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12 Tips For Nurses And Doctors Treating Transgender Patients

Massachusetts is drafting rules that will define the transgender services insurers will be required to cover. The Association of American Medical Colleges (AAMC) has just released guidance on training doctors to treat lesbian, gay, transgender and gender nonconforming patients. And Boston University Medical School has what Dr. Joshua Safer, a professor there, says is the nation’s first transgender medicine curriculum focused on the biology of gender identity.

Dr. Joshua Safer and Dr. Jennifer Potter (Courtesy photos)

Dr. Joshua Safer and Dr. Jennifer Potter (Courtesy photos)

Like I said: brand new stuff. But what do all these new rules mean for the doctor or nurse, in an examination room, who meets their first transgender or gender-fluid patient?

Here’s some advice from Dr. Safer, associate professor of medicine at Boston University Medical School, and Dr. Jennifer Potter, associate professor of medicine at Harvard Medical School. (Dr. Potter is a co-author of the AAMC guidelines.)

1) When greeting a new patient, or one you haven’t seen for some time, you cannot assume anything about their gender identity based on the masculinity or femininity of their appearance or the timbre of their voice. To avoid making mistakes, ask each new patient how they identify, what name they prefer to be called and what pronouns they want you to use. Note: Pronouns may be male (he), female (she), they or another gender-neutral option. Continue reading

Report Shows Stark Care Disparities, More Amputations Among Black Diabetics

Dartmouth Atlas Project

Dartmouth Atlas Project

Consider this alarming statistic: The rate of diabetes-related amputations is nearly three times higher among blacks compared to other Medicare beneficiaries.

This, according to a new report from the Dartmouth Atlas Project, located at the Dartmouth Institute of Health Care Policy and Clinical Practice. This is the influential consortium that issues eye-popping reports detailing often painfully unfair regional and ethnic variations in medical care. Here are some of the findings from the report, “Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease” released today:

•Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease.

•Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. (Think Mississippi.)

•The amputation rate for black patients is seven times higher in some regions than others

•There is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. In a news conference announcing the report, Marshall Chin, MD, a leading expert on racial and ethnic disparities in health care and a professor at the University of Chicago called these types of diabetes-related amputations “entirely preventable.” “In some ways,” Chin said, “these disparities are hidden unless we look for them.” And here’s more from the Dartmouth news release:

There are significant racial and regional disparities in the care of patients with diabetes. According to a new report from the Dartmouth Atlas Project, blacks are less likely to get routine preventive care than other patients and three times more likely to lose a leg to amputation, a devastating complication of diabetes and circulatory problems…

Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease (PAD), the report found. Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. Furthermore, the amputation rate for black patients is seven times higher in some regions than others and there is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. Continue reading

‘Good Death’ Still Eludes U.S. Health System Despite Decades Of Debate

reclaimedhome/flickr

reclaimedhome/flickr

By Richard Knox

Death is back in the news again. And it should be.

Death comes to us all. And in the U.S. at least, it’s increasingly likely to be inhumane, institutional and full of misery. That’s according to a growing body of evidence, including:

•A report last month from The National Institute of Medicine called “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” It’s a 500-page indictment of U.S. end-of-life care.

•A new book by Boston writer-surgeon Atul Gawande on the subject called “Being Mortal: Medicine and What Matters in the End.”

•And recently, a must-read New York Times article — a powerful case study of how the American way of death has gone badly awry.

From these and other sources, one thing is clear: Too many Americans are still dying in hospitals and nursing homes; getting aggressive but futile care; and suffering more from the complications of treatment than from the pain of dying.

And with about 10,000 Baby Boomers turning 65 every day, it’s way past time to do something about it. “What is it going to take to ensure that patients in this country are receiving the right care at the right time in the right location, consistent with the right to choose?” Dr. Joan Teno wonders. “These are the things that keep me up at night.”

Teno, a Brown University faculty member, is among 21 authors of the recently issued Institute of Medicine report on dying in America. Continue reading

WSJ: Women At Risk, Doctors Split On Procedure Linked To Rare Cancer

Here’s another excellent Wall Street Journal report on the controversial procedure known as “morcellation.”  Reporter Jennifer Levitz notes that even after the FDA issued a warning on the practice (which involves a “laparoscopic power morcellator” that allows for less invasive surgery to remove fibroids by slicing them up, but can also potentially spread a rare type of cancer through the body) doctors are split on how to proceed.

According to the report:

The FDA said women undergoing surgery for what look like benign fibroids actually have a 1 in 350 risk of hosting an undetected cancer called a uterine sarcoma. Morcellating these tumors can spread cancerous tissue internally and significantly worsen the odds of long-term survival, the agency said.

So what are women to do when the medical community itself is divided? From the WSJ:

(wikimedia commons)

(wikimedia commons)

A number of doctors believe the FDA overreached, and think the cancer risk is so small that gynecologists can go an entire career without seeing a case. Others call the advisory a necessary precaution.

Hospitals and private practices are taking an array of approaches. The University of Pittsburgh Medical Center system, which has more than 50 obstetrics and gynecology practices, opted to continue using the device.

The medical system changed its informed-consent forms to include wording on cancer risk and told doctors to discuss the risk with patients. But Allen Hogge, chairman of obstetrics, gynecology and reproductive sciences there, questioned the data behind the FDA’s estimate. The FDA began looking at the issue after media reports late last year about a prominent Boston doctor who discovered she had sarcoma after morcellation.

“I think this is mostly public relations and not science,” Dr. Hogge said. In response, the FDA said it conducted a rigorous analysis of published literature.

The common practice of morcellation, which is often used for hysterectomies, came under fire when Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital and his wife, Dr. Amy Reed, an anesthesiologist at Beth Israel Deaconess Medical Center launched a publicity campaign aimed at stopping the procedure, Continue reading

The Global View: Lessons For Mass. Health Care From Abroad

By Dr. Jonathan D. Quick
Guest contributor

A study released last week found that insurance is saving lives in Massachusetts. Expanded coverage will mean 3,000 fewer deaths over the next 10 years. We have state-of-the-art health facilities and are among the healthiest of Americans. Despite the fiasco of our failed enrollment website, the state maintains near-universal health coverage, and inspired the Affordable Care Act.

Our example is heartening not just for America, but for the many low- and middle-income countries around the world working toward universal health coverage. These countries aren’t just taking a page from our book, though — they have valuable lessons for us, too.

Dr. Jonathan Quick (Courtesy)

Dr. Jonathan Quick (Courtesy)

Here are four things Massachusetts could learn about health from developing countries:

1. Bring health care to the community level

Community health workers (CHWs) have been a staple of health systems in developing countries like Ethiopia for decades. Community members trained in basic prevention and treatment interventions, such as oral rehydration for childhood diarrhea and family planning education, are making a big difference. Although not as specialized as doctors or nurses, they work in places where those professionals either aren’t present or are overburdened. CHWs are not only cheaper to train and deploy, but they are also trusted neighbors, who don’t require the four-hour walk necessary to reach the nearest health facility.

CHWs are now catching on in Massachusetts and other places in the U.S. In NPR’s “A Doctor’s 9 Predictions About The ‘Obamacare Era,’” an American physician predicts “A new category of health worker will flourish: the community health worker.” Few Americans face long walks to health facilities, but many face other challenges, such as mental or physical disabilities, chronic pain, lack of transportation or difficulty navigating the health system. CHWs provide low-cost outreach that helps patients deal more effectively with these barriers.

2. Make it convenient

Another approach used in global health is accredited drug dispensing outlets. When people get sick in Tanzania, their first stop is a local drug shop. Although cheaper and more convenient than seeing a doctor, they often get the wrong drug, of poor quality, and at a high price. Through training and licensing, drug sellers are able to provide live-saving treatment for common problems like malaria and childhood diarrhea at reasonable prices. Not only has this model been successful in improving access to essential medicines, but drug sellers quickly proved they could do more to improve health: advise on HIV/AIDS prevention, check symptoms for tuberculosis, and dispense some forms of contraception.

Similarly, in the U.S. programs like CVS’s MinuteClinic and Walgreens’ Healthcare Clinic are broadening the role of pharmacy services from flu shots to screening, treatment, monitoring and other basic health services. Like the accredited drug dispensing outlets, these services are more affordable and more convenient. They are a shrewd business move by the pharmacies, but also a paradigm shift in how we provide health services.

3. Generate revenue while saving lives

Developing countries have also been figuring out how to make the most of limited resources. In Mexico, a tax on soda is providing new revenue for public health — with the added bonus of reducing consumption and improving health outcomes. Continue reading

Midnight Friends: How Wired Patients Are Transforming Chronic Illness

(mic_000/Flickr)

(mic_000/Flickr)

By Nell Lake
Guest contributor

Over the years, I’ve watched my cousin Deborah Haber struggle with several chronic, painful medical conditions, including fibromyalgia and a rare incurable disorder called Ehlers-Danlos Syndrome, a connective tissue disease that causes profuse sweating, a high heart rate and insomnia, among its many symptoms.

Largely housebound, and managing the life of her 11-year-old daughter, Deborah faces social isolation and persistent pain.

But along the way, my cousin has discovered a lifeline that’s lifted her outlook and improved her health. It combines the best qualities of a mother, best friend, therapist and trusted doctor to help her cope: it’s social media.

Deborah, 39, used to lie awake at night with “agonizing, shooting nerve pain,” feeling helpless and alone. She began going online, where she found others who were also awake and in pain; they became her midnight friends. “When you cannot sleep,” she says, “and you know your kid’s going to be up in a couple of hours, and you’re going to have to get her to school on time,” even if you’re exhausted — “knowing that you are not alone is a life-saver.”

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

Early on in her social media journey, Deborah mostly used Twitter. It was through people she met there that she learned about Ehlers-Danlos syndrome. She talked with her doctor, who did her own research and sent Haber to a specialist, who diagnosed the rare congenital disease. Deborah’s online activity, then, led directly to the diagnosis, which led to “far better care.”

Clearly, Deborah’s not alone: she’s part of a large and growing group of people with chronic illness in the U.S. who are using the Internet and other online technology to take charge of and improve their own health. This goes far beyond Googling your child’s weird rash: these millions of “empowered patients” are joining social-media communities, consulting online health databases, learning and sharing knowledge about drug side effects, crowdsourcing research studies, electronically monitoring their health and becoming health care activists who share what they’ve learned with their doctors.

Online patients with chronic illness use social media to improve both mental and physical health and to better connect with an understanding community, says Jennifer Covich Bordenick, chief executive officer of eHealth Initiative, which published a study earlier this year on patients’ social media patterns.

“It’s really incredible, if you look at what social media is allowing patients…to do right now,” she says. “It’s providing tremendous access to support, information, and it’s connecting people in a way that they haven’t been able to do before. … People with chronic illness are more motivated. … There’s an urgency there.” Continue reading

The Lowdown On ‘Low T': Men’s Health Craze Booming Despite Risks

NPR reports that sales continue to soar for prescription testosterone to treat men plagued by low energy and a sluggish sex drive even while doctors fret over risks:

The number of testosterone prescriptions written in the U.S. more than tripled in the past decade. But researchers suspect that much of the testosterone dispensed at low-T clinics isn’t tracked, since it’s often bought with cash. This unfettered flow of testosterone — officially a controlled substance — has raised concerns among doctors who specialize in hormonal problems.

“In most doctors’ offices, you don’t see a big shingle over their door saying, ‘Get your testosterone here!’ ” says Dr. Edward Karpman, a board certified urologist and the medical director of the Men’s Health Center at El Camino Hospital in Los Gatos, Calif. Karpman says low-T clinics aren’t in the business of treating the complex medical problems that often masquerade as low energy and decreased sex drive. Those can include sleep apnea, depression and, perhaps most importantly, heart disease.

(Linden Tea/flickr)

(Linden Tea/flickr)

“Any man who presents, especially in his 40s and 50s, with new onset erectile dysfunction is at an increased risk for cardiovascular disease and even heart attack or myocardial infarction,” says Karpman.

Hormone treatment itself isn’t without risk: A recent study of more than 55,000 men found a doubling of heart-attack risk among older men who used testosterone. Younger men who had a history of heart disease had a higher incidence of nonfatal heart attacks. In addition, men who are on prolonged high-level testosterone replacement therapy can experience testicular shrinkage.

Earlier this year, WBUR’s Tom Ashbrook highlighted the risks of prescription testosterone and explored the meteoric rise of the ‘Low T’ diagnosis. Continue reading

My Mother’s Surgery And One Doctor’s Substance Abuse

By Karen Shiffman
Guest contributor

USA Today reports more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction. This wasn’t news to my family.

Some 20 years ago, my mother was mauled by a dog. She was on vacation in Florida and went over to a friend’s house for dinner. To understand what happened next, you need to know a few crucial facts about her: She is afraid of dogs and barely five feet tall. When her friend opened the front door, her daughter’s dog — an Akita- tore out of the house and lunged . My mother turned away quickly. The dog lunged again. Because of her short stature, his teeth sunk into her calf. He all but ripped it off.

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

Blood everywhere. Screams. Tears. Ambulance. Thirty-nine stitches at the ER. She would need a skin graft.

And then there was the drama with the friend. Turns out, this wasn’t the first time the dog had bitten someone. Still, the family didn’t want the dog put down. Eventually, he was. My mother and her friend of 30 years never spoke again.

Back home in Boston, my mother was referred to a plastic surgeon at what is now Beth Israel Deaconess Medical Center. He was kind and I agreed with my mother that he should do the surgery.

The operation went well. I went with her to the post-surgery checkup. We both thanked the surgeon for doing such a great job and for taking such good care of my mother.

So, imagine my shock, in 2008, to read in The Boston Globe that my mother’s surgeon was fired for being impaired in the OR. And that he had been struggling with substance abuse for the past six years. Continue reading

Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Dr. Dan Alford

Dr. Dan Alford

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients. Continue reading

Circumcision Boost: Study Cites Benefits, Notes Foreskin-Related Health Problems

New findings may offer a boost to proponents of newborn male circumcision: Researchers in the U.S. and Australia report that the health benefits of undergoing the procedure “exceed the risks by over 100 to 1,” and note that “over their lifetime, half of uncircumcised males will contract an adverse medical condition caused by their foreskin.”

The review, published online in the Mayo Clinic Proceedings, bolsters the position of mainstream physician groups, such as the American Academy of Pediatrics, which supports insurance coverage of the practice and full access for families who choose circumcision for their infants. But the new report is unlikely to silence critics of the practice, who have called it “insane” and a “disservice to American parents and children.”

Here’s some context, from the study, which shows a slight increase in circumcision among older men, but a decline among newborns:

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

“The latest data on male circumcision in the United States show a 2.5% overall increase in prevalence in males aged 14 to 59 years between 2000 and 2010. In contrast, there has been a downward trend in neonatal circumcisions, with the present analyses finding that the true extent of this decline is 6 percentage points.”

And here’s more from the news release:

Whereas circumcision rates have risen in white men to 91%, in black men to 76%, and in Hispanic men to 44%, the study authors found an alarming decrease in infants. To get the true figures they had to correct hospital discharge data for underreporting. This showed that circumcision had declined from a high of 83% in the 1960s to 77% today.

There seemed to be two major reasons for the fall.

One is a result of demographic changes, with the rise in the Hispanic population. Hispanic families tend to be less familiar with the custom, making them less likely to circumcise their baby boys.

The other is the current absence of Medicaid coverage for the poor in 18 US states. In those states circumcision is 24% lower. Continue reading