going to survive.

It is not easy to tell someone that he or she is going to die. I will 
never forget entering her room. Her eyes told me that she knew. Yet I 
was struck by how happy she was to see me and how comfortable she 
made me feel. For her, I was a familiar face in unfamiliar circumstances. For me, she was a patient I had tended to for some 
time and was now about to lose. It did not seem fair. Suddenly, in 
hushed tones she drew me near her and said: “You know, the woman 
lying in the bed next to me—she’s going home tomorrow. She almost 
died in childbirth, but now she and her baby are going home.” I 
glanced beyond the curtain that divided the room and peeked at the woman sleeping in the bed. It was the patient I had help resuscitate three weeks earlier.

The paths of life intersect in unexpected ways. At that moment, I realized that in this room lay a microcosm of what we do as family physicians. We are there at the beginning and at the end. Our work is 
about life and death and the time in between. There are some things 
over which we have control and many things over which we do not. Yet, 
we are lucky because we share moments of sublime intimacy with our 
patients and can touch one another in profoundly precious ways. For 
all of this, we are truly blessed.

Tuesday, October 14, 2008

The Scan That Didn’t Scan -

This is a story about M.R.I.'s, those amazing scans that can show tissue injury and bone damage, inflammation and fluid accumulation. Except when they can't and you think they can.

I found out about magnetic resonance imaging tests when I injured my forefoot running. All of a sudden, halfway through a run, my foot hurt so much that I had to stop.

But an M.R.I. at a local radiology center found nothing wrong.

That, of course, was what I wanted to hear. So I spent five days waiting for it to feel better, taking the anti-inflammatory drugs ibuprofen and naproxen, using an elliptical cross-trainer, and riding my road bike with its clipless pedals that attach themselves to my bicycling shoes. By then, my foot hurt so much I had to walk on my heel. I was beginning to doubt that scan: it was hard to believe nothing was wrong. So I went to the Hospital for Special Surgery in New York for a second opinion from Dr. John G. Kennedy, an orthopedist who specializes in sports-related lower-limb injuries. And there I had another M.R.I.

It showed a serious stress fracture, a hairline crack in a metatarsal bone in my forefoot. It was so serious, in fact, that Dr. Kennedy warned that I risked surgery if I continued activities like cycling and the elliptical cross-trainer, which make such injuries worse. And I had to stop taking anti-inflammatory drugs, since they impede bone healing.

As I hobbled around the office on crutches, one of my colleagues, James Glanz, asked what had happened. As we chatted, it turned out that he had had a much more sobering experience than mine.

Jim, the Baghdad bureau chief for The New York Times, was playing touch football in New York in late 2005 when he landed hard while diving to make a catch, both elbows hitting the ground at once. The next day, his fingers and hands hurt so much he couldn't type.

But an M.R.I. showed nothing except some bulging disks in his neck that, he was told, were common in people his age, 50. He was advised to do neck exercises, and eventually he felt better.

About a year later, he fell again while playing football. His symptoms came roaring back.

The worst was when he woke up in the morning, Jim said. The two middle fingers on each hand were so stiff they would not even bend. He would massage his fingers and loosen them, but his hands and knuckles ached all day. He tried ibuprofen, to little avail.

Finally, last spring, he sought help at New York University, where he had another M.R.I. It turned out he had a nerve impingement so serious that he was warned that he risked permanent paralysis if he did not have surgery. So this summer, he had a major operation called a French-door laminoplasty, in which his surgeon, Dr. Ronald Moskovich at the N.Y.U. Hospital for Joint Diseases, opened and widened four or five vertebrae to free the trapped nerves.

How could M.R.I.'s have come to such different conclusions for both Jim and me?

Jim asked his doctors whether he could have really had nothing wrong at the time of his first scan. Unlikely, they replied, although they cautioned that no one had directly compared the two scans.

I asked Dr. Kennedy the same question and received the same answer. He explained that in my case the quality of the two images was vastly different. "It's like the difference between a black-and-white TV and HDTV," he said.

All well and good, but how was I supposed to know? The radiology center I first went to is accredited by the American College of Radiology, and there is no way I can tell a good M.R.I. image from a bad one. In fact, I never even saw the images. All I saw were the radiologists' reports.

Academic radiologists say that, unfortunately, they see patients like Jim and me all the time.

"That's the bane of our existence in an academic medical center," said Dr. Howard P. Forman, a professor of diagnostic radiology at Yale University School of Medicine.

And it's not just patients who have to deal with the problem, said Dr. William C. Black, a professor of radiology and community and family medicine at Dartmouth Medical School. Doctors do, too. Radiology centers send written reports to doctors, but the doctors may have no idea whether the M.R.I. was done well and interpreted well. "It's a huge problem," Dr. Black said.

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Online Tools for Managing Health Information -

BUSY people can easily forget to take their medications, or to write down symptoms or reactions during a course of treatment — information that could later be meaningful to a doctor.

New tools are being developed that may help harried patients, including those with chronic health conditions, monitor their medications, home tests and other details. The information can then be posted to a Web page that the patient can choose to share with a doctor, pharmacist, friend or caregiver.

Zume Life, of San Jose, Calif., for example, is testing a small hand-held device, the Zuri, that prompts users to take their pills on schedule and to keep track of health-related matters like diet and exercise.

"We're going after users who are mobile, social, active people" who need to follow a health routine in the midst of busy lives, said Rajiv Mehta, the chief executive of Zume Life.

All of the data from this pocket-size electronic minder, which beeps or flashes when it's time to take a pill, are uploaded to a Web portal. There, users can inspect, for example, graphs or charts of their exercise or other activities of the last few days or week. And, if the users wish, a caregiver can do so, too.

The Zuri will cost about $200 when it is released in the spring, Mr. Mehta said. Users will also pay about $40 to $50 a month for Web services. A software version of the device that will run on an iPhone is also in the works.

Kathleen Weaver, a high school teacher of computer science in the Dallas Independent School District, is testing a Zuri, using it to keep track of symptoms as well as medication related to diabetes, cardiovascular complications and a persistent cough.

"If I had to write all of this down, I don't think I could," she said. "I'm busy all day taking care of other people."

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Monday, October 13, 2008

Women weigh options on breast reconstruction -

Recent data suggest fewer than 20% have immediate reconstruction after a mastectomy, despite improved surgical techniques and attempts to increase insurance coverage, says Amy Alderman, a plastic surgeon at the University of Michigan Medical Center in Ann Arbor.

A lack of information does not fully explain differences among women. Here are other reasons women don't have immediate reconstruction:

• Medical considerations. Other treatment priorities can delay reconstruction.

• Money. A 1998 federal law says any insurer that covers mastectomy must cover reconstruction. But with rising co-pays and more limited policies, insured women may pay more now, says two-time breast cancer survivor Missy Fish of St. Louis. She paid $205 for reconstruction of one breast in 1991 and $5,000 for the same procedure in 2005.

• Choice. Some women don't want it.

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NYTimes: Children: Higher Expectations Help Fight Asthma

If doctors want to help children suffering from asthma, they should spend some time offering encouragement to their parents, researchers say.

A new study finds that the higher the parents' expectations for controlling the asthma, the better their children do. Those with lower expectations tend not to be aggressive enough in managing the illness.

The study appears in the October issue of Pediatrics. The lead author is Dr. Lauren Smith, now with the Massachusetts Department of Public Health.

For the study, researchers surveyed the families of more than 750 asthmatic children and asked them about their symptoms in the two previous weeks. For more than 35 percent of the children, the condition was found to be insufficiently controlled.

The parents were also asked about medication use and about their beliefs about asthma, including whether they thought the children could be free of symptoms most of the time and not miss school.

The senior author of the study, Dr. Tracy A. Lieu of Harvard Medical School, said many parents made the mistake of looking at asthma as an intermittent disease, not a chronic one. That means they respond only when their child is having a serious problem, instead of looking for warning signs and using medicine preventively.