Keep Scope of Practice Limited - Patients Depend On Us

There has been much discussion and some movement on the issue of expansion of the "scope of practice" of nurse practitioners. While nurse practitioners are important to the health care team, simply giving full independence on the level of trained physicians may not result in improved patient care.

Non-physician caretakers, such as nurse practitioners, are a crucial component of our healthcare system. They are hard-working, dedicated, patient-centered individuals who are more than likely the first person a patient encounters. Together, the nurse practitioner and physician care for patients. The nurse practitioner typically obtains the information and creates a coherent list of a patient's presenting complaint, history and physical exam findings. Nurse practitioners work collaboratively with physicians for their patients, communicating information and findings, arming the physicians with the necessary information to allow him/her to put together accurate diagnoses. Such collaboration saves time for everyone involved. The physician considers the gathered information and generates a clinical picture from the various pieces, thereby making a diagnosis. That is not to say that a few nurse practitioners may exceed the clinical expertise of a few physicians. But physicians have a long head start due to their years of training and education. The clinical acumen that physicians acquire cannot be underestimated, nor discounted. 

To better understand the levels of training of various caretakers, including physicians and nurse practitioners, click here for a graphic depiction. Importantly, the very different types of training and lengths of education make physicians and nurse practitioners well-suited to work collaboratively. The vast importance of the medical school years, coupled with years of residency and standardized, extremely rigorous and challenging medical board exams has to be acknowledged and understood in this context. 

But what is also important to note is that the physician is the person who is primarily responsible, from a legal standpoint, for the patient's care. Expansion of the scope of practice of nurse practitioners, allowing them to practice independently, must also carry the same liability as physicians currently carry.

The Florida House (@MyFLHouse) recently agreed to expand the scope of practice of nurse pratitioners but, fortunately, the Florida Senate (@FLSenateGOP) did not. This mixed result has many people thinking that it is only a matter of time before the scope of practice expansion bill passes, allowing nurse practitioners to practice independently, without physician oversight and guidance.

Fortunately, there is an alternative plan that deserves much consideration. The Florida Medical Association has published the Five Pillars of Expanded Access, which addresses the shortage of physicians and access to care issues. It calls for increased collaboration between physician assistants, nurse practitioners and physicians. And it aims to regulate and codify telemedicine, an important developing component of health care in the 21st century. It is worth understanding this plan as the preferred alternative to unnecessarily expanding the scope of practice of nurse practitioners.

If you understand this issue as I do, and you live in Florida, please call your Representative and let them know that the solution to the physician shortage is not independently practicing non-physician caretakers. The solution to access to care issues is the Five Pillars plan promoted by the FMA. Please call your state Senator and thank them for not passing the bill and also impress upon them the importance of maintaining a firm stance against the expansion of the scope of practice of nurse practitioners. Ask them to keep the valuable and long-standing cooperative structure in place, allowing nurse practitioners and physicians to continue to work together for the safety and health of all patients.

Patients depend on their caretakers to give them the best care possible. The highest level of expertise must remain clearly spelled out in the laws so that people everywhere can continue to have confidence in the medical profession. 

 

Chew Longer. Lose Weight!

One of the simplest things to remember is chew your food thoroughly. So many people wolf down their meals like there's no tomorrow. The simplest thing to remember is the longer you chew, the sooner your brain will indicate the "full feeling." 

From the AMA daily email:

Devices, apps help people eat more slowly by chewing longer.

On the front of its Personal Journal section, the Wall Street Journal (8/12, D1, Reddy, Subscription Publication) reports on new medical devices and applications designed to help people eat more slowly by chewing longer. Chewing food thoroughly appears to make people feel fuller sooner, and some studies indicate that people who chew their food the most may consume fewer calories. One group of researchers is using funding from the National Institutes of Health to design a study which will test the efficacy of a diet in which participants will be restricted to just 100 bites of food on a daily basis.

FDA Approves First Colon cancer Screening Lab Test

My hope is that a simple screening test soon replaces colonoscopy or CT colonography, eliminating the discomfort, preparation and small risk of perforation.

As reported by the AMA daily email: 

Bloomberg News (8/12, Edney) reports the FDA gave approval to Exact Sciences Corp. to sell “the first noninvasive DNA screening test for colorectal cancer that patients can use at home.” The article notes that the FDA “cleared Cologuard, which screens stool samples for the presence of red blood cells and DNA mutations that may indicate the presence of cancer.” The article notes that in a study, Cologuard “detected 92 percent of cancers and 42 percent of advanced precancerous growths, significantly more than an older test that looks only for blood in the stool.”

        The AP (8/12, Perrone) notes that the new test, however, “was not superior on all counts.” The AP notes that Cologuard “was less accurate than older blood tests at correctly ruling out cancer, reporting more growths when none were actually present.”

        The news was also covered by the Wall Street Journal (8/12, Walker, Subscription Publication), the St. Paul (MN) Pioneer Press (8/12), the Wisconsin State Journal (8/12), Medscape (8/12, Nelson) and HealthDay (8/12).

Caretakers are Products of Years of Training AND Experience

DON'T just take a drug because your doctor prescribes it.

Ask WHY?

We doctors are products of the knowledge we gain through training AND years of experience. Nurse practitioners and physician assistants have vastly different training pathways and typically much different experiences compared to licensed, board-certified physicians. This point cannot be under-emphasized (although it is certainly being under-appreciated of late).

Personally, I also subscribe to the tenet "If it ain't broken don't fix it." So many people nowadays are swayed by unfortunate social standards that prompt them to cut and change and alter otherwise intact parts of their bodies simply to achieve a more desirable aesthetic. As an interventional radiologist, I often see the complications of some of those adventures. 

Just something to consider.

As to the excerpt below, get informed so you know what the risks and benefits are.

As reported by the AMA: 

Pfizer faces mounting number of lawsuits over Lipitor side effects.

The Wall Street Journal (8/8) reports on the growing number of lawsuits filed against Pfizer by women who claim the company failed to warn the public about the side effects of type 2 diabetes or memory loss from the use of its cholesterol medication Lipitor (atorvastatin calcium). Over the past five months lawsuits by women in the US who allege Lipitor caused them to develop type-2 diabetes soared to almost 1,000 from 56.

Powdered Caffeine is Dangerous! Do Not Use!

Please educate everyone, especially teenagers who might not realize the dangers associated with this powerful drug! Powdered caffeine is causing deaths. Only 1 teaspoon is equivalent to 25 cups of coffee! 

As reported in my daily AMA email: 

Use of powdered caffeine may result in death.

"NBC Nightly News (8/3, story 7, 2:40, Holt) reported on the “troubling trend involving caffeine, including the growing use a pure powdered form” which is marketed as a dietary supplement to increase “alertness and athletic performance.” NBC News correspondent John Yang explained that just one teaspoon of the unregulated substance “is the equivalent of 25 cups of coffee.” Taking it can result in “irregular heartbeat, muscle spasms and kidney failure.”

        The NPR (8/1, Hobson) “Shots” blog reported that in the aftermath of an overdose last May, the “Food and Drug Administration issued a warning about powdered caffeine, saying it’s impossible to accurately measure it with your standard kitchen equipment.” An excess of caffeine powder “can speed the heart and cause seizures and death, the FDA says.”"

"The Pill Linked to Breast Cancer Risk"...OR NOT! Whatever Happened to Responsible Journalism?!

The recently published article, entitled "The Pill linked to breast cancer risk for younger women," is an example of the typical irresponsible journalism rampant in today's media publications. The title is inflammatory and unnecessarily raises fears where there is already enough fear. To make matters worse, the conclusion of the article is that birth control pills remain safe for thousands of women and no change in behavior is recommended on the basis of the study. So why write the article? The title is obviously a pathetic ploy to get more people to read it. Beyond that, I see no redeeming qualities.

Excerpts as follows:

"But birth control pills have evolved over the decades since their introduction and the hormone doses they contain have dropped steadily, so many studies are based on data for formulations that are no longer used, Beaber and her colleagues point out in the journal Cancer Research."

""Use of formulations with high dose estrogen, ethynodiol diacetate (synthetic progestin), and specific triphasic oral contraceptives in the past year was associated with an increased breast cancer risk in our study, while other formulations, including low dose estrogen oral contraceptives, did not appear to be associated with an elevated risk," Beaber told Reuters Health."

"“Weak associations, consistent with noise and not signal, were the overall finding,” Dr. David A. Grimes told Reuters Health by phone.

Grimes is a clinical professor in the department of Obstetrics and Gynecology at UNC School of Medicine in Wilmington, North Carolina."

The new results are not important for women or doctors, Grimes said. Other, better studies have found no increase in breast cancer risk with birth control, which is essential for women’s health, he said."

Physician-Patient Relationship Is Obsolete

Well, of course I'm not serious about the title! I'm merely pointing out the obvious lunacy associated with a recent court decision that Florida physicians are not permitted to imquire (merely ASK?!!!) about firearms or discuss firearm safety with their patients. 

How unbelievably intrusive must your physician be (sarcasm alert) to want to inquire into whether you have guns, like guns, want to shoot guns, and whether you might possibly keep them safely locked up when not in use!  

We physicians understand the importance of privacy. With HIPAA rules, and associated large fines, ever hanging over our heads, no physician wishes to knowingly violate the sanctity of the physician-patient relationship.

In that same vein, don't you think it is reasonable for a physician to want to discuss aspects of a person's life that may affect their health?  seems acceptable to me, but I'm sure I may hear equal and opposite reactions to such a query.

Here are some excerpts of the reports of the AMA reaction (from the daily AMA email): 

AMA critical of ruling upholding Florida law restricting physicians from discussing gun risks with patients.

Politico (7/30, Villacorta) reported in a brief piece in “Politico Pulse” that the AMA is not “pleased” with a recent “court ruling upholding a...Florida law that restricts” physicians from discussing the risks of firearms with patients. AMA President Robert Wah said, “This law poses real harm to patients as it interferes with physicians’ ability to deliver safe care, and hinders patients’ access to the most relevant information available.”

        MedPage Today (7/30, Wallan) reported, “The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the” AMA “all issued statements condemning the legislation and the...ruling.”

        In the New York Times (7/30, Subscription Publication) “The Upshot” blog, Aaron E. Carroll, a professor of pediatrics at Indiana University School of Medicine, wrote that physicians “who ask about guns aren’t doing so because they’re nosy.” Carroll writes, “If the courts decide that people have the right never to be asked sensitive questions, they’re interfering with the relationship between” physician “and patient,” and “they’re deciding that some health risks are worth minimizing and others are not.”

 

Renal Cryoablation Delivers Excellent Long-term Results

...And Could Become Standard of Care for Cancers <3cm.

-----------------------------------------------------------------------------------------

Galil Medical, a company that has developed the technology to enable interventional radiologists to perform the procedure, recently promoted an article that I excerpt as follows from their brochure:

Summary:

In a 2014 article describing their prospective study, Christos S. Georgiades and Ron Rodriguez summarized the results following cryoablation of 261 renal tumors.

Outcomes at 5 years:

  • Overall survival: 98.7%
  • Recurrence free survival: 97%
  • Cancer specific survival: 100%

Low rate of clinically significant complications:

  • CTCAE Grade ≥ 3:  6%

-----------------------------------------------------------------------------------------

To say that these results are exciting would be an understatement. I and my partner have been performing renal cryoablations for approximately ten years. We have developed a high degree of comfort with the available devices.

The ideal kidney cancer projects posteriorly (towards the back) and is smaller than 3cm. While larger cancers can be treated with this freezing technique, recurrence rates rise as cancer size increases above 4cm. The procedure also becomes technically more challenging and the procedure time becomes longer the larger the cancer size.

We have seen very few recurrences in our patient population. In addition, these procedures are extremely well-tolerated. We routinely treat people who are well into their 80s, and/or who are not able to undergo traditional surgical resection.

In our experience, patients who undergo this treatment do extremely well, with the great majority being sent home the same day, after several hours of observation to ensure no immediate complications arise.

This procedure is typically performed under moderate or deep sedation, meaning that we enlist the services of the anesthesia team. They administer heavier sedation than the usual interventional procedure, in order to keep patients as comfortable and still as possible so that we physicians can perform the procedure with no risk of patient movement compromising safety.

In summary, as I am typically asked, I would certainly want my loved ones to undergo this procedure if they were unfortunately diagnosed with a kidney cancer that was anatomically appropriate. In the right hands, as with most things, the procedure is effective, fast, safe, and definitive.

#iloveinterventionalradiology !

 

 

ACA Is Working, Sort Of. Now Fix It.

U.S. uninsured rate falls to 15%. Millions of people have found insurance through the Affordable Care Act and healthcare.gov. I think it is becoming clear that such a program, while flawed in many ways, has begun to help us down the road to improve healthcare in this country. While insuring these millions of people will presumably cost taxpayers more in the short run, perhaps overall health care expenditures may decrease through better care.

What I hope now is that Congressional leaders realize that fixing the existing laws makes much more sense than continuing to flail around, helplessly arguing for full repeal, something that doesn't look even remotely possible. Exhort your leaders to fix ACA now.

Excerpts as follows from the AMA:

Survey: US uninsured rate fell to 15% under ACA.

A late-breaking report garnered coverage across several major national websites Thursday morning. The New York Times (7/10, Sanger-Katz, Subscription Publication) “Upshot” blog highlights the new survey, out of the Commonwealth Fund, which shows that not only did many people sign up for health insurance under the Affordable Care Act, but those that did so are “pretty happy with their purchases.” In total, the study found “that about 15 percent of adults younger than 65 now lack health insurance, down from 20 percent before the Affordable Care Act rolled out in January.” Moreover, “73 percent of people who bought health plans and 87 percent of those who signed up for Medicaid said they were somewhat or very satisfied with their new health insurance.”

        McClatchy (7/10, Pugh, Subscription Publication) reports that the survey determined that “some 9.5 million Americans gained health coverage during the recent marketplace enrollment period.” And, “young adults ages 19-34, whose participation in the Affordable Care Act’s coverage initiative was crucial but always uncertain, saw some of the largest coverage gains.” Overall, “their uninsured rate fell from 28 percent to 18 percent.”

        CNBC (7/10, Mangan) reports that the survey reveals that “young adults, Latinos and the poor” have emerged as “Obamacare’s big winners.” These groups, the article explained, “long had the toughest time affording health insurance,” yet have seen “larger drops in their uninsured rates after the launch of Obamacare than any other group.”

        In its coverage, the Huffington Post (7/10, Young) points out the discrepancy in the figures between states that expanded Medicaid and those that did not. Indeed, in states that opted out, “more than one-third of their lowest-income residents remain uninsured, a rate virtually unchanged from last year, even as millions gained coverage elsewhere.”

Interventional Radiologists Irradiate Responsibly

Radiation exposure, in the course of caring for patients, is of paramount interest to radiologists. So controlling the amount of radiation administered, and reducing the dose wherever possible, are ongoing goals to those of us who use it every day in the care and treatment of our patients. As an interventional radiologist, I deal with radiation exposure every day. Most of the time, the procedures that I perform involve relatively short exposure times. There are few procedures that may result in lengthy exposure times. I do everything possible to keep the exposure as low as reasonably achievable (ALARA), the American College of Radiology-sanctioned principle that guides all radiologists.

It is important to note that the radiation risks are real and affect not just the patient on the table in front of us, but also the physician and support staff standing next to them.

Nowadays, it is not just radiologists who perform fluoroscopic-guided procedures. Many different physician specialties have seen the remarkable benefits of imaging guidance. Traditionally, radiologists were the only physicians who had a lot of training with radiation. Now that image-guided procedures have become more widespread, patients need to be ever more aware that their treating physician has received appropriate training in radiation safety.

Radiologists are focused on reducing the amount of radiation exposure to both patients and health care workers alike. It is imperative that patients are aware and understand, not only that radiation exposure is necessary, but that the physician operating the equipment understands the risks and is adhering to the ALARA principle, helping to keep patients safe while treating them. 

Fears arise through a lack of understanding, which is why proper education is so important. As an interventional radiologist, some of my goals are to help people understand the radiation risks, that the risks and benefits of every procedure must be appropriately considered, and that imaging (e.g. CT scans and fluoroscopy in the interventional suite) saves lives and will and should continue to play a huge part in our health care delivery.

Stroke - Know The Risks and Signs

Know Stroke!
-- 4th leading cause of death in the U.S.
-- 795,000 people in the U.S. suffer strokes each year
-- Strokes are responsible for 133,000 deaths each year
-- Stroke kills more than twice as many American women every year compared with breast cancer deaths
-- More women die than men from stroke
-- Women suffer greater disability after stroke than men
-- Incidence of stroke among African Americans is nearly double that of Caucasians
-- Incidence of stroke among Hispanic Americans is higher than that of Caucasians

Lifestyle Changes
-- Keep blood pressure controlled
-- Avoid all tobacco products and second-hand smoke
-- Eat healthy diets containing 5 or more servings of fruits and vegetables per day
-- Exercise, be active!
-- Lose excess weight
-- Keep cholesterol controlled (ideal LDL <100mg/dl)
-- Reduce sugar intake/ control diabetes

Recognize Stroke Symptoms (F.A.S.T.= Face, Arms, Speech, Time)
-- Sudden and severe headache
-- Sudden vision changes or difficulty seeing out of one or both eyes
-- Sudden dizziness or difficulty walking
-- Sudden confusion or difficulty speaking
-- Sudden numbness or weakness of the face, arm or leg

Remember, ANY age group is at risk!

CALL 911 IF YOU SEE ANY OF THESE SIGNS!

TIME IS BRAIN. EVERY MINUTE COUNTS!

Physician's Regional Healthcare System - Pine Ridge is the only Certified Comprehensive Stroke Center in Southwest Florida.

Your Weight and Your Health are Your Choice

I heard a mother-daughter exchange that gave me pause. I pondered, and have come up with an answer that I think may help anyone who faces the same query from an obviously vulnerable, slightly defensive child. Please read, ponder and share:

Daughter: 'I'm hungry.'

Mother: 'You're always hungry.'

Daughter: 'So you think I'm fat?'

I did not hear the mother's next comment. In front of them, however, was another mother-daughter pair. The mother says, with a wistful smile: 'Same thing, every family,' having obviously overheard the same exchange.

I have, as I said, pondered these comments, in light of today's mixed up world. Here is the correct answer that a caring parent should share:

First of all, when a mother (or father) states a truism such as 'You're always hungry,' it is simply because every young person, from about the age of 7 until the child goes to college and leaves the daily routine of the family home, IS hungry. So it is neither a positive or negative comment, at face value, for a parent to state that a child is 'always hungry.'

Second, and however, you should have enough self-awareness to already know the answer to your question as to whether you are 'fat.' But, as your loving parent, I am the last and only person who may ever love you enough to be completely honest with you. Because I care about you, I will answer your query and tell you if you are overweight so that, if you are unable or unwilling to be honest with yourself, you may gain self-awareness and do something about it. 

The human body needs nourishment to thrive. What the body takes in, it uses to create energy. What it does not need as energy, and what it does not burn off through exercise, it stores as fat. Hence, if you take in more than your body requires to thrive, and do not burn off the excess through exercise, you will gain weight - another truism. The self-aware individual, therefore, understands this fact of life and realizes that being overweight mostly has to do with the choices we make as individuals, excluding a small percentage of people whose genetic makeup decreases their ability to adequately metabolize what they eat. 

For the vast majority of us, therefore, being overweight is not a state of mind; It is a state of being and it is less healthy than if an individual can attempt to maintain a balanced weight. We each follow various health recommendations and read, listen and share many of them every day. But what is so very important for each of us to understand is that the choices we make, in large part, determine the health we will or will not enjoy during our lifetimes.

A third truism is the most important: 'All things in moderation.' 

 

E-cigs: Cute But Still As Addictive

An insidious new campaign to capture new smokers at the youngest ages has started. Make no mistake, Big Tobacco companies are much more savvy than any consumer group out there. They know exactly what it takes to capture an entirely new segment of consumers before the individuals even know that they are consumers.

E-cigarettes may look cute and not have the typical and readily-identifiable noxious smell of "real" tobacco, but nicotine-delivery is just as efficient. Addiction is therefore assured and incumbent health risks remain ever-present.

As reported in Bloomberg-Businessweek: "As e-cigarettes become more popular, the federal government is looking for ways to regulate their use, especially among teens. A March study in the journal JAMA Pediatrics reported that 3.3% of 6th to 12th graders said they'd tried e-cigarettes in 2011. In 2012 the number more than doubled, to 6.8%. Using data from the CDC and Prevention, the study found kids who tried e-cigarettes were more likely to try real cigarettes than those who hadn't."

Message to Congress: Please Repeal The Flawed SGR Now!

I can't tell you how dissatisfied I am to now be an unwilling part of the Republican agenda to overturn and/or dismantle the Affordable Care Act. In my opinion, and I believe most physicians would agree, the law needs to be improved, not dismantled. Attempting to repeal or dismantle it is counterproductive and time wasting. Hence, the recent House Republican push to bundle the SGR repeal bill with an attempt to further delay individual mandate of the ACA is unfortunate.

Read below for an email I received:

 

House Republications Expected to Propose SGR Repeal Funded by Delaying Individual Mandate

Posted on March 11, 2014 by Geoff Cockrell

Republicans in the House are expected to vote this week on legislation that would permanently repeal the sustainable growth rate (SGR) Medicare physician payment formula.

To pay for the SGR fix, the legislation is expected to propose a delay or repeal of the Affordable Care Act's individual mandate, according to multiple news reports including a Modern Healthcare report.

If the SGR fix legislation is bundled with a bill that would call for the delay or repeal of the individual mandate, the Senate is not expected to approve the merged legislation.

The deadline for the next doc fix is March 31. If a temporary or permanent fix is not in place by then, Medicare physician payments under the SGR will be cut by about 24%.

 

White Noise Machines - Not So Infant Soothing?

For any new parents out there, please read these excerpts and do some research. It seems the white noise sleep monitors may not be easy on your child's ears after all. There are reasons for and against using these devices, not the least is that they are probably not necessary. I mean, isn't a baby supposed to get used to some ambient noise? I always thought it made for better sleepers as they get older.

AMA excerpts as follows:

Noise machines may put infants at risk of developing hearing loss. USA Today (3/3, Healy) reports that research published online in Pediatrics suggests that “parents should be cautious with” infant sleep machines “because they can generate sound levels that could place infants at risk of developing noise-induced hearing loss.” These “machines – which can be used to mask environmental noises or provide ambient noise designed to soothe an infant during sleep – ‘are capable of producing levels that may be damaging to babies’ hearing,’ says Blake Papsin...senior author of the study.” The New York Times (3/3, Louis, Subscription Publication) reports that according to Dr. Gordon B. Hughes, the program director of clinical trials for the National Institute on Deafness and Other Communication Disorders, “Unless parents are adequately warned of the danger, or the design of the machines by manufacturers is changed to be safer, then the potential for harm exists, and parents need to know about it.” Dr. Hughes was not involved in the study. On its website, NBC News (3/3, Mantel) reports that in the study, investigators “tested 14 widely available machines that play white noise and other soothing sounds.” The researchers found that “at one foot away, three of the machines produced such intense sound levels at maximum volume that, if played through the night, they would exceed allowable noise limits for adults at work.” Also covering the story are CNN (3/3, Landau) and Reuters (3/3, Seaman).

Unintended consequences of genetic manipulation

Scientific advances must be viewed from all angles as we attempt to understand the ramifications of progress. So it comes as no surprise to read the following excerpts from the daily AMA communication.

Scientists are now able to manipulate genes in order to eliminate some genetic diseases. On its surface, this development is favorable. But the unintended consequences include something on the lines of "I'll have a blue-eyed, blond-haired genius boy please and leave out the Tay-Sachs disease."

From that possibility, we must proceed cautiously.


Excerpt:

FDA panel considers controversial fertility procedure. CBS Evening News (2/25, story 7, 1:35, Pelley) reported in its broadcast that an FDA panel “began two days of meetings” on Tuesday and Wednesday “about a controversial medical procedure that critics believe could lead to designer babies.” CBS’ Dr. Jon Lapook said, “It’s controversial because in addition to the DNA of the mother and the father, material from a third person is used in the process.” Lapook noted that the concerns over the procedure range from technical issues such as how to make it “safe and effective” to ethical issues of creating “designer babies.” The New York Times (2/26, Tavernise, Subscription Publication) noted that the agency has asked an expert committee “to summarize current science to determine whether the approach – which has been performed successfully in monkeys by researchers in Oregon and in people more than a decade ago – is safe enough to be used again in people.” The paper pointed out the meeting is “meant to address the scientific issues around the procedure, not the ethics.” Specifically, the scientists have been asked to discuss “the risks to the mother and the potential child and how future studies should be structured, among other issues.” The Washington Post (2/26, Cha, Somashekhar) noted that the FDA’s disclosure “several months ago” about its intention to hold a public hearing on the matter “elicited an outcry from scientists, ethicists and religious groups, who say the technology raises grave safety concerns and could open the door to creating ‘designer’ babies, whose eye color, intelligence and other characteristics are selected by parents.” Marcy Darnovsky, executive director of the Center for Genetics and Society and a vocal critic of the procedure, “said human trials would mark the first time the FDA had approved a gene-modification technique whose effect is transmitted to a person’s descendants,” according to the Post. Reuters (2/26, Begley) provided background information, noting that during the in-vitro fertilization, the father would donate the sperm while the mother would provide her egg and its nucleus. However, if the mother is a carrier of harmful genetic mutations in the cell’s mitochondria, scientists will replace that with a healthy mitochondria from the second woman, so the child will not have any harmful mitochondrial disease. In an editorial, the Los Angeles Times (2/26) argued that “manipulation of human genes could provide huge advances in our ability to cure or prevent terrible diseases.” Still, the paper suggested, “it is vital to proceed with extreme caution on research that involves possible permanent changes in the human genome.” The news was also covered by the AP (2/26, Perrone),MedPage Today (2/26), HealthDay (2/26) and Bloomberg News (2/25).

The State of Healthcare in America??

Is this the state of healthcare in America??

Recently I read a CT scan and identified large clots in the right and left main pulmonary arteries. ("Bilateral pulmonary emboli") As summarized here, studies have "estimated that more than 1,000,000 people in the United States are affected by pulmonary emboli each year, with 100,000 to 200,000 of these events being fatal."

When I finally, after 15 minutes of trying, reached the nurse practitioner on call for the hospitalist group caring for this patient, she asked me, "Is that critical? Do I need to call the ICU?"

WHAT DO YOU THINK?!!!

Holding back a bit, I politely replied, "Although that decision is up to you taking care of the patient, this is a life-threatening emergency. I would do so if I were taking care of her."

I have several friends who are excellent hospitalists. It's not an issue whether the hospitalist is good or bad, though that of course is important to note. But it is very important that we recognize that care by hospitalists is fragmented unless said hospitalist is on duty on a more continuous basis. There are solo hospitalist practitioners who care for their patients on a daily basis and have more exclusive practices than others. But hospitalist groups tend toward more shift work and I think that is a major failing of the current method of inpatient care.

Oh, and by the way, in Florida, there is a bill being pushed in the Florida House and Senate to allow nurse practitioners to care for patients independently. I know several excellent nurse practitioners. But it's the overall system failing I am pointing out to inform and educate so that patients are aware of what is happening. Nurse practitioners work best in concert with physicians. Nurse practitioners and physicians train differently and gather differing experiences. They are best when working together and complement each other. Hospitalists best know their patients when they are not on-off-on-off shift workers. I know several hospitalists who only care for certain issues, or who work in a small group or solo, allowing for a continuity of care that large hospitalist groups can absolutely not match. Those are important distinctions that are being overlooked thanks to meaningless discussions about slow websites!

Use Appropriateness Criteria When Ordering CT Scans

Following excerpt is from my AMA daily email. I have often opined on the same subject. It is imperative that the public and caretakers alike understand the risks and benefits of medical imaging. As a radiologist, I know too well the number of scans I see daily. Most of the scans I read and see in a day are hopefully helpful to the physicians and caretakers ordering them. But there are studies that cross my path that make one question. Appropriateness criteria assist ordering physicians and caretakers in hopefully decreasing the number of inappropriate studies being ordered.

Excerpt:

Physicians point to health risks associated with CT use.

"In a strongly-worded New York Times (1/31, A27, Redberg, Subscription Publication) op-ed, cardiologist Rita F. Redberg and radiologist Rebecca Smith-Bindman discuss the increased cancer risk associated with medical imaging. In particular, they decry the overuse of CT scans, and argue that the scans are not always performed as safely as they should be. Redberg and Smith-Bindman say that medical professionals have taken steps to combat the problem; they point out, for instance, that “the American College of Radiology and the American College of Cardiology have issued ‘appropriateness criteria’ to help doctors consider the risks and benefits before ordering a test,” but the authors contend that “we need clear standards, published by professional radiology societies or organizations like the Joint Commission or the FDA.” The authors conclude that “we need to find ways to use” CT scans “without killing people in the process.”"

PET Scans - Not All "Hot Spots" Mean Cancer!

As a radiologist, a challenge is to clearly explain the limitations of the imaging modalities we use to diagnose disease. For instance, people think of a PET scan as the best way to diagnose a cancer. If a "spot" is "bright," i.e. "hot," it must be cancer right?

Wrong.

Here is an excerpt from "Radiologic Clinics of North America: PET/CT," September 2013, which nicely sums up the limitations of PET scans for "patients with known or suspected lung cancer:"

"Information can mimic malignant tissue on FDG-PET, and this must always be kept in mind. For example, small spiculated nodules can because by pneumonitis, and present a management dilemma as they are not generally suitable for biopsy. Radiation pneumonitis can be FDG-PET positive, making it difficult to assess possible residual or recurrent lung cancer after radiation treatment. A pulmonary abscess can be indistinguishable from a pulmonary cancer based on CT and FDG-PET findings. Not all malignant neoplasms are FDG avid, and, in the lungs, well-differentiated adenocarcinoma and carcinoid tumors can be minimal or essentially negative on FDG-PET images. Small foci of FDG tracer activity in the skeleton can be caused by degenerative joint changes or healing fractures, or even Schmorl's nodes and vertebral body end plates and mimic small metastatic deposits. Benign adrenal adenomas can present modest FDG uptake. In contrast, certain benign tumors such as Warthin's tumor in the parotid gland or pituitary adenomas at the skull base can be very FDG avid and be mistaken for distant metastases based on the PET images alone. Patients with lung cancer can have additional unrelated neoplasms, and incidental thyroid and early colon cancers are commonly seen on FDG-PET images."

So if you or a loved one or a friend needs or has undergone a PET scan, please make sure you understand the findings and discuss them fully with either your doctor or, if possible, the radiologist who interpreted the study.

UnitedHealthcare Drops Providers - Patient Access Nightmares Will Ensue

Below is a forwarded email that comments on the UnitedHealthcare activity. This major insurer has been dropping doctors from its networks across the country, resulting in major disruptions to the access to care of thousands of patients just like you. Stay tuned, the final chapters have not been written on this insidious activity, all done under the guise of quality improvement, when in reality it is absolutely nothing more than cost-cutting at its worst.

Read on and stay informed:

 

The ruling only affects members of the Hartford County Medical and Fairfield County Medical associations. The ruling does not cover the state’s other medical associations, including the Connecticut State Medical Society and its members. - See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/federal-judge-grants-temporary-injunction-against-unitedhealthcare#sthash.pkr1lnch.dpuf

 

 

Federal judge slaps UnitedHealthcare with injunction hours before dropping thousands of physicians from Medicare Advantage network

Two Connecticut medical associations won a temporary injunctive order against UnitedHealthcare in federal court hours before the insurer was set to drop hundreds of doctors and thousands of patients from its rolls

Publish date: DEC 06, 2013

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By: Keith Griffin

Two Connecticut medical associations won a temporary injunctive order against UnitedHealthcare in federal court hours before the health insurer was set to drop thousands of physicians and patients from its rolls. The order prevents the insurer from removing any of the doctors until the court can rule on the merits of the case.

U.S. District Court Judge Stefan Underhill ruled Friday, December 6, that the Hartford County Medical Association and Fairfield County Medical Association "met their burden of demonstrating that they will suffer harm that is imminent and cannot be adequately compensated through damages."

The associations sought a temporary restraining order preventing UnitedHealthcare from removing the physicians, approximately 20% of the UnitedHealthcare provider panel, from its Medicare Advantage networks. Anywhere from 20,000 to 30,000 patients could be affected, the medical groups say.

The injunction forces UnitedHealthcare to start proceedings from the beginning and “do it the right way,” says Roy Breitenbach, JD, legal counsel for the medical associations.

“[The decision] levels the playing field, and we're prepared to go forward,” contends Breitenbach, a partner/director of Garfunkel Wild PC in Great Neck, New York. “If they start from scratch and follow the termination proceedings, there are certain rights to follow the termination."

UnitedHealthcare intends to immediately appeal the decision, the company says in an e-mailed statement.

“We believe the court’s ruling will create unnecessary and harmful confusion and disruption to Medicare beneficiaries in Connecticut,” says Terry O'Hara, of UnitedHealthcare Group. “We know that these changes can be concerning for some doctors and customers, and supporting our customers is our highest priority. United Healthcare will continue to stay focused on the people we serve.”

The ruling only affects members of the Hartford County Medical and Fairfield County Medical associations. The ruling does not cover the state’s other medical associations, including the Connecticut State Medical Society and its members. The majority of the affected 2,200-plus physicians are reported to be in Hartford, New Haven, and New London counties.

The judge's ruling boiled down to evidence that UnitedHealthcare appears to have breached its contract with the physicians by removing them without cause or explanation, in apparent violation of Medicare regulations. Bollepalli Subbarao, MD, president of the Hartford County Medical Association, characterized those actions by United Healthcare as "pure abuse."

Underhill wrote: "At oral argument, United suggested that it routinely amends [the contract] without the consent of participating physicians as a way of removing physicians from participation in a particular plan." But the judge noted the insurer provided no evidence of that in follow-up documents and, in fact, only used the amendment "to add physicians to the network, not delete them."

According to Rick Fiorentino, executive director of the Hartford County Medical Association, the two associations were willing to go to mediation to resolve the dispute. He said United Healthcare opposed this move, which would have delayed implementation for a year, and took its chances on the court ruling. "The judge was angry that (the company) wouldn't go to mediation," Fiorentino said.

Both medical associations took strong advocacy roles against United Healthcare once the cuts were announced in October, as reported by Medical Economics. In addition to the court filings, the two associations organized a November "townhall-like meeting" for those providers and patients impacted by the UnitedHealthcare Group action in Westport, Connecticut and West Hartford, Connecticut. The two groups also hosted a press conference December 5, 2013, at Connecticut's Legislative Office Building on future steps that will be taken to prevent similar actions by insurance companies.

Here are links to other coverage related to this developing story:

Physicians gather to fight UnitedHealthcare's cancellations

AMA, medical societies fight mass physician cancellations

UnitedHeathcare cuts thousands of physicians from network

- See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/federal-judge-grants-temporary-injunction-against-unitedhealthcare#sthash.pkr1lnch.dpuf