The Blog that Ate Manhattan

When the Electronic Medical Record Goes Down

2007-03-15T22:12:00.009-04:00

Shortly after 10 am on a busy morning not too long ago, our office electronic medical record system went down. It was a system-wide failure, and it lasted for over 12 hours.

Given that we had been online since last June, I was actually pretty impressed when I realized that we had gone as long as we had without a major glitch. But that realization didn’t help much while I was in the midst of busy office hours.

Because, as these things always go, we had done nothing in advance to prepare ourselves for the inevitability of a major EMR down time. Now, of course, we know what to do, and that is the point of this post - to prepare you for the same inevitability in the hopes that you won’t have to go through what we did.

Twelve Steps to Recovery from an EMR Downtime

Step 1 - Admit that you are powerless over the EMR – and that your practice has become unmanageable without it... Oops, sorry. Wrong 12 step program...

Step 1. Don’t panic. There is a back up. If you work in a big place like I do, I can’t imagine you don’t have a mirror server. Have you IT folks prepared to give you read-only access to it while they work on the problem in the background.

Step 2. Be prepared. You would be surprised how quickly all the paper disappears once you’ve been online for a few months. By the time we went down, we had nothing left but a few old lab reqs and blank computer paper. So, long before you ever need it, make a list of paper supplies necessary to function during a prolonged down time. Things like your old visit templates, superbills, radiology and lab requisitions, labels, receipts, message books, etc. Ask input from the entire office staff on this one. Gather a supply of these things (enough for several days if need be) and put it all in a big box or file drawer labeled “EMR Downtime supplies”. Make sure everyone knows where it is, and check it periodically to be sure no one has rifled through it.

And keep a supply of prescription pads locked away in your desk drawer. I had none, and ended up calling in all my scripts that fateful day.

Step 3. Go back to the future. While you are down, shift into paper mode, just like the old days. Write your SOAP notes, check off those boxes in your paper exam template and write your assessment and plan. Write full notes. (Don't worry - I'll tell you what to do with those notes in step 9). Don't count on having the time to recreate it all later - you won’t. I spent an entire Saturday in the office getting back on track because I only wrote little shorthand notes and brief exam summaries, and then had to create the visit note once we were back online.

Step 4. Don’t try to do it all. Patients calling for non-emergent appointments should be asked by your staff (nicely and with profuse apologies) to call back tomorrow. Better yet, have your staff take their number and call them back the next day to schedule. Tell patients needing refills that you’ll get to it tomorrow unless it’s urgent. No point overburdening the staff and you at this moment.

Step 5. Manage the Spin. Make sure your staff notify patients in the office about what's going on, so they understand if things seem a bit chaotic. No whining and complaining, just cheerful efficiency and mild jokes. Don't lose track of what's important - your interaction with the patient. When he/she leaves that day, they should remember that they were the focus, not the office systems.

Step 6. Don’t expect yourself to remember everything. If you can’t get read-only access to your patients’ online records, ask them to fill out a new patient history form in the waiting room before you see them. Since you'll be running way behind anyway, it'll give them something to do to feel useful while they're waiting. I told my patients - "Pretend this is your first visit, and I don't have your chart - because essentially, I don't have it. So don't assume I know everything about your medical history, and tell me anything you think I need to know. You won't insult me." No one complained.

Step 7. Don't compromise patient care. If it’s not an emergency, and you’re uncomfortable starting a new treatment or medication without access to the record, don't. Tell the patient you'll review her record once you are back online and call her to finish up the treatment plan at that point. I did this with several patients, and was I glad I did – one woman had forgotten to note in her history form a condition which happened to be a major contraindication to the very treatment option we were discussing. I saw it immediately upon reviewing my records the next day and was able to switch gears with no harm done.

Step 8. Enjoy the down time. Take the time you would have used online checking email or writing consult letters to get to know your office staff. Maybe even order in lunch for everyone. And, since there’s nothing anyone can do once the last patient is seen, you all get to go home early. (That’s the best part...)

Step 9. Plan for an easy catch-up. Next day, when you get back on line, open up your visits from yesterday and write a (very) brief online visit note summarizing any info you’ll need later on to care for the patient. Have your staff scan your paper notes in to the electronic chart as support documentation, and you’re done.

Step 10. Check your charge interface. If you have a direct EMR to billing interface (we don’t – yet), check to be sure that no charges were lost during the down time. Charges from the previous day may have been transferring in at the time of the crash, or been lost during recovery.

Step 11. Learn something from the experience. As soon as possible, meet with your IT team to debrief and plan for the next downtime. Because you all know now that it’s going to occur again. But hopefully, not in the near future.

Step 12. Carry the message. If any of you have gone through a similar experience, and have additional suggestions, do drop a comment below. After all, we're all in this together.

And, having had a spiritual awakening as the result of these steps, we must try to carry this message to other EMR users, and to practice these principles in all our electronic affairs...

Swedish Meatballs

2009-11-17T11:25:00.006-05:00

Swedish Meatballs are one of Mr TBTAM's specialties, made from a recipe given to him by my mother-in-law Irene, who modified it from The Casserole Cookbook. We usually serve the meatballs with buttered noodles, but they are also traditionally paired with boiled potatoes.

Perfect for those cold winter nights, which I hear they have a lot of in Sweden.

Meatballs Stockholm (Swedish Meatballs)

3 slices toasted rye bread
½ cup milk
1 lb. ground beef
1 egg, slightly beaten
½ small onion, grated
½ small onion, sliced
½ tsp. salt (or more, to taste)
¼ tsp. pepper
¼ tsp. grated nutmeg, ½ tsp. paprika, 1 tsp. dry mustard
4 tbsps shortening
2 cups beef bouillon
2 tbsps. flour
2 tbsps chopped parsley

Trim crusts from toast, break into small pieces and soak in milk for 10 minutes. Mash with a fork until smooth. Mix with meat, grated onion, egg and seasonings. Form into small balls about 2 inches in diameter. Heat shortening in saute pan. Add meatballs and sliced onion to pan and saute until meatballs are nicely browned on all sides. Pour off excess fat from pan and add bouillon. Cover and simmer for 15 minutes. Remove balls from gravy and keep warm. Mix flour with a little water and carefully add to gravy. Add parsley. Replace balls in gravy and heat just to boiling. Serves 4.

Veal and pork may be used in place of some of the beef. The meatballs are especially good if made early in the day and then reheated just before serving.
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Swedish Meatballs from around the web

There are lots of ways to make Swedish meatballs. Variations include using white instead of rye bread, substituting potatoes for bread, adding pork, and even using soy sauce in the gravy. Here are just a few recipes I found -

- Cooks Illustrated's recipe at What's on My Plate

- Ikea's recipe, from their cookbook. Like their furniture, not quite as well-made as one would have hoped. Assembly required.

- Kevin Week's recipe uses dill and mixes ground pork with the beef. I may try this one next time...

- Jamie tweaks Alton's recipe by using a tablespoon instead of a scale to portion out the meatball, making the recipe accessible to non-obsessive compulsive cooks.

- Twinkle at Yum Sugar does a streamlined version without gravy, served with lingonberry jam. She gets points for actually being in Sweden while making them...

- Cheap Talk spends way too much time wondering why Swedish meatballs are smaller than their American counterparts. (Very funny...)

Pink Glove Dance

2009-12-01T11:20:00.002-05:00

I've been too busy to blog yet about the new mammo and cervical cancer recommendations, but promise that I will very soon. In the meantime, enjoy this video made by employees of the Providence St Vincent Health System in Portland, Oregon to raise breast cancer awareness.(Thanks to Carrie for forwarding it to me)

Supplemental Folic Acid in Late Pregnancy Associated with Childhood Asthma

2009-11-16T07:00:00.005-05:00

In yet another study assessing the impact of folic acid supplementation in pregnancy, Australian researchers have found an association between use of folic acid supplements in late pregnancy and the risk for asthma in childhood. The risk was not found with use of folate when it was confined to the prenatal period and the first trimester of pregnancy, a time when its use decreases the incidence of neural tube defects such as spina bifida. Intake of folate from dietary sources was also not associated with childhood asthma.

The study is quite muddied with confounding variables, imperfect data sources and no data on supplement use in childhood. Still it raises important concerns, and if its findings are replicated in other studies, it would suggest that folic acid supplementation should be limited to the prenatal and first trimesters. It's also important not to exceed current dosing recommendations for this important vitamin.

It also underscores what I've been telling my patients for years - it's always preferable to get your vitamins from dietary sources rather than supplements.

Drugs for Cancer Prevention - NY Times Misses the Point

2009-11-14T02:31:00.009-05:00

In yet another article addressing the war on cancer, The New York Times today tackles cancer prevention, focusing on alternative and mainstream Pharma products marketed to reduce the risk for cancer.

While author Gina Kolata seems to have done her homework when it comes to the failure of alternative medicine to prevent cancer, she has missed the story completely when it comes to telling why the medical profession and patients may have failed to embrace Big Pharma's push to use their drugs to prevent breast and prostate cancer. Of course, that's not surprising since almost exclusively, the experts she interviewed were those who conducted the clinical trials of these drugs.

Since I'm not a urologist, I'm not going to comment on the use of finasteride to prevent prostate cancer, except to point out that the one expert quoted in favor of its use has served as a consultant to Merck and AstraZeneca, both of whom make the drug, while the other works for Astra Zeneca.

So let's talk about tamoxifen and raloxifene, two drugs that are approved for the prevention of breast cancer.

Tamoxifen and Raloxifene

The maker of Evista (raloxifene) is targeting both docs and women, urging them to calculate their lifetime risk for breast cancer and consider taking the drug if that risk for breast cancer is increased. Since raloxifene is also approved for treatment of osteoporosis, the drug makers are selling it as a two for one.

Both tamoxifen and raloxifene cut the risk for breast cancer in half among high risk women who use the drug for 5 years. Tamoxifen also prevents DCIS and LCIS in addition to invasive cancer, while raloxifene does not reduce these risks.

But, Tamoxifen can cause uterine cancers. The risk is low, about 1 in 500, but includes uterine sarcomas, a particularly aggressive tumor, and may persist even after the drug is discontinued. There is no screening for uterine cancer in tamoxifen users - ultrasound is useless, since the endometrium very frequently appears abnormal even if there is no cancer. We docs are left telling women just to tell us if they bleed.

Now, for women who are taking tamoxifen for treatment of breast cancer, the risk for uterine cancer is almost always outweighed by the benefits in terms of cancer treatment. But for woman who have never had (and may never get) a breast cancer, the uterine cancer risk is a deal breaker, especially when she asks what I can do to screen her and I tell her "nothing". I can quantify it for her - look, your risk for breast cancer will be reduced from 20% to 10%, I might say - and your risk for uterine cancer increased by less than one percent.

Okay, I'm interested, she might say. So tell me - Are there any other risks?

Yes, I'll say.

Both raloxifene and tamoxifen carry an increased risk of thromboembolism. According to the package insert for Evista (raloxifene), DVT occurred in 1 out of every 100 women using the drug for an average of 2.6 yrs, over twice the rate for placebo users. Fatal stroke risk was about 1.5 times higher in Evista compared to placebo users, though that risk was concentrated in postmenopausal women at increased risk. Unfortunately, nowhere in the marketing materials for Evista is there a risk calculator that helps me or my patients assess their personal risk for these complications from the drug.

So, I'll fudge it. Now my risk calculation for this patient looks something like this - Breast cancer, lowered from 20% to 10%. Uterine cancer, increased by 0.2%, but no screening. Blood clot risk = 1%. Fatal stroke risk = 0.3% over 5 yrs if you have risk factors, miniscule if you don't.

Okay, she'll ask me. How is it going to make me feel?

Probably fine, I say, but there are some side effects that might bother you, the most common of which is hot flashes in about 10% of users. Some women experience joint pains and leg cramps as well. These symptoms can occasionally be severe, although only about 1% of users stopped the drug because of hot flashes in the clinical trials. And most women will notice an increase in vaginal mucus that, as a gynecologist, I don't have concerns about. Not uncommonly, my patient will have had a friend who has experienced a bothersome side effects from taking Tamoxifen. That's usually the kiss of death for any drug - a girlfriend with a side effect...

And oh yeah, there's also the increased risk for cataracts with Tamoxifen, but not raloxifene.

Now, if a woman has osteoporosis, I can add that to the plus side of the balance scale for raloxifene use. Now I've got to do her risk for fracture based on her bone density and talk to her about the other options she may have to treat her osteoporosis as well.

Is anyone really wondering why we docs and our patients haven't jumped onto Big Pharma's cancer prevention bandwagon? We're asking patients to balance competing statistical risks for conditions she may never get, in return for a benefit she may never need.

I do prescribe raloxifene it for treatment of osteoporosis, and if there is a strong family history of breast cancer, I may even try to steer my osteoporotic patients who are not at increased risk for clots towards using it. However, it is the rare patient who chooses this drug over a bisphosphonate such as Fosamax and Actonel when I inform her of the risks and benefits of both these classes of drugs. Even patients with strong family histories of breast cancer just don't want the potential side effects of a drug in return for a reduced risks for a cancer they may never get.

Hello - Birth Control Pills?

Kolata completely misses out on the fact that millions of women are already taking a pill that reduces their risk for cancer - the birth control pill. It cuts ovarian cancer by up to 80% and endometrial cancer by almost half.

Like Tamoxifen and Raloxifene, the pill carries an increased risk of blood clots, a trade off many women are willing to make in return for prevention of pregnancy, which itself carries an even higher risk of clotting. Not to mention the benefits the pill can confer for women with menstrual disorders such as dysmenorrhea, menorrhagia, endometriosis and its efficacy in treating acne and even PMS. For most healthy young women, the balance of benefits and risks of pill use is favorable, even before considering the cancer prevention aspects of the pill.

For the record, I inform each and very patient who starts estrogen containing birth control that there is an increased risks of clots. I quantify it for them, tell them that it is a real risk and give them strategies they can use to minimize these risks. Surprisingly, that discussion has rarely deterred a patient from starting on hormonal birth control. It may be that pill patients are younger and feel more invincible than the older women being targeted by the makers of Evista. But I think most of them are actually weighing their risks of pregnancy against the risks of blood clots, comparing this to their perceived downsides of barrier methods and/or the IUD, and coming out on the side of using the pill.

Prevention is the holy grail for Big Pharma

Let's face it - an indication for prevention of a disease grows the potential market of a drug by millions. But if you're going to market a drug to healthy individuals, it better be free of risk or have some other benefit that patients can see right away.

Otherwise, it just ain't gonna' sell.

Which probably explains why Kolata tells the story of the cancer prevention challenge as though it were a failed pharmaceutical marketing campaign. Missing from her article, unfortunately, is the question that asks whether pharmaceuticals are really the right strategy to prevent cancer. Or that asks if we really mean to ask 100% of men over 50 to take a drug to prevent prostate cancer, when, in the same breath, we are telling them we should stop screening for it? Or whether 100% of women over 60 take a drug that increases their risk for thromboembolism and uterine cancer so that 20% of them won't get breast cancers that some are suggesting may regress or be so indolent that they will die of something else before it kills them?

Of course, we could just sell them another drug to lower their clotting risks..

Photoshop Healthcare Reform

2009-11-15T17:15:00.001-05:00

Congress clearly hasn't gotten the picture on what America really needs for healthcare reform. Which means you'll have to create it for them.

To that end, Dr Wes and his wife are holding the first and only US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

See Dr Wes' blog for rules, get out your cameras and your laptops and make it happen!

Dr Oz Gets it Right

2009-11-15T00:07:00.005-05:00

As much as I rant against Dr Oz and as much as the Huffington Post is beginning to annoy me with it's celebrity gossip and daily almost nude photos, they both just redeemed themselves this week with Oz's wonderful column entitled. "Real Health Reform - What's Next?"

We need to create a culture of health and wellness that fosters a nationwide understanding that personal behaviors are a major factor in health and well-being. And at the same time, we need to make the necessary societal changes so that all individuals are supported in making the correct choices. We need to make it easier to do the right thing.

Oz recommends changes as sweeping as reforming the food supply, changing how we feed our children in school, improving air and water quality and finding ways to reduce stress and incorporate physical activity into our daily lives. Its an agenda much larger than anything facing the Senate right now, but includes many things that most American people can start to do today that don't require an act of Congress.

Ambitious, yes. Impossible, no.

Do the right thing.

I like it.

How to Delete a Calendar from Your iPhone

2009-11-14T07:00:00.001-05:00

****Geek alert****

Ignore this post unless you came searching for this solution.

After switching from Blackberry to Iphone, I forgot to remove Pocket Mac from my Macbook. As a result, when I synced my calendar to my iPhone using Mobile Me, a second calendar was created on my I Phone. Even when I removed Pocket Mac from my Macbook, he calendar remained. I searched everywhere for instructions on deleting it, without success. Then I figured it out. So simple.

Open up iCal on your macbook. You will see a list of your calendars on the top left. Cntrl click the one you want to delete, then scroll down to the "delete" option and Viola - Gone! Now re-sync your iPhone with iTunes. The offending calendar is gone.

This should work with any extraneous calender you've accidentally created on your I Phone. Mine just happened to be my Pocket Mac calendar.

Feeding the Chemo Tummy

2009-11-13T15:57:00.000-05:00

The good thing about being both a doctor and a cook is that when you don't have any more medicine to offer, there's always the food.

Case in point - my sister's chemo-induced nausea. Despite maximum doses of Zofran, she still finds herself quite queasy, usually between meals. We decided to try some mint lemonade and bingo! - the stuff really works for her. She'll nurse a tall glass all afternoon to help keep her tummy in control.

Then, her good friend Lorraine, an onco nurse, told us she heard anectodal reports from her colleagues that macaroons were also helpful for chemo and radiation induced GI distress, both upper and lower. Well, that was all I needed to head to the kitchen to whip up a batch of cousin Jessie's macaroons. Indeed, Sis found them useful when she has that empty stomach queaziness. (They didn't work if she had already eaten something that makes her nauseus.)

Unfortunately, Sis is now on a low residue diet and macaroons are off the list. Coconut is a nut, after all, so don't overdo it, and avoid them completely if you are at risk for obstruction. And remember, both these foods are high in sugar, so take them in small doses. Fortunately, that's the way they seem to work best - a sip here, a nibble there...

Minted Lemonade

Make lemonade either homemade or from canned concentrate. (I would not use powdered) in a 2 qt pitcher withy a lid. Tear up a whole lotta' mint leaves (we use about a 1/4 cup torn leaves) and mix them in with the lemonade. Store in the fridge - it will keep for several days. Serve over lots of ice. Alternatively, freeze the mint with water in ice cube trays and use the mint ice cubes in your lemonade.

Jessie's Macaroons

I'm sure any macaroon recipe would work, but these macaroons are the best I've ever had. Cousin Jessie makes for Passover every year, so of course, they are flourless. Be sure to use unsweetened coconut - the sweetened stuff has additives like propylene glycol and sulfites.

2/3 cup egg white
¾ cup sugar
1/8 tsp salts2 ½ cup natural coconut
1 tbsp cornstarch
1 tsp vanilla
½ tsp almond extract
1 tbsp white corn syrup
Almonds

Combine all ingredients, stirring well, in a moderate size saucepan. Heat over mod heat till warm. Off heat let stand 10 mins. Line baking sheet with parchment paper. Drop by tsp or small scoop onto baking sheet and place half an almond on top. Bake in 325 oven 18-20 mins till golden. Let cool on the paper. Store in a tightly covered container.
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Sorry for Poor Quality photo - it was taken with my old phone.

Impaired Physicians - in the Bathroom?

2009-11-12T00:01:00.000-05:00

So I'm sitting here taking my required annual hospital online training, and I read that one of the signs of an impaired physician is "frequent bathroom use".

Guess that puts all us perimenopausal and pregnant female docs who drink water and coffee and also happen to have bladders under suspicion.

Treating Vitamin D Deficiency

2009-11-11T07:00:00.001-05:00

If, like me, you are doc who is increasingly screening for and finding vitamin D deficiency, you're probably wondering the best way to replenish body stores of this essential vitamin.

I have found that simply telling my vitamin D deficient patients to increase their daily intake of Vitamin D3 to 800-1200 IU does not result in adequate levels. I have had success using 50,000 IU Ergocalciferol (Vit D2) weekly for 12 weeks, transitioning to 1000-1200 IU Vit D3 daily after that for long term replacement.

Now a study has been published showing that a regimen of 50,000 IU ergocalciferol weekly for 8 weeks, followed by 50,000 IU ergocalciferol every other week is effective for up to 6 yrs at restoring and maintaining adequate vitamin D levels in most vitamin D deficient patients. For those with normal levels to start, the every other week regimen alone is sufficient to maintain them. This regimen is fairly cheap, about $6 a month here in NYC.

This study reinforces the results of another recent study showing that, for most patients, Vitamin D2 is as effective as D3 in restroing and maintaining normal levels of vitamin D.

That's good to know.

Suzanne Somers, Larry King and Cancer - Enough is Enough

2009-10-26T07:00:00.029-04:00

Suzanne Somers appeared on Larry King Friday night touting her book and pushing docs who use untested cancer therapies, including drugs called Anti-neoplastins and dietary regimens that include large amounts of enzymes coupled with coffee enemas.

In typical fashion, King set the stage in support of Somers by seating her at a table with three of her alternative medicine cronies, leaving Dr Otis Brawley, CMO of the American Cancer Society and the single voice of sanity, to appear via satellite. Despite this, Brawley clearly took the upper hand in the discussion, balancing Somer’s babbling with calm, reasoned facts that in the end, made her appear as exactly who she is – an uninformed layperson who has no idea what she is talking about.

Here's how it went down -

In 2008, from what I can piece together from a rambling story that took us over a commercial break, Somers had either an allergic reaction or a pulmonary embolism after having dinner with friends, a meal which included a glass of Merlot. While in the hospital, further tests showed multiple masses throughout her lungs and livers, which Somers states, were initially mis-diagnosed as "full body cancer". However, “for some reason" (like maybe to make a diagnosis?) the docs did a biopsy that showed a fungal infection (coccidiomycosis). This infection, while common, is rarely disseminated except in immune-compromised persons.

How is it that Suzie, the picture of perfect immunity, got such a severe infection?

Here, I’ll let Suzie and Larry tell you what she thinks happened ( if only to give you a sense of what I had to listen to for an hour)…

KING: And what was the final result?
SOMERS: I had none of those diseases. I was either poisoned or I was a substance.
KING: The merlot?
SOMERS:Salir, the merlot, yes….
KING: Do they think that was the cause?
SOMERS:Nobody -- nobody knows, because at the...
KING: Could it have been sour?
SOMERS: At the time -- at the time, I kept saying, couldn't this be a poisoning? Couldn't this be a severe allergic attack? No, it doesn't look like that on the C.T. scan. What happened? Something blew out my immune system. My immune system, that had been at 43, like that, in five minutes, my immune system was wiped out. And they think what happened was a dormant fungus that all of us in Southern California could have was dislodged. And the day before I was in perfect health and I had had my immune system tested, because I do that because of the books I wrote. And the doctor had said, "Wow, you're at 43". And I said…
KING: " I don't have a frame of reference."
SOMERS: He said, "Well,usually, people's immune systems at your age is two or three. Really good is 10. You're at 43.
KING: Oh and it was 43.
SOMERS: Forty-three. So I thought...
KING: And you were 63.
SOMERS: No, no, no, no. My immune system.
KING: Oh, I see.
SOMERS: I'm 63 years old.
KING: OK. I've got it.
SOMERS: My immune system is 43.
KING: All right

So what Suzie is saying is that a glass of merlot that others had drunk without any adverse effects blew out her entire immune system in less than 5 minutes so that in less than 24 hours, her entire body was riddled with fungal tumors. I won't even begin to address this - I believe the idiocy speaks for itself.

Oh, and for the record? There is no valid immune test such as she describes.

11/10/09 ADDENDUM - Turns out Suzie was taking adrenal hormone supplements aka "steroids" (think prednisone...) These most likely suppressed her immune system. I have no words to describe the stupidity.

Suzie’s life-changing experience with medical mis-diagnosis leads her on a nationwide chase to interview every quack who exists out there. Larry and Suzie focus on Stanislaw Burzynski, MD, a doc with a big clinic in Houston who claims to have treated over 8000 cancer patients with drugs he calls "anti-neoplastins". Suzie is incredibly impressed with anectodal stories of miracle cures in Dr Burzyinski’s patients, and even more impressed that Dr B has drugs are in phase 2 clinical trials. Brawley then proceeds to calmly cut down Burzynski, although he is careful not to completely dismiss alternative medicine.

A look at the FDA website finds that indeed, Dr B has over 60 clinical trials of anti-neoplastins initiated since 1998. And of these, not a single one has had published final results. Several studies have been closed due to prolonged inactivity or failure to recruit. A pub med search finds that Dr B has published only preliminary (I presume cherry-picked) results of his phase 2 trials, all in all less than 100 patients.

Thus, while Dr B appears to have started the FDA approval process, he has clearly stalled. (Perhaps because his treatments don't work?) In the meantime, his attempts to promote these treatments before they are finished being tested is unethical and should be illegal. And his use of Somers, a well-meaning but ill-informed and gullible patient, to promote him is truly astounding.

Yesterday, I blamed the media for kow-towing to Suzie, and allowing her to spread her misinformation to the public. Today, I'm adding her publisher to the blame list. I cannot believe such a book was allowed to be published, let alone publicized the way this book is being sold to the American public.

Since the program, King seems to be at long last backing off in his support of Suzie. His website no longer highlights her appearance, and a video of the segment on CNN's website mostly features Brawley.

Hopefully Oprah will get the message, and will decline to feature Suzie on her show.

Because enough is enough.

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Read the NCI information on Anti-neoplastins
Newsweek health author Pat Wingert's take on Suzie's new book -"Mostly Wrong"
Otis Brawley, MD (CMO NCI) commentary on Somer's book
David Gorski, MD at Science-based Medicine takes on Somers full force. Most comprehensive post on the topic I've read.
Houston Chronicle on Dr Bursynski - He's treated thousands of people from all over the world, so why can't he get FDA approval?

Bye-Bye Consultation Codes

2009-11-09T17:24:00.002-05:00

Consultation CPT codes are being eliminated by Medicare starting January 1. 2010. (The link is to the federal register - the relevent section starts p 162.)

In the CY 2010 PFS proposed rule (74 FR 33551), we proposed, beginning January 1, 2010, to budget neutrally eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes) by increasing the work RVUs for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our PE and malpractice RVU calculations.

Medicare claims the rulting will be budget neutral, and has balanced it with a 6% increase in RVU's for office-based and 0.3% for in-hospital E&M services. There will be new modifiers used to identify the admitting physican and the consultants.

There's still another 30 days to comment, though it appears pretty final to me. I'd expect managed care to follow suit.

I have mixed feelings on this one. It's always nice to be consulted by a colleague on a challenging case, and to have this recognized by an increased reimbursement. But I know there are specialists out there who bill each and every new patient as a consult and require a referral physician name before even seeing any patient. I resent their consultant letters thanking me for referring my patient for a routine preventive service, when I never even made the referral.

One could argue that there needs to be compensation for the additional years of training and expense that specialists incur. At the same time, the imbalance in reimbursement between subspecialists and primary care has led to a shortage of primary care docs.

This ruling may be one small step towards a resolution of the primary care shortage.
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Addendum - According to this analysis, the elimination of consultation codes will save Medicare $534.5 million anually. The authors point out that the ruling "sends a signal that primary care cognitive services are not valued equally with such services provided by other specialties."

Mammogram Screening Comes under Question

2009-11-03T22:40:00.029-05:00

Denise Grady frames the recent debate on mammogram screening in today's New York Times. The article tag teams and improves upon Gina Kolata's recent story on the topic.

These articles highlight what we health professionals have known for some time about mammograms - they are not perfect.

About 10% of cancers will be missed by mammography alone. About 65% of so-called "positive mammograms" end up being benign on biopsy. We really don't know what we are supposed to be doing with DCIS - is it precancerous, and should we be treating it? And finally, some cancers are faster-growing and more likely to kill you than others, and mammography is not so good at figuring out which is which.

Countering this imperfection is the one very important little piece of information that barely gets mentioned in these articles about mammogram screening - the mortality rate from breast cancer is lowered by mammography, by about 20% or so, depending upon which study you quote.

If you've never really heard all this before, it's not surprising. The debate now being played out on the pages of the Times has until now been held pretty exclusively among health care experts, with the results of that debate becoming the recommendations we all know and love - mammograms every 1 to 2 yrs from ages 40 to 50, then annually thereafter, till an as yet not defined upper age, when one weighs the need for mammograms against the overall health and projected longevity of the individual.

If it sounds complicated, well, that's because it is. And until now, the approach doctors and patients took to complex issues like this was simply - we docs know more than you do. Allow us to weigh and measure the risks and benefits for you, consider costs while we're are at it, and then we'll tell you what we think is best and you'll do it.

The price we are now paying for this simplistic approach to screening is a loss of faith on the part of the public, who have taken our endorsement of mammograms to be a guarantee of infallibility and a promise to lower breast cancer mortality across the board. We've struck out on both counts.

So now, like a parent whose child one day sees us as the imperfect humans we are, we docs are having a bit of a mid-life crisis. Do we stick to our guns and keep the same old recommendations, imperfect as they are? Or do we arm our patients with the facts and let them begin to make their own decisions about mammography?

One thing I think we do need to be careful about is allowing the pendulum to swing too far in the other direction - making the decision to advise women to forgo mammography due to a risk of over-diagnosis and over-treatment. This approach, framed in terms of prevention of anxiety and morbidity, but with an underpinning of financial cost savings, uses the same simplistic thinking we've used in the past to aim patients in the opposite direction, away from screening.

I for one am not quite ready to change my recommendations on mammography screening. While there is much talk about how screening may not benefit more indolent cancers, the fact remains that we don't have reliable non-invasive testing to identify which cancers are slower growing and which are not. Nor do we know how to stratify women into high and low risk groups for these cancers, other than genetic testing and imperfect modeling, which only identify a subset of at-risk women. To substitue another imperfect screening methodology for current guidelines just trades one set of problems for another.

I am more than happy to entertain the mammography debate with my patients, some of whom may want to forgo annual screening when they learn what I know. If so, it will be their decision, and not my recommendation. If I know my patients, I predict that most will continue to accept a chance of a false positives in return for a potentially reduced mortality from breast cancer.

But stay tuned - this discussion is likely to go one for some time.
_________________________________________________________

Orac takes on the topic. Nice discussion of the issues.

My First I Phone Dinner

2009-11-10T07:00:00.019-05:00

Driving home from Brooklyn Sunday afternoon, trying to figure out what to have for dinner, Mr TBTAM recalls a recipe for Butternut Squash Ginger Soup that he heard that morning on Weekend Edition. Using the google app on my new I Phone, I find the recipe and consult it at the supermarket, where I buy the ingredients we need. Then, still using my I Phone, I consult the same recipe in the kitchen and cook up the soup. Never once heading to the computer or printing anything out.

Now if someone could just write an app that does the dishes...

Butternut Squash Ginger Soup

Modified from the recipe on the NPR website. I made my own 5 spice, and found it quite strong, so I reduced the amount by half in this recipe. I also did not do the whole fried ginger and orange peel topping in the original, but it looks like a fun idea. I also decided to cube the squash before roasting it, both to speed up the process and to get additional carmelization. Finally, depending on the size of squash you use, you may find you need to add addtional broth to thin the soup a bit.

Soup

1 medium-size butternut squash
1 tbsp olive oil
salt and pepper
2 -3 cups of vegetable broth
2 tablespoons finely minced ginger
1/2 teaspoon Chinese 5 spice
1 cup white wine
Salt and pepper to taste

Topping

1 cup creme fraiche
1 tablespoon fresh squeezed orange juice

Preheat oven to 350 degrees. Peel and cut butternut squash in half lengthwise, remove seeds and then cut into 2 inch cubes. Toss with olive oil, salt and pepper and roast on baking sheet for about 30 minutes, tossing halfway through so it evenly browns. Put in food processor and process with ginger and spices till smooth. Add one cup of the broth into the feed tube, process a few seconds then transfer to a medium sized stock pot and whisk in remaining 1 cup broth and wine, adding more broth if soup seems to thick. Heat through until simmering. Salt to taste.

Mix creme fraiche and orange juice together.

Serve soup in bowl with creme fraiche swizzle on top.

On the Doctor Shortage

2009-11-05T12:20:00.001-05:00

Well said.

To address the shortage of doctors and the incentives that compel young doctors to eschew primary care, Congress needs to think about how to increase doctor pay, institute malpractice reform, and provide subsidies to reduce the amount of debt doctors have to take on. Residency caps should also be raised so teaching hospitals can train more doctors. Without these actions new doctors would be foolish to enter primary care, and thankfully our medical schools do not recruit foolish people. (Herb Pardes, CEO New York Presbyterian Hospital)

The suggested interventions are not mutually exclusive, and movement on any of them will decrease the need for the others. If you reform malpractice and lower debt, doctor's pay will increase as less income is funneled off to insurance premiums and interest payments.

(HT Howard Luks via Val Jones)

Don't mistake your birth control for Flintstone Vitamins

2009-11-05T00:01:00.003-05:00

From Jake and Amir. If you don't know who they are, then you must not have a 13 year old living in your house.

Falling Water

2009-08-21T11:54:00.011-04:00

I never imagined that a building could evoke tears.

Until today, when I visited Falling Water.

If you know me well, you are probably thinking it was something else.

Like the fact that we were on our way home from dropping my eldest off at college to start her freshman year.

Or my sister's recent cancer diagnosis, difficult surgery and more to come chemo.

Or our family's coming to terms with the fact that we have been unable to save my mother from her chronic pain or failing memory and must now make difficult decisions about where she will live.

But you would be wrong.

Yes, all those things have been going on lately. And while they certainly explain why I haven't been blogging, they are not why I cried this afternoon.

I cried because this building, this home, this marvel of cantilevered concrete, steel and glass was so beautiful, so ingenious, so damned glorious that I could find no other response than tears.

How could I not cry, when the sudden downpour that began during our tour, a cascade of water from the sky that poured down around us as we walked under the covered walkway to the guesthouse so that we felt that we were actually within a water fall, turned into a radiant sun shower and then stopped just as we stepped out onto the highest terrace?

Or when I learned that Wright was 67 years old and at the low point of his career when he designed Falling Water and at an age when most of us would be heading to retirement, he jump started the second half of his career, the half in which he created some of his most memorable designs, including the Guggenheim?

Or when I stood in the woods later, looking at that famous view of Falling Water that we all know, and realized that man, when he does it right, can actually enhance nature rather than destroy it?

There are those who will say that Falling Water as it was initially conceived and built was not perfect, and they would be correct. The concrete cantilevers needed steel reinforcements Wright had not planned, as did the stairs. Cracks appeared in the main floor cantilever almost immediately and as it continued to sag over the years, they threatened to bring the building down. But Falling Water was saved - not by restoring the cantilever to its original position, but by stabilizing it where it had settled. As a result the building is slightly different, but stronger and just as beautiful as when it was first built.

As I write this, I feel as if I am again standing on the concrete cantilever at Falling Water, and can feel the forces of gravity and counter tension pulling upon me.

I’ve survived my daughter's senior summer and the move into the dorms with our relationship now settled into something different, but intact - better even, for the transition.

And as for my larger family - my eight sibs, my parents and I - we are learning that, despite our numbers, we are not invincible. Like Wright's folded concrete cantilevers, we have sustained a crack or two. Already we are finding ourselves changed, settling into a different place than before, and will need some reinforcement and some shoring up as we go on.

But we will go on, strong and beautiful as ever.

Phils vs Yanks

2009-11-03T22:16:00.006-05:00

I'm from Philly, and I love New York. And now, both my teams are playing one another.

This must be how Mr Williams feels when Serena's playing Venus in the finals. I wonder how he handles it?

Certainly not the way my father used to handle it when we kids set at one another fighting. He'd grab a shock of hair on each of our heads and bang our noggins together. (Not hard, just enough to get our attention...)

Go Phils! Go Yanks! Whoever wins, I'll be proud. Now get out there and have fun!

Or I'll knock your heads together.

Thank You, Mr Violinist, Whoever you are...

2009-11-01T23:13:00.005-05:00

Mr New York Philharmonic Violinist in the third row stage left, whoever you are, thank you for making last night's concert a truly joyous experience.

I mean, first there was the Egmont Overture (nice), then Emanual Axe playing Beethoven's 3rd (such emotion), then the Symphonic Dances from West Side Story (I cried at the third movement), and I thought - why don't they just stop the program there? What is this Three Cornered Hat business anyway? I was only here because it was Mr TBTAM's birthday present, and while I like classical music and all, heading to the orchestra is generally not at the top of my Saturday night to-do list, forget it also being Halloween and the third night of the Yanks vs the Phils. Enough is enough.

Then I caught sight of you, barely able to contain yourself in your seat as you played the third part of the Three Cornered Hat, making music not just with your bow, but with your entire body. How much fun was it watching you? You played with pure, unadulterated joy, unembarrassed by the fact that you were the only member of your section moving anything other than the bow. You did not distract from the music, you channeled it, enhanced it. And I will never be able to listen to that piece again without thinking of you.

And smiling.

(Oh, and thanks to the rain delay, we got home by the bottom of the fourth inning, even though we had walked home instead of taking the bus.)

Seinfeld Saturdays

2009-10-31T07:00:00.001-04:00

First in an occasional series.

Jerry on doctors.

Gastrc Bypass Surgery May Impact Oral Contraceptive Effectiveness

2009-10-30T07:00:00.002-04:00

A review article on the effects of bariatric surgery on reproductive function published this month in Fertility and Sterility highlights two studies suggesting that gastric bypass surgeries may make oral contraceptives less effective. (Note - this does not apply to simple gastric banding procedures that limit stomach size but don't induce malabsorption.)

The studies are very small, but the findings are concerning.

In one study of 40 women, 2 of the 9 women using oral contraceptives became unexpectedly pregnant after jejunal-ilial bypass surgery, despite having used the same method before without failure. None of the women using other methods got pregnant. The second study, conducted in 7 bilio-pancreatic bypass subjects, found that hormone levels 8 hours after taking a progesterone-only birth control pill were lower compared with normal controls. By 24 hours, there was no difference in levels. No unplanned pregnancies were reported.

The paper's authors hypothesize that malabsorption due to the bypass may be at work here. I also wonder if perhaps the pill's "effectiveness" in subjects prior to bypass was really the negative impact of their weight on fertility, since we know bypass can improve ovulatory function.

What do we do with this information?

I don't think that these data are enough to recommend that all women who have had a gastric bypass avoid all oral contraceptives, though it certainly gives one pause. I think it is worth discussing with your surgeon exactly what areas of the stomach and intestine were bypassed and what your risk of malabsorption is. Certainly if one is having diarrhea induced by a bypass procedure, then one must consider that medications are not being properly absorbed.

What I am doing at this point is avoiding the progesterone-only pill in the gastric-bypass population unless I have to use it, since in general, the efficacy of these pills occurs within a narrower range of serum levels. In women who are taking combination pills, I tell them to be extra careful with compliance, and if they miss a pill, to use back up barrier contraception for at least a week, especially if they notice spotting.

Heading to a standard 35 ug rather than a lower dose 20ug pill would be worth considering in this population. The Nuvaring also seems like it may be a good option, since it does not rely on intestinal absorption. Given that the estrogen exposure in the contraceptive patch is about 60% higher than in pills, I would still tend to avoid this method, even in this group, unless I know I have to use it to maintain levels. But that's just me - talk to your doctor about what's best for you.

We definitely need larger studies and some consensus guidance on this issue, since more and more women are undergoing bariatric surgery.

"Usual and Customary" is About to Get Redefined

2009-10-29T00:01:00.004-04:00

NY States Attorney General Andrew Cuomo yesterday announced the formation of a new not-for-profit research consortium that, within a year, will develop an independent database to determine just what "reasonable and customary" fees are for medical care patients receive from docs outside their insurer's network. The database will replace the Ingenix database, which was essentially an arm of United Health.

Insurers often promise to cover as much as 80 percent of those rates for claims from providers outside their network. However, Cuomo's investigation found that Ingenix had a vested interest in helping set rates low, thus allowing companies to underpay patients for out-of-network services by as much as 28 percent.

Cuomo said the Ingenix database intentionally skewed "usual and customary" rates downward through faulty data collection, poor pooling procedures and the lack of audits.

The new database, to be operated independently by FAIR Health, will remove the conflict of interest and determine fair out-of-network reimbursement rates for consumers throughout the United States, Cuomo said. It also will be an aid to researchers and engine for health care reform, he said.

Cuomo said officials hoped to have the database and consumer Web site operating within a year. (via AP)

It's amazing what can be accomplished with a little legal muscle, isn't it? Single-handedly, Cuomo has done more to move health reform forward than the entire Congress has so far.

Just take a look at this timeline to get a sense of the momentum this guy has -

Beginning in January, Attorney General Cuomo secured agreements with every national and regional health insurer operating in New York State to end their use of the Ingenix database and financially commit to the new, independent database:
January 13, 2009: UnitedHealth Group Inc. agrees to shut down the Ingenix database and contribute $50 million towards the new, independent database.
January 15, 2009: Aetna agrees to end its relationship with Ingenix and contribute $20 million towards the new, independent database.
February 2, 2009: Aetna also agrees to reimburse over 73,000 students at over 200 colleges nationwide for underpaying out-of-network claims.
February 4, 2009: MVP Health Care agrees to end its relationship with Ingenix and contribute $535,000 towards the new, independent database.
February 4, 2009: Cuomo announces intent to sue Capital District Physicians’ Health Plan for defrauding consumers across New York by manipulating rates.
February 10, 2009: Independent Health and Health Now, New York Inc. agree to end their relationships with Ingenix and contribute $475,000 and $212,500, respectively, to fund the new database.
February 17, 2009: CIGNA agrees to end its relationship with Ingenix and contribute $10 million towards the new, independent database.
February 17, 2009: Cuomo announces intent to sue Excellus Health Plan for defrauding consumers across New York by manipulating rates.
February 18, 2009: WellPoint, Inc. agrees to end its relationship with Ingenix and contribute $10 million towards the new database.
March 3, 2009: Guardian Life Insurance Company of America agrees to end its relationship with Ingenix and contribute $500,000 towards the new database.
March 5, 2009: Excellus Health Plan and Capital District Physician’s Plan agree to end their relationships with Ingenix and contribute $775,000 and $300,000, respectively, toward the new database. The companies also agree to re-process claims over the past six years and reimburse members who were underpaid.
March 10, 2009: GHI and HIP agree to end their relationships with Ingenix and contribute $1.5 million towards the new database
June 18, 2009: Health Net agrees to end its relationship with Ingenix and contribute $1.6 million towards the new database.

God only knows what he was threatening them all with...

Go, Andy!

More IKEA Lamp Love

2009-10-28T13:00:00.001-04:00

It's like having your second child. You can't imagine there's room in your heart to love another lamp as much as you love those two matching 365+ Lunta lamps in your den.

Then you fall in love with this gorgeous Alang floor lamp you got to replace the broken lamp in your office. The shade is a gorgeous basket weave, the height is adjustable, and it takes a regular incandescent bulb. (I hate halogens and the new energy saving fluorescents make me depressed...)

We'll see how long it lasts, but at only $39.99, if it makes it through a year I'll be happy. It feels pretty solid though, so I'm betting on it for the long haul.

I like the shade so much, I may just do what this Ikea hacker did, and buy another to make me some pendant lamps for over the dining room table.

The Selling of the Blogosphere

2009-10-27T07:00:00.004-04:00

Dr Val warns medbloggers what solicitations they receive really mean -

Dr. Val: So let me get this straight, you’d like me to ask my bloggers to embed links to product sites without directly disclosing that they’re paid to do that, leverage their trust and credibility to get people to click on the links - and once they get to the product site you’ll be collecting personal information about them so you can target them more effectively with offers for drugs and other products? …And how much would you pay the blogger?
SalesGuy: About $7 per completed survey.
Dr. Val: So that’s how much it costs to sell a soul these days? We’re not interested. [Click]

Good for you, Dr Val!

I had my own little email solicitation last week, asking me if I would be interested in being paid to review products on my blog. I headed to the website (Seoblogreviews.com), where I was informed that I would be paid per review, with this little hint -

Are you willing NOT TO MENTION the fact that those reviews are Paid/Sponsored Reviews? (You'll receive MUCH MORE Paid Reviews Offers if you choose YES).

So basically, advertisers are looking for bloggers to write favorable reviews without revealing that these are ads. If you're honest, forget about making money. You'll be outbid by those willing to hide their conflicts of interest.

The FTC is not a day late in their proposed ruling that requires bloggers to reveal income related to their postings.