Friday, October 20, 2017

The View from Here

The View from Here

One of my other lesser known blogs is "The View from Here".  My topics there are in a slightly different realm.  I was reviewing it last night and came across several germane topics for Health Train Express.

When the Doctor Doesn’t Look Like You (or me)

So, your doctor doesn't look like you ?  Don't sweat it !

For more than 50 years, international medical school 
graduates have filled the gaps in the physician work force
 in the United States. Currently, they make up fully 
one-quarter of all practicing physicians, and 
although a majority 
are foreign-born, approximately 20 percent are 
American citizens who have chosen to go abroad, most 
notably to the Caribbean, for medical school.
Regardless of whether they are United States citizens, 
all international graduates must go through an arduous 
regulatory process before practicing in this country, a 
process that includes verification of medical school 
diplomas and transcripts, residency training in 
American hospitals and the same national three-
part licensing exams and specialty tests that their 
medical school counterparts in this country take. 
Many go on to choose specialties or work in the rural 
and disadvantaged geographic locations that their 
American counterparts shun. International graduates, 
for example, now account for nearly 30 percent of all 
primary care doctors, a specialty that has had increasing 
difficulties attracting American medical 
Now researchers from the Foundation for Advancement of
 International Medical Education and Research in 
Philadelphia have published the first study incorporating 
new research methods for evaluating the performance 
of large groups of physicians. And it turns out that contrary 
to certain individuals’ worst fears, accent or nationality 
did not affect patient outcomes. Rather, the main factor 
was being board-certified: completing a full residency at an 
accredited training program, passing written and, depending 
on the specialty, oral examinations, and having proof of 
experience with a defined set of clinical problems and technical 

Foreign medical graduates also tend to 'cluster' choosing to practice in like minded communities, Asian, Phillipino, Latino, Jewish, and other minorities. These demographics also tend to refer internally when possible.

Racial prejudice exists even in health care.

Teaching Doctors the Art of Negotiation - The New York Times

Doctors negotiate every day, almost constantly — sometimes dramatically, often imperceptibly. They hold family meetings to resolve sensitive end-of-life issues. They address barriers to medication adherence. They encourage patients to receive uncomfortable screenings like colonoscopies and mammograms. They refuse treatments that are requested but not medically indicated. Yet they receive almost no formal instruction in how to do so.
Dealing with medical colleagues creates an additional layer of negotiating complexity—especially in busy academic centers with competing demands on specialists’ time. Medicine is increasingly a team sport. In 1970, only about 2.5 full-time clinical staff cared for the average hospital patient; today, that number is greater than 15.
Doctors consult other doctors many times a day to discuss potential treatment options and decide on the best course of action. They work closely with residents, students, nurses, physician assistants, care coordinators and others to implement those plans. At each interaction, opportunities for collegiality and efficiency — or rancor and resentment — abound. That can mean the difference between a timely or delayed blood draw, accepting or refusing a consult, or getting those biopsy results today versus tomorrow.
Recognizing the importance of negotiation, medical schools are starting to invest in communication training for students — and it seems to be paying off. Research suggests communication training can improve patient adherence, diagnostic accuracy and chronic disease management. But good communication, by itself, is only part of the solution. We need to teach doctors how to negotiate.
Negotiation, in this context, is not about winning or losing, or haggling over price or scare resources. It’s about exploring underlying interests and positions to bring parties together in a constructive way. It’s about creative, innovative thinking to create lasting value and forge strong professional relationships. It’s about investigating what is behind positions that may seem irrational at first to understand the problem behind the problem.
The medical profession is no longer one in which doctors dictate a given treatment course to patients, who are then expected to follow it. Rather, clinicians and patients deliberate about treatment options, weigh costs and benefits together, and determine the best course of action. This approach requires eliciting patient concerns and addressing underlying fears to arrive at the most effective strategy for maximizing health and well-being. As diseases like H.I.V. and some cancers that were once uniformly fatal become chronic conditions, and a greater diversity of treatment options becomes available, the ability to negotiate long-term care plans will only grow in importance.

Healthcare Stole the American Dream - Here’s How We Get it Back | Dave C..., Bay Area Cancer Patient.. 

Health Train Express   Remove
17 hours ago  .  Save  .  Twitter  .  Facebook
Healthcare Stole the American Dream - Here’s How We Get it Back |   TEDx TalkThanks to Rob Lambert M.D. a pioneer in direct primary care for bringing this to m.. Read More →

Something all patients should know if you live in California and five other states, Oregon,  District of Columbia,Vermont, Washington and California. It is an ..Read More →
20 hours ago  .  Save  .  Twitter  .  Facebook
Doctors giving regular checkups will get the most bang for their buck if they advise adults to quit smoking, convince teens to never start, and keep children 

Sunday, October 15, 2017

The American Health System is Shameful

Steve Grocott
Steve Grocott, Political insider /investor / businessman

Saturday, October 14, 2017

The Revised Declaration of Geneva: The Modern-Day Physician’s Pledge

A newly revised version of the Declaration of Geneva was adopted by the World Medical Association (WMA) General Assembly on October 14, 2017, in Chicago.

As the contemporary successor to the 2500-year-old Hippocratic Oath, the Declaration of Geneva, which was adopted by the World Medical Association (WMA) at its second General Assembly in 1948,1 outlines in concise terms the professional duties of physicians and affirms the ethical principles of the global medical profession. The current version of the Declaration, which had to this point been amended only minimally in the nearly 70 years since its adoption, addresses a number of key ethical parameters relating to the patient-physician relationship, medical confidentiality, respect for teachers and colleagues, and other issues. A newly revised version adopted by the WMA General Assembly on October 14, 2017, includes several important changes and additions (Supplement).
  • I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
  • THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
  • I WILL RESPECT the autonomy and dignity of my patient;
  • I WILL MAINTAIN the utmost respect for human life;
  • I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
  • I WILL RESPECT the secrets that are confided in me, even after the patient has died;
  • I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
  • I WILL FOSTER the honour and noble traditions of the medical profession;
  • I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
  • I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
  • I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
  • I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
  • I MAKE THESE PROMISES solemnly, freely, and upon my honour.
For 2500 years The Hippocratic Oath has been referenced as the 'gold standard' of medical ethics.  


I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Ethical Principles for Medical Research

The Revised Declaration of Geneva: The Modern-Day Physician’s Pledge | Law and Medicine | JAMA | The JAMA Network

Wednesday, October 11, 2017

Predict Asthma Conditions using an App

Propeller launches API that predicts local asthma conditions

“Smart inhaler” player Propeller Health is rolling out an application programming interface (API) that provides information on local asthma conditions.
The service, dubbed Air, uses machine learning to analyze millions of days of anonymized asthma-related data to forecast the potential effects of the local environment on people’s breathing, Propeller said in a statement. These data include when people have asthma symptoms and the environmental conditions at the locations and times they have symptoms.
Propeller markets a sensor that attaches to an inhaler and tracks where a patient uses his or her inhaler. The sensor then transmits this data via Bluetooth to a smartphone, where an app analyzes where, when and why a patient took his or her medication.

GlaxoSmithKline and Propeller Health are expanding their R&D partnership, inked in 2015, into a commercial one, under which both companies will be able to commercialize Propeller’s digital respiratory health management system for use with Glaxo’s Ellipta inhaler.
Propeller’s platform includes a sensor that attaches to various inhalers and tracks when patients take their medication. These data are sent via Bluetooth to a smartphone app, which uses machine learning to help patients and physicians better understand what may be causing asthma or COPD symptoms.
In December 2015, Propeller signed on to create a custom sensor for GSK’s Ellipta inhaler, to be used in clinical studies of asthma and COPD. A year later, the company notched an FDA clearance for the use of its platform with Ellipta, its eighth FDA clearance.

"We are excited to be working closely with GSK to make the sensor for the Ellipta inhaler available in our commercial programs, and for the first time, as part of commercial pilots with GSK outside the US," said Propeller CEO David Van Sickle in a statement. "Companion digital experiences simplify and personalize the management of chronic respiratory disease, and help ensure individuals and their physicians realize the benefits of inhaled medicines."

Revolutionizing the Delivery of Care for ED Patients

In the 7 years since the passage of the Affordable Care Act, the number of Emergency Department (ED) visits has steadily increased while the number of EDs has fallen —  resulting in increased pressure on hospitals. Consequently, health care systems find themselves challenged to develop innovative ways of accommodating this growing volume while still providing high-quality and efficient medical care. The surge in smartphone use, combined with the advancement of provider-focused telehealth capabilities, has created an opportunity for systems to leverage technology in service of these goals. Today, the American Telemedicine Association reports that there are currently 200 active telemedicine networks, with over half of U.S. hospitals now using some form of telemedicine.

This is the context in which NewYork-Presbyterian (NYP) and Weill Cornell Medicine jointly launched their cutting-edge Emergency Department Telehealth Express Care Service (ECS). This innovative program has enabled us to provide a much better experience for low-acuity patients presenting to the EDs at NewYork-Presbyterian/Weill Cornell Medical Center and NewYork-Presbyterian/Lower Manhattan Hospital. Building upon this success, NYP has recently expanded ECS to the Columbia-affiliated NewYork-Presbyterian/Columbia University Medical Center and NewYork-Presbyterian/Allen Hospital campuses, and similar expansions at the NYP regional hospitals are expected in the coming months.

NYP OnDemand ED Express Care Service
This was the context in which we conceived and launched the ED Telehealth Express Care Service for low-acuity patients presenting to the ED. To operationalize this program, we first identified the conditions that would be amenable to treatment via telehealth, including minor rashes, sprains and contusions, upper respiratory infections, wound checks, suture removals, and tetanus immunizations. Next, we developed our workflow: after an initial RN triage and medical screening exam by a physician assistant or nurse practitioner, qualifying ED patients are offered a real-time video visit with one of our board-certified Emergency Medicine faculty physicians.

This ECS consultation is conducted in a private patient room with comfortable lounge chairs and a monitor, and the patient is connected to a physician located in a separate room. Patients are interviewed by the physicians remotely while they are in the private room and then directly discharged from the room. Discharge paperwork is printed directly in the room and prescriptions are called in electronically to the patient’s pharmacy. Importantly, the remote physician covers both Express Care sites, offering us economies of scale by having a single “server” for multiple queues.

This has been a pilot program at NYP and is undergoing evaluation for effectiveness, cost and reimbursement issues.  At this time the visit is billed as an ED event, which reimburses greater than a telemedicine or office visit.

This usage of telehealth is a unique application of telemedicine.  A single telehealth physician could evaluate patients from many different EDs.

Tuesday, October 10, 2017

The Future of the Neurologic Examination | Medical Education and Training | JAMA Neurology | The JAMA Network

Has the development of high tech obsoleted the neurologic physical examination?  

Michael J. Aminoff, MD, DSc, FRCP1
JAMA Neurol. Published online October 2, 2017. doi:10.1001/jamaneurol.2017.2500

The development of precision medicine, gene therapies, advanced imaging techniques, novel monitoring systems, ingestible or injectable sensors, and remote medical care (telemedicine) is leading to remarkable changes in health care. But the increasing ability to deliver care remotely will also reduce physical interactions between physicians and patients, with implications that have barely been explored.

There is no doubt that the art of the neurologic examination is already being lost, as some of these advances come to supplant rather than complement the clinical examination. Indeed, the modern trainee neurologist can perhaps be pardoned for wondering about the place of the clinical examination when, for example, magnetic resonance imaging or computed tomography can detect, localize, and provide prognostic information about a central lesion in just a few minutes and genetic studies can diagnose certain disorders regardless of the clinical findings. The neurologic examination requires time, patience, effort, and expertise and may have to be performed in difficult or unpleasant circumstances, whereas an imaging or laboratory study simply requires completion of a request form and the responsibility is passed to a colleague. Why, then, examine the patient?

This gradual technical change will cause a paradigm shift for authorization of high cost imaging studies which have for to with required an A-OK from insurance companies. It makes sense when it comes to accuracy and the speed of correct diagnosis.
Implantable Vagus Nerve Stimulation for Epilepsy
This is also true of other organ systems, where imaging and/or genetic testing are used.

The Future of the Neurologic Examination | Medical Education and Training | JAMA Neurology | The JAMA Network

Public Health Issue: Epidemics, blame the Smartphone

I resisted buying a smartphone until about two years ago.  All my sons have had them for 10 years or more.  No they did not have them when they were three or four.  My eldest son bought an iPhone when he was 18.  ( I couldn't afford one, with 3 in college.

My first was a prepaid LG which was a month to month...These phones are all cheaply made, with poor screens, inadequate memory and other issues I do not fathom. I found one for $125 with a monthly fee of $45.00 The idea of having a contract appealed less to me than paying  $125 dollars or more for a 'bundled cable/internet/phone service.  

By now my brother had an iPhone, Macbook and iMac.  My son had traded up twice with his iPhone and also a Macbook. Two of my sons are computer scientists . I cautioned them about the technical of DUI (of smartphones).I doubt they listen to me.  It is equivalent to having 2 or 3 alcoholic drinks or having an open bottle in the car.

Suggestions for safer us of your smartphone

The smartphone has insidiously crept into our lives, much like antibiotic resistant bacteria. It can be found in our toilet areas, and other private spaces. No longer do hormonally gifted girls and boys flirt with a wink, they can do it electronically or even more boldly with suggestive photos. How does one use "protection" in such a situation?

Like any opiod it soothes and eases pain and eventually is an addiction. The temptation was too great   I caved, at first trying an was not so great !. I opted for the latest greatest most expensive Galaxy S8+.   Then I perseverated over cases and protectors.!  Another story and not worth explaining here to my entrapped audience.

Along with my own opinions I found several articles written about the subject. Andrew Doan, M.D., PhD in neuroscience and fellow ophthalmologist has done research into video game and internet addiction, discussing the role of endorphin release in users of videogames and the like.

Associated literature (from PubMed)

Tendon rupture associated with excessive smartphone gaming.



Excessive use of smartphones has been associated with injuries.


A 29-year-old, right hand-dominant man presented with chronic left thumb pain and loss of active motion from playing a Match-3 puzzle video game on his smartphone all day for 6 to 8 weeks. On physical examination, the left extensor pollicis longus tendon was not palpable, and no tendon motion was noted with wrist tenodesis. The thumb metacarpophalangeal range of motion was 10° to 80°, and thumb interphalangeal range of motion was 30° to 70°. The clinical diagnosis was rupture of the left extensor pollicis longus tendon. The patient subsequently underwent an extensor indicis proprius (1 of 2 tendons that extend the index finger) to extensor pollicis longus tendon transfer. During surgery, rupture of the extensor pollicis longus tendon was seen between the metacarpophalangeal and wrist joints.


The potential for video games to reduce pain perception raises clinical and social considerations about excessive use, abuse, and addiction. Future research should consider whether pain reduction is a reason some individuals play video games excessively, manifest addiction, or sustain injuries associated with video gaming.

Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports.


Traditional factors that once explained men's sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brain's motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography's unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use. In the interim, a simple diagnostic protocol for assessing patients with porn-induced sexual dysfunction is put forth.

Excessive Video Game Use, Sleep Deprivation, and Poor Work Performance Among U.S. Marines Treated in a Military Mental Health Clinic: A Case Series.


Excessive use of video games may be associated with sleep deprivation, resulting in poor job performance and atypical mood disorders. Three active duty service members in the U.S. Marine Corps were offered mental health evaluation for sleep disturbance and symptoms of blunted affect, low mood, poor concentration, inability to focus, irritability, and drowsiness. All three patients reported insomnia as their primary complaint. When asked about online video games and sleep hygiene practices, all three patients reported playing video games from 30 hours to more than 60 hours per week in addition to maintaining a 40-hour or more workweek. Our patients endorsed sacrificing sleep to maintain their video gaming schedules without insight into the subsequent sleep deprivation. During the initial interviews, they exhibited blunted affects and depressed moods, but appeared to be activated with enthusiasm and joy when discussing their video gaming with the clinical provider. Our article illustrates the importance of asking about online video gaming in patients presenting with sleep disturbances, poor work performance, and depressive symptoms. Because excessive video gaming is becoming more prevalent worldwide, military mental health providers should ask about video gaming when patients report problems with sleep.
The evidence is strong that persistent use of many types of electronic devices may be addictive and contributory to multiple disorders, even extending to traumatic injury.