Need Surgery? Pick the Right Hospital

When your doctor says you need surgery, ask to go to a hospital that does a high volume of the procedure you’ll need. You’re more likely to live and avoid major complications.

There are lots of research articles on this, but one study of 29,000 patients who hasurgery 12.29.15d total hip or total knee replacement tells the story well. Published in  Arthritis & Rheumatism, the researchers found that at hospitals that did fewer than 200 of the procedures a year, patients were more likely to die within a year after surgery or get a serious side effect (venous thromboembolism, or a blood clot in a vein) within 30 days of surgery than were those treated in a hospital that did a high volume of the cases.

Why? It’s not clear. It could be related to hospital systems and procedures, lack of prevention, how people are educated and cared for before and after surgery, and other factors.

Now, here’s the rub. If your physician suggests a hospital that does a lot of the surgery you need, you can take a sigh of relief. But if he or she doesn’t, you should have a conversation about why you’d prefer going to a different hospital, perhaps one your doctor doesn’t like or may not have “privileges” at (that is, doesn’t do surgery there). You may even have to decide if you’ll have to leave this surgeon and go with another who is “on staff” (has permission to operate) at the hospital with the higher-volume of the surgery you need.

It isn’t always easy. But if you improve your odds of a quick recovery, it’s well worth it.  Just remember, this shouldn’t be an emotional decision. You’re in charge of your body. Base your decision on the facts.

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Just Got Bad News? One Word To Get You Better Health Care

When you’ve just heard you have a troubling health condition, there’s one word that will virtually guarantee you better health care:

Time.

Hourglass 12.14.15When you’re first dealing with bad news about your health,  unless your situation is immediately life threatening, your first reflex should be to pause. Not react. Not immediately see a specialist or a surgeon. Your very first and most important step is to do nothing.

Most people feel they need to act immediately: get another test, a biopsy, a procedure, or sign up for surgery just to stem the tide of what they picture as rapidly reproducing cancer cells, or the quick spread of infection, or the possible blockage of arteries. They want action. They want quick solutions. Fast remedies. They want the fear and the confusion to end. They want a plan.

Here’s a better approach:

  1. Take a deep breath and pause. Sit back and consider what you’re hearing from your physician. Try not to react emotionally.  If you can compose yourself and think clearly, pose some questions. Ask: how much time may I take to evaluate the pros and cons of different options?  If you’re too upset to think, ask how you might be able to ask more questions — perhaps by emailing, or at another visit in a few days.
  2. Learn the basics about your condition. Become fully briefed on your situation. Get a handle on your own data: learn exactly how your situation was diagnosed and what precise next steps are being suggested. Do your homework. Read about your condition. Talk with friends. Then go back to your healthcare provider with a set of well-informed questions.
  3. Get more data and other points of view. Depending on your situation, you may want to get your blood test re-done by a different lab to confirm the situation, or have biopsy slides or test results reviewed by another pathologist or other physician. If surgery or an invasive procedure is being proposed, you may want to ask if there are alternatives such as medications, radiology or other treatments. Get a second opinion or two. Talk to someone who advocates a traditional tried-and-true method and another who suggests using a proven new approach.  Talk with others who have personally dealt with a diagnosis such as yours.
  4. Decide on your best course of action. Consider which alternatives are most palatable to you — what seems to be the right approach — given your personality and what you’ve heard from your physicians. Talk with the people you love.

And then, and only then, decide how you would like to move forward.

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Dental X-Rays? What a Brain Surgeon Recommends

I have a common sense approach to the dentist. Since teeth don’t heal themselves, it seems smart to do all you can to catch problems early. So I  have a cleaning and check-up every six months, and once a year, I bite for the bitewing x-rays.dental xrays 12.4.15

It turns out, we probably shouldn’t.

Research published in Cancer suggests that early or repeated dental x-rays increase the risk for meningioma, a common brain tumor. While often benign, meningiomas can grow or cause symptoms which may require surgery or radiation therapy. The study is the largest ever to analyze the effects of common dental x-rays.

At every age, having more frequent bitewing x-rays was associated with increased risk. People with mengiomas were 1.4 to 1.9 times more likely than were control subjects to have had bitewing x-rays annually or more frequently.

The study is especially interesting because it shows how low-dose radiation exposure, when repeated, can have a cumulative negative impact on your health.

If you or your kids have had orthodontia, you’re probably familiar with panorex x-rays, which give a two-dimensional picture of the jaw and  teeth including the surrounding bones. Most orthodontists work from panorex x-rays as they develop the treatment plan for straightening teeth. When our daughter had braces, I gave the OK for one set of panorex, but when she was finished with treatment, I said no to an “end of treatment” panorex the orthodontist wanted because I felt it was unnecessary. It turns out I was right.

Kids who had a panorex when they were less than 10 years old had a five percent increase in the risk of developing brain tumors.Now, my dental hygienist and dentist are now pushing adults to get panorex xrays “just for the record.”

Keith L. Black MD, chair and professor of the Department of Neurosurgery at Cedars-Sinai Medical Center in Los Angeles, told Medscape that dental xrays aren’t without risk. “As a general rule, we need to be more concerned about x-ray exposure, particularly in the younger population,” he said.

 If there is no evidence of a problem, such as a cavity or the need for a root canal that might warrant further exploration, Black suggests saying no to dental x-rays. For more than 20 years, his dentist has asked him after his twice-yearly dental cleanings whether he wants x-rays. Without fail, he says no. “If I have no complaints and they see no cavities, I don’t see the point in getting the x-rays, so I refuse,” he said.

X-rays are a revenue source for dentists. My friend,  a dental hygienist, says many dental offices offer their hygienists a bonus if their patients say yes to x-rays. In light of this study, that’s especially aggravating.

The bottom line? Know that every treatment and test has an upside and a downside. Discuss your questions and concerns with your dentist to see if you have a situation in which you really would benefit from an x-ray. But on the whole, you probably won’t need annual x-rays.

If you do need an x-ray, be sure   our body and your thyroid  are covered with protective “aprons”  to minimize radiation exposure.

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Four Things to Say at Your First Visit with a New Doctor

talking to your doctor 11.30.15It’s always a little awkward getting to know a new physician. After the first hellos, and before the examination begins, it’s smart to set the stage for an effective relationship.

Physicians can’t read your mind. They don’t know what role you’d like to play in your own health care. If you’re like many people, you want to know everything necessary to make the decisions that will naturally and ultimately be yours to make.

You should see your physician as a consultant to you, someone whom you have chosen to evaluate your situation and give you recommendations and options. Recognize that while doctors, lawyers, accountants, and other professionals typically  know more about their specialty than you do, you should still see yourself as the ultimate decision maker.

Here are four things you should say at your first visit:

  1. I’d like to be told the pros and cons of whatever you’re suggesting I do.
  2. I’d like a copy of all data and reports generated from my care. Ideally, I’d like to see the notes you write down about me at each visit and get a copy of  every one of  my lab reports or test results.
  3.  I want to be told if there’s an option to wait and see. If you recommend I get a test or procedure, I’d like to know if we can watch the problem for a few months and revisit my situation to re-evaluate. If you believe my health problem is urgent, I’d like to know why.
  4. I want to know if there is a potential conflict of interest when you recommend something. If you suggest a drug, procedure or surgery, please let me know if you have  an ownership interest in the facility, or get paid by a drug company for teaching or consulting.

There may be other things you’d like to ask beyond this list. If your new physician balks at your questions or seems irritated or taken aback, unless he or she is the only doctor in town, this would be the perfect time to put your clothes back on and say goodbye.

All you have to say is something like, “From our conversation, I see we’re not a good fit. Thank you.”

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Was It Something You Ate?

You know the feeling. It starts with a few twitches or cramping in your abdomen and ends up with weakness, loss of appetite, diarrhea, and sometimes vomiting anfood-poisoning 11.24.15d a fever.

What nobody ever seems to know is whether the illness was really caused by genuine food poisoning, or if it is  a stomach virus.  It’s tough even for healthcare providers to tell the difference. Most people tend to just call it food poisoning.  Others decide it’s the stomach flu.

Either way, most physicians will diagnose your problem as “gastroenteritis.”  That’s a non-specific term for a range of abdominal troubles that are associated with diarrhea, nausea, vomiting and abdominal pain. The illnesses can range from inconvenient to life-threatening.

It’s hard to know how many people get this sort of stomach trouble every year because many are not reported. It’s estimated that there are 100 million cases a year, and that children alone account for 1.5 million outpatient visits because of stomach trouble.

Food poisoning happens when you eat or drink something contaminated with infectious organisms, bacteria, parasites or viruses passed on to you through food or water. Some of the most common carriers include raw oysters, contaminated water or ice cubes, lettuce, bagged spinach, alfalfa sprouts and cantaloupe. Bacteria-caused food poisoning typically hits you 12 to 36 hours after ingestion.

The majority of cases of gastritis are caused by the norovirus. It’s very contagious and quite resistant to alcohol-based products, including hand sanitizers. You can get norovirus by eating something people have prepared without properly washing their hands (fecal contamination); from the air (if you’re in a bathroom, dorm, classroom or hostel when someone vomits and the virus is airborne); from water; from deli meats; and from touching contaminated surfaces.

So you see, you can get a food-borne illness that most people would call food poisoning just by touching the counter at a store or using the handrail when you’re running down stairs. And because so many people attribute their troubles to something they ate, they may be less careful about taking the necessary precautions to prevent passing it on to roommates, friends and family.

If you’ve been infected by the norovirus, the incubation period is 12-48 hours  and the onset of symptoms is sudden. The illness usually lasts between 12 hours and 2 or 3 days.

No matter how you’ve gotten a stomach virus, the recommendations are the same.

See your healthcare provider if:

  • Your symptoms persist for more than a few days, see your healthcare provider.
  • Your symptoms suddenly get worse, or
  • Your fever goes above 102 degrees Fahrenheit, or you see blood in your stool or vomit, see your healthcare provider.
  • You can’t keep food or water down for more than 24 hours

And…

  • Keep hydrated by drinking sips of water, chewing on ice chips, having a popsicle, and starting to have clear liquids and soft foods as soon as you feel you can.
  • Consider taking over-the-counter medications like Immodium for diarrhea, Emetrol for nausea.
  • Rest.

When people say they have food poisoning,  tell them that whatever they call it — stomach flu, stomach virus, food poisoning, or gastroenteritis — they should follow these tips for when to see a healthcare provider and how to keep from becoming severely dehydrated.

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Do Teens and Adults Need Another Whooping Cough Shot?

I had whooping cough a few years ago and it’s no picnic, even as an adult. It starts like a moderate cold or flu and ends up with several weeks of a cough you won’t forgewhooping cough 11.11.15t. It sounds different than any cough you’ve had or heard, thus its moniker, “whooping.”

Whooping cough (pertussis), a highly contagious bacterial respiratory infection, was widely known as a killer in the first half of the 20th century. After the vaccine was discovered in the 1940’s, the disease gradually was considered “old news” because kids in developed countries would rarely get it.  Infants and children are given five different shots at 2, 4 and 6 months, and then at 15-18 months and again when they’re 4-6 years old. They should also get a booster shot at about 11 or 12.

And now, because the resistance fades, teens and adults are being encouraged to get yet another shot. Kids get the DTap and teens and adults get the TDap. (The T is for tetanus and the D is for diphtheria, which are also included in these vaccines).

Childhood is the time of greatest exposure and risk, since infants and kids can get extremely sick from  pertussis. Adults rarely die from it  but they do transmit it, so even if you don’t mind whooping for a while, if you’re in contact with kids or seniors, it’s smart to get the vaccine.

A  study presented at an American Society for Microbiology conference  by David Witt, MD, chief of infectious disease at Kaiser Permanente Medical Center in San Rafael, Calif., suggests that the vaccine loses much of its effectiveness after just three years, a lot faster than health professionals previously thought.( More than 80% of the kids who got whooping cough in Witt’s study had been fully vaccinated). During 2014, 32,971 cases of pertussis were reported to CDC. This represents a 15% increase compared 28,639 cases reported during 2013. (There were probably more; I’m sure no one reported my case a few years ago!).

What should you remember about whooping cough and your family?

  • Make sure your kids get all the recommended doses at the right ages. Teenagers may need another vaccine. (Keep accurate records of who got what and when).
  • The CDC emphasizes that the vaccination is still much better than no vaccine; it reduces the severity of the illness.
  • Get a TDap for yourself, for the other adults in your household and for people who are in contact with the very young and  the older and oldest.

Find out more about whooping cough from the CDC (the U.S. Centers for Disease Control and Prevention).

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5 Things to Know Before Making Healthcare Decisions

Do you really feel prepared to make most healthcare decisions for yourself or your family?

Maybe you expect your healthcare providers will tell you whatever it is you need to know. Or it could be that your physician is  Decision Making 11.9.15underestimating the value of involving you in the decision-making process.

So says a study published in Medical Decision Making by researchers at the University of Michigan. They surveyed more than 3,000 U.S. adults about nine common medical decisions. They learned that the majority  of patients don’t have enough information to make the best decisions.

One of the researchers, Brian Zikmund-Fisher,  knows the value of making the right choices.  While a graduate student in Australia, he was told he had to decide whether he would die from a blood disorder within a few years or undergo a bone marrow transplant that could either kill him in a few weeks or cure him. (He chose the bone marrow transplant but had to wait nine months for a bone marrow match). As you can imagine, he learned a lot from that experience.

Here are five important things you should know from his research:

  1. People aren’t always told the downside of a procedure or medication. For example, only 20% of people considering breast cancer screening and 49% considering blood pressure medications reported hearing about the potential negative consequences of those actions.
  2. Don’t expect a healthcare provider to ask you what you want to do. You may have to speak up for yourself or for your family member. For example, only 50% of people considering cholesterol medications reported being asked whether they wanted them.
  3. You may be over-estimating your risk of cancer and therefore putting more emphasis on screening than you need to. Most people think they’re more likely to get cancer than they are, and also believe cancer screening tests are more accurate than they are. You may be unaware of some of the downsides of what is now called “over diagnosis.”
  4. Men and women think about risks differently. For instance, women are more active in making cancer screening decisions no matter how at risk they think they are, while men tend to get involved only if they feel they are at high risk.
  5. You must A -S-K.  If your physician doesn’t tell you why he or she thinks you should do something, and doesn’t discuss reasons why you might decide to opt out of a treatment or procedure, ASK.
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Teaching Kids How to Be Effective Patients

Kids develop attitudes about health care very early on. The sooner you start teaching them how they can play a role in asking questions and understanding what’s happening, the more likely they will grow up to be effective patients.

There are basically four categories of “health education” messages most families try to impart to their kids: basic nutrition (eat your vegetables), dental care (brush and floss your teeth),  infection prevention (wash your hands before you eat) and sex ed (which varies from family to family in facts, timing, tone and style). While that’s a good start, there’s a lot more parents can do from the time their little ones are babies and toddlers through college age to help ensure their kids learn how to take charge of their own health care.

Kids need to learn as much as possible about how their bodies work, whatChildren at the doctor 11.6.15 symptoms mean, and how to make the best possible use of the knowledge healthcare providers offer. Parents can also help their children develop a positive attitude about going to a doctor’s office or clinic. Even at a relatively young age, kids can gain  the necessary confidence and learn how to ask good questions and participate in decision making.

Here are some things you can do to help ensure your kids will be comfortable managing their own health care:

  •  From the time you first start to bring your newborn in for well baby exams, make sure you’re managing your own anxiety about the check-ups and other interactions with health care providers. Kids of every age pick up on adult stress, and it will change how they react to seeing a doctor or nurse. (I can still remember the walkway to my pediatrician’s office and can feel the anxiety I felt when the front office door opened and a little bell went off).
  • Vaccinations are often among an infant and toddler’s first experiences with pain. I have heard parents freak out before, during and after their children have injections. In front of their kids, they say things like, “I am so sorry, but you just have to have this shot,” or “I just can’t watch!” (as if it were a horror show) or “Don’t blame this on me; the doctor says you have to have it.” None of those are good things to say.  Instead, say something to describe the whole experience before you go, geared to the child’s age. Perhaps, “the doctor will be checking your weight, talking to you to see how you’re feeling, and giving you a shot that will keep you healthy.” Smile. Don’t frown. A shot doesn’t really hurt any of us all that much, especially kids, who are used to falling down, cutting their knees and bumping their way around the universe. Don’t give them a reward if they “get through it.” (Kids are smart; they sometimes figure that the more they cry, the bigger the payoff).  Make routine health care routine.
  • As your child gets older, if he or she wants to watch an injection, tell the doctor or nurse that that’s fine. Kids frequently feel more afraid if they are told they can’t see what’s being done (as do adults, actually).  Tell your children that they can choose to watch if they want, and convey that to the staff. Watching what’s being done to you typically makes you feel less out of control.
  • Ask them to think about whether they have any questions they’d like to ask the doctor. You’ll be surprised what they come up with. Some want to know why their stomach occasionally hurts, or why they sometimes get really afraid at the movies, or how the doctor would know if they, like their friend, ever needed surgery. You’ll be teaching them how to seek information from a healthcare provider and how to listen to what they hear.
  • As children mature, involve them as much as you can in their own healthcare decision making. For example, hepatitis B vaccinations were coming out when our kids were young teenagers. I explained the vaccine to them, that it was not required by schools at the time, and how they were unlikely to need it now. But I also told them that as they matured, they might find themselves doing things that would put them more at risk for the disease. They responded very logically. “Let’s have it, ” they said. Don’t give them options if the stakes are so high you couldn’t live with their decisions. But help them learn to evaluate what’s right for them in the face of currently known facts when you can live with the choices they might make.
  • Talk to school-age children as you make healthcare decisions on their behalf. For example, explain how vaccines protect them from diseases that could make them very sick, and how they work: “They help build cells that can fight off sickness without you even knowing its happening.” (Granted, that’s a really basic explanation of the immune system).  If they fall off a bike and the emergency department doctor wants an x-ray, explain why it’s a good idea to know whether the bone is broken or not, and how an x-ray works, giving a good view of what happened inside.
  • Take the magic out of what you do as you help your kids deal with injuries and illness.  Make the healthcare hassles of childhood into “teachable moments.” For example, when our kids were little and they cut their knees, I’d say “We’re washing this off so you won’t get an infection, and then using the band-aid to protect the area. Then tiny cells will be knitting new skin, and soon it will be as good as new!”
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6 Ways to Ensure Your Test Results Get Noticed

Silence isn’t golden.

It turns out that over the last 10 years, physicians have been ordering a lot more diagnostic tests. Partly due to the sheer volume of medical data created, a significant number of diagnostic test results may not end up being seen by your doctor or communicated to you.

In short: you get an important diagnostic test and the right people may never review the results.

That’s what researchers reported in the Journal of the American College of Radiology (JACR). Researchers, led by Brian Gale, MD, MBA, of the Department of Radiology, State University ofFeatured image New York Downstate Medical Center, in Brooklyn, New York, found 306 of 8,417 medical malpractice cases between 2004 and 2008 were related to failure  to communicate test results. The cases accounted for 7% of payouts, with radiologists cited as the primary defendants in about 8% of the cases. Total malpractice payouts in the U.S. for all medical specialties related to diagnostic test communication failures went from $211.7 million in 1991 to $91 million in 2009, according to the researchers.

There are some ways to ensure your test results get reviewed and reported to the necessary clinicians and to you:

  • Make sure the tests you get are needed in the first place. If your physician suggests you should have a test, ask what he or she hopes to learn from the test and why it is being done now. Find out what the downsides of skipping the test might be, and whether it would make sense to wait and see whether your medical situation improves. You can also ask whether there are reasonable alternatives to the test.
  • Before you go for the test, ask your physician how soon he or she will have the results and whether the office will notify you. If you don’t hear from the office, don’t assume your test results are fine. Always call.
  • Ask for a copy of the written evaluation of the diagnostic test, read it carefully and keep it in your own “medical record” file at home.
  • Send a copy of the written report to your internist or other physicians if you think they should be aware of the test results. Don’t assume that one physician will automatically communicate with your other doctors.
  • If you or a family member is in the hospital, it’s equally important to follow up on medical tests and ask about the results. Do not assume they have been evaluated by your physician or consulting specialists. A S K and follow up.
  • If you or a family member is about to get discharged from the hospital, ask what test results are still pending and talk to the physician about how to get the results if they’re not back yet when you leave the hospital. Many studies have shown these tests tend to fall in the gap between hospital and home.
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Are You Afraid to Ask for a Second Opinion?

Does the thought of getting a second opinion for something you’re facing freak you out a little bit?

Maybe your doctor is telling you to get surgery, or an invasive test, or a procedure you’re not sure you need.  Perhaps they’ve found cancer, and you’d like to know more about your options for next steps. Could be your 90-year-old mother is on a respirator and they want to do lung surgery. Should you sign for that? How do you know what to do?

Getting a second opinion for something significant or high risk is almSecond opinion 11.4.15ost never a bad idea. But when I talk to my friends about their healthcare concerns, even the most assertive people often stumble and stammer when they confront the possibility that they might have to tell their doctor they’d like to talk with someone else. To some people it feels like dating two people at once, or turning your back on a trusted friend.

They’re sometimes afraid they’ll anger their physician and injure that important relationship. Or they feel they just want clear direction, and getting diverse opinions will only serve to confuse them. They also might be overwhelmed with the question of how to find another physician, and worry about how to get their test results and medical record information transmitted from one doctor to the other.

Why bother with a second opinion? It can only benefit you. There really is no downside.  If the second or third healthcare provider agrees with your initial physician, then you may have more confidence in following the path first suggested. Sometimes, however, you’ll hear about another approach that appeals to you more or that data suggest is better for you.  You may discover you like the style or personality of another doctor, or you prefer the hospital where the other physician has privileges (is approved to do surgeries, procedures and see patients).

So how do you do it? You can tell your physician, “This is a really important decision for me and I appreciate everything you have told me. I’d like to take the time to get a second opinion.” Or you could say, “I understand there may be a few different ways to go from here. I trust you would understand that I would like to get a second opinion before making my decision about how to proceed.”  If your physician is not supportive of getting another doctor’s point of view, move on. Most doctors, if in your position, would absolutely get a second opinion for themselves or their family.

The next step is finding the right doctor to render that second opinion. There are a few ways to do this. You can talk with your physician, friends, and family. You can call a major medical center and ask for a physician experienced with treating people with your diagnosis or situation.

When you phone the second doctor’s office, tell them your situation, in brief, and ask them what information they would need from you and your current physician, and information they would like send before they see you (usually your physician’s recent notes on your condition, and sometimes your recent lab work,  xrays, MRI scans, biopsy slides or  results, etc.).  Then just ask your current physician’s staff to send them.

The time and effort you invest in a second opinion will serve you well. And it’s a step in the right direction, asserting your role as the ultimate decision maker about your health care.  

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