Just read an interesting article about bottle feeding toddlers. Here is the bottom line:
Bottle use at 24 months predicted body-mass index 95th percentile at age 5.5 years.
Since I am preparing to be a father, these type of articles are starting to catch my attention. I'm sure all the parents out there already know this stuff and it may seem common sense, but I'm still posting it because I find it interesting. Here are a few other tidbits from the article:
-children who are bottle users at 24 months have a 1.3 times higher risk of being obese than non bottle users of the same age(confidence interval 95%)
-No significant difference found in risk for obesity in daytime and bedtime users
-early experience with a cup at 6 months will make it easier to wean off bottle or nursing
-parents should be encouraged use other soothing methods for bedtime other than nursing or drinking from bottle
-parents should be advised to stop using a bottle after 12 months, especially if there are concerns for child to be overweight.
citation: Gooze RA et al. Prolonged bottle use and obesity at 5.5 years of age in US Children. J Pediatr 2011 Sep; 159:431.
Thursday, October 6, 2011
Tuesday, October 4, 2011
Congress and the Budget; a newly christened Physician's point of view
I apparently have been in a blogging mood as of late, likely due to the great schedule I have this month with emergency medicine...which has allowed me a little free time.
So I received an email this morning that kinda got me fired up. Here it is:
In the debt compromise just reached in Washington, mandatory cuts of $1.2 trillion are scheduled to take effect if there is no new agreement.
What are the targets for these cuts? You guessed it: “Medicare providers” … physicians.
The group charged with deciding who will receive cuts is a 12 member “supercommittee.” This panel, selected a few weeks ago by House and Senate leadership, consists of Members of Congress with a broad range of experience. Interestingly, the panel, which has the ability to drastically affect physicians and their patients, does not have a single physician. Since there are only twelve slots on the committee, many regions will not have representation.
Physicians are particularly vulnerable to the agenda of the supercommittee. With a 30 percent cut in Medicare payments already looming, Congress is not going to be able to simply patch the broken SGR formula as it has done in the past. Funding for Graduate Medical Education is also an area the supercommittee will look to cut.
The “Supercommittee” has the power to fix one of our most pressing issues – the SGR. Every year that the SGR issue is not addressed the cost to fix the problem increases.
I know the budget is broken. I know the economy is tanking. I know there will be painful steps, cuts, tax hikes, etc to fix the problem. But doesn't 30% slashing of one group's salary seem excessive? From my vantage point, this is HUGE! Before go any further let me say emphatically I did not go to medical school to get rich. I chose medicine because I felt it would offer good job stability and allow me to provide a good income for my family and allow my wife to stay at home and not work if she chose not to, and of course to help people. But talking about a 30% decrease in provider payments makes me shake in my boots. Every year the physicians have to fight with congress to patch up the SGR. What is the SGR? It is the sustainable growth rate formula. Some whiz kid on capitol hill developed it years ago and it schedules cuts every year to medicare to keep it sustainable, and yes it mostly targets the providers(Ben is probably grimacing right now with that crude explanation...oh well). There are a lot of flaws in the formula and fails to take alot of things into account. Every year congress comes through at the last second and patches it up with a 6 month or one year hold for the cuts. But like the email says, every year the formula isn't fixed, it becomes more and more expensive for a permanent fix.
You might be saying whats the big deal? It is only medicare that will be cut, there are alot of insurance companies out there! True, there are alot of insurance companies out there, but unfortunately they all base their reimbursement schedule on what medicare is doing. You might be saying, "well doctors are rich, they can handle a 30% cut in there salary." Hold on there cowboy, todays doctors are not yesterdays doctors. The average salary of a physician has been dropping steadily for years(minus a few select specialties). While most other careers reward an employee with a higher salary with the more experience they accumulate, most physicians I have worked with are telling me their salary has flatlined or decreased over the past 10 years, despite seeing more patients, becoming more efficient and skilled and doing more paperwork! Imagine that in your chosen career, doing more work, with more experience, AND getting paid lees than when you started! If that is not a deterrent for hard work, I'm not sure what is. I look at the hours i'm working and see some of the Real(not resident) doctors working longer hours and think to myself "that is what I have to look forward to, with a 30% decrease in what he/she is making?" I also look at the average debt load of newly graduated physicians, over $180,000 (p.s my debt load is higher) and worry about repaying that, on top of life expenses(i.e.mortgage) with nearly half of what physicians are now making? Scary. I think of the malpractice insurance I will be required to pay, along with the constant looking over my shoulder for the lawyer watching every decision I make, waiting to pounce and sue me for all I'm worth. (p.s. for those of you who think the threat of lawsuits is NOT driving up health care costs, I have news for you...IT IS! I've over ordered tests to protect myself on several occasions even if my suspicion is low, and I've only been doing this for a couple of months!)
Then I think of the ripple effect that a cut like this will have in addition to the new health care law (ie Obamacare) on society (ie: YOU) and it looks frightening. Let me paint the picture for you: Several current practicing doctors have told me they will RETIRE early and do something else if these changes are implemented. That will leave young physicians like myself who have too much debt to switch careers to care for a huge baby boomer population in addition to everyone else. You think you wait a long time to see a physician right now? You think the physician doesn't spend enough time with you right now? I forsee wait times nearly doubling and physician time spent with patients dropping dramatically with these changes. Additionally, a doctor would be required to see 50-60 patients a day(almost double the average patient load right now), and maybe more with a 30% paycut to make what they are currently making. Do ya think that will increase quality of care??? Then there is the viscious cycle that will happen to medical training that i've been saying for years. Who in their right mind would want to become a doctor with everything i've said above? It is true that medical schools right now only accept a mere fraction(most less than 5%) of applicants applying to their school, thus have a Huge pool to choose from. But I forsee the quantity and quality of those applicants diminishing significantly with these cuts as brighter students choose to pursue other fields. Then as income from tuition decreases for medical schools, and salaries decrease for professors, the brightest educators will start leaving medical schools for greener pastures. And thus the spiral will continue downward with less qualified students being taught by less qualified educators, and thus our overall healthcare quality suffers and dwindles.
It is true that by the WHO classification, the USA's current healthcare grades are not very high compared to other places in the world. I believe a part of that is our focus on prolonging life and keeping people alive that other countries simply do not keep alive, which increases our morbidity(sick) rate. The american diet doesn't help our statistics either. But everybody knows there are problems that need to be addressed with healthcare and I agree. (and I don't buy into the scare tactics of death panels etc that republicans use to detract obamacare). That being said, I don't think 30% cuts of physicians salaries and obamacare as presently outlined will bring the change some people think it will. I feel my concerns are valid. Please leave me a comment and tell me what you think. Am I way off base? Am I right on target? Please share your viewpoint.
END OF RANT.
So I received an email this morning that kinda got me fired up. Here it is:
In the debt compromise just reached in Washington, mandatory cuts of $1.2 trillion are scheduled to take effect if there is no new agreement.
What are the targets for these cuts? You guessed it: “Medicare providers” … physicians.
The group charged with deciding who will receive cuts is a 12 member “supercommittee.” This panel, selected a few weeks ago by House and Senate leadership, consists of Members of Congress with a broad range of experience. Interestingly, the panel, which has the ability to drastically affect physicians and their patients, does not have a single physician. Since there are only twelve slots on the committee, many regions will not have representation.
Physicians are particularly vulnerable to the agenda of the supercommittee. With a 30 percent cut in Medicare payments already looming, Congress is not going to be able to simply patch the broken SGR formula as it has done in the past. Funding for Graduate Medical Education is also an area the supercommittee will look to cut.
The “Supercommittee” has the power to fix one of our most pressing issues – the SGR. Every year that the SGR issue is not addressed the cost to fix the problem increases.
I know the budget is broken. I know the economy is tanking. I know there will be painful steps, cuts, tax hikes, etc to fix the problem. But doesn't 30% slashing of one group's salary seem excessive? From my vantage point, this is HUGE! Before go any further let me say emphatically I did not go to medical school to get rich. I chose medicine because I felt it would offer good job stability and allow me to provide a good income for my family and allow my wife to stay at home and not work if she chose not to, and of course to help people. But talking about a 30% decrease in provider payments makes me shake in my boots. Every year the physicians have to fight with congress to patch up the SGR. What is the SGR? It is the sustainable growth rate formula. Some whiz kid on capitol hill developed it years ago and it schedules cuts every year to medicare to keep it sustainable, and yes it mostly targets the providers(Ben is probably grimacing right now with that crude explanation...oh well). There are a lot of flaws in the formula and fails to take alot of things into account. Every year congress comes through at the last second and patches it up with a 6 month or one year hold for the cuts. But like the email says, every year the formula isn't fixed, it becomes more and more expensive for a permanent fix.
You might be saying whats the big deal? It is only medicare that will be cut, there are alot of insurance companies out there! True, there are alot of insurance companies out there, but unfortunately they all base their reimbursement schedule on what medicare is doing. You might be saying, "well doctors are rich, they can handle a 30% cut in there salary." Hold on there cowboy, todays doctors are not yesterdays doctors. The average salary of a physician has been dropping steadily for years(minus a few select specialties). While most other careers reward an employee with a higher salary with the more experience they accumulate, most physicians I have worked with are telling me their salary has flatlined or decreased over the past 10 years, despite seeing more patients, becoming more efficient and skilled and doing more paperwork! Imagine that in your chosen career, doing more work, with more experience, AND getting paid lees than when you started! If that is not a deterrent for hard work, I'm not sure what is. I look at the hours i'm working and see some of the Real(not resident) doctors working longer hours and think to myself "that is what I have to look forward to, with a 30% decrease in what he/she is making?" I also look at the average debt load of newly graduated physicians, over $180,000 (p.s my debt load is higher) and worry about repaying that, on top of life expenses(i.e.mortgage) with nearly half of what physicians are now making? Scary. I think of the malpractice insurance I will be required to pay, along with the constant looking over my shoulder for the lawyer watching every decision I make, waiting to pounce and sue me for all I'm worth. (p.s. for those of you who think the threat of lawsuits is NOT driving up health care costs, I have news for you...IT IS! I've over ordered tests to protect myself on several occasions even if my suspicion is low, and I've only been doing this for a couple of months!)
Then I think of the ripple effect that a cut like this will have in addition to the new health care law (ie Obamacare) on society (ie: YOU) and it looks frightening. Let me paint the picture for you: Several current practicing doctors have told me they will RETIRE early and do something else if these changes are implemented. That will leave young physicians like myself who have too much debt to switch careers to care for a huge baby boomer population in addition to everyone else. You think you wait a long time to see a physician right now? You think the physician doesn't spend enough time with you right now? I forsee wait times nearly doubling and physician time spent with patients dropping dramatically with these changes. Additionally, a doctor would be required to see 50-60 patients a day(almost double the average patient load right now), and maybe more with a 30% paycut to make what they are currently making. Do ya think that will increase quality of care??? Then there is the viscious cycle that will happen to medical training that i've been saying for years. Who in their right mind would want to become a doctor with everything i've said above? It is true that medical schools right now only accept a mere fraction(most less than 5%) of applicants applying to their school, thus have a Huge pool to choose from. But I forsee the quantity and quality of those applicants diminishing significantly with these cuts as brighter students choose to pursue other fields. Then as income from tuition decreases for medical schools, and salaries decrease for professors, the brightest educators will start leaving medical schools for greener pastures. And thus the spiral will continue downward with less qualified students being taught by less qualified educators, and thus our overall healthcare quality suffers and dwindles.
It is true that by the WHO classification, the USA's current healthcare grades are not very high compared to other places in the world. I believe a part of that is our focus on prolonging life and keeping people alive that other countries simply do not keep alive, which increases our morbidity(sick) rate. The american diet doesn't help our statistics either. But everybody knows there are problems that need to be addressed with healthcare and I agree. (and I don't buy into the scare tactics of death panels etc that republicans use to detract obamacare). That being said, I don't think 30% cuts of physicians salaries and obamacare as presently outlined will bring the change some people think it will. I feel my concerns are valid. Please leave me a comment and tell me what you think. Am I way off base? Am I right on target? Please share your viewpoint.
END OF RANT.
Monday, October 3, 2011
A Cautionary Tale
I went for a jog this morning and savored the azure blue sky with sunshine and perfect 55 degree running weather. I also started thinking about a few recent experiences I've had as a new resident and wanted to write them down, perhaps as a caution about some pitfalls of some media outlets and others(mostly males) current thinking about doctors.
The first story is about a 60 year old pleasant gentleman who presented to the emergency room with a complaint of these strange sudden episodes of weakness and blurry vision that had no pattern. It would occur on the left side of the body for approx 5 minutes, both arm and leg, then completely resolve, then would occur suddenly on the right side of the body for a couple of minutes then resolve, then would happen to his right arm and left leg, etc. Sometimes there would be days in between these episodes. Again no pattern. He came to the ED because the episodes were becoming more frequent. I was called to admit him to the hospital and figure out the cause of the episodes. They did not sound completely like seizure activity because he was never confused during the episodes or had a loss of conciousness or bit his tongue or lost control of his bladder or in other others none of the classic seizure signs. It did not sound stroke like because the symptoms would not relapse and remit so quickly. It didn't fit in with any of the other most common causes of sudden weakness either. Truly bizzarre. The only significant piece of history the patient mentioned to me was that he'd last seen a doctor 28 years ago and his feet started going numb 5 years ago. He also was found to have high blood sugar and high blood pressure on admission. So after numerous lab tests and imaging(including MRI's, CT scans etc) that were essentially negative, hours of studying and looking for rare causes of weakness and blurry vision, consulting neurology, and 3-4 days of the patient staying in the hospital, it was finally decided after excluding all the other big bad things, that this man was suffering from complications of untreated diabetes and high blood pressure. He had a few more episodes but they seemed to be slowing down after we started medications to lower his blood pressure and sugar. I discharged him after hospital day #4 with his commitment he would see a family doctor in the next few days and get his BP and sugar under control.
Unfortunately, this story does not end happily. He was brought back to the ER the next day by his son after suffering a more severe episode of weakness that was more prolonged. In the ER, he appeared to go into status epilepticus(a series of sustained seizures) and had to be intubated to protect his airway and sedated to stop the seizures. He was then admitted to the ICU and put on a ventilator. The MRI showed alot of bleeding into his brainstem and other critical structures of his brain that were not there before. He was kept on the ventilator for 10 days when the family decided to remove the life support. He died a few hours later.
Why do I share this story? Because this death was TOTALLY PREVENTABLE, though unfortunately not by me because by the time I saw him it was too late. This man's high blood pressures for over 20 years eventually caused his plumbing inside his body to fail and the blood leaked into his brain. I tried to lower the blood pressure when I saw him, but the damage had already been done. The high sugars also hurt the blood vessels and most certainly caused the numbness in his feet and the blurry vision. He was started on the appropriate medications, and was even started on the proper stroke prevention meds, but it was just too late. Is my point coming clear yet? Why this man didn't go to his doctor when his feet turned numb is beyond me. But intervention at that point, although still late, may have saved his life. I still see his face sometimes at night and feel a small amount of responsibility for his death even though there was NOTHING I could have done differently. The damage was already done.
I have several friends that are approaching the age of 30 who probably haven't seen a doc in years and prob don't intend to for several more. Its just not manly to see a doctor, especially if you are not sick. I plead with you to remember this story and see a doctor, soon. Just for a healthy screening at least. I recently had a physical at the urging of my wife and although nothing was found, had the reassurance I was healthy. Some docs recommend yearly physicals for males, much like the females. I think while in your 30's and money is tight, you should at least have a physical every couple of years, if not yearly. I really don't want to see your face at night, knowing a death could have been prevented if you saw a doctor early and regularly in your adult life.
The first story is about a 60 year old pleasant gentleman who presented to the emergency room with a complaint of these strange sudden episodes of weakness and blurry vision that had no pattern. It would occur on the left side of the body for approx 5 minutes, both arm and leg, then completely resolve, then would occur suddenly on the right side of the body for a couple of minutes then resolve, then would happen to his right arm and left leg, etc. Sometimes there would be days in between these episodes. Again no pattern. He came to the ED because the episodes were becoming more frequent. I was called to admit him to the hospital and figure out the cause of the episodes. They did not sound completely like seizure activity because he was never confused during the episodes or had a loss of conciousness or bit his tongue or lost control of his bladder or in other others none of the classic seizure signs. It did not sound stroke like because the symptoms would not relapse and remit so quickly. It didn't fit in with any of the other most common causes of sudden weakness either. Truly bizzarre. The only significant piece of history the patient mentioned to me was that he'd last seen a doctor 28 years ago and his feet started going numb 5 years ago. He also was found to have high blood sugar and high blood pressure on admission. So after numerous lab tests and imaging(including MRI's, CT scans etc) that were essentially negative, hours of studying and looking for rare causes of weakness and blurry vision, consulting neurology, and 3-4 days of the patient staying in the hospital, it was finally decided after excluding all the other big bad things, that this man was suffering from complications of untreated diabetes and high blood pressure. He had a few more episodes but they seemed to be slowing down after we started medications to lower his blood pressure and sugar. I discharged him after hospital day #4 with his commitment he would see a family doctor in the next few days and get his BP and sugar under control.
Unfortunately, this story does not end happily. He was brought back to the ER the next day by his son after suffering a more severe episode of weakness that was more prolonged. In the ER, he appeared to go into status epilepticus(a series of sustained seizures) and had to be intubated to protect his airway and sedated to stop the seizures. He was then admitted to the ICU and put on a ventilator. The MRI showed alot of bleeding into his brainstem and other critical structures of his brain that were not there before. He was kept on the ventilator for 10 days when the family decided to remove the life support. He died a few hours later.
Why do I share this story? Because this death was TOTALLY PREVENTABLE, though unfortunately not by me because by the time I saw him it was too late. This man's high blood pressures for over 20 years eventually caused his plumbing inside his body to fail and the blood leaked into his brain. I tried to lower the blood pressure when I saw him, but the damage had already been done. The high sugars also hurt the blood vessels and most certainly caused the numbness in his feet and the blurry vision. He was started on the appropriate medications, and was even started on the proper stroke prevention meds, but it was just too late. Is my point coming clear yet? Why this man didn't go to his doctor when his feet turned numb is beyond me. But intervention at that point, although still late, may have saved his life. I still see his face sometimes at night and feel a small amount of responsibility for his death even though there was NOTHING I could have done differently. The damage was already done.
I have several friends that are approaching the age of 30 who probably haven't seen a doc in years and prob don't intend to for several more. Its just not manly to see a doctor, especially if you are not sick. I plead with you to remember this story and see a doctor, soon. Just for a healthy screening at least. I recently had a physical at the urging of my wife and although nothing was found, had the reassurance I was healthy. Some docs recommend yearly physicals for males, much like the females. I think while in your 30's and money is tight, you should at least have a physical every couple of years, if not yearly. I really don't want to see your face at night, knowing a death could have been prevented if you saw a doctor early and regularly in your adult life.
Sunday, October 2, 2011
Two day weekends
I had almost forgotten there was such a thing. They are precious, beautiful, wonderful, heavenly, otherworldly, amazing, remarkable, relaxing, enjoyable, awesome, outstanding, and fantastic! I actually just finished my first two day weekend in almost 3 months and will get two more this month...what a blessing! We are probably going to check out San Fran one weekend and go camping the other. Here is a pic of Mak at the Galena Creek park, one of the many beautiful recreation areas around Reno and the other pic is from Lake Tahoe that I took back in July.
So the moral of the story: when you are enjoying your next two day weekend, be grateful and remember to have fun for me...who is probably working on the weekend and will be lucky to get one day off. (I'm really not begging for sympathy here) :)
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