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Simon Nath

Running 2 ORs: Is it always wrong?

Karen Sullivan SibertIs it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

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Snake Bite Anti-Venom Shortages: A Preventable Public Health Crisis

bayalpata_lg (1)“This is a 32 year old male who presented early this morning with a snake bite. He has received anti- venom per the protocol sir. He is asymptomatic and we can discharge this afternoon if he remains stable.” The health assistant presented the patient to his senior doctor – we were on morning inpatient rounds at Bayalpata Hospital in rural Achham, Nepal. “Excellent work bhai, this saved his life.”

Snake venom can be rapidly fatal; globally snake bites kill over 100,000 people per year, and permanently disable four times that number. Anti-venom treatment can save hundreds of thousands of lives annually, but without rapid access for patients, it can’t help anyone – not two weeks earlier our team lost a 39 year old mother of four after a snake bite on her ankle while she slept on the dirt floor of her home; she died within 24 hours as she did not have access to anti- venom. Tragically, this live-saving medication will soon be much less available.

Many of the world’s most toxic snakes are located in Sub-Saharan Africa, Australia, and South Asia, including Nepal where our team works with the Ministry of Health. Snakebites are one of the many “diseases of poverty” – that is, medical conditions that effect primarily the impoverished of our world due to lack of medicines and access to necessary healthcare. In Nepal – currently one of the world’s thirty poorest countries – regular stock-outs of anti-venom, as well as limited access to healthcare, leads to frequent and unnecessary deaths due to snake bites. Globally there are multiple types of anti-venoms, each made specific to the species of snakes they treat. While the anti-venom stock-outs we struggle with in Nepal is similar in dozens of other countries, in sub-Saharan Africa the anti-venom shortage is about to get much worse.

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Plastic Surgery Industry needs Comprehensive Overhaul and Stricter Regulations

Elizabeth MPlastic surgery has never been more popular, and is on the rise most everywhere in the world. According to a study performed by the International Society of Aesthetic Plastic Surgery in 2013, well over 23 million cosmetic surgeries were performed worldwide. Not only is plastic surgery becoming more popular, but the gender bias is also shifting. Over 3 million cosmetic procedures were performed on men, which comes to 12.8% of the total. Although this might seem fairly insignificant, it represents a 273% increase in a five year period.

In the public eye, cosmetic surgery has gone from a serious medical procedure to an almost recreational and in vogue past time, with facelift clinics opening up in malls, and plastic surgery coupons being used as birthday presents.

The extent of the problem

With such great demand, it is no wonder so many have jumped on the plastic surgery bandwagon. Unfortunately, an alarming percentage is made up of under-qualified or even unqualified practitioners. How alarming? A recent study showed that only 3.5 percent of practicing plastic surgeons in the USA are truly qualified to perform aesthetic procedures.

As it stands now, regulations in most countries do not differentiate between a qualified plastic surgeon and a doctor with a basic medical degree. This means that a general practitioner can perform rhinoplasty or a breast augmentation within the full confides of the law. Plastic surgery is often viewed as little more than a nip here and a tuck there, but the truth is that it carries the same risks as any other surgical procedure. Unlike other surgeries, however, practitioners of cosmetic surgery are seldom held responsible for mistakes, ranging from scarring to infection and even death. In the majority of cases patients have willingly opted for the procedure, so surgeons are often not held liable for any malpractice. These legal loopholes mean that many plastic surgeons have become salesmen rather than medical professionals.

Attempts at regulation

The majority of attempts at regulating the cosmetic surgery industry have been self-regulatory in nature. This hinges on compiling a registry of certified surgeons and practices, on a voluntary basis. This approach has, for the most part, failed. It has done so largely because these voluntary codes only incentivize the best doctors in the field to better their practices, while the unqualified and unscrupulous are free to continue their unsafe practices unhindered. It might be argued that voluntary codes have only augmented the disparity of this rapidly growing field. In addition, nothing is being done to regulate the psychological aspects of plastic surgery. Many patients who want plastic surgery are suffering from body-image issues that cannot be solved with a scalpel. It is crucial that patients talk to a trained psychologist, are given time to think about their options and are informed about alternative solutions. Without these kinds of regulations, it is easy to see why less scrupulous surgeons are nudging their patients towards plastic surgery in a bid for profit. Unlike most countries, France is paving the way for safer and more regulated plastic surgery. As a reaction to many severe plastic surgery scandals, the French government worked closely with top surgeons to make the industry safer. The result was a law that is designed to avoid abuse and monitor the practice of cosmetic surgery. This law dictates that patients must be informed on the surgeon’s qualifications, the cost of the procedure as well as a detailed breakdown of risks involved.

Marketing as a part of the problem

Plastic surgery has lost almost all of the stigma and taboo that went along with it only a few decades ago. It is glorified in the media, with celebrities flaunting their implants and procedures to a susceptible public that is often unaware of the risks. Plastic surgery is being treated more as a coveted commodity than a serious medical procedure. This can clearly be seen in the marketing of cosmetic procedures in printed media, television, and especially the internet. Cosmetic procedures are often advertised using limited offers including “buy one get one free” deals, vouchers and even surgery holidays to exotic countries where regulation is non-existent and procedures are inexpensive. These and similar advertising efforts are often misinterpreted by those it is aimed at, and trivialize the entire industry. Top surgeons around the world are calling for a ban on this type of marketing, in much the same way that there was an outcry against tobacco advertising.

Calls for action

Around the world, the rise in plastic surgery-related deaths has caused both a public and professional outcry for more stringent and functional regulations. From a beauty pageant winner in Venezuela dying after complications resulting from abdominal liposuction, to three recent deaths of women in Australia, the casualty count is rising. Australian doctors are calling for a mandatory two week waiting period after consultations before a person can get a plastic surgery. The British Association of Plastic, Reconstructive and Aesthetic Surgeons is fully backing new attempts at regulating the industry. They maintain that cosmetic surgery is effective and safe when carried out by well-trained, experienced surgeons in sterile and properly staffed and equipped surroundings.

What the industry needs is a comprehensive overhaul, led by an independent and unbiased umbrella body that will monitor training, facility conditions, qualifications, counseling and aftercare. Better communication between medical professionals and governmental bodies is essential if effective legislature is to be passed. In addition, the public needs to be made aware of the risks and alternatives, rather than being exposed to fraudulent or misleading advertising campaigns. Until such a time, the domain of plastic surgery will remain a veritable wild west of medicine.

Elizabeth Marigliano is an alumna of Stanford University. Her interests include cosmetic & plastic surgery. 

Weight-Loss — I’ve got An App for That…..and It doesn’t Work)

flying cadeuciiYoung American adults own smartphones at a higher rate than any other age group. Researchers from Duke University wanted to see if capitalizing on that smartphone usage with a low-cost weight-loss app might help the 35 percent of young adults in the U.S. who are overweight or obese.

If you’re rooting for smartphones to solve all our health problems, you’re not going to like what the researchers found. The smartphone app didn’t help young adults lose any more weight than if they hadn’t been using the app at all.

The study, which was published Wednesday in the journal Obesity, looked at 365 young adults ages 18 to 35. A third of the participants used an Android app specifically created for the study, which not only tracked their calories, weight and exercise but also offered interactive features like goal setting, games and social support.

Another third of the participants received six weekly personal coaching sessions,followed by monthly phone follow-ups. Plus, this personal coaching group was also encouraged to track their weight, calories and exercise via smartphone. The last third of the participants was put into a control group and given three handouts on healthy eating and exercise — nothing else.

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That Tremor? It’s U.S. Healthcare Crumbling under Pressure

flying cadeuciiOn the road to healthcare reform, let’s not forget the basics: Americans still need affordable, fast access to doctors. By steamrolling too much change at one time, the risk is that basic needs will go unmet amid reforms that aren’t widely understood and that ultimately will result in patient care determined by government-approved treatment plans.

It is important that average Americans be aware of what’s happening, and what’s at stake, while there is still time to preserve stability in our current healthcare system as it transitions to high technology.

A major problem is that too much of healthcare reform is being planned and executed in a vacuum – apart from important considerations such as thepotential for mass retirements of aging doctors, potentially leading to severe shortages and longer wait times for patients, all at a time of increased demand on the system due to aging baby boomers. Curiously, doctors must focus now on entering patient data into electronic devices, when by the federal  government’s own timetable, the necessary technology to accomplish healthcare reform won’t be in place until 2024. 

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The Unlikely Heroes of Healthcare

The unlikely heroes of American health care do not have fancy degrees. They are ordinary workers with high school degrees who can do their jobs with as little as an additional year of training. On average, they earn between $30,000 and $40,000 annually. Many have never worked in health care before. They work as employees, and almost all are female. They are the indispensable go to workers of the new American health care system because they are inexpensive to use and they can be plugged into many different workflows within a medical setting. They are medical assistants.

According to the Bureau of Labor Statistics (BLS), medical assistants perform both administrative and clinical duties under the direction of a physician. In 2014 there were almost 600,000 medical assistants employed in the United States, earning on average fifteen dollars an hour. Most of these work in physician offices, primarily in ambulatory care settings. Three states—California, Florida, and Texas—employ almost a third of all U.S. medical assistants. Every health care delivery organization in the Boston area now leans heavily on these workers to meet their production demands.

Medical assistants are a highly practical, cost-effective disruption that makes doctors’ lives easier, nurses able to upskill and do more, and patients gain easier access to and reliability around their care. No other workers in health care are involved in such a wide array of duties. Physicians increasingly rely on them as their jack of all trades support staff. Many patients in primary care now have more face and phone time with an MA than they do with their primary care doctor, who increasingly is hidden from our view, funneled towards the most complex patient visits coming through their door each day.

Beyond their direct interface with patients, medical assistants also support the quality reporting and performance measurement work in today’s doctors’ offices, often making sure quality data are complete and accurate within electronic health records, tracking down needed information, steering patients to required services, and getting performance data to the various insurance plans and accrediting agencies. This work is increasingly important for health care organizations to get paid, and for patients to get better care.

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Addiction Nature versus Nurture –Which? Both?

flying cadeuciiFor those of you who missed the first essay in this series, on the genetics of addiction, in all of us there is a genetic code, a code, which along with billions of other variations , contains a fairly common single gene genetic variation , the Folic Acid ( Vitamin B9) transport gene, which we can test for, using a cheek swab.

This deficient/diminished Folic Acid transport gene variation, present in many of us, slows or halts the transport of folic acid into our brains, predisposing us to lifetime depression and , in many cases, into early drug or alcohol experimentation, in an attempt to “feel better”. Why?

Folic acid is required by the brain in order to construct the neurotransmitter substances; Dopamine, Norepinephrine, and Seratonin. So, too little or no Folic acid present ,and too little or no brain neurotransmitters get constructed, and the patient’s darkened mood reflects that lack. Experimentation often follows early and often in such patients’ lives.
As most of you know, I run a Suboxone Clinic as well as a standard general practice, and I have yet to discover a Suboxone Clinic patient who transports Folic Acid normally from blood stream into their brain.

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Income Taxes and Healthcare: The Disconnect

After leaving Navigant in February, my pondering of ‘what’s next’ was interrupted by the reality of income taxes due weeks later. By midnight tonight, 240 million Americans will have filed, 53% will have paid something to Uncle Sam and all of us will be puzzled by where it goes and how it’s used.

Our federal individual taxes provide 47% of the federal government’s revenues, or $1.48 trillion for FY15.  Payroll taxes paid jointly by workers and employers make up another 34%, or $1.07 trillion and corporate taxes 11%, or $342 billion.

The federal government will spend more than it receives: for FY2015 just ended, federal receipts from all sources were $3.25 trillion and expenditures were $3.68 trillion billion. And 25% of that went to Medicare and the federal its portion of the CHIP and Medicaid programs.

Healthcare makes up the biggest chunk of Treasury spending followed by Social Security (24%), Defense (16%), and a bucket of expenditures called Discretionary Spending (16%) over which Congress exercises its influence most directly. And when Defense spending for healthcare is added ($51 billion annually), the state portions of Medicaid and CHIP payments are added, and health coverage for federal employees are added, more than 30% of the federal spending goes to healthcare. So one might reason that if individual income taxes are 47% of total federal receipts, income taxes paid for more than $500 billion of the healthcare tab. But that’s not widely known or understood by taxpayers nor is it a complete picture.

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150 Ways to Measure Healthcare Quality. Which One is Best?

In a previous article, we referenced CMS’s new provider reimbursement model, called Medicare Access and CHIP Reauthorization (MACRA), which replaces the current reimbursement formula. MACRA will include an incentive component that will replace the incentive programs in plans today, and the details of the performance criteria are being determined for roll-out in 2019. From the providers’ lens, they are faced with the need to hire more administrative resources to keep up with the tracking of their performance, and the big question is – are consumers making different choices based on the performance results of a physician or hospital? When there are over 150 different measures in place today, how is an occasional consumer of healthcare services able to assess the most important criteria in finding the right physician?

During a recent employers’ conference on the east coast, the forum featured two panels consisting of the healthplans and the providers. The panels were set in a Q&A format to enlist the leaderships’ views on various topics facing the employers, and it was a fascinating dialogue that we have attempted to capture below.

In the first panel with the execs of five major carriers, the opening question asked for a one minute overview of their healthplan’s area of focus in addressing the employers’ challenges. The responses were consistent amongst the leaders – the focus is on the individual consumer and value-based contracting. When we evolved the discussion into quality criteria and outcomes to identify high performing physicians, the leaders acknowledged that defining quality and outcomes is a challenging endeavor, and each health plan has their own formula to assess the providers’ performance. One commented that a physician practicing in the morning could be viewed as a top performer by a carrier, while that afternoon, they could be ranked as a poor performer by another, even though the physician was delivering the same process of care for all their patients. They agreed that the employers really needed to weigh in on what was important to them, so there was greater consistency in the scoring logic with the physician community.

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Measurement of Interoperability and the Transaction Receipt

Our aptly named Office of the National Coordinator needs your help. Congress wants to know if the regulations are working to enable interoperability and reduce information blocking. So, ONC wants us to “Help Inform the Department of Health and Human Services’ (HHS) Measurement of Interoperability” and has produced a helpful 19-page description of the issue. This interesting issue also made it to last week’s most august Joint HIT Committee for some lively discussion.

The only reasonable way to measure something is to consider the denominator as well as a numerator. Without the denominator to indicate the scope of what’s being measured, the numerator is likely to be misleading. With respect to interoperability, the denominator is simply all transactions that move individual-level patient data in or out of an institution.

Data moves in or out of an institution for different reasons and in different ways. The reasons include HIPAA Treatment, Payment, or Operations (TPO), to business associates, under patient authorization (regardless of whether it’s opt-in or opt-out), for research (e.g.: the Precision Medicine Initiative), and de-identified (to various data brokers and analytics services).

The ways that individual-level data moves is via analog fax, paper and film, digital media, or digital network. Measurement of interoperability would do well to consider all of these transports as part of the denominator.

We can define a data sharing transaction and hopefully allow a patient to request notification of that transaction. As individuals, we expect an accounting for data movement from our banks, email, and package services and we should expect the same for our health records. Specifically, I would define the following essential elements of a personal health data transaction:

Transaction Receipt and Notification

  • Resource (medication, problem, demographic, note, order, etc…HL7 coded, if possible)

  • Transport (fax, paper, film, digital device, digital network)

  • Client / Requesting Party (by institution, app, or individual name)

  • Date /Time (for any single client or requesting party, a monthly notice might be sufficient)

  • API Class (is the specific Resource also available through a patient-directed interface?)

  • Fee (who paid how much for this transaction or a link to the appropriate contract)

For a description of the API Class see

Establishing the denominator from the transaction receipt perspective works whether or not an individual patient chooses to supply an email address for notification. The mere fact that such a notification is available improves transparency, cybersecurity, and trust.

As Bob Wachter has said, transparency is an essential step to health system improvement. Let’s start with a transaction receipt and notification whenever our personal data is shared.


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