With advanced cancer, there are no guarantees"I just want to know that she'll be able to travel," my patient's husband said. Stan and Jane Jackson (names changed) sat side-by-side on the mauve loveseat in the exam room. A binder filled with sheaths of paper -- copies of Jane's lab reports, CT scan reports, discharge papers, and chemotherapy information handouts -- sat open on his lap. On top ...

Read more...

I wrote recently about getting started with an evaluation for a child who’s not doing well in school. Don’t rush to just do ADHD testing: There are many reasons for attention problems, and it’s best to not just zero in on ADHD at the start. Still, there’s a time when confirmation and testing for an ADHD diagnosis is appropriate. What kinds of tests are available? A clinical history is, well, talking ...

Read more...

Is the practice of medicine more of an art or an applied science? It’s a debate patients may not even know is taking place. But the way your primary care physician, surgeon or hospital answers this question may determine whether you live or die. Doctors on the far “art” side of the spectrum maintain that every patient and physician is different. Therefore, they believe there is no one right way to treat ...

Read more...

In recent months, there has been a lot of talk on social media and in the press about how miserable many doctors are. These conversations have also brought inspiring alternatives to the forefront. For example, Zubin Damania, MD, founder of Turntable Health, and Pamela Wible, MD, a leader in the Ideal Practice movement, have notably and smartly encouraged doctors practicing on the front lines to take matters into ...

Read more...

It is so nice to be right. To summarize what I wrote almost 4 years ago, based on my experience, patients and families will accept the theoretical risk of a future cancer if it means they'll get an accurate diagnosis. A recent study validates that opinion. MedPage Today reports that before receiving any recommendation for CT scanning, 742 parents of children who presented with head injuries ...

Read more...

In an effort to promote transparency in healthcare, the Association of Health Care Journalists (AHCJ) has published a database of recent hospital deficiencies discovered by Medicare and Medicaid  inspectors. They then highlighted 168 reports containing the phrase “immediate jeopardy.” This, of course, piqued my interest as I presumed that hospitals who were putting putting patients in “immediate jeopardy” must be some pretty bad actors. After sifting through the hospital names, I ...

Read more...

Back when Prozac (fluoxetine) and Zoloft (sertraline) were new, I remember the mental acrobatics doctors made to justify giving these drugs to anxious patients. The drugs were approved for treating depression, but we knew they often seemed to help anxiety. The reason, we were told, was that some anxious patients were actually depressed, deep down, and we had just failed to recognize their depression. Now, with studies to support their use ...

Read more...

As an emergency physician used to working in busy, urban ERs, I like to think that I’m not easily surprised. The other day, someone did something that really amazed me. Our patient was a young woman who had a headache and requested medications to take it away. On an average ER shift, we see dozens of patients with similar complaints to hers. On busy days, the evaluation and treatment become rote: ...

Read more...

Imagine this:  You are sick.  You are the sickest you’ve ever been.  You want to die.  You almost did die.  You want to bury your head in your cozy bed for the next two years. But you’re not in your bed.  This bed has plastic for covers and sandpaper for sheets.  You need to throw up every thirty minutes but you have to share a bathroom with someone you don’t know, ...

Read more...

One of the frustrating aspects of medical practice is trying to decide if the medication I am prescribing is covered by the patient’s insurance company. Even with the advent of electronic medical records, which should be able to determine this, we are often left to hope and pray. Here’s how it works. Individual insurance companies have formularies -- lists of approved drugs -- that they encourage patients and their physicians to use. ...

Read more...

For days, I have been trying to get long-term patient, Stan, on the phone; his blood work came back abnormal, and we need to repeat it.  I called the number in our file a bunch of times. The odd thing is that sometimes it rings without stopping, sometimes it is answered by a machine, which immediately beeps and disconnects, and at least once it sounded as if the receiver was ...

Read more...

A wish list for Apples HealthKit Apple has been making headlines again, which is not unusual for a company that sets trends and moves markets. Recently, they announced that iOS 8 would have a built-in app to collect all of your health info in one place. Then there was the announcement of the partnership with Mayo Clinic and Epic Systems. This generated even more headlines.  I saw all ...

Read more...

I have a confession to make.  The purpose of a recent blog post was to set up this one.  What I questioned, at that time, is whether the future of primary care will come from outside change (business, politics, or even specialist physicians and administrators) or internally, hence creative destruction versus internal combustion. When I entered my first primary care practice in 2002, I had great doubts that the traditional ...

Read more...

Recently, a family physician colleague asked me to explain why the Affordable Care Act requires private health insurers to provide first-dollar coverage for preventive services that the U.S. Preventive Services Task Force assigns an "A" or "B" (recommended) rating, but allows public insurers (Medicare and Medicaid) to determine if and how they will cover these services. Until recently, the question hadn't come up, since Medicare has agreed to cover pretty ...

Read more...

Disruptive innovation is competitive strategy for an age seized by terror. - Jill Lepore, author of The Disruption Machine: What the Theory of Innovation Gets Wrong "What do you want me to do with all the stuff in this box?" my wife asked this weekend. I looked inside and saw my former self: one of BNC and pin connectors, wires, a notebook with sin, cos, theta, and a host of other equations -- a ...

Read more...

All of the focus that CMS is putting on hospital readmissions via the Readmissions Reduction Program, and the financial penalties that readmissions can generate, is causing hospital administrators to look to the emergency department and emergency physicians to intervene and resolve the issues that interrupt recovery for post-hospitalization patients. In today’s world of budget-constrained financing of government health care programs and narrow hospital margins, the question of how best to ...

Read more...

Our nation has recently witnessed another tragedy involving a young adult, with young adult victims. Facts often emerge slowly and it is important not to speculate about diagnoses through the news media; however, it seems clear in this case that mental illness is a factor -- even though few people living with mental illness are violent. To avoid tragedies, solutions are needed.  One area of real promise is early ...

Read more...

Is the phone in your pocket increasing your risk of being sued for medical malpractice? As more and more of our daily lives is being recorded and shared -- with or without our permission -- health care is no longer a fully safe harbor of privacy and consent. For reasons both clinical and social, in practices both ethical and ill-advised, individuals are sharing the intimacies of health care far beyond the ...

Read more...

A total knee replacement is a very common operation and more than 700,000 of them are performed each year in the United States. With a mean cost of about $16,000 each, in 2011 we spent over eleven billion dollars paying for knee replacements. Projections are that, by 2030, we’ll be doing 3.5 million per year. The operation has great results and patients generally do well during and after their surgery. Anesthetic care has improved dramatically ...

Read more...

Without a doubt, the death of American veterans as a result of the VA waitlist debacle is tragic and unacceptable. The Obama administration must move quickly and deliberately to fix the underlying problems and restore faith in the agency. If these issues were common throughout the VA network of hospitals and clinics, it might make sense to consider dramatic, earth-shaking alternatives like moving veterans to private providers and shuttering the ...

Read more...