Friday, April 18, 2014

JWoww's Pregnancy Scare

Jenni Farley aka JWoww of "Jersey Shore" fame (or infamy) described the impact of learning about a minor abnormality in her prenatal ultrasound.

Jenni reported on her blog recently that a routine ultrasound turned into a moment of pure terror when her doctor informed her that he identified what may be a cyst on the fetus' brain. "At this point I honestly can't tell you what he's saying because I go numb and tears are just flowing," Jenni wrote of the incident. A scary diagnosis, to be sure, but using her trademark tenacity, Jenni secured an appointment with a specialist who delivered some good news: Jenni writes that the new doc informed her: "It's called choroid plexus cyst and over time the cyst should go away." She added, "Honestly I was happy but still my heart felt heavy. And even though I know I did nothing to cause it, I felt guilty and so helpless." Well, apparently Jenni has developed a skill for suspenseful storytelling during her months of sobriety because she ends the blog post by revealing that this all happened several weeks ago: "Fast forward to this check-up which brings me to 25 weeks aka 6 months," JWoww writes. "My daughter's cyst went away!"

There are a variety of findings whose significance seems relatively minor to obstetricians and sonographers yet strike fear in the hearts of moms to be. Choroid plexus cyst is one of these findings. Choroid plexus cyst or CPC is a small fluid-filled structure found in the choroid tissue in the ventricle of the developing fetal brain. CPC's are found in about 1 - 2% of all fetuses so these are quite common. While earlier descriptions found an association between CPC and Trisomy 18 (an extra copy of chromosome 18,) this association has not panned out in further investigations. CPC's do not cause swelling on the brain or hydrocephaly. They are not in and of themselves a major abnormality and have no effect on mental development. In the absence of other risk factors for chromosome problems, eg. age, family history, previously affected children, or other malformations, these should not warrant either worry or further investigation. In fact, most, as in Ms. Farley's case, resolve spontaneously.

For more information, or to schedule an appointment, please call my office: (718)-925-6277.

Thursday, April 17, 2014

Bloody Cycles

The transition to menopause is thought to consist of increasingly prolonged intervals between menstrual flow. The recently published SWAN study, however, suggests that early in that transition, the frequency of heavier and longer cycles may be far more common.

... We found that the large majority of women in SWAN, over 50% of whom were not white, reported menses duration of 10+ days, spotting of 6+ days and/or 3+ days of heavy bleeding during the MT. The likelihood of experiencing these menstrual bleeding events varied by race/ethnicity, BMI and reported uterine fibroids. These data confirm that two types of bleeding, longer menses with more days of spotting and heavier menses, occur in most women during the MT. These data provide clinicians and women with important normative data regarding the expected frequency of these bleeding changes during the menopausal transition, data that may facilitate decision-making in clinical practice. Such information, particularly when coupled with the emerging information about duration of the stages of the menopausal transition, will be of great value to women in this life-stage who wish to be active participants in their own health care. Such normative data can greatly alleviate concerns about midlife changes in ones bleeding patterns and facilitate coping with what, in most cases, will probably be a time-limited experience. Further research on the correlation between such bleeding and documented pathology is warranted to better support recommendations for watchful waiting versus clinical intervention.

Changes may be marked by differences in estrogen and progesterone production, signifying either greater or fewer ovulatory episodes. These changes may also signify underlying pathology such as uterine fibroids, adenomyosis, polyps or even hyperplasia. The last is especially troubling as prolonged estrogen stimulation without the periodic interjection of progesterone may lead not only to unscheduled bleeding but in a few cases, cancer.

A transvaginal sonogram is a simple test to gauge the thickness of the endometrial lining and should be considered as an integral part of the workup for abnormal bleeding. For more information, or to schedule an appointment, you can call my office at North Shore LIJ: (718) 925-6277.

Tuesday, April 15, 2014

Humbling

It's really something when you receive props from your peers. Over the weekend, the Medical Society of the State of New York had its annual House of Delegates. At that meeting, officers were elected. One of the new officers is yours truly.

Tarrytown, NY (4/14/14)--Arthur C. Fougner, MD, was elected Assistant Secretary of the Medical Society of the State of New York (MSSNY) at its 208th annual House of Delegates (HOD) meeting in Tarrytown, NY, on April 12. Board certified in Obstetrics and Gynecology, Dr. Fougner is Chief of Gynecologic Ultrasound at North Shore LIJ.

A graduate of the University of Notre Dame, Dr. Fougner earned his MD degree from Tulane University School of Medicine. He completed his postdoctoral training in OB-GYN at St. Clare's Hospital, NYU Medical Center, Bellevue Hospital and Booth Memorial Medical Center.

An attending OB-GYN at North Shore University Hospital, Long Island Jewish Medical Center and Forest Hills Hospital, Dr. Fougner is an assistant professor of OB-GYN at the Hofstra North Shore- LIJ School of Medicine at Hofstra University and formerly an assistant clinical professor at SUNY Stony Brook and Albert Einstein College of Medicine.

Dr. Fougner is a member of the International Society for Ultrasound in Obstetrics and Gynecology and of the American Institute of Ultrasound in Medicine.

Active in organized medicine since 1979, Dr. Fougner served as MSSNY's Commissioner of Communications from 2012-2013. He previously served as MSSNY's Assistant Commissioner of Public Health from 2009-2010 and Commissioner of Governmental Affairs from 2010-2012. He serves as both a trustee and a Councilor for the Medical Society of Queens.

Founded in 1807, the Medical Society of the State of New York is the state's principal non-profit professional organization for physicians, residents and medical students of all specialties. Its mission is to represent the interests of patients and physicians to assure quality healthcare services for all.

http://readme.readmedia.com/Arthur-C-Fougner-MD-Elected-Assistant-Secretary-Of-State-Medical-Society/8430504

I guess every organization needs a Marv Throneberry.

I am truly humbled.

Monday, April 7, 2014

Hepatitis C: To Screen Or Not To Screen, That Is The Question

Recently, NY State passed a law requiring screening for Hepatitis C be offered to all patients born between 1945 - 1965. Hepatitis C is a potentially fatal disease which can attack the liver silently over time. It is thought that as many as 1 in 30 "Baby Boomers" could be infected with the virus. For these reasons, screening this group makes sense. But of course, as always, there is a catch. It seems the cost of treatment for those infected is prohibitive for all but those on research protocols, better than platinum insurance plans, or those with incomes in the Warren Buffett range. Sovaldi, a new drug for Hep C treatment, costs about $84,0000 for a 12 week treatment.

What can be done about the cost? Right now, not much save to check with your insurer about treatment coverage and copay, etc. Still think screening asymptomatic folks is a good idea? For each individual, the answer may be different. Before asking a question, it's always best to know what you'll do with the answer.

Tuesday, April 1, 2014

You Now Have Health Insurance - Now What?

Now that Open Enrollment in Individual Health Plans is over (for most folks,) what do you do now?

For starters, go to either the webpage or the healthplan's book and check out what it is you actually purchased. You need to know three numbers - your premium, of course, your co-pay, and your deductible. When you selected your plan, you should have noted each of these numbers but many haven't. Please note them now for the true cost of your plan is not merely the monthly premium.

Now look at the "Provider Book" or the list of so-called Healthcare Providers on the plan website. Being a physician, let me point out that I didn't go to "Provider School." But that's a matter for another day. If you have an ongoing relationship with a doctor, make sure that your doctor is on the network list. If you can't find this information, call the plan's info number and find out. Again, you should have checked this out before choosing a plan, but that's water under the bridge now. Most if not all of the new individual plans set up under the "Affordable Care Act" are In-Network only plans and these networks are usually quite narrow with fewer choices. If after calling the plan and/or your doctor's office, emailing the plan, or sending out an APB, you still can't find out if your doctor participates in this plan, alert your state's insurance department. In NY State, that would be under the Department of Financial Services. Unfortunately for many, you may have to choose a new Primary Care Physician and you should do so asap. If you have a chronic illness for which you are undergoing treatment, you also have to find out if your specialist doctors are "in network" as well. If not, sadly, you will have to choose whether to pay a rather large bill for care or switch to a whole new set of treating physicians and start from square one.

Here's the problem - these new plans are for the most part "In Network" only. That means that whatever benefits your plan involve services provided only by In Network Providers. There are NO Out of Network Benefits for most Individual Plans save for a few scattered exceptions. If you need to go "Out of Network," the insurance version of "Off the Res," NONE of those services will be covered unless you get a special dispensation from the plan's hierarchy, usually the Medical Director. For example, if you have advanced colon cancer and wish to be treated at a Cancer Center like NY's Sloan Kettering which you find is not in your network, expect that you will be responsible for the entire bill. Moreover, and here's the kicker, none of the money you shell out will count toward your plan deductible - zip, zero, nada.

If you do not think this is fair, you are not alone. Unfortunately, the law isn't about fairness and it is what it is. My suggestion is that while you're still upset, you contact the State Insurance Dept (Again, in NY State, the Dept of Financial Services) and register a complaint. You should also call your state legislator and your local news consumer affairs reporter. The more light you shine on this issue, the sooner this will be dealt with. Everyone in NY State I've spoken with has acknowledged this problem with the individual plans.

Now, you may luck out. You may be healthy, not need care, and, if you do, find In Network doctors who are competent, caring and professional to handle your medical issues. But it shouldn't be left to luck, chance or God, should it?

Realize also that many doctors are in the same boat. It seems the plans were not so forthcoming at giving doctors the choice of either joining an insurer's new plan networks or informing them that they were either in or out of the new narrow network. This is a recipe for chaos. Also, if the plan lists a doctor as In Network but the doctor really is not, you will assuredly get a bill. And as I pointed out above, that bill will not count toward your deductible.

In reality, most of these plans are the worst of all worlds - an amalgam of an old HMO with a High Deductible Plan. There's little anyone can do about this situation right now, unfortunately. If you do run into a problem, please don't take it out on the doctor. Most of the doctors I know have been pleading with the states to do something as the end of enrollment approached. During the Second World War, the motto in Britain was "Keep Calm And Carry On." Both doctors and patients will need to do that. However, that doesn't mean you shouldn't complain. You should. For sure, it really is the squeaky wheel that gets the grease.

One last suggestion - other resources you should consider are your County and State Medical Societies. They have dedicate staff who are well-acquainted with the situation and are well-positioned to get you advice and also, to pursue your issues as they meld with their doctors' issues.

"Fasten your seatbelts, it's going to be a bumpy night." Bette Davis

Monday, March 24, 2014

Disruptive

There are many disruptions in the flow of care these days, especially in the Emergency Department. However, Disruptive has taken on a whole meaning lately, what with the proliferation of mobile and even wearable tech. Today, I cam across this post by Dr. Teresa Wu..

...As you are supervising two of your residents putting in bilateral chest tubes, your eager medical student runs up to the trauma bay with a pair of Google Glass. You are researching ways to incorporate wearable technology like Google Glass into your clinical practice and medical education so you and your medical student have a few pairs of Glass with you at work. You put on Glass and ask your medical student, “What can I help you with?” He informs you that your senior resident wants you to take a look at an ocular ultrasound of a patient he staffed with you a little while ago. He knows you are going to be tied up in the trauma bays for quite some time and wants to know if he can discharge the patient with ophthalmology follow up.

...You turn on Google Glass and link to your senior resident who is also wearing Google Glass while performing the bedside ocular ultrasound (Image 1). Through Glass you can see the ultrasound screen as he views it. What does the B-mode ocular ultrasound demonstrate? What’s the patient’s diagnosis?

Bedside Ultrasound meets Google Glass. Read the whole thing.

Just Wow!

Wednesday, March 12, 2014

EMR: Promises Unfulfilled

Welcome to my nightmare.

My practice is limited to consultative ultrasound in Obstetrics and Gynecology. It's been that way since the mid 1980's. My routine used to be simple. A medical assistant or sonographer would escort a patient into the exam room and take a history, inserting pertinent information on a report form. Patient identifiers would then be entered into the name and data fields on the ultrasound screen. After seeing that the patient was properly set up and doing some preliminary scanning, I would be called in. After asking the patient a few questions and a little small talk, I would then perform the ultrasound exam. I would give the patient a synopsis of my findings sans medicalese and then leave to write a preliminary report. The chart would then go to for transcription and from there to billing. Life was good.

Then I joined a large health system which had incorporated all the 21st century technology, including both an EMR and Ultrasound Reporting software as well, neither of which talk to each other. My routine is considerably different.

Now I am either handed a stack of demographic info or obtain my own demographic info off a computer screen. I then enter this data into another computer screen. This is invariably incomplete as it's usually unclear who referred the patient and to whom the report will be sent. A medical assistant fetches the patient and escorts her into the exam room, but usually I am the one to enter the info into the data field in the ultrasound machine. I am most often the one now who takes patient's history. I also figure what needs to be done and in what order. I then leave the room so the patient can change. After an appropriate interlude, I return and perform the ultrasound examination. I again give the patient a synopsis of my findings and then leave to write my report.

I return to the computer and then finish entering the demographics and some historical data. Because the images are usually not incorporated with a patient's demographics (remember, I couldn't enter that until I spoke with the patient,) I have to "attach the images" to a patient. Then I am ready to write my report. I pull up an image and input data from it into the appropriate field in the report page. I find some fields arranged in a nonintuitive fashion. I entered descriptive information by keyboard now rather than pen as I am now the transcriptionist.

Periodically, I have to launch an additional program to find the appropriate diagnosis codes so the examination I performed can be justified. The present diagnosis code system of about 14,000 codes is set to switch to a whole new system featuring 70,000 codes, which will not make my life any easier. After completing the report and seeing that the exams are entered, the indications are entered and they all are coded, I electronically sign the report and then send it to a network fax driver. Unfortunately, because many of these reports find themselves mysteriously transferred to Altair 4, I also print the report and then walk over to a fax machine to do that myself. In some cases, when the patient's physician is in the same group of offices, I will leave the report with the office staff to be scanned into the EMR. (Remember, I told you the EMR and the reporting software don't talk to each other.

Looking at the two practice systems, I ask myself which system enhances productivity? I used to be a doctor. Now I not only see patients, but I'm a transcriptionist, a biller and a coder as well. And this in a health system with an army of billers and coders. I am not the only practioner with these issues. I can tell you that the increased time subsequent patients wait for their exam because I am dealing with tech issues is not boosting my patient satisfaction scores. But that's a topic for another day.