Category: Uncategorized

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

Oct 1, 2018

By RYAN SCHWARZ & BIKASH GAUCHAN

“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.

Running 2 ORs: Is it always wrong?

Oct 1, 2018

By KAREN SIBERT, MD

Is 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.

Plastic Surgery Industry needs Comprehensive Overhaul and Stricter Regulations

Oct 1, 2018

By ELIZABETH MARIGLIANO

Plastic 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)

Oct 1, 2018

By LYNNE SHALLCROSS

Young 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.

Will Healthcare Law Pit Obama vs. Roberts?

Oct 1, 2018

By James F. Simon

President Franklin D. Roosevelt reacted with fury when major legislative pillars of his New Deal were declared unconstitutional by a Supreme Court anchored by four ideological conservatives. He lashed out at the justices, accusing them of practicing crass politics disguised as constitutional law.

Seventy-five years ago last month, FDR proposed his ill-fated court-packing plan that would have allowed him to stack the court with new appointees sympathetic to the New Deal.

Will history be repeated this term when the Roberts court decides the constitutional fate of President Obama’s signature legislation, the Affordable Health Care Act?

The justices will hear five-and-a-half hours of arguments over three days, March 26-28, on the healthcare law and deliver their judgment by the end of the term. If the court strikes down all or part of the law, Obama, like FDR before him, will almost certainly denounce the court’s decision. After all, he has already had practice in publicly criticizing the court. At his 2010 State of the Union address, with the justices sitting directly in front of him, he accused the court majority in the Citizens United decision of reversing a century of constitutional law to open “the floodgates for special interests… to spend without limit in our elections.”

Besides the willingness of both FDR and Obama to criticize the court, there are other parallels between the two Democratic presidents. Both came to office as liberal reformers who envisioned a large role for the federal government in promoting the nation’s welfare. But in defending their policies, they revealed their very different political styles and temperaments.

Supreme Court Needn’t Fear Healthcare Law’s Individual Mandate Provision

Oct 1, 2018

By Vikram Amar and Alan Brownstein

The Affordable Care Act faced a possibly fatal challenge when the constitutionality of its individual mandate provision was argued in the Supreme Court.

Much of the terrain was easy going. Neither the justices nor the lawyers doubted that the healthcare and healthcare insurance markets involve interstate commerce — insurance and healthcare providers are usually national or at least regional operations, folks who cross state lines get sick and must be cared for away from home regularly, and people are often unable to relocate to another state for fear of losing employer-based coverage. Nor was it disputed that the mandate was sincerely motivated by and closely related to the regulation of these interstate markets. Those two conclusions are usually sufficient to justify the exercise of congressional power under the commerce clause of the Constitution.

But then things got more treacherous. The problem, suggested by numerous questions from the conservative justices on the court, was the slippery slope they saw created by the mandate — the idea that Congress was requiring individuals to buy something. If the feds can require each person to buy health insurance, what can’t they force people to purchase?

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

Oct 1, 2018

By DIANE EVANS

On 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.

The Unlikely Heroes of Healthcare

Oct 1, 2018

By TIMOTHY HOFF

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.

Expensive Hospitals: The Enemy Within

Oct 1, 2018• 18

By ANISH KOKA MD

Everyone agrees that health care is bankrupting the nation. The prevailing winds have carried the argument that a system that pays per unit of health care delivered and thus favors volume over value is responsible. The problem, you see, was the doctors. They were just incentivized to do too much. This incontrovertible fact was the basis for changes in the healthcare system that favored hospital employment and have made the salaried physician the new normal. Yet, health care costs remain ascendant.

Why?

It turns out overutilization in the US healthcare system isn’t what its cracked up to be.

Figure 1. Utilization rates in different health care systems

A recent analysis (Figure 1) by Papanicolas et al., in JAMA demonstrates that while the United States is no slouch with regards to volume of imaging and procedures in a variety of different categories, it does not explain a health care system twice as expensive as its nearest competitor. The problem turns out not to be volume, rather its the unit price of healthcare in the United States.

Health Care Costs and Glass Houses

There are many stones cast by all the various players in healthcare when it comes to cost, and of course, everyone bears some degree of responsibility, but it’s also clear that some folks live in larger glass houses than others. The most beautiful of all the glass houses are those built by hospitals. From 1996 to 2013, it was not population growth, health status, doctors visits, or prescription drugs that drove spending increases. Sixty-three percent of the increase in cost over an almost 20-year time span can be attributed to hospital stays and testing during doctor visits. Consider that the average hospital stay in the US costs $18,142, and lasts 4.9 days compared to other industrialized countries where average hospital stays last 7.7 days, and cost $6,222. But despite these exorbitant prices hospital systems in the United States complain they barely stay afloat.

Escaping COVID-19

Sep 30, 2018

By RAGHAV GUPTA, MD

“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”
– William Osler

A colleague shared an experience with me about testing one of his patients for the novel coronavirus and it left me a bit puzzled. An elderly gentleman with past medical history of severe COPD and non-ischemic cardiomyopathy came to ER with shortness of breath, edema and fatigue. Chest X-ray suggested pulmonary edema. He wanted to test him for SARS-CoV-2 but hesitated. Eventually he was able to order it after discussions with various staff administrators. Dialogue included sentences like “why do we need testing? He has CHF, not COVID-19” and “it could create panic amongst staff taking care of him”. I applauded my colleague’s persistence as eventually the test was done. Few of us have probably gone through or are going to encounter a similar scenario as we ‘re-open’. To not test is counter-intuitive and more like an escape from diagnosing the virus rather than the virus itself.

One – the mere fact that we might hesitate before testing for a virus which is a cause of a (currently ongoing) pandemic should ring all the bells of concern about lack of an optimal strategy. Inadequate testing has remained the Achilles heel of our stand against COVID-19 because, to have a lasting stand, we must know where to take the stand.