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5 OTC Meds to avoid, and better choices

Most people use non-prescription medications without giving much thought to the potential side effects or problems that may be associated with their use.  Here are 5 pretty popular OTC meds you should avoid, and better alternatives.  I bet most of you use one or more of these.  Neosporin, Topical Vitamin E, Afrin nasal spray (or other short acting nasal decongestant sprays), daily headache medications, and sedating antihistamines.  Continue reading ‘5 OTC Meds to avoid, and better choices’

Health Insurers – Too big for the common good?

P4P: Easier Said than Done for Primary Care

P4P,  pay for performance, compensate quality care.  These are buzzwords in policy makers rhetoric these days, and for good reason.  Everyone wants to promote high quality care and reward those who provide it, while encouraging those who don’t to get up to speed.  The problem is defining quality, figuring out if an individual physician or even practicing group of physicians meets standards in a statistically significant way.  Here is an interesting article on the AAFP web site that suggests the approaches being used by Medicare now are not valid.  

New Research on Performance Measurement

Few Primary Care Practices Large Enough for Reliable Measurement of Quality, Costs

By News Staff
2/23/2010

Although the federal government and other health care stakeholders have expressed interest in moving the nation’s health care system toward a value-based system that relies on measuring the quality of health care delivered against the dollars spent to provide that care, new research suggests that this may not work well for primary care practices.

The study, “Relationship of Primary Care Physicians’ Patient Caseload With Measurement of Quality and Cost Performance,” was funded by grants from the Commonwealth Fund and the National Institute on Aging. The study suggests that few primary care practices are large enough to reliably measure quality and cost performance measures among fee-for-service Medicare patients.

“It is unlikely that individual primary care physicians annually see a sufficient number of eligible patients to produce statistically reliable performance measurements on common quality and cost measures, calling into question whether their performance can be differentiated with respect to national benchmarks,” say the study authors. Continue reading ‘P4P: Easier Said than Done for Primary Care’

Good news for Coffee Drinkers

How to spot a drug seeking patient

This is posted as a supplement to an earlier post, Can’t find a doctor to prescribe pain meds?   Here is an article in Family Practice Management with an approach to identify patients in the office to obtain drugs for other than legitimate causes of pain.  This is a difficult problem,  and no physician wants to be “used” as a source of pain meds to overtly abuse or sell.  A still more difficult problem is to help patients with legitimate pain conditions manage their pain without developing a secondary problem with drug tolerance, subsequent overuse of the pain medication or a development of a chronic pain syndrome.   If anyone has a systematic approach that works for this?  If so let me know. 

From Family Practice Management

A Systematic Approach to Identifying Drug-Seeking Patients

Richard W. Pretorius, MD, MPH; Gina M. Zurick, PharmD, BCPS

Posted: 09/04/2008; Family Practice Management. 2008;15(4):3-5. © 2008  American Academy of Family Physicians

Introduction

A request for pain medication came from a 23-year-old male from New York City who showed up at a rural emergency room. He complained of two days of continuous pain in his left flank that radiated into his groin and was getting worse. Although suggestive of renal colic, the pain did not follow the natural history of obstructive nephropathy: It was not spasmodic and was nonspecific except for its purported severity. His physical exam, too, showed inconsistencies including diffuse guarding and generalized – rather than localized – tenderness to even light palpation. Although his urinalysis report showed red blood cells too numerous to count on the microscopic exam, the physician had her doubts and asked to see the urine specimen. While the urine was an amber color, there were small clots of blood on the bottom of the cup, which were more consistent with droplets of fresh blood from a pricked finger than from the microscopic ooze from a ureteral mucosa irritated from an entrapped stone. After the patient declined a request for a urine specimen via an in-and-out catheterization, non-narcotic analgesics were administered. A follow-up renal ultrasound was scheduled for the next day, an appointment – not surprisingly – that the patient did not keep.

As the misuse of prescription medications has increased dramatically in the past few years, particularly for opiates, it has become increasingly important to identify drug-seeking behavior, such as that depicted above. Currently, up to 30 percent of prescription narcotics are diverted for illegal use by someone other than the person for whom it was prescribed.^[1] Narcotics are not only shared with family and friends; they are often sold to strangers or exchanged for illegal substances. Continue reading ‘How to spot a drug seeking patient’

Brooke Douglas on Portion Control

Brooke Douglas

PORTION CONTROL: Don’t Go Overboard!

No one wants to gain 10# at the end of one year?  But in order for the weight to ‘creep’ on, all you have to do is eat 100 extra calories per day.  If you want to lose 20# at the end of one year?  Then eat 200 less calories daily.  Healthful living involves nutrition education not just on WHAT you eat, you must also become more aware of HOW MUCH you eat!

The next time you pour yourself a bowl of cereal, STOP before you pour the milk on.  Get out a measuring cup and see how much your ‘typical pour’ is?  Is it ¾ cup or is it 2½ cups?  Most cereals call for about a cup – about the size of a tennis ball.  For meat, you want about 3 oz/meal – about the size of a deck of cards.  Portion size makes a big difference when you are adding up the calories per serving.  Especially when you discover that you are eating 4 or 5 servings … according to the label.

We all eat in food ruts. We eat the same foods every week to ten days. So take the time, (just once or twice) to check the true quantity you are eating.  Then do the math! It’s a great idea to write down what you eat in any given day in order to figure out how many calories you are eating.  Can you shave 100 calories from each meal by eating a smaller portion?  If you saved 300 calories a day you could lower your blood sugar, blood pressure, cholesterol levels and lose 30# in just one year without too much effort! 

 Here are some tips:

 Use smaller plates and cups

• Read Nutrition Facts Labels
• Order small or a la carte
• Beware of big baked goods
• Share large entrees
• Don’t eat out of the bag
• Don’t eat in front of the TV
• Eat before you go out

 The difference between a smaller portion and a super-sized portion could be much more than you realize.  For example:

                                                             Large                                      Small

French fries                                         570                                          250

Burger                                                 730                                          260

Soda                                                    310                                          150

Cookie                                                 470                                          110

Ice cream                                             560                                          230

  Totals                                                  2,640                                       1,000

 Awareness is key!  Becoming more aware of common portion sizes is a good idea, especially if you have never paid attention in the past to how much you are really eating!

 Brooke Douglas, RD

www.nutritionauthority.com

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Medical Marijuana – The Wrong Patients Want it.

I frequently have patients ask me about using medical marijuana.  Unfortunately they are not the patients I think would benefit most from its use.  I found a very good article in Psychiatric News that discussed the issue in detail and with good balance.  The evidence is scant, but suggests some usefulness of medical marijuana for limited conditions. Continue reading ‘Medical Marijuana – The Wrong Patients Want it.’

Letter to the President

I was a supporter of President Obama, and have an open mind about health care reform, but have been really frustrated that what is going on in Washington seems all about what’s best for the politicians, political parties and has little to do with what’s best for America or Americans.  Rob Lambert in Health Care Blog writes an open letter to the president that I think echos a lot about what I hear too. 

February 25, 2010

Dear Mr. President

By ROB LAMBERTS

I am writing this as a representative of the examination room – one who sits facing patients, dealing with   our healthcare delivery “system” on a daily basis. I am writing this as one who will bear the brunt of what you accomplish or fail to accomplish in your attempts to reform our “system.” I write this as a primary care doctor who makes a living (or not) by what I earn from that “system.” I write as someone who has seen people not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.”

I talk to patients every day about what you folks are doing, and let me tell you what they are saying: nobody has any confidence in you whatsoever. Whether conservative or liberal, insured or not, black or white, elderly or young, all of my patients express frustration, disillusionment, and pessimism over your chances at getting it right. Nobody is confident, nobody is all that passionate anymore, and nobody is holding their breath.

Why no passion? Why wouldn’t people be invested in something so vital as our healthcare system? Because it seems to all that what you are doing in Washington is not about people’s health, it’s about politics. It’s not about caring for the frail and elderly, it’s about holding on to your power or regaining the power you lost. The cross-section of people I talk with is convinced that you would sacrifice what’s good for the country to get what’s good for your party. It’s hard to get passionate about your games and power struggles. It is as if the house is burning down and you folks are arguing about what color to paint it.

So what do people want? What is really important to my patients? Here’s what I see: Continue reading ‘Letter to the President’

Difficult choices

                                    Rock                                       Hard Place

At my office we provide care for a fair number of patients without medical insurance. Sometimes we are faced situations with no good options. At a patient visit oftentimes the diagnosis is not clear without doing some diagnostic tests other than the history and physical exam. Many of these tests are ordered from sources outside the office where I have little or no control over the cost of the test to the patient. In other than straightforward visits where the diagnosis is apparent and treatment can be recommended from what is learned at the visit, these tests can cost more, often far more, than the charges from my office. The old saying, “The most expensive medical instrument is the physicians pen,” is true in these cases. The dilemma is that I know ordering these creates a real problem for some of my uninsured patients. When do I order the CT scan to look for an atypical presentation of appendicitis in the 23-year old woman who probably has a simple ovarian cyst, but could have a ruptured appendix? When do I order the MRI looking for the unlikely but possible brain tumor in the 25-year old with severe headaches for 6 weeks who likely has stress headaches?

We use a program called “Simple Care” to avoid contractual issues with our third party payers, both governmental like Medicare and Medicaid, and private insurers. Simple care patients are required to pay at the time of the visit, saving us the need to bill, collect, and code for the visit. We have convinced our lab and primary radiology referral sources to discount their services to our Simple Care patients. This works well for most visits, but when a patient has a potentially serious problem where the standard of care is to order tests outside the office it gets complicated. The patient may be able to afford the $50. or $60 dollar visit, but the $1500. CT scan or MRI, or the several hundred dollars of lab tests may be another matter altogether. Few of my specialist consultants discount fees for cash paying patients, and these patients often do not have the cash to pay at the time of service for more expensive tests, consultations, or procedures. In some cases I can feel comfortable using time, therapeutic trials, and inexpensive tests to get to a diagnosis of exclude more serious problems. Other times the diagnostic possibilities include problems so serious that delay in diagnosis puts the patient at such risk that I have to strongly request they spend the money, of more often incur the debt to get the tests done.

It is easy to argue that a physician just needs to provide the same level of care for the uninsured patient as the insured patient, but in the world we live in the consequences of subjecting the patient to debt payments for months or years, or possibly bankruptcy has to be taken into account. The chances of a negative test are usually higher than the chances of a test showing the problem you are looking to exclude or confirm. In these cases I sometimes second guess myself. Could I have safely avoided exposing my patient to the expense of these tests that turned out negative. I don’t have an answer for this dilemma. I try to give a recommendation, present options, and involve the patient in the solution. Still I struggle often with the responsibility of urging a patient to get testing I know they can neither afford to have done or to not have done.