Patient Receptivity to Spiritual Subjects

How do patients feel about the subject? Not surprisingly, it depends. World War II Army Chaplain William T. Cummings famously declared, "there are no atheists in fox holes." Patients seem to have the same sentiment when it comes to talking to physicians about their spirituality.

In a survey published in 2003 in the Journal of General Internal Medicine, researchers asked 456 outpatients in North Carolina, Florida, and Vermont whether they wanted their doctor to ask them about their spirituality. Only one third of respondents interviewed in a clinic setting liked the idea, but the number climbed to 40% in a hospital setting and 70% in hospice.^[2]

"Should we do this in every primary care practice and patient interaction?" asks Drew Rosielle, MD, director of the University of Minnesota's Hospice and Palliative Medicine Fellowship. "Realistically, of course not."

But when a doctor has a little more time, such as during an annual physical, or when a patient is faced with a major diagnosis, working a question or two about spirituality into the conversation can help a physician better understand and support a patient, he says. Rosielle routinely asks a couple of questions about spirituality as part of his initial palliative care consultation with patients so he can refer them to the chaplain on his care team if necessary.

"For patients who are not interested, it's a non-issue," he says. "You just move on. I've never had a patient get offended about being asked."

But for patients with spiritual concerns, the conversation helps him connect them with the support they need. "When you get sick -- especially when you're facing a terminal illness or a life-changing situation, it affects your entire being emotionally, spiritually, existentially," he says. "Patients are hungry for any support they can get."

Puchalski sites an example from her own experience. Several years ago her father, a devout Catholic, underwent surgery for colon cancer. Prior to the procedure, the nurse asked him whether he was spiritual and what that meant to him. A retired opera singer, he responded that he couldn't live without music. Intrigued, she asked him to sing and he responded with a heart-felt aria. Afterward he felt more relaxed and uplifted. The nurse noted his love of singing on his chart. After the operation, other clinicians read her notation and encouraged her father to sing as a way of exercising his lungs.

For her father, Puchalski says, bringing music into the hospital was a profoundly positive experience, "but how would the doctors and nurses have known that if the nurse hadn't asked the question?" she asks.

Assessing Spiritual Outlook

Still, fitting spiritual assessments into practice is a hodgepodge. "From what we've seen in our research almost nobody is using those acronyms," says Farr Curlin, MD, co-director of the Program on Medicine and Religion at the University of Chicago. "It's the rare physician who uses these pneumonic tools. Rather they try to pay attention to signs from the patient and then they try to query them to bring those issues out and connect the patient with spiritual resources in the community or their organization's pastoral care department."

Taylor, says clinicians are caught in a theory-practice gap.

"The problem is we say, 'spiritual care matters,' but we haven't gotten to the point where clinicians can identify spiritual need," she says.

Should Physicians Be Involved With Patient's Spiritual Care?

Science and religion have always had a complicated relationship, so it's not surprising that, as interest in holistic care grows, physicians are trying to come to grips with whether they should play a role in patients' spiritual care.

"We've always talked about the limitations of the biomedical model that would reduce people to our physiology," says Carol Taylor, PhD, director of the Center for Clinical Bioethics at Georgetown University. "When we talk about holistic health, we talk about biological, psychological, and social needs and now we're talking about spiritual needs as well. They're all interrelated."

More than half of physicians believe that religion and spirituality affect patient health in some way, according to research conducted by the University of Chicago. In a survey of 2000 physicians, 56% believed that religion and spirituality have much or very much influence on health, but only 6% believed they often changed "hard" medical outcomes.  Rather, respondents suggested that religion and spirituality help patients cope, give them a positive state of mind, or provide emotional and practical support via the religious community.

While doctors might believe religion and spirituality influence health, acknowledging a connection raises some fundamental and tricky questions. The American College of Physicians' ethics manual encourages physicians to explore a patient's religion and spirituality as part of an overall physical. But how are they to do that? What does it mean, and what are they to do with the information?

Stethoscope and Spiritual Care?

Spirituality, broadly defined, is what gives a person's life meaning. Religion may or may not factor into the picture. In asking about spirituality, clinicians are seeking to identify a patient's source of hope, strength, and values, not their dogma or doctrine.

Research indicates that roughly 80% of medical schools now offer spiritual care courses or integrate spirituality into their curricula, according to Christina Puchalski, MD, an internist at George Washington University and director of the George Washington Institute for Spirituality and Health. But what's included and how it's taught differs tremendously from one institution to the next. In an effort to bring consistency to the spiritual history and assessment process, various proponents have development of myriad tools represented by apropos acronyms such as FAITH, SPIRIT, and HOPE as well as the slightly less catchy FICA and FACT.

Assessing a patient's spiritual health is important, because spiritual issues can not only impact a patient's health, but they can impact a patient's medical compliance and treatment choices as well, says Puchalski.

"What if they don't want to take medicines because they believe God will heal them? What if they're very nature-centric and don't want to put medications in their body? What if they don't believe in blood transfusions?" she asks. "Physicians need to know these concerns if they're going to treat a patient."

However, not everybody believes spiritual care belongs in the examination room. Indeed, those who oppose the idea present a litany of arguments: Spirituality is a private matter. Over-zealous physicians might abuse their position and proselytize to their patients. Pragmatically, many note that in the real world of 15-minute office visits, taking the time to ask questions about spirituality would come at the expense of addressing clinical issues.

Most worrisome says Richard Sloan, professor of behavioral medicine at Columbia University Medical Center and author of Blind Faith: The Unholy Alliance of Religion and Medicine, taking a spiritual history sets a doctor up to be a spiritual guide, "which they are completely untrained and unequipped to do."

"Nobody should deny that spirituality is important to a great many people, but I don't think it's grist for the physician's mill," he says. Doctors need to know about all facets of their patients' lives, he says, but shouldn't ask more than "Is spirituality important to you?" A simple "yes" or "no" answer suffices, he says.

As for the possibility that patients' spirituality might impact their care, Sloan notes that spiritual, financial, transportation, and other potential barriers to care are more likely to surface if a doctor asks, "Is there anything that would keep you from taking this medication?"

Has your physician ever asked you about your spirituality??

My next blog will be how this is recieved/percieved by the patient.  Please make comments.  I'd love to hear your thoughts.

Big Physician Pay Cut in 2012

In the category of not exactly good news, the Centers for Medicare and Medicaid Services (CMS) yesterday announced that it would cut Medicare reimbursement for physicians by 27.4% on January 1, 2012, instead of 29.5% as previously planned

To physicians, this resembles telling a condemned man that his firing squad will consist of 5 riflemen instead of 6.

The slightly lower reduction in reimbursement appears in the final regulations that CMS released yesterday regarding the 2012 Medicare Physician Fee Schedule. Medicare sets these fees using the so-called sustainable growth rate (SGR) formula, which organized medicine wants to abolish. The SGR formula establishes an annual target for Medicare spending on physician services based in part on annual growth of the gross domestic product. If actual spending exceeds the target, the difference is taken out of next year's outlays for physician services.

In March 2011, CMS estimated that physicians would be subject to a 29.5% reduction in reimbursement. The change to 27.4% reflects the fact that Medicare costs this year have grown more slowly than expected, according to the agency's announcement.

The SGR has triggered annual pay cuts for physicians since 2002, but starting in 2003, each one has been postponed by an act of Congress. The postponed cuts then accumulate, leading to the deep one scheduled for January 1. Organized medicine has warned that such a steep drop in revenue would cause droves of physicians to stop seeing new Medicare patients or drop out of the program altogether.

The slightly lower reduction announced yesterday is not changing anybody's tune. Robert Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, told Medscape Medical News that "27.4% isn't going to make doctors any happier than nearly 30%."

Glen Stream, MD, president of the American Academy of Family Physicians, said in a written statement that the 27.4% reduction "poses a serious threat to the financial viability of physician practices." He cited a survey showing that even a 25% cut would put nearly 13% of family physicians at risk of shutting their doors.

The American College of Physicians, American Academy of Family Physicians, and other medical societies have pressed the new Congressional Joint Select Committee on Deficit Reduction, known as the "super committee," for short, to include a repeal of the SGR formula in its recommendations to Congress.

Tort Reform...A Legal Critics Opinion

A day after 3,000 "Occupy Chicago" discontented protesters gathered outside the Art Institute of Chicago—where members of the Futures Industry Association and the Mortgage Bankers Association were holding a reception—about 50 people gathered nearby to hear activist, attorney and author Philip K. Howard declare "Nothing is working the way it should."
According to Howard, one step to help set things right would be to implement special health courts—a concept he has worked on with the Harvard School of Public Health.

Speaking away from the lectern and without a microphone, Howard noted that there are nine medical categories for injuries caused by sea lions and 12 for bee stings, and that a doctor can't say "How are you, Mr. Howard?" in a hospital for fear of violating federal privacy laws.
But it's not just healthcare that's suffering, Howard argued. He said fear of litigation has caused school playgrounds to be "stripped of anything fun."

Howard told the audience of doctors, lawyers, healthcare administrators, civic leaders and Columbia College journalism students that these problems are caused or exacerbated by people feeling powerless to oppose nonsensical legal or bureaucratic rules imposed on them by well-meaning politicians—many of them now dead—who sought through the rules to keep anything bad from ever happening. And now legislators lack the will to amend rules to fit current circumstances, he said. Howard urged the students to question and make fun of the rules and "write about this with clear eyes."

The current environment won't be changed by caps on malpractice damages or other simple fixes, he said.

Tort reform, he asserted, will not put seesaws back in playgrounds. Texas physicians still admit to engaging in costly defensive-medicine practices even after that state's much ballyhooed malpractice caps were put in place, Howard noted.

The system Howard envisions would not have juries but would be led by full-time health judges with a budget to hire neutral experts to testify on the merits of a malpractice case.
Jerry Latherow, president of the Illinois Trial Lawyers Association and the husband of a physician, "respectfully disagreed" with just about every point Howard made—especially with regard to the scope and cost of defensive medicine. He also questioned the ability of the courts to remain impartial, saying health judges would most likely travel in the same social and business circles as defendants rather than plaintiffs.

But health courts are just a part of Howard's crusade to "restore the capacity for humans to take responsibility." He gave several plugs for Project Start Over, the campaign launched by his not-for-profit organization.

He urged audience members to join the fight, and noted that former New Jersey Sen. Bill Bradley and current Indiana Gov. Mitch Daniels have expressed interest in the cause as has Jon Stewart.

American Medical Association Fails According to Physicians

A New Doctors’ Survey Says AMA Fails on Health Reform, New Voice Needed. Seventy-Seven Percent of Doctors Surveyed say AMA No Longer Represents Their Views.

Almost 18 months after President Obama signed healthcare reform into law, America’s physicians have not forgiven the American Medical Association for supporting the Patient Protection and Affordable Care Act, according to a new survey released by Jackson & Coker, a division of Jackson Healthcare.

Post Mortem CT instead of Autopsy??

Sorry everyone its been so long since i've posted.  I've just been super busy lately with starting an MBA program for physicians. So...expect to see some posts involving medicine and business now...Anyway, this caught my attention since I'm a pathologist and have done plenty of autopsies (thank God I don't do them anymore).  Hope ya'll enjoy!!!!


Several research groups champion the potential for postmortem CT (PMCT) to replace the invasive postmortem (PM), however, many questions still remain. Perhaps the two most important questions are whether PMCT can provide the same level of information as an invasive PM autopsy?  Arguably more important is the question, can it meet the needs of the end users of the PM report.  The authors of a recent study show that PMCT is good at providing accurate causes of death and that the interpretation of cases is not significantly altered by the absence of histology or actualy autopsy. The authors show that in straightforward trauma deaths such as road traffic incidents, there exists the potential for the replacement of the invasive PM by PMCT examination. However, as yet, PMCT cannot provide all of the information that is expected by the criminal justice system in complex forensic cases.


So needless to say post mortem CT may have a role in certain "autopsies" in the future. 

Mammogram Parties...The New Fad?

Every 12 minutes a woman in America dies of breast cancer.  With early detection though, doctors believe that number could be significantly reduced, that’s why they’re hosting mammogram parties.
Relaxing with a massage, being pampered with a manicure. No, this isn’t a day spa. It’s a mammogram party. The parties are sweeping the nation, helping take the stress out of getting mammograms.


"This way being around other people it takes away the nervousness,” Judith Wiersema, Mammogram Party Attendee said.
“We would like to see more women come out and participate in screening mammography. It saves lives,” said one radiologist.

The American Cancer Society recommends all women over the age of 40 get a mammogram every year. But only two out of three women say they’ve gotten a mammogram in the last two years.

 “I’ve never had a mammogram I’m just too afraid to go,” one attendee said.

But you don’t have to be. Let’s separate fact from fiction. True or false? You do not need to get a breast exam if you get a yearly mammogram. That's false! A mammogram only picks up 85-percent of lesions.  Drinking caffeinated beverages can cause breast cancer.  That's also false! A new study shows it may reduce your risk, but drinking high amounts can make your breasts more sensitive during a mammogram. The radiation you receive from a mammogram does not cause cancer. True! The risk of harm from radiation exposure is very small and that risk decreases as a woman ages.

These parties just may make mammograms worth toasting to.

Health Care Reform Law Loses in Appeals Court

In a 304-page opinion, the 11th U.S. Circuit Court of Appeals in Atlanta on Friday struck down the individual insurance mandate in the Patient Protection and Affordable Care Act, but allowed the rest of the sweeping law to stand.

In its decision, a divided three-judge panel of the federal appeals court ruled in favor of 26 states that had joined a lawsuit in Pensacola, Fla., which argued the reform law should be struck down because it relies on an unconstitutional expansion of federal power.

The ruling means that the Supreme Court will now have the classic split in the circuit courts that it often relies on when deciding whether to take on a case. The 6th Circuit Court of Appeals upheld the law in June, and the losers in that case filed for permission last month to have their case heard by the Supreme Court.
Critics said—and the 11th Circuit judges agreed—that Congress' ability to regulate interstate commerce cannot be expanded to include a power to compel private individuals to buy health insurance. Under the law, nearly all Americans who can't prove they have health insurance would face a penalty on their income taxes starting in 2014.

“What Congress cannot do under the Commerce Clause is mandate that individuals enter into contracts with private insurance companies for the purchase of an expensive product from the time they are born until the time they die,” the judges wrote.

A dissenting opinion from U.S. Circuit Judge Stanley Marcus said the majority opinion ignored decades of Supreme Court precedents to expand and define the scope of Commerce Clause powers to include over-arching regulatory schemes.

“The individual mandate was designed and intended to regulate quintessentially economic conduct in order to ameliorate two large national problems: first, the substantial cost shifting that occurs when uninsured individuals consume health care services—as virtually all of them will, and many do each year—for which they cannot pay; and, second, the unavailability of health insurance for those who need it most—those with pre-existing conditions and lengthy medical histories,” Marcus wrote.

Although the ruling technically only strikes out the individual mandate, legal observers have said that it's not clear whether the law is workable from a practical perspective without the provision. Proponents of the law have said the mandate was necessary to offset insurers' costs, since the reform law also took away their right to turn away sick patients.

The 11th Circuit is the second federal appeals court to issue a ruling on the merits of the reform law.

In June, the 6th Circuit Court of Appeals in Cincinnati upheld the law on a challenge from a federal lawsuit in Detroit after hearing a nearly identical set of arguments as the 11th Circuit judges did. The Thomas More Law Center, which lost the Detroit appeal, has already filed a petition for writ of certiorari with the U.S. Supreme Court to hear oral arguments in the lawsuit.
Still outstanding are rulings from the 4th Circuit Court of Appeals in Richmond, Va., which heard oral arguments in May on two different lawsuits challenging the reform law. The judges have not yet ruled on those cases.

What are your thoughts on the new health care reform?

Back to School...How to Keep Kids Alert

I can't believe school has started already for many.  Here are some more back to school tips and healthy advice to help keep kids alert during the school day.

As parents prepare to send their children back to school, they need to remember that nutrition is an important factor in academic performance, an expert advises.

Studies have shown that children who eat healthy, balanced breakfasts and lunches are more alert throughout the school day and also earn higher marks than those who have an unhealthy diet.

A healthy breakfast includes a variety of foods such as fiber-rich and whole-grain cereals with low fat milk; yogurt and berries; toast, eggs and 100 percent fruit juice; or whole wheat bagels and cream cheese with low-fat milk.

When packing lunches, use the U.S. Department of Agriculture's Food Guide Pyramid. Include at least two servings from the bread group and one serving from each of the other food groups.

One way to prevent children from becoming bored with their lunches is to use pitas, bagels, English muffins, crackers or tortillas to make sandwiches instead of using bread all the time.

You can pack fruit such as grapes, strawberries, apple wedges or melon chunks that's quick and easy to eat.  Including a toothpick and a dipping sauce made with yogurt can coax reluctant fruit eaters to try it.

Children should be encouraged to drink low-fat white milk or plain or sugar-free flavored water. They should not drink beverages with added supplements such as herbs and caffeine.

Scientist Create A Dog That Glows

South Korean scientists said on Wednesday they have created a glowing dog using a cloning technique that could help find cures for human diseases such as Alzheimer's and Parkinson's.

A research team from Seoul National University (SNU) said the genetically modified female beagle, named Tegon and born in 2009, has been found to glow fluorescent green under ultraviolet light if given a doxycycline antibiotic, the report said.

The researchers, who completed a two-year test, said the ability to glow can be turned on or off by adding a drug to the dog's food.

"The creation of Tegon opens new horizons since the gene injected to make the dog glow can be substituted with genes that trigger fatal human diseases." 

The dog was created using the somatic cell nuclear transfer technology that the university team used to make the world's first cloned dog, Snuppy, in 2005.

The scientist said that because there are 268 illnesses that humans and dogs have in common, creating dogs that artificially show such symptoms could aid treatment methods for diseases that afflict humans.

The latest discovery, published online May 31 in Genesis, took four years of research with roughly 3.2 billion won ($3 million) spent to make the dog and conduct the necessary verification tests.

Is Your Brain Bigger Based on Where You Live?

 People from northern parts of the world have evolved bigger brains and larger eyes to help them to cope with long, dark winters and dim skies, scientists said on Wednesday.

Researchers from Oxford University studied the eye sockets and brain capacity of 55 human skulls from 12 different populations across the world and found that the further human populations live from the equator, the bigger their brains.

It's not because they are smarter, however, but because they need bigger vision areas in the brain to cope with the low light levels at high latitudes, the scientists said in a report of their findings published online July 27th in Biology Letters.

"As you move away from the equator, there's less and less light available, so humans have had to evolve bigger and bigger eyes," said Eiluned Pearce from Oxford's School of Anthropology, who led the study. "Their brains also need to be bigger to deal with the extra visual input.

"Having bigger brains doesn't mean that higher latitude humans are smarter, it just means they need bigger brains to be able to see well where they live."

The skulls used in the study dated back to the 1800s and included samples from indigenous populations of England, Australia, Canary Islands, China, France, India, Kenya, Micronesia, Scandinavia, Somalia, Uganda and the United States.

The researchers plotted the volume of the eye sockets and brain cavities against the latitude of the central point of each individual's country of origin and found that the size of both the brain and the eyes could be directly linked to the latitude of the country.

Oxford's Robin Dunbar, who also worked on the study, said the results showed the speed at which humans had evolved to cope with the challenges of new habitats.

"Humans have only lived at high latitudes in Europe and Asia for a few tens of thousands of years, yet they seem to have adapted their visual systems surprisingly rapidly to the cloudy skies, dull weather and long winters," he said.

Using Brain Signals to Assist in Breaking While Driving

Is this the future of our automobile's breaking technology?  Very interesting out of Germany. Enjoy!!!!


German researchers have used drivers' brain signals, for the first time, to assist in braking, providing much quicker reaction times and a potential solution to the thousands of car accidents that are caused by human error.

Using electroencephalography (EEG) - a technique that attaches electrodes to the scalp - the researchers demonstrated that the mind-reading system, accompanied with modern traffic sensors, could detect a driver's intention to break 130 milliseconds faster than a normal brake pedal response.

Driving at 100km/h, this amounts to reducing the braking distance by 3.66 meters - the full length of a compact car or the potential margin between causing and avoiding accidents.

A detailed video of one of the subjects driving the simulator can be seen here. 

Healthy and Happy Meals from McDonalds

Is a Happy Meal still happy when it's healthy? 

Starting in September, children will get apples with their McDonald's Happy Meals -- and fewer fries at a McDonald's in Oak Brook, Illinois.

McDonald's first experimented with eliminating French fries completely from the menu, but the company says children and parents rebelled. So they brought them back, only in a smaller portion. By the beginning of next year, McDonald's will include a half-order of apples and a half-order of fries in the Happy Meal. But, customers can request a full order of one or the other.

McDonald's says the apples are currently available in Happy Meals instead of fries, but only 11 percent of people ordered them.

Under the new progam:

• McDonald's pledged to reduce sugars, saturated fats and calories through "varied portion sizes, reformulations and innovations" by 2020. By 2015, it will reduce sodium by 15 percent.
• McDonald's will introduce a new mobile app focused just on nutrition information.
• McDonald's USA president Jan Fields and other executives will go on a "listening tour" in August to hear suggestions from parents and nutrition experts. The chain will also launch a new online forum for parents.

The changes are what customers are asking for, according to Cindy Goody, McDonald's senior director of nutrition. 
"We've been in the nutrition game for over 30 years in providing nutrition information to our customers," Goody said. "Now what we're doing is we're adding more food groups and ... creating nutritional awareness."

Do you think your kids will still want Happy Meals???

Back to School Health for Children

Parents should keep in mind three key routines as they track their children's health over the school year, says Randall Cottrell, a University of Cincinnati professor of health promotion and education. In addition to physical activity, children need a good night's sleep and a proper breakfast before they head to school.

Cottrell, who has evaluated school health programs for the Ohio Department of Health, says the school year can cause children to decrease their physical activity in order to increase their study time. "All children need to maintain some level of physical activity when they go back to school. The mind works best when it's physically stimulated." Cottrell says that activity could be as simple as playing an hour of hoops with the neighborhood kids after school, rather than an hour of computer games. When it gets too cold to play outdoors, recreational leagues can offer activities that range from basketball to swimming and wrestling. "When the snow falls, children can go sledding as they continue to stay physically active through the school year."

A proper diet will lower the risk of childhood obesity and increase the likelihood of academic success. Cottrell says it all begins with a proper breakfast. Without it, the blood sugar level falls, making children fatigued and less able to concentrate. "All children should have breakfast. If they don't like cereal, they can have yogurt and toast, but they must have those calories. Studies have shown breakfast benefits learning." Cottrell also suggests sending children to school with healthy snacks and if they pack their lunch, keep it healthy, avoiding high fat, high sugar and high salt foods.

An earlier nighttime routine is often a source of conflict between kids and parents, but Cottrell says proper rest impacts learning. "Students should get a minimum of eight hours of sleep and it's better if they can get between nine and 10 hours," says Cottrell. Because their bodies are still growing, he says children need more rest than the average adult. That can be a challenge for teens who wish they could "sleep in." Studies have shown teenagers have a harder time waking up because of their changing biological clocks.


What do you do differently when the school year starts back?

Robo-Doc...Can Computers Replace Your Physician?

Automation in Medicine: Humans vs. Machines

Robots don't need vacations. Unlike humans, they don't get tired. Whether serving as a robotic scrub nurse, a miniature mobile sewing machine, or a remotely controlled surgical arm equipped with a high-speed CT scanning eye, bots offer some real advantages over humans. They can maneuver into tight anatomical spaces, require only small keyhole incisions for access, and are less likely to contaminate the field. Robots are also less likely to complain about bad lighting, table height, and room temperature. Unlike most humans, they have no life at all outside the hospital (although this is true for some physicians).

Newer cameras allow robotic assistants to respond to hand gestures. Surgeons can use hand signals to bring up an imaging study or electronic medical record data into view, without touching a thing. Similar gesture-sensing technology is available in consumer electronic games that track hand movements in 3-D space. 

Have You Met Dr. Watson?

Robots are not the only high-tech newcomers to medicine. Enter Watson, the artificial intelligence supercomputer from IBM. It processes natural-language questions and scours massive databases looking for answers. After beating uber-contestant Ken Jennings at Jeopardy , Watson went to medical school at both Columbia and University of Maryland. Watson will spend a few years learning about the types of diagnostic and therapeutic questions that arise in clinical practice. Is it possible that unearthing facts buried within massive volumes of medical journals and other data can support tailored clinical decision-making for an individual patient? Maybe we will find out in a few years. 

Humans Behind the Machines

Famed heart surgeon Michael DeBakey (who is from my hometown) learned to stitch from his mother, a seamstress and sewing teacher. He described the thrill of sewing his first synthetic bypass grafts by hand. He went on to invent dozens of machines and surgical instruments that are now commonplace in medicine. I am reminded that behind all these great mechanical and electronic innovations are real human beings. When it comes to beside manner-actively listening, expressing genuine caring, and delivering encouragement—the vast majority of human clinicians have the clear advantage over robots, hands down. Don't you think?

What is the Best Hospital In the U.S.?

The title of "Best Hospital" in the United States goes to ... The Johns Hopkins Hospital. Again.

The Baltimore-based Johns Hopkins earned the top spot among about 5,000 hospitals in the United States for the 22nd year, according to U.S. News and World Report's 2011-2012 rankings released on Tuesday. It has earned the top spot every year since the U.S. News Media Group began publishing the annual list in 1990.

The latest report recognized 720 hospitals of 4,825 nationwide that rank among the best in their metro area or in at least one of 16 medical specialties.

This year only 140 of the total number of hospitals evaluated performed well enough in even one medical specialty to earn a national ranking, according to the U.S. News media release Tuesday.

The list covers all 94 metro areas that have a minimum of both 500,000 residents and one hospital that performed well enough to earn a place, as well as 16 medical specialties, from cancer and heart disease to urology and respiratory disorders.

The rankings derive from statistics in these specialties, such as fatality rates, patient safety and volume of procedure. They also rely on a national survey in which physicians named the hospitals they consider best in their specialty for the toughest cases.

Johns Hopkins earned the top spot of 17 "Honor Roll" hospitals given the distinction for "rare breadth and depth of medical excellence," according to U.S. News.

In 2010-2011, 152 hospitals made the rankings cut but only 14 placed on the honor roll for high scores in six or more of the total 16 specialties.

This year Massachusetts General Hospital in Boston overtook the Mayo Clinic for the number two spot with the Rochester, Minnesota-based clinic taking third.

Brigham and Women's Hospital, also in Boston, traded places with Barnes-Jewish Hospital at Washington University Medical Center of St. Louis, moving up three spots to eighth while Barnes-Jewish dropped to 11th.

Vanderbilt University Medical Center in Nashville, Mount Sinai Medical Center in New York, and Stanford Hospital & Clinics of California all joined the 2011-2012 honor roll list.

The mission of "Best Hospitals" is to serve as a guide for patients in need of a high level of care, according to the U.S. News report. 

"These are referral centers where other hospitals send their sickest patients," Avery Comarow, U.S. News Health Rankings Editor said.

"Hospitals like these are ones you or those close to you should consider when the stakes are high."

Gotcha! When Malpractice Plaintiffs Fake or Exaggerate Injuries

A video presented at a malpractice trial showed a pitiful 56-year-old man grimacing in pain, hobbling on crutches, unable to even brush his teeth without his wife's assistance. His sex life was over. His disabilities were caused by a botched back operation, he testified.

The defendant neurosurgeon and his insurer were convinced the man was lying. But how to prove it? Investigators with video cameras staked out his house for 3 days, but the man stayed inside. The investigators were about to quit the surveillance when the man finally emerged, jauntily carrying a hydraulic jack and cinder blocks to prop up his car. He then changed the shock absorbers and performed other tasks with the dexterity of a pit crew at the Indianapolis 500.

The surgeon's attorney presented the video to a judge who promptly dismissed the malpractice case. Prosecutors then charged the man with perjury. He was convicted and sentenced to 30 days in jail.

In malpractice cases, it's almost expected that plaintiffs will "gild the lily" by exaggerating their disabilities. However, even the most egregious examples of fraud generally go unpunished -- unlike the case mentioned.

In many cases, searching through public records and databases can turn up phony claims without the expense and uncertainty of video surveillance. A check of motor vehicle records showed that one plaintiff had several speeding tickets issued 90 miles from the home he claimed he couldn't leave because of his "injury."

When his employment records were subpoenaed, it turned out he worked as a long-haul trucker, shifting gears in an 18-wheeler all the while claiming that his left leg was immobile as a result of a physician's negligence. In a case that involved a claim for loss of consortium, a check of divorce records found that the couple had broken up several years earlier but supplied false information about their marital status to boost the value of the lawsuit.

Finding the Fakes

How can doctors and their attorneys confirm suspicions that a plaintiff is faking? "The first tip often comes from the doctor who says the patient is acting or moving in ways that are inconsistent with the allegations," says James Lewis Griffith Sr., an attorney in Philadelphia who represents both patients and physicians. "A careful reading of the medical record can lead you to investigate further. At depositions, you develop a sixth sense about whether someone is telling the truth, often when they act too smart for their own good. Outright fraud may occur in 1% of cases and it's difficult to prove. But exaggeration is pretty common."

"We look for red flags, especially if the claimed injury doesn't follow the typical pattern," says Peter Leone, New Jersey program director for Academic Insurance in New York, which insures almost 3000 physicians. "Whenever the plaintiff says there's something he can't ever do again, especially if he's a young man, that's suspicious and we dig deeper."

Shortage of Healthcare Professionals Predicted by 2025

 Advanced practice nurses (APNs) and physician assistants (PAs) are frequently touted as the solution to the physician shortage, but there will not be enough of all 3 professionals combined to meet the nation's healthcare needs in 2025, according to a study published in the June issue of theJournal of the American College of Surgeons.

Lead author Michael Sargen, a medical student at the University of Pennsylvania in Philadelphia, and coauthors write that although the United States needs to expand the workforce of these 3 types of "advanced clinicians," healthcare personnel with less training must assume more patient care responsibilities, especially as more Americans gain insurance coverage under the Affordable Care Act.

Right now, the nation fields close to 300 advanced clinicians for every 100,000 Americans. That number is roughly 7% less than needed, based on the demand for services, which the authors extrapolate from healthcare spending. The authors write that if training programs for PAs and APNs — which include nurse practitioners — grow as currently projected while physician residency programs fail to expand, the per capita supply of advanced clinicians in 2025 will resemble the current level.

However, the workforce of 2025 in this scenario will be 20% less than needed because of burgeoning demand for services. The authors cite government studies that forecast a 65% increase in healthcare spending from 2009 to 2025 based on its historic growth rate of 2.5% above the growth of the gross domestic product (GDP).

The healthcare reform law aims to reduce that growth rate to 1% above GDP, the authors write, but even if reformers hit this target, demand for services will still outstrip the supply of advanced clinicians.

Coauthor Richard Cooper, MD, an authority on physician workforce issues and a professor at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, chalks up the continued rise in spending not only to costly technologies but also to the sheer proliferation of new therapies.

"Research is finding ways to treat diseases that were once untreatable," Dr. Cooper told Medscape Medical News. "We once didn't treat lung cancer. Now we do. We don't treat Alzheimer's disease now, but we will in the future."

"Everyone Should Work to Their Level of Education"

A 20% shortfall in the advanced-clinician workforce in 2025 is the study's worst-case scenario. The nation will more likely face a 15% shortage that year, the authors write, given the pressure to add more first-year slots to residency programs.

The study authors mention several wild cards that were not factored into their analysis but that could aggravate the shortage. Physicians, they write, are working fewer and fewer hours. And all clinicians are increasingly pulled away from patient care by chores such as documenting what they do for the sake of getting paid. These factors could increase unmet demand for advanced clinicians by an additional 10% to 15%, according to the authors.

Wild cards aside, even under the rosiest scenario for advanced-clinician head counts, the nation still "must broaden the spectrum of healthcare workers who can assist in delivering services," write the authors. That means advanced clinicians must learn to delegate responsibilities that can be performed by personnel with less training and to focus on the services that only they can provide, said Dr. Cooper.

"Everyone should work to their level of education," he said. "This is easy to talk about when you work in a hospital with a lot of people [to delegate to]," he said. "It's more difficult when you're a solo practitioner."

The need to spread out the work, he predicts, will drive more physicians to join larger, more organized systems, such as hospitals and large group practices.

Medical DIagnosis Via Facebook-Who Would Have Thought It?

Facebook Helps Solve Child's Disease 

One desperate mom, through a series of photos, used Facebook to reach out and eventually figured out what her son's medical condition was and how to treat it.  Kawasaki Disease (KD) is rare, but the social network might have saved the child's life.

So, virtual friends looked at her posted photos, and simply commented on them. She rushed her son to the hospital.

An unofficial Facebook blog stated: 

"There is no virtual in feelings of that magnitude. Perhaps just as in the real world, with your real life, and quote-unquote real friends, your Facebook friend network is what you make it. Accordingly, old adages apply: Choose your friends wisely. Put in as much as you expect to get out."

So what is Kawasaki disease? 

The disorder, first described in 1967 by Dr. Tomisaku Kawasaki in Japan, often begins with a high and persistent fever that is not very responsive to normal treatment with paracetamol (acetaminophen) or ibuprofen. The fever may persist steadily for up to two weeks and is normally accompanied by irritability.

Kawasaki published the first English language report of 50 patients with Kawasaki disease in 1974. Since that time, KD has become the leading cause of acquired heart disease among children in North America and Japan. Although an infectious agent is suspected, the cause remains unknown. However, significant progress has been made toward understanding the natural history of the disease and therapeutic interventions have been developed that halt the immune-mediated destruction of the arterial wall.

Inflammation of the mucous membranes in the mouth, along with erythema (redness), edema (swelling) with fissures (cracks in the lip surface), desquamation (peeling) and exsudation of the lips become exceedingly evident. Rashes occur early in the disease, and the cutaneous rash observed in patients with KD is non-specific, polymorphic, non-itchy and normally observed up to the fifth day of fever.

Some of these symptoms may come and go during the course of the illness. It is a syndrome affecting multiple organ systems, and in the acute stage of KD, systemic inflammatory changes are evident in many organs.

If left untreated, some symptoms will eventually relent, but coronary artery aneurysms will not improve, resulting in a significant risk of death or disability due to myocardial infarction. If treated in a timely fashion, this risk can be mostly avoided and the course of illness cut short.

Children with Kawasaki disease should be hospitalized and cared for by a physician who has experience with this disease. When in an academic medical center, care is often shared between pediatric cardiology and pediatric infectious disease specialists (although no specific infectious agent has been identified as yet). It is imperative that treatment be started as soon as the diagnosis is made to prevent damage to the coronary arteries. 

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As stated this is not a common diagnosis, however, every physician treating children should know the symptoms like the back of their of hand.  In fact, every medical student in their second year or beyond should also know this disease well as it is very high yield on every board exam.  

Please feel free to email or comment about anything you'd like to see included in my blog.  

Thanks for reading!!!!!

Should Doctors Apologize for Being Late?

Fortunately in my specialty I don't have to worry about this too much.  However, if your physician believes his time is more valuable than yours, you may want to consider finding a new more considerate physician.

Being Late -- Should Doctors Apologize?

No one can be perfectly punctual all the time. The question then is how doctors should handle their own lateness, especially when patients become upset or critical in the face of a delay.

In a recent discussion on Medscape's Physician Connect (MPC), an all-physician discussion group, a general practitioner asked for advice on dealing with the "rudeness" of a patient who "scolds me for being 20 minutes 'late.'"

Many responses suggested that the original poster had it backward: A doctor who does not arrive on time for a scheduled appointment is the one who has committed the discourtesy.

"Wait--you were 20 minutes late, and she was rude? Place yourself in her shoes. She does not know what you were doing before you entered the room. All she knows is that she had to wait 20 minutes. To her, you were the one that was rude by making her wait," wrote a neurologist.

"We have a responsibility to respect the patient's time as it is as valuable as ours. Apologizing if I am late is the first thing I should always do," a public health specialist added.