BRCA

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According to retrospective studies of three nationwide cohorts in Europe, young women with BRCA1 and BRCA2 are at greater risk from diagnostic radiation. Any exposure before the age of 30, increased breast cancer risk 90%. In another study reported in BMJ, any mammography before the age of 30 raised the risk by 43% (question of statistical significance?) The American Cancer Society recommends MRI screening for BRCA mutation carriers. No mention was made of physician breast examination.

Mammography suffers in silence from a lack of sensitivity. Women are given to believe that mammography will protect them whereas it occasionally misses the diagnosis of a palpable lesion. In my practice, it angered me to find four patients with negative mammograms who came to me with palpable lesions much further advanced than they might have been but for a simple breast examination. Admittedly, four in my practice was probably a skewed series. The women involved, however, would not think so.

Sadly, today women are reluctant to remove their clothing for examination and providers are all to happy  to forgo the challenge out of expediency and for the sake of time. It comes to a sad state of affairs when providers and patients look to a machine for a diagnosis --- to say nothing of the widespread abusive application of CT scans.

Flora E. van Leeuwen, PhD, Netherlands Cancer Institute and reviewed by Dori F. Zaleznik, M.D.; Assoc. Clin. Professor of Medicine, Harvard Med Sch.

CDC: 35 Million Americans Have Uncontrolled Hypertension « CardioBrief

CDC: 35 Million Americans Have Uncontrolled Hypertension « CardioBrief

30.4% of US adults (about 66.9 million people) have hypertension.

53.5% have uncontrolled hypertension (about 35.8 million people).

39.4% with uncontrolled hypertension (about 14.1 million) are unaware that they have hypertension.

89.4% with uncontrolled hypertension have a “usual source of health care and insurance, representing a missed opportunity for hypertension control.”

The so called team approach accounts for the missed diagnosis of HT on a consistent basis. Taking a BP in most institutions is relegated to the lowest level assistant’s assistant or to an automated BP cuff that consistently records low readings. This "team approach" fails to give reliable readings.

When administrators make cost saving medical decisions, cutting corners that real doctors would never knowingly cut, a surprising level of negligence can grow unnoticed to a National scale.

I speak in part from personal experience. I’m a teaching clinical physician but old enough to have a number of problems that take me to the doctor’s office, ER or major clinic. Including Cleveland Clinic, I have yet to have my BP properly taken and never by the attending physician.

Assistants consistently ignore which arm to use, take the pressure through clothing, and utterly disregard arm position. I submit that the physician will never know who has HT unless he or she takes the BP themselves, nor will he or she know who is under control and who is not.
The Ophthalmologist can tell you but the assistant cannot. Relegating the BP to apothecaries, bathers and other so called providers will not help either and for the same reason — never mind an adequate HT work-up..

Confidientiality and Autopsy

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Federal regulations unwittingly but systematically ended the modern era of medical education with current almost paranoid confidentiality rules and the abandonment through neglect of routine autopsy.

More than anything else, modern medicine evolved through bedside teaching and autopsy. The microscope helped. Dissection of cadavers despite the resistance of the church, the teaching of anatomy, post mortem examination and bedside teaching created the groundwork for scientific medicine.

Today confidentiality and patient choice more or less prohibit both autopsy and bedside teaching. Once, a covenant bound seriously ill patients willing to aid in the advancement of medicine, to a teaching program offering low cost treatment and advanced knowledge in accessible medical school hospitals and clinics.

Today, the medical school competes for the insurance dollar. Medical services cannot be discounted and the patient's medical conditions cannot be verbalized where others might hear. I encounter a bizarre situation wherein first year medical students can take a history directly from the patient but do not have access to the patient chart; they no longer use a microscope and some must make do with paid actors as patients.

I'm old enough to have learned medicine on a 20 bed ward when we did the admitting lab work and patient workup. Daily rounds were accompanied by the assigned professor, intern, resident and medical student. The student verbalized a brief summation of the patient's history followed by the intern, the resident and the professor -- expanding in depth on the pathology and the likely outcome. (Patients on the ward with similar conditions knew about and supported one another.)

Very little bedside teaching gets done today and not at all in non-medical school hospitals. --- We were, furthermore, required to attend 12 autopsies for the semester and write a summation of the findings with two journal articles relevant to those findings. A good life long habit to get into, that and looking yourself at your patient's gram stain or peripheral smear will find many mistakes before and after they happen.

While the didactic curriculum in today's medical school covers more ground in greater depth and at the molecular level, the absence of live patients suffering live pathologies leaves too much to the imagination. Lacking the visible, gross and microscopic findings from an autopsy, followed by a live conference arguing the facts, further detracts from the learning experience, and I might add the evolution of medicine. I think that these deficiencies may account for some of today's unfavorable outcomes.

Health care in the US produces dismal results at obscene costs by any public health metric. We were once indeed the envy of the world in medicine, but today, sadly, despite the glitter and the price, we turn out something like 37th in both longevity and perinatal mortality. By any reckoning we preform many unnecessary procedures and surgeries. 15% of diagnoses proves wrong. The first two providers statistically misdiagnosis or fail to diagnose cancer 45% of the time. We blithely claim that CAT scans eliminate the need for autopsy, and in the occasional post mortem actually preformed, we find as high as 60% unsuspected or misdiagnosed pathologies.

We might reinvent medical education with the mnemonic, "something old, something new, something borrowed and something blue," translated as old fashion bedside teaching, routine autopsies, genomics, a lesson from Europe and something blue. I would take the later to mean aggressive leadership from our medical schools rather than a profitable but unsustainable adaptation to the status quo.

Primary Care Doctor's Delima

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Not politically correct:

Everybody knows that problems plague the healthcare system, but few are aware of the glaring statistics.  The US is 37^th in the world for longevity and 36^th in infant mortality. Part of the problem is lifestyle and part of the ranking results from the developing world catching up and surpassing us. Many experts believe that our lack of primary care physicians and a maldistribution of physicians underlie the problems.

 Unfortunately, efforts to improve the situation included the perception that there were not enough doctors. As a result educators and legislators expanded enrolment in medical schools and promoted physician extenders. Physician assistants and nurse practitioners came into vogue. This may have been a help whilst they practiced under the direct supervision of a physician. Nurse practitioners prove invaluable in many isolated small villages where only an itinerant-physician might travel, but when we authorized them to practice independently in direct competition with primary physicians, we unwittingly further aggravated the economic problems at the primary care level. The only way primary care physicians can charge modest fees and stay in practice requires a modestly high volume of patients. Today primary care finds itself displaced by public health clinics, Planned Parenthood, midwives, mobile mammograms, pharmacist consultations and and other less scientific providers once thought of a quacks. It would be an over statement to compair us with Rome when Aesclapian physicians were called in to fight the plague, but there is a paralell.

The physician extenders follow ridged but limited protocols. This results in missed diagnosis and early referrals to specialists both creating added cost. These providers receive the same highly discounted fee for service that primary care physicians receive. This practice, now well entrenched, tends to solidify the discounting of pediatricians', internists' and family doctors' services. In addition, many patients elect to receive care only from sub-specialists, further eroding the qualified base of primary care physicians. Why would any graduating physician elect primary care under these circumstances?  As a result we have too many specialists and not enough primary care doctors.
Too many specialists, leads to, too many procedures -- both diagnostic and surgical. The better specialists have plenty to do in that patients tend to channel to the physicians with the best reputation and outcomes. Less successful specialists tend to over treat to make up for lack of volume. Patients who go only to specialists find it difficult to choose which specialty to go to with multiple problems. Specialists find it difficult to diagnose or treat patients outside of their own specialty. Thus, patients fall through the cracks between specialties.

Too many specialists results in an overwhelming and immediate increase in medical care costs. The not so simple solution involves specialty training on a pyramid system as was once used in leading medical schools. Only the top residents progress to the next year of training. Thus, only one resident emerges as chief resident in the last year. The dropouts then migrate to either another specialty program or to primary care residencies. The primary care residency should be every bit as demanding as the surgical or sub-specialties but without the pyramid system.
Something needs be done to reduce the enormous reimbursement discrepancy between primary care physicians and surgical specialties. Otherwise, we will have a serious sub standard level of primary care.

We must also curtail the plethora of so called alternative care practitioners and unsupervised physician extenders. The “Home Base Physician” proposal in the Affordable Care Act goes a long way, but does not address the economic discrimination against primary care, the maldistribution of physicians or the issue of too many specialists.
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Continuity of Care

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Continuity of care from my perspective involves the primary care physician, not an assistant but the physician himself. Know thy patient. Communicate with the patient. Return phone calls promptly. Be available.

As a primary care physician, secure in advance an understanding with your specialty consultants: that when you refer a patient, you will have access to and remain involved in the care, that as the primary, you will read and write notes on the hospital chart, (Somebody has to read the nurses notes) that you will receive written consultations and summaries of care in a timely way, that you must approve of any secondary referrals, that your patient be charged fairly according to his or her means, that you will assist but not interfere with the specialist’s care. (This entails making hospital rounds, often without pay, but in the long run it pays off)

Specialists, especially the best ones, welcome these assertions as a refreshing breath of old fashion medical ethics. They will welcome the agreed-upon source of referrals and consultations. Surgeons especially will recognize a reduced liability from your presence and from the added continuity of care your presence brings. They will treat you and your patients with deference. Although they will most likely refer you patients, do not make that a stipulation.

These guidelines of professional ethics once dominated and still play within organized medicine at the county level.

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Healthcare Waste

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Certainly the need is urgent to bring down cost for both public and private patients.

Donald M. Berwick is affiliated with The Rand Corporation and he makes graphically clear six ways that our healthcare system fails us. In the order of significance, he lists administrative complexity, over treatment, fraud, overpricing, lack of good care, and lost continuity of care as patients fall through the cracks of over specialized and overcrowded doctor populations.

I would add another -- that also may be considered a pricing failure -- and that is government imposed pricing regulations that prohibit free or reduced price for needy patients. As a result, everybody gets the maximum charge whether they can afford it or not. ---

Furthermore, missed diagnosis and wrong diagnosis adds yet another layer of added cost, waste and morbidity to the mix. Dumbing down the provider education system to get more providers -- and a strategy of letting private insurance companies through free market practices, solve the problems -- seem to be further major mistakes.

Berwicks contends that solving the waste can bring accelerating healthcare cost down to the level of the cost of living curve. It could do much more if it were to improve the quality of care.

JAMA April 11, 2012-Vol 307, No. 14 features Donald M. Berwick's essay, Eliminating Waste in US Health Care.

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Privatization

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Privatization of basic drug research takes the cost of academic grants and basic research out of the government’s budget and passes it through to the consumer along with industry profits, executive bonuses and marketing expenses. The greatest cost burden then falls to the middle class considering that the poor simply do without and land in the emergency room. Adding prescription insurance merely adds another industry’s profits, bonuses and marketing expense onto the already over burdened consumer.