Tuesday, July 22, 2014

Insulin Use is NOT a Stigma

I was quite pleased when I read this article. And no- it wasn't because she is eye-candy. All too often, people don't like to talk about insulin. Insulin is often seen as a punitive action, thanks to us docs who threaten patients with "if you don't eat right, you're going to eventually need insulin!". Or, insulin is seen as a sign of failure when it should not be.
After all, the person with type 1 is dependent on insulin- her life depends on it.
 
 
And I've seen one too many patients who went into DKA, or have uncontrolled diabetes, because they were embarassed by the fact that they used insulin, and preferred to skip their shots.
And so, I was proud to read about this young lady who decided not to hide the fact that she was insulin dependent.
She would be an excellent role model for many out there. Bravo!

Saturday, July 19, 2014

Management of Diabetes Patients During the Fasting Month

I have quite a few Muslim patients, mainly those from the Middle East. And it always surprises them when I show a little awareness of what they have to go through during the month of Ramadan. After all, in the USA there is much ignorance about Islam, and being raised in Malaysia we've certainly had our share of exposure.
Obviously, the glycemic management of a person who is fasting for religious or medical reasons will change. And so, these perhaps might be some helpful tips:
  • When fasting, one should not take any oral hypoglycemics. This refers to the sulfonylureas like glyburide, glipizide and glimepiride. These are 'blind' secretagogues- you take the pill, you will make insulin- whether or not you need it
  • It should still be OK to continue metformin and incretimimetics like Sitagliptin, Linagliptin, or the injectables like Exenatide or Liraglutide. After all, one 'defect' in type 2 diabetes is excess hepatic gluconeogenesis even when one is fasting- so it is often helpful keeping patients on these. And recall these medications do not cause hypoglycemia (as even for the incretimimetics, the insulin secretion is glucose-dependent) so it will be safe, even if one is not taking any caloric intake
  • For insulin users, it is often OK to continue the basal insulin like Glargine or Detemir. If the dose was appropriate to begin with, there should be no need to even reduce the basal insulin though the truth is many overdose their basal insulin to partially compensate for meals. And so it might be prudent to advise a 10-20% reduction in the basal insulin dose when one is fasting
  • For rapid-acting insulin (Aspart, Glulisine, Lispro) users, recall there are two parts to this: the nutritional dose, and the 'sliding scale' or correctional dose (though in reality it's all given the same time). And so when one is fasting and not consuming any carbs, then it's logical to skip the nutritional portion- but if the blood glucose is high, then it's still OK to give the correctional dose of this
  • Same goes for insulin pump users: when one is fasting, just leave the pump running on basal insulin. May need to bolus for hyperglycemia; but obviously there should be no carb boluses. Again, in these patients there should be no need for reduction in the basal settings in the fasting state, though if one notices a decrease of >20 mg/dL/hour of glucose on the basal insulin alone, this suggests that the basal rate should be reduced anyway
And so, these are some tips that might be helpful in the management of patients with diabetes. It is also prudent to advise patients to carry glucose tabs even if one plans to fast, in case one experiences hypoglycemia.

Friday, July 18, 2014

MH17

I was in disbelief when my wife texted me to read the news. This time, it was not accident, but a vile act of war.
It makes me boil. It breaks my heart. While we are in the business of saving lives, and how every single one is so precious, how can another human being so callously take 298 souls away?
Enough of this nonsense we are reading in the Malaysian news- let's try to put our petty differences away and remember the big picture. Let us take a moment to remember the lives lost, and try to make this world a better place.
RIP
 

Tuesday, July 15, 2014

2014 US Hospital Ranking

It was with great pride when I read of the news today.
The US News and World Report published their annual hospital ranking.
And this time, for the first time ever, my alma mater was ranked number one.
RankHospitalPoints*High-ranking specialties*
1Mayo Clinic, Rochester, Minnesota2915
2Massachusetts General Hospital, Boston2815
3Johns Hopkins Hospital, Baltimore2615
4Cleveland Clinic2614
5UCLA Medical Center, Los Angeles2315
6New York-Presbyterian University Hospital of Columbia and Cornell, New York 2212
7Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia1911
8UCSF Medical Center, San Francisco1710
9Brigham and Women's Hospital, Boston1510
10Northwestern Memorial Hospital, Chicago1310
 
For many years, she has ranked number two, just behind Johns Hopkins. This was in spite of being number 1 for many subspecialties. But this time, it barely beat out the competition and ended up on the top, with Mass Gen (Harvard) being right behind.
Well done, Mayo!
As one of the thousands of your graduates, today we beam with pride at the news. This was well-earned, and reflects well on the teachings of the Mayo brothers, one of which I hold dear to my heart even today: The needs of the patient comes first


Tuesday, July 08, 2014

Do Healthcare CEOs Deserve More Money Than Doctors?

This was the interesting article I read on Medscape recently.
It's certainly a timely article, when many of us in the frontlines of seeing patients, who really abhor the politics, business and economics of things and really just want to play the role of the healer, is being caught between a system that is cutting down costs and reimbursing doctors less, versus trying to provide quality care without being restricted by policies.
Some excerpts from the article:
 
When politicians and government officials talk about high healthcare costs, physician earnings and salary tend to be at the heart of those discussions. And yet, there are other players in the healthcare arena who earn much more than physicians- in particular, much more than primary care physicians.
At a lot of health insurance companies, hospital systems, and large academic hospitals, many chief executive officers (CEOs) earn millions of dollars per year, far exceeding what any practicing physician makes.
 
This wide gap is troubling to some doctors. They wonder what it says about the importance of clinical work, the stress of patient care, and the training needed to become a physician.
 
Researchers have pinned the average income for a CEO at a nonprofit hospital at almost $600,000, with CEOs at large networks and large teaching hospitals making much more than that. In California, for example, no fewer than 32 CEOs at nonprofit hospitals made more than $1 million per year in 2013. In addition to base pay, healthcare CEOs can make a great deal more in bonuses- and, at for-profit organizations, in stock options.
 
Does the amount of CEO pay have anything to do with raising quality of care, or even improving the hospital's bottom line? Not according to a recent study in JAMA Internal Medicine, which examined pay for CEOs at not-for-profit hospitals. The study found no significant association between CEO compensation and the hospitals' finances or these organizations' quality, mortality, or readmission rates
At the 11 largest for-profit insurers, CEOs earned an average of $11.3 million in compensation in 2013.
 
Hospitals, by contrast, haven't done as well financially as insurers have, owing to stagnant reimbursements and lower volume of inpatient services. But CEOs at the largest hospital systems, especially the for-profits, nevertheless managed to make good money- in some cases up to about $12 million
That kind of compensation raises the ire of many physicians. "An insurance company is only interested in the bottom line," said Richard M. Dupee, MD, a primary care internist in Wellesley, Massachusetts. "When I'm not paid $30 for an electrocardiogram because it's supposedly not indicated, I think of the insurance company CEO who is making millions of dollars a year."

That bitter statement is something I can relate to, when I think about the 5-20 minutes my CMA or I spend on the telephone per patient when we are trying to obtain approval from the insurance company to do a scan, even if it's something as simple and as textbook as a thyroid I123 scan in working up hyperthyroidism- needing to be passed from one person to another over the phone. Or, having some nonmedical person on the phone deny my request for a Thyrogen-stimulated radioiodine whole-body scan in a thyroid cancer patient with an unstimulated thyroglobulin of 30, because the levels were not "increasing compared to the previous". Yes, I'm referring to you, United Healthcare- of all the insurors, you disgust me the most- clearly, patient health is not your priority. But the others are just as stupid. I can't even keep track if I'm allowed to check a lipid panel every 365 days, every 335 days, every 90 days, or whatever (all of the above are different restrictions for the different health insurance companies!). So if I have a pancreatitis patient with serum triglycerides of 1200 mg/dL and I put him on insulin and a fibrate, if this was Company X, I'd have to wait a fucking year to retest him, or have him pay for the test out of pocket???
 
Another doozy- having to contact the thousands of patients of our clinics when the new year comes along and the stupid insurance decides this year to cover Novolog, and not Humalog, or that the preferred Testosterone medication is now Androderm, and not Androgel. And the fun part is the formulary often changes yearly.

All these for what reason? To "save money"- but does it lower premiums for patients? Hell no. Saving money probably gives the CEO or VP-this-or-that a higher year-end bonus.
 
It does make you bitter, feeling like you can't really do your job as a doctor, but yet someone way up there is getting paid millions, with little direct knowledge (and probably concern) of your patient and his welfare.
 
Even at a local level, to have policymakers force clinics to adopt a certain defective EHR (electronic health record), only to make sure the 'Go-live' dates was on track- never mind that the system was flawed. Or to be forced to use a certain lab for tests, even if that lab frequently messes up the test, even as simple as getting the damn gender wrong, and issuing the wrong reference ranges. Just for the sake of 'uniformity'. Not patient care or safety.
 
It's true that we always judge our self-worth to be more than what it really is; and so my personal bias when I read that article was that CEOs of healthcare systems are getting paid too much. But then again, it probably has something do to with that envy that I'm getting paid 2-5% of what the CEO is. And they say envy is a sin, no?
 
So, the option is to 1) Get an MBA and hope on the bandwagon- but I'm not smart enough, or 2) Find a new job.
 
And there are days when I'm REALLY tempted to go to option 2.