Friday, September 27, 2013

Soy - Yes Or No

After the WHI Study resulted in women's abandoning estrogen replacementt therapy after menopause, the use of soy-based phytoestrogens became popular. Today's NY Times, however, asks if it's it's safe to eat soy.

... As far as any downside, most of the health concerns about soy stem from its concentration of phytoestrogens, a group of natural compounds that resemble estrogen chemically. Some experts have questioned whether soy might lower testosterone levels in men and cause problems for women who have estrogen-sensitive breast cancers. Animal studies have found, for example, that large doses of phytoestrogens can fuel the growth of tumors.

It should be pointed out that soy and other phytoestrogens have only weak estrogenic effects so cancer concerns are probably overblown. In fact, there is some evidence that moderate soy intake may actually decrease cancer risk.  There is one caveat. This only holds for  soy-based food. Supplements are highly concentrated and poorly studied so all bets are off.

Remember, if something is truly all-natural, why does it come in a factory-sealed bottle?

Here's to your health.

Tuesday, September 24, 2013

Life After Cancer

According to the American Association for Cancer Research, there are over 13 million cancer survivors living in the US today. That number is supposed to grow to 18 million by 2022. The CDC found that about half are women  and one third are younger than 65 years old. For younger survivors, the question of fertility is an important issue.

Today's NY Timess hightlights this concern.

... At one time, oncologists rarely worried about the reproductive side effects of treatment because so few pediatric patients survived. But as more children with cancer live into adulthood — death rates have plunged 66 percent since the 1970s — the landscape of fertility has changed. Doctors are offering patients preservation options at the time of diagnosis, and researchers are finding that for many survivors, the odds of overcoming clinical infertility are surprisingly good.

Last month, a large study in The Lancet Oncology found that about two thirds of female survivors who sought out fertility treatments as adults ultimately became pregnant — a rate of success that mirrored the rate among other infertile women. 
Women with newly diagnosed cancers need to ask about fertility-sparing options, now more available than ever. Doctors, in turn, need to broach the subject with their patients. Cancer does not have to mean the "End of the Line." There is life after cancer.
Oh yes, for one more week, September is Gynecologic Cancer Month.

Thursday, September 19, 2013

It's All About The Data

Today, we learn Google is launching a healthcare company.

... Larry Page, chief executive, unveiled the venture, called Calico, with a characteristically ambitious and vague claim that “with some longer term, moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives”.

While outlining a highly ambitious overall goal for the new company, however, Google did not disclose any information about how much it would invest in the venture, which areas of healthcare science the spin-off company would specialise in, or what the initiative was likely to lead to in terms of new products.

Big Data is the big mantra. But we need to ask the critical question before things get out of hand: Who Owns The Data?

Stay tuned.

Wednesday, September 18, 2013

The Color of Debt

This morning, I had the pleasure of receiving an article  co-authored by MSSNY's former Student Councilor Robert Dugger MD, The Color of Debt. 

The conclusion -

Black medical students had significantly higher anticipated debt than Asian students. This finding has implications for understanding differential enrollment among minority groups in US medical schools.

Interestingly, whites did not fare as well as Asians either.

The study does have so e weaknesses, with more than a hint of selection bias. Nevertheless, the matter warrants serious reflection by policymakers and further investigation.

Kudos again to Dr. Dugger for this publication.

Monday, September 16, 2013

The Dark Side of Wellness at Penn State

Rising employee healthcare costs are the bane of employers across the country. HR departments deal with the issue of providing benefits while keeping expenses manageable. Wellness programs are one possible solution to this quandry - healthy employees need fewer services. But wellness itself may have costs as well. Recently, Pennsylvania State University launched its own wellness program, Taking Care of Your Health. However, in order to encourage participation, PSU chose a coercive stick rather than a carrot approach.

The plan requires nonunion employees, like professors and clerical staff members, to visit their doctors for a checkup, undergo several biometric tests and submit to an extensive online health risk questionnaire that asks, among other questions, whether they have recently had problems with a co-worker, a supervisor or a divorce. If they don’t fill out the form, $100 a month will be deducted from their pay for noncompliance. Employees who do participate will receive detailed feedback on how to address their health issues.
At a university where some employees earn less than $50,000 annually, the faculty members contended that an $1,200 annual surcharge for nonparticipation — or $2,400 if the employee has a spouse or domestic partner on the school’s plan when that person has the option of coverage from his or her own employer — amounted to a strong-arm tactic. What’s more, they argued, the online questionnaire required them to give intimate information about their medical history, finances, marital status and job-related stress to an outside company, WebMD Health Services, a health management firm that operates separately from the popular consumer site,
This has sparked calls for a faculty insurrection. 
Over at The Healthcare Blog, Vik Khanna and Al Lewis suggest an alternative strategy for the outraged faculty.
... However, there is an alternative approach, and one that will break the bank in HR: get every preventive test possible and then get all the follow-up care you can for every conceivable dubious or positive result, many of which will be false positives.  Faculty should also use their paid time off to rest up from the physical and emotional stress of getting all this unnecessary medical care and perhaps even think about filing workers comp claims since these stressors are all directly job related.
PSU administrators thought they could slip this coercive program in during the summer downtime and that the white collar faculty, without benefit of union strong arms, would simply rollover and comply. They chose ... poorly.

Friday, September 13, 2013

Healthgrades Epic Fail

In selecting a new doctor, many check like to check them out online at rating sites such as The more satisfied the patients, the better the doctor, right? Well, it ain't necessarily so. Check out the case of a Texas neurosurgeon.

... The article chronicles how a neurosurgeon in Texas permanently injured and likely even killed multiple patients during surgery and how the Texas Medical Board failed to timely respond to complaints that were raised. As a result, the neurosurgeon, Christopher Duntsch, continued operating on patients and patients continued having bad outcomes from his surgeries. 

This does not sound like a doctor I'd want to see or refer folks to, does it? Well, according to Healthgrades (until they scrubbed his profile,) this was a highly rated doctor.

... the same doctor who was reported to have caused the deaths of several patients and who reportedly permanently injured multiple other patients was rated as a 4.3 out of 5 in patient satisfaction. Dr. Duntsch rated above the national average in every one of Healthgrades’ patient satisfaction survey details except the total wait time in exam rooms – where he rated the same as the national average.

Now has decided to remove all of the satisfaction information from Dr. Duntsch’s profile, so all you’ll see is a bunch of blanks on his ratings page. But I got a screen grab of the ratings before Healthgrades erased them.

While patient satisfaction is important, high ratings are not equivalent to high quality care. As the author of the Whitecoat piece demonstrates, this doctors' patients thought highly of him until they woke up dead. The author goes further:

In fact, has many complaints about the accuracy and validity of its ratings. It is rated at the lowest score by 88% of all people giving it a rating I had one reader write me about how published that he was still seeing patients when he has been retired for 10 years, how Healthgrades published his home phone number, and how patients call his home phone number at all hours of the day and night, then yell at him because he is retired.

When physicians complain about such sites, what is the response? Press Ganey CEO Patrick Ryan suggests physicians "Suck It Up." Oh and did I mention that Healthgrades CEO Roger Holstein is a member of the Board of Press Ganey?

Tuesday, September 10, 2013

I Robot

It seems as if you cannot open a magazine, listen to the radio or watch a tv program without catching an ad for robotic surgery. The surgical robot is indeed a remarkable instrument with the potential to take minimally invasive surgery to a whole other level. However, the proliferation of surgical robots also has a downside. Witness today's NY Times:

... The new study follows a series of reports critical of robotically assisted surgery. Documents surfacing in the course of legal action against Intuitive have outlined the aggressive tactics used to market the equipment and raised questions about the quality of training provided to surgeons, as well as the pressure on doctors and hospitals to use it — even in cases where it is not the physician’s first choice and she has little hands-on experience.
Nevertheless, robotic surgery has grown dramatically, increasing more than 400 percent in the United States between 2007 and 2011. About 1,400 da Vinci systems, which cost $1.5 million to $2.5 million, have been purchased by hospitals, according to Intuitive’s investor reports.
The expansion has occurred without proper evaluation and monitoring of the benefits, said Dr. Martin A. Makary, an associate professor of surgery at Johns Hopkins and the senior author of the paper.
“This whole issue is symbolic of a larger problem in American health care, which is the lack of proper evaluation of what we do,” Dr. Makary said. “We adopt expensive new technologies, but we don’t even know what we’re getting for our money — if it’s of good value or harmful.”
As of yet, it's been difficult to demonstrate that the expensive robots result in outcomes that are worth the investment. ACOG released a statement on robotic surgery concluding:
... Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.
While it's a poor carpenter who criticizes his tools, periodically we need to know that a particular tool is, as R Crumb's Mr. Natural put it, "the right tool for the right job."
Also, if you are considering robotic surgery, be sure to ask the surgeon some very specific questions about experience, volume, and outcomes. 
Of course that's just my opinion. I could be wrong.

Friday, September 6, 2013

Surviving The Unsurvivable

Today's amazing "feel good story" involves Abigail Rose Beutler, born after a prenatal diagnosis of invariably fatal renal agenesis. Faced with this terrible diagnosis, Abigail's parents, Daniel Beutler and Congresswoman Jaimie Herrera Beutler of Ohio, elected to embark on an experimental therapy - weekly treatments of amnioinfusion, instilling solution into the amniotic sac, to replenish the meager fluid surrounding the fetus in an attempt to allow some semblance of normal lung development. After five weeks of therapy at John's Hopkins, little Abigail was born, weighing in at less than three pounds. 

A day after the fifth infusion, the congresswoman went into preterm labor. After four days of trying to prevent preterm delivery, the baby arrived.
“The doctors and nurses were prepared for the worst, but immediately after she was born, she drew a breath and cried,” Herrera Beutler said. “After a few minutes, it was clear that her lungs were very well developed for a baby born so early.  The infusions had stopped the Potter’s Sequence.”
To be sure, Abigail still needs to overcome significant hurdles including kidney transplant. However, this remarkable case is truly historic.
But riddle me this - how would little Abigail have fared had PPACA's IPAB been in place to review the cost/benefit ratio of fetal therapy? 

The Moving Finger writes; and, having writ,
Moves on: nor all thy Piety nor Wit
Shall lure it back to cancel half a Line,
Nor all thy Tears wash out a Word of it.

The Rubaiyat Of Omar Khayyam

Thursday, September 5, 2013

EHR's - The Forecast Is Cloudy

Though discussion of EHR benefits is still an open item, that costs can be considerable is universally accepted. For this reason, many physicians and hospitals are going to The Cloud.

Eighty-seven percent of all physician practices agree their billing and collections systems need upgrading, according to a new survey. The majority favor moving to a fully integrated practice management, EHR and medical software product, accessible through the cloud on any browser or device.
The first of eight revenue cycle management studies to be released by Black Book, the "Top Physician Practice Management & Revenue Cycle Management: Ambulatory EHR Vendors," is an analysis of the convergence of the replacement EHR market with the needs of physician practices to upgrade patient billing processes.
According to Black Book Rankings, the RCM software and services industry recently surpassed the $12 billion in the ambulatory physician practice segment 
However, as Andi Mann, VP of Stategic Solutions at CA, puts it, with new technologies come new risks.
The proliferation of cloud connected devices and users accessing data from outside the firewall demands a shift in the way we secure data. Security is no longer about locking down the perimeter – it’s about understanding who is accessing the information and the data they’re allowed to access.

IT needs to implement an identity-centric approach to secure data, but according to a recentPonemon study, only 29% of organizations are confident that they can authenticate users in the cloud. At first glance, that appears to be a shockingly low number, but if you think about it, how do you verify identity?

Usernames and passwords, while still the norm, are not sufficient to prove identity and sure, you can identify a device connected to the network, but can you verify the identity of the person using the device?
In a recent @CloudCommons tweetchat on cloud security, the issue of proving the identity of cloud users kept cropping up:
And then there's the issue of PRISM.
To quote Sgt. Esterhaus from Hill Street Blues, "Let's Be Careful Out There."

Wednesday, September 4, 2013

Texas Tort Reform - Ten Years Later

From the Texas Medical Association:

... Ten years ago, TMA physicians and medical students banded together to push for passage of landmark medical liability reforms. The Medical Malpractice and Tort Reform Act of 2003, House Bill 4, went into effect Sept. 1 that year. Twelve days later, Texas voters approved Proposition 12, an amendment to the Texas Constitution that validated the legislature’s actions. HB 4 caps noneconomic damages in medical liability cases. Texas’ $750,000 total cap includes a $250,000 liability limit per physician for noneconomic damages such as pain and suffering. The tort reform act doesn’t restrict economic damages.

Since that law passed, record numbers of physicians have relocated here to care for Texas patients. Physicians already practicing here say they can recruit more specialists trained in Texas and from out of state, thanks to tort reform. In the fiscal year that ended Aug. 31, 2012, the Texas Medical Board received 4,253 medical license applications and processed 3,630. Compare that to 2003, when the board received only 2,561 applications and processed 2,513.

“Tort reform has done wonders for the state by attracting more physicians to practice here, improving access to care, and making it economically possible for physicians to continue caring for patients,” Dr. Justin Hensley said.

Read the whole thing. 

Liability Reform IS Healthcare Reform.

Ovarian Cancer Awareness Month

September is Ovarian Cancer Awareness Month. Ovarian cancer kills over 20,000 women a year. Despite often being described as a silent killer, ovarian cancer does have signs and symptoms. While there is still no universally accepted screening for this dread disease, some women at high risk, eg. BRCA 1 & 2 carriers, can discuss risk reduction surgery with their gynecologist. Moreover, oral contraceptive use may offer some protection.

For more information about ovarian cancer awareness, check out the National Ovarian Cancer Coalition website.

Monday, September 2, 2013


Having just returned from our annual I 95 Florida road trip, I prepare to embark along a new path. That's right - a new position at this stage of my life - is this a sign of maturity or early stages of dementia? Beginning next week, I will assume the mantle of Chief of Gynecological Ultrasound for the North Shore LIJ Health System. In this new era of so-called healthcare reform with its added administrative burdens, basically they made me an offer I couldn't refuse. So off I go on a new adventure, with new challenges and new responsibilities. Don't worry, though. I will still continue to post here on various topics concerning healthcare, women's health, and anything I feel is worth sharing. So please don't touch that dial.

I watch the ripples change their size
But never leave the stream
Of warm impermanence
So the days float through my eyes
But stil the days seem the same
And these children that you spit on
As they try to change their worlds
Are immune to your consultations
They're quite aware of what they're going through

(turn and face the strain)
Don't tell them to grow up and out of it
(turn and face the strain)
Wheres your shame
Youve left us up to our necks in it
Time may change me
But you can't trace time

- David Bowie