With little gudiance about caring for Zika patients, hospitals are planning on their own

As many of you know I have been advocating (unsuccessfully) for the designation of Zika Regional Referral Centers (ZRRFs).

Perhaps this article from STAT will convince policy makers that it is time to stage Zika hospital preparedness.

With little known about Zika virus, hospitals scramble to stay ahead

By Andrew Joseph  https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/

“The threat of Zika virus is reshaping operations at hospitals across the country, as medical teams rush to figure out how best to provide care for pregnant women with the disease and monitor and treat babies with related brain damage.

With scientists still trying to better understand the virus — and without any treatments available — hospitals have been forced to adapt to a changing Zika outbreak, particularly in states such as Florida, Texas, and New York that are at risk for local transmission or have seen large numbers of travel-related cases.

Hospitals say they have built up their diagnostic tools, started performing more regular ultrasounds for patients, and are keeping closer-than-usual watch on amniotic fluid levels and fetal heart rates. Social workers and physical, speech, and occupational therapists are preparing to work with babies born with Zika-associated defects, should they require their care.”


“To bridge the gap, hospital officials say they have assigned doctors to keep up with the growing body of literature and confer with public health agencies. They are also bringing together obstetricians trained in high-risk pregnancies, pediatrician specialists, and virologists and other biomedical researchers.

Doctors say they don’t have good answers yet to the most pressing questions they get from pregnant patients, including if their fetuses are at risk throughout the pregnancy or only certain stages, and how likely their children are to have some sort of developmental problem.

Doctors also worry about what might happen to children who appear to be fine at birth. In the case of other congenital infections like cytomegalovirus, hearing and vision problems can emerge in apparently healthy children years down the road.”


To read the full STAT article click on    https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/

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The ER clerk asked me “How do you spell Zika?

CDC’s revised Zika Interim Response Plan (July) states:  ”Neither vaccines nor proven clinical treatments are expected to be available to treat or prevent virus infections before local transmission begins within CONUS or Hawaii.”; “Scientific understanding of Zika virus continues to evolve, and new characteristics of the virus and how it is spread may arise.” (A)

“CDC director Tom Frieden has said that the mosquitoes carrying Zika in Miami could be developing resistance. Researchers can project what Zika infection rates will look like in multiple scenarios, but not what will happen if Zika is evolving at the DNA level or if its vectors multiply beyond sex and mosquitoes, both of which are real possibilities.” (B)

The New Jersey and New York Departments of Health Zika pages focus on community awareness, default to CDC, then stop at the door to the hospital ER. (C)

So we are not dealing with Zika “evidenced based medicine” but “best practices” aggregated and amended from Swine Flu, Ebola,  Dengue, and other mosquito transmitted viruses.

Examples of some recent news reports make it clear that Zika parameters are changing so quickly, that only medical school affiliated teaching hospitals should be caring for Zika patients.

  1. “Zika virus infection during pregnancy may be related to a severe birth defect called arthrogryposis, whereby the joints – particularly those in the arms or legs – are deformed. This is the finding of a new study published in The BMJ.” “Researchers focused on seven babies whose mothers were infected with Zika while pregnant. Six of the seven developed microcephaly—  the most widely publicized birth defect from Zika— but six also had trouble swallowing, six had clubfoot, five had eye abnormalities, and two needed breathing and feeding tubes.” (D)
  2. “NEW ORLEANS — Officials at the front lines of fighting the Zika virus are warning residents that mosquitos that carry the disease are already here.” (E)
  3. “Texas reported its first Zika-related death Tuesday after a baby girl whose mother traveled to El Salvador while pregnant died shortly after birth in a suburban Houston hospital. The girl, who died a few weeks ago, had microcephaly linked to the Zika virus….” (F)
  4. “In an effort to detect any local transmission of the Zika virus, the New York City Department of Health and Mental Hygiene said on Tuesday that it had expanded the guidelines on who should be tested for the disease to include anyone with its most-common symptoms.” (G)
  5. “Amid news of a Zika outbreak in the Miami area, the U.S. Food and Drug Administration’s Center for Veterinary Medicine (FDA-CVM) has cleared the experimental release of genetically modified (GMO) mosquitoes in the Florida Keys to help combat the virus. “ (H)
  6. “Suncoast Blood Bank announces they are testing all donated blood for the Zika virus. Effective immediately the blood bank will test all donors for the virus.” They say this is a proactive measure to protect the community blood supply.” (I)
  7. “I got Zika. The US health care system had no idea what to do with me. How do you spell Zika?”I stood at the front desk of a major Washington, DC, hospital last month. I had a head-to-toe rash that developed after I’d returned from the Dominican Republic, where Zika is much more common than it is stateside. The friend I’d traveled with was showing symptoms of the virus. I’d come to the emergency room to find out if I had it too.This was not a question I wanted to hear from the man who was checking me in.But ignorance of what Zika is, and uncertainty about how to deal with it, was common in my quest to get diagnosed — even from parts of the medical community that I expected would know what to do.” (J)
  8. “On Thursday, scientists described two cases in which the semen of men who contracted Zika in Haiti early this year continued to test positive for the virus, even though it has been six months since they were infected.The semen of one tested positive 188 days after he first experienced symptoms of the illness. Testing on day 181 came back positive for the other man. Both men are still being followed. Previously, the longest period in which evidence of virus was seen in the semen of a Zika-infected man was 93 days.” (K)
  9. “Until this week, there had been no reported cases of birth defects related to Zika in Canada.Public health officials are releasing no other information about the fetus, including whether or not he or she is alive. It represents the second confirmed case of maternal-to-fetal transmission of the Zika virus in Canada.” (L)
  10. “U.S. Sen. Bob Menendez can add a personal motivation to his efforts to get Congress to approve federal funding to combat the spread of the Zika virus. Menendez said this week his daughter is five months’ pregnant in Miami with his first grandchild.”(M)
  11. “Beyond Zika: How Congress Is Flirting With Medical Disaster. The dysfunctional response to the Zika virus lays bare a system that is increasingly ill-equipped to respond to outbreaks.” (N)
  12. “While the Zika virus has its moment, few people are discussing the problems underlying the worldwide increase in emerging infectious diseases.” (O)
  13. “Zika fits into the category of unforeseen emerging threats that migrate into new environments where they suddenly pose major hazards to unprepared populations — think severe acute respiratory syndrome (SARS) or Ebola, for instance. These required “urgent mobilization to protect and manage the introduction of these alien, and dangerous, pathogens,”….(P)

Soooooo……if you are concerned that you may have been exposed to Zika, until there are national protocols in place, bypass your community hospital ER, and go to the nearest medical school affiliated teaching hospital.


EMERGENCY ROOMS are not all created equal! (Q)

Stop the name games! University hospitals and regional medical centers should live up to their billing. (R)




(A)   http://www.cdc.gov/zika/pdfs/zika-draft-interim-conus-plan.pdf

(B)   http://www.vogue.com/13464580/why-zika-is-scarier-than-donald-trump/

(C)   http://www.nj.gov/health/cd/zika/  https://www.health.ny.gov/diseases/zika_virus/

(D)   http://www.medicalnewstoday.com/articles/312229.php

(E)    http://www.wwltv.com/news/health/mosquitos-that-carry-zika-already-in-new-orleans/292487541

(F)    http://blackamericaweb.com/2016/08/10/infants-death-is-first-zika-related-fatality-in-texas/

(G)  http://www.nytimes.com/2016/08/10/nyregion/zika-testing-new-york-health-dept.html?_r=0

(H)   http://www.nationofchange.org/2016/08/08/fda-approves-genetically-modified-mosquitoes-combat-zika-florida/

(I)     http://www.snntv.com/2016/08/09/suncoast-blood-bank-begins-testing-zika/ 

(J)     http://www.vox.com/2016/8/11/12422314/zika-virus-united-states

(K)   https://www.statnews.com/2016/08/11/zika-virus-semen-sexual-activity/

(L)    http://ottawacitizen.com/news/national/only-a-matter-of-time-first-zika-related-birth-defects-reported-in-canada

(M) http://www.wftv.com/news/local/us-sen-bob-menendez-has-personal-stake-in-push-for-zika-funding/421039501

(N)  https://newrepublic.com/article/136022/beyond-zika-congress-flirting-medical-disaster

(O)  http://www.americanscientist.org/issues/pub/2016/5/zika-goes-viral

(P)   https://www.thecipherbrief.com/article/exclusive/north-america/zika-national-security-threat-1095

(Q)  http://doctordidyouwashyourhands.com/2016/04/emergency-rooms-are-not-all-created-equal/

(R)   http://doctordidyouwashyourhands.com/2016/07/stop-the-name-games-university-hospitals-and-regional-medical-centers-should-live-up-to-their-billing/



Many of you might be familiar with my advocacy for designating Zika Regional Referral Centers. If not see links below.

We don’t know what we don’t know” – The challenge to emergency preparedness….. http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/

Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/

Suspending a chicken over your bed could protect against Zika virus and malaria (A)  http://doctordidyouwashyourhands.com/2016/07/suspending-a-chicken-over-your-bed-could-protect-against-zika-virus-and-malaria-a/





Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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Have you ever coerced your doctor into prescribing an antibiotic?

I used to. I stopped. Here’s why.

Like many people I know I also stockpiled antibiotics thinking I knew when to call my physician and get his approval or would infrequently simply start myself on an antibiotic regimen. ZPack for an upper respiratory infection. Augmentin for a sinus infection. Cipro for a prostate discomfort. Doxycycline for Lyme disease.

Here’s the chain of antibiotic abuse and its consequences.

“You’re sick. You’re not sure what it is, but you know you would really love for this achy feeling, stuffed-up head or painful cough to go away. So you go to the doctor and demand drugs.If recent research is any indication, your physician will probably prescribe you an antibiotic, even if he or she knows it won’t make you better any faster.” (A)

“Antibiotic agents don’t work for viral infections and should not be prescribed. However, it is often easier to write a prescription than to explain to a patient why you won’t. I have had patients leave my office very angry and immediately go to another doctor to get the antibiotics that I have declined to give.” (B)

“Antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria. While antibiotics should be used to treat bacterial infections, they are not effective against viral infections like the common cold, most sore throats, and the flu. Widespread use of antibiotics promotes the spread of antibiotic resistance. Smart use of antibiotics is the key to controlling the spread of resistance.” (C)

“Antibiotic resistance is highly problematic because it severely hinders our ability to treat infectious diseases. In addition, surgery is dependent on the administration of antibiotics before and after the operation. Cancer patients and patients who have received organ transplants rely on antibiotics to protect them from bacteria, as the former have compromised immune systems while the latter needs to suppress their immune systems from attacking the transplanted organs.Without effective antibiotics, basic medical procedures and surgical operations could become very high risk because there’s a much higher risk the patient could be infected with an antibiotic microbe and be without appropriate treatment while recovering from the operation.”In addition to causing deaths and preventing basic infectious conditions to be treated, antibiotic and antimicrobial resistance will lead to steeper healthcare costs. Patients will need to spend more time in hospital in order to receive more expensive types of treatment.” (D)

“As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies…. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.” (E)

“Any species of bacteria can turn into a superbug. Misusing antibiotics (such as taking them when you don’t need them or not finishing all of your medicine) is the “single leading factor” contributing to this problem, the CDC says. The concern is that eventually doctors will run out of antibiotics to treat them. “What the public should know is that the more antibiotics you’ve taken, the higher your superbug risk …… The more encounters you have with the hospital setting, the higher your superbug risk.” (F)

“For the first time, researchers have found a person in the United States carrying bacteria resistant to antibiotics of last resort, an alarming development that the top U.S. public health official says could mean “the end of the road” for antibiotics.The antibiotic-resistant strain was found last month in the urine of a 49-year-old Pennsylvania woman. Defense Department researchers determined that she carried a strain of E. coli resistant to the antibiotic colistin, according to a study published Thursday in Antimicrobial Agents and Chemotherapy, a publication of the American Society for Microbiology. The authors wrote that the discovery “heralds the emergence of a truly pan-drug resistant bacteria.” (G)

“Taking antibiotics you do not need will not help you feel better, cure your illness, or keep others from catching your infection. But taking them may cause side effects such as: • Nausea. • Diarrhea. • Stomach pain. •An allergic reaction. In rare cases, this reaction can require emergency care.

Antibiotics also can cause Clostridium difficilecolitis (also called C. difficilecolitis), a swelling and irritation of the large intestine, or colon camera.gif. This happens because the antibiotics kill the normal bacteria in your intestine and allow the C. difficile bacteria to grow. This problem can cause diarrhea, fever, and belly cramps. In rare cases, it can cause death. Women may get vaginal yeast infections from taking antibiotics.” (H)

Final Note

“When an antibiotic is prescribed, it is wise to ask what the drug is and whether it is necessary, what side effects to be alert for, whether there are effective alternatives, when to expect the diagnosed condition to resolve, and when to call if something unexpected happens or recovery seems delayed.” (I)

NOTE: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) http://www.cnn.com/2014/05/21/health/antibiotics-virus-bacteria/

(B) https://www.healthtap.com/user_questions/409225-why-would-a-doctor-prescribe-an-antibiotic-for-a-patient-with-viral-pneumonia

(C) http://www.rxlist.com/antibiotic_resistance-page3/drugs-condition.htm

(D) https://www.cbhs.com.au/news/2014/11/24/antibiotic-resistance-causes-and-consequences

(E) http://www.brookings.edu/blogs/up-front/posts/2014/05/22-antibiotic-resistance-fda-phrma-biotech-danielg

(F) http://www.webmd.com/news/20150417/superbugs-what-they-are

(G) https://www.washingtonpost.com/news/to-your-health/wp/2016/05/26/the-superbug-that-doctors-have-been-dreading-just-reached-the-u-s/

(H) http://www.webmd.com/a-to-z-guides/using-antibiotics-wisely-topic-overview

(I) http://well.blogs.nytimes.com/2012/09/10/popular-antibiotics-may-carry-serious-side-effects/?_r=0


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I was flabbergasted when Trump said “We can’t continue to allow China to rape our country.” (A)

There are some words that evoke dramatic imagery and should not be used casually. The recent passing of Elie Wiesel reminds us of the power of the word “holocaust.”

And “rape” is one of those words.

“The use of “rape” in such a casual way misrepresents the gravity of sexual assault. Rape is no laughing matter. In the United States, approximately 16 percent of women and three percent of men have been victims of attempted or completed rape. Fifteen percent of sexual assault victims are under 12. Sexual assault victims are three times more likely to suffer from depression and four times more likely to contemplate suicide than non-victims.” (B)

Rape evokes: sexual abuse on college campuses; Bill Cosby; sex trafficking; out-of-control professional athletes, Comfort Women, Spotlight…..

A new movie makes it very clear.  “The Innocents” begins at the end of World War II in Poland, December 1945. Serene, austere Benedictine nuns sing sweetly in the quiet stillness of morning—until a piercing scream echoes through the stone hallways, sending a chill. Turns out, it’s coming from an extremely pregnant, young nun who’s on the verge of giving birth—and she’s not alone…..As the Reverend Mother (Kulesza) and her right-hand woman Maria (Buzek) matter-of-factly explain it, Soviet soldiers invaded the convent and repeatedly raped the women as the war was ending.” (C)

A college student recently wrote: ” With that said, I urge all of you to stand up. Next time someone makes a joke, tell him or her that it isn’t funny. Next time someone uses rape as a substitute word, tell him or her that it isn’t OK. Stand up because chances are the person those jokes are really hurting is unable to do so—myself included. (D)

Health care providers take this seriously. For example, The Mount Sinai Hospital Sexual Assault and Violence Intervention Program’s mission is:  1. “To meet the needs of rape, sexual assault and domestic violence survivors by offering immediate crisis intervention in hospital emergency rooms. 2. To follow up with psychotherapy, counseling and information both for past and present survivors and their families and friends. 3. To educate the public and professionals regarding services and issues of sexual and domestic violence. (E)

Searching the internet I could not find a single reference that uses “rape” as an (academic) economic term.

Maybe Trump’s children will explain this to him. 

(A)   http://www.cnn.com/2016/05/01/politics/donald-trump-china-rape/

(B)   http://www.huffingtonpost.com/2012/01/09/teen-slang-why-the-word-r_n_1194059.html

(C)   http://www.rogerebert.com/reviews/the-innocents-2016

(D)   http://timesdelphic.com/2011/10/23/misuse-of-the-word-rape-is-a-problem

(E)    http://www.mountsinai.org/patient-care/service-areas/community-medicine/areas-of-care/sexual-assault-and-violence-intervention-program-savi/about-us

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It’s like the Wild, Wild West, the (physician specialty) turf wars…. (A)

My first experience with clinical turf competition was in 1968 as administrator of the Department of Surgery at Wilford Hall U.S.A.F. Medical Center. The Chiefs of general surgery, E.N.T., and Oral Maxillofacial Surgery each needed Head & Neck surgical cases for their residents. Time and time again protocols were agreed upon to rotate the cases but they always broke down when residents in one specialty or another needed the required number of H&N cases before they graduated. Interestingly I never recall that any of the Chiefs thought the patients had a role in the decision-making.


Fast Forward! STENTS

We all know about cardiac stents. Now cardiologists have seamlessly moved on to use stents for treatment of renal artery stenosis (B) and carotid artery disease (C).

But this is just the tip of the iceberg. “Currently, the major interventional specialties are interventional (or vascular) radiology, interventional cardiology, and endovascular surgical (interventional) neuroradiology. All three are perfecting the use of stents and other procedures to keep diseased arteries open, while also evaluating the application these procedures. The rapid new development of imaging technologies, mechanical devices, and types of treatment, while certainly beneficial to the patient, can also lead to ambiguity regarding specific specialty claims on certain techniques and devices.” (D)


Some other clinical areas where specialties overlap or may not be intuitively understood.


Urogynecology. Female Urology.

An urogynecologist is an obstetrician/gynecologist who has completed fellowship training in the evaluation and treatment of pelvic floor disorders. (E)

Urology is a surgical specialty which deals with diseases of the male and female urinary tract and the male reproductive organs……Female Urology (urinary incontinence and pelvic outlet relaxation disorders) (F)


Child Neurology. Pediatric Neurology.

Child neurologists are medical doctors who have completed: Four years of medical school; At least 1 to 2 years of pediatric residency; Three or more years of residency training in adult and child neurology. In addition, most child neurologists have certification from the American Board of Pediatrics and the American Board of Psychiatry and Neurology (with special competency in child neurology). (G)


Sports Medicine

AOSSM members are orthopaedic surgeons and allied health professionals who demonstrate scientific leadership, involvement and dedication in the daily practice of sports medicine. (H)

Sports medicine physicians, who may be allopathic or osteopathic physicians, focus their practice on health care for athletes and physically active individuals. Sports medicine primary care physicians treat anyone who is physically active help them improve performance, enhance overall health, prevent injury and maintain their physical activity throughout their lives. Some work with professional and amateur sports teams. (I)


Pain Medicine

The American Academy of Pain Medicine (AAPM) is the medical specialty society representing physicians practicing in the field of pain medicine. As a medical specialty society, the Academy is involved in education, training, advocacy, and research in the specialty of pain medicine.

The practice of pain medicine is multi-disciplinary in approach, incorporating modalities from various specialties to ensure the comprehensive evaluation and treatment of the pain patient. AAPM represents the diverse scope of the field through membership from a variety of origins, including such specialties as anesthesiology, internal medicine, neurology, neurological surgery, orthopedic surgery, physiatry, and psychiatry. (J)


Board Certified

No matter which type of physician you choose, only go to those who are BOARD CERTIFIED. “Board Certification is a voluntary process, and one that is very different from medical licensure. Obtaining a medical license sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board Certification demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice.” (K)

Typically, for example a Board Certified surgeons will have F.A.C.S. (Fellow, American College of Surgeons) after their names. John Smith, M.D., F.A.C.S. There is no modesty here, a Board Certified physician will let you know.

There used to be the term “Board Eligible” which meant a physician finished residency training but had not taken and/ or passed the Board exam. Some physicians called themselves Board Eligible for their entire careers. Beware the use of the term Board Eligible unless the physician has just finished training and waiting to take the Board exam the first time it is given.


On the horizon a new clinical specialty? Complex Care Management

“Persons whose conditions require complex continuous care and frequently require services from different practitioners in multiple settings.

Care management of patients with complex care needs Usually patients who are Medicare beneficiaries with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges. Patients with complex health care are patients at the far end of a population-wide spectrum ranging from health individuals to people with serious medical problems and high utilization of heath care services.” (L)


Dentistry is getting confusing too:

We are used to the traditional array of dental residency training programs and Board Certification: Dental Public Health; Endodontics; Oral and Maxillofacial Pathology; Oral and Maxillofacial Radiology; (Pathology and Radiology are news to me) Oral and Maxillofacial Surgery; Orthodontics and Dentofacial Orthopedics; Pediatric Dentistry; Periodontics; Prosthodontics. (M)

Now we see: the elevation of general dentistry (N); cosmetic dentistry (O); sedation dentistry (P); geriatric dentistry (Q); and full mouth reconstruction (have you seen the TV ads for FMR all in one day, financing available!)

As always when faced with difficult and complex clinical options, in this case being certain you are going to see the right specialist, your primary care physician should be your advisor and advocate (and should disclose any “conflicts” he or she has related to the issue at hand).

(A) http://nymag.com/nymetro/health/columns/strongmedicine/n_9311/

(B) http://www.wkhs.com/Heart/Services/Peripheral_Vascular_Disease_Treatments/Renal_Angioplasty_and_Stents.aspx

(C) http://www.texasheart.org/HIC/Topics/Proced/carotidangioplasty.cfm

(D) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2745361/

(E) https://www.cornellurology.com/clinical-conditions/female-urology-urogynecology/

(F) https://www.auanet.org/about/what-is-urology.cfm

(G) https://healthychildren.org/English/family-life/health-management/pediatric-specialists/Pages/What-is-a-Child-Neurologist.aspx

(H) http://www.sportsmed.org/AOSSMIMIS/Members/About/Members/About_AOSSM.aspx?hkey=170bd237-cc97-4dd0-aa54-3a20f82cf8e3

(I) http://explorehealthcareers.org/en/Career/168/Primary_Care_Sports_Medicine

(J) http://www.painmed.org/

(K) http://www.abms.org/board-certification/

(L) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0051448/

(M) http://www.ada.org/en/education-careers/careers-in-dentistry/dental-specialties/specialty-definitions

(N) http://www.agd.org/membership.aspx(O)http://www.aacd.com/american-board-cosmetic-dentistry/

(P) http://www.yourdentistryguide.com/sedation/

(Q) https://www.deepdyve.com/lp/wiley/american-society-for-geriatric-dentistry-GFcIS0a637(R) http://www.yourdentistryguide.com/fmr/

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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Do you want to be treated by a stranger when you are admitted to the hospital? Every practicing physician should have hospital privileges.

Two recent health care episodes have sharpened my conviction that every practicing physician should be affiliated with a hospital.

In December I was admitted to the hospital for one night for observation. My care was managed by my gastroenterologist and my primary care physician, both of whom I have been with for almost twenty years. There coordination was perfection, I was fully informed, and all worked out well.

While I have been on the faculty of Mount Sinai medical school in New York City for forty+ years, over time, with the exception of my urologist, all my physicians (PCP, GI, orthopedics, ophthalmologist, and dermatologist) now practice near where I live in Hoboken, are on the same hospital medical staff, and know each other well.

Recently I was at physician’s office for a routine periodic screening. A Family Practice resident was shadowing my doctor and when we chatted he said it was not necessarily his plan to be on a hospital medical staff after he finished his training. I was flabbergasted that the GME program had not emphasized that as an “automatic”.

More and more primary care physicians are in full time office practice and hand patients off to hospitalists for inpatient care. Not to be confused with Intensivists: A physician who specializes in the care of critically ill patients, usually in an intensive care unit (ICU). (4)

The American Academy of Family Physicians defines a PRIMARY CARE PHYSICIAN as follows:

A primary care physician is a specialist in Family Medicine, Internal Medicine or Pediatrics who provides definitive care to the undifferentiated patient at the point of first contact, and takes continuing responsibility for providing the patient’s comprehensive care. This care may include chronic, preventive and acute care in both inpatient and outpatient settings. Such a physician must be specifically trained to provide comprehensive primary care services through residency or fellowship training in acute and chronic care settings.”

“All physicians should obtain hospital privileges in accordance with their individual qualifications, i.e., documented training and/or experience, demonstrated abilities, and current competence.” (1)

A Hospitalist is: ”A hospital-based general physician. Hospitalists assume the care of hospitalized patients in the place of patients’ primary care physicians.” (2) *The trend toward full time, salaried hospitalists is driven by “….convenience, efficiency, financial strains on primary care doctors, patient safety, cost-effectiveness for hospitals, and need for more specialized and coordinated care for hospitalized patients.” (3)

Well, I am not convinced!

Why develop a relationship with a PCP only to be treated by a “stranger” team of hospitalists?

Even if you are admitted to the service of a hospitalist or specialist (e.g., neurologist for evaluation for Parkinson’s disease) don’t you want your PCP by your side as well, even if it is not as the primary diagnostician?

If PCPs don’t participate in the care of sick patients don’t their diagnostic skills diminish by what they no longer see and do?

You don’t get to pick you hospitalist. These physicians work in shifts and you are likely to be cared for by multiple hospitalists during a hospital stay.

In my mind the solution is that every practicing physician should be required to have hospital privileges. Every hospital medical staff develops criteria to maintain privileges in the context of accreditation, licensure and other compliance requirements.

The key ones have to do, for example, with attending departmental conferences and serving on clinical committees.

The most important reality is that being on a hospital medical staff subjects each physician to interaction with other physicians on best practices and now many hospitals have physician quality metrics. And it is a safety valve to make sure impaired physicians are identified and helped, and “senior” physicians do not practice outside the scope of their capabilities.

But mostly it is to remember the importance of “continuity of care” (apparently now out of favor) and respect for the patient who must not be handed off to a stranger when serious illness strikes.

1. http://www.aafp.org/about/policies/all/primary-care.html

2. http://www.medicinenet.com/script/main/art.asp?articlekey=8384

3. http://www.medicinenet.com/script/main/art.asp?articlekey=23392

4. http://www.medicinenet.com/script/main/art.asp?articlekey=93946

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.


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Stop the name games! University hospitals and regional medical centers should live up to their billing *

Remember when a hospital was just a hospital, and its reputation spoke for itself? Now we have a plethora of self named healthcare institutions such as clinics, community hospitals, institutes, medical centers, national hospitals, specialty hospitals, and teaching hospitals.

My home state of New Jersey, for example, started with one children’s hospital in Newark, followed by a few more designated under state Health Department competitive certificate-of-need guidelines, followed by a few politically designated by the Legislature, followed by a bunch of sound-alikes such as a “children’s medical center” mischievously bypassing the fact that “children’s hospital” is a legislatively restricted name.

For the most part these appellations are used to define the hospital to its community and publicly compare it most positively to other nearby competitors. However, more and more hospitals are now calling themselves regional medical centers and university hospitals. These are very robust terms, sometimes used interchangeably or together, and imply characteristics such as comprehensive critical-care services, cardiac surgery/interventional cardiology, comprehensive stroke care, an academic environment, the latest cutting-edge technology, and a full-time cadre of 24/7 on-site superspecialist physicians, including intensivists.

And the not-so-subliminal message is that when you are very sick or injured you should bypass your local hospital.

The reality is that in New Jersey a hospital can call itself whatever it wants—there is no name regulation or oversight by state authorities. A few years ago Robert Wood Johnson University Hospital challenged and lost, when St. Peter’s Hospital added “University” to its name. Since then a number of other hospitals have added “University” as well, and more will follow. Certainly this phenomenon is not limited to New Jersey.

The Association of American Medical Colleges states: “Teaching hospitals are providers of primary care and routine patient services, as well as centers for experimental, innovative and technically sophisticated services. Many of the advances started in the research laboratories of medical schools are incorporated into patient care through clinical research programs at teaching hospitals.”

I believe a university hospital/regional medical center should have most of the following characteristics typical to “major league” hospitals:

■ First and foremost, it should have a written affiliation agreement with a medical school that includes the rotation of medical students to the hospital for required third year clinical rotations in internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery.

■ The hospital should have full-time chairmen in the core clinical departments (e.g., medicine, pediatrics, surgery) selected by a joint hospital-medical school search committee, and not as a reward for seniority or admitting a lot of patients.

■There should be at least three physician residency-training programs under the supervision of the medical school.

■ All physicians teaching students and residents should qualify for faculty appointments at the affiliated medical school.

■ A dean’s committee composed of senior medical and administrative staff from the hospital and school should meet regularly to jointly set strategic priorities and evaluate program efficacy and performance.

■ The hospital’s medical staff bylaws should mandate automatic removal from the staff of any physician who does not achieve board certification after a given period of time, such as five years.

■ The hospital should have at least three state-designated critical-care services such as trauma center, regional perinatal center (high-risk obstetrics), stroke center, children’s hospital or cardiac surgery. There should be full-time intensivists in all ICUs.

■The hospital should be a member of all major statewide multihospital clinical-care quality projects such as the New Jersey Hospital Association’s ICU and pressure-ulcer collaboratives. It should participate in clinical trials that the medical school has undertaken, and be a training site for students in nursing, pharmacy, physical therapy and other health professions.

■It should have a full-time chief medical officer, a senior physician preferably with a master’s degree earned through the American College of Physician Executives (or equivalent) and a chief nursing officer with an appropriate doctoral degree.

■Finally, the hospital’s board, administration and medical staff must have a demonstrable unwavering “safety net” commitment to the medically underserved.

These steps are, of course, easier said than done, so here are some initial steps for the states to consider:

State hospital associations should set up task forces to develop a policy and strategy to make sure hospital names are educational to the public, not exaggerations of capability.

A state could pass a law or the health department could promulgate regulations defining the requirements to be designated a university hospital or regional medical center. These designations should be subject to periodic state review.

Obtaining the appropriate and best hospital care should not be complicated by creative and clever hospital marketing but by easily understandable evidenced-based standards and metrics—and names.

* By Jonathan M. Metsch, Dr.P.H., August 18, 2008 • Modern Healthcare

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