The New England Journal of Medicine recently published an article by David Reuben, MD and Mary Tinetti, MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these "hospital dependent" patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, ...

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My home hospital is small. In a town of just over 20,000 people, this hospital has 25 beds and is designated "critical access" by Medicare because it is felt to be necessary to the health care of the community. Critical access is a designation which was introduced in 1997 when modernization of Medicare payment systems threatened to close a large proportion of hospitals in small communities which were unable to ...

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The other day at an interdisciplinary rounds meeting at the hospital, one of our nurses who is also an emergency medical technician mentioned that in Britain injured patients receive tranexamic acid before arriving at the hospital because it reduces death from bleeding. "What's that?" I said. I kind of barely remembered hearing this medication's name associated with the treatment of a rare disease, but not treatment of trauma. So I was guessing ...

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I have been doing admitting shifts at a large hospital, as hospitalist. It is flu season, so volumes are large. Even people without the flu are sick. It often happens that way. And they are so very sick! The thing about the very sick patients I see is that they are generally what might be called medical "train wrecks." They are very sick because they have had interventions over the years ...

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Recently, I attended a dinner and lecture at the local dining venue where they served huge hunks of prime rib and sauteed snow peas from some far away place where it's spring, and chocolate mousse and wild rice. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the health care ...

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In 1950 Ernst Wynder, MD and colleagues began to produce convincing data that cigarette smoking caused lung cancer. Over the ensuing many years evidence has arisen linking cigarette smoking to many different cancers, chronic lung disease and heart attacks. In 1964 the surgeon general reported that cigarette smoking was the most important risk factor for development of lung cancer and that quitting smoking reduced that risk. Since that time a concerted ...

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David Blumenthal and others recently published a paper in the New England Journal of Medicine entitled "Health Care Spending -- A Giant Slain or Sleeping?" In it they look at the ongoing, and rarely discussed, phenomenon of slowing of health care spending, which has persisted over several years. Health care spending grew remarkably after the establishment of Medicare and Medicaid in the 1960's, resulting in the fact that health care costs ...

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Rural medicine, I guess, can be defined as health care that happens in places that aren't big cities or referral centers. The vast majority of the populated earth's crust that has any health care at all is served by rural practitioners. I have done a little bit of rural medicine in Haiti, in Mexico and now a bit more in South Sudan. I have also worked in a rural health ...

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The American Heart Association, in collaboration with the American College of Cardiology, recently released recommendations that should change the way we prescribe medications called statins, including drugs like Lipitor and Crestor and their generics, atorvastatin and rosuvastatin. The headlines say stuff like, "More Americans may be Eligible to Receive Cholesterol Lowering Drugs!" I am a bit skeptical of news about statin therapy because Lipitor, before it went generic, was responsible for over ...

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A 100-year-old woman is brought to the emergency room by a concerned friend because she can no longer get out of bed to get food or go to the bathroom. Other than being unwashed and a little confused, she is fine. Her electrolytes are pristine, her electrocardiogram the definition of normal, her blood count and chest x-ray perfectly mirror the expected physiology for her age. Even her urinalysis is normal. ...

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