Latest news with #physician
Medscape
16 hours ago
- Health
- Medscape
Supplemental Oxygen Therapy: Tailor to Your Patient's Needs
Nothing captivates patient (or physician) imagination quite like oxygen. Its power and necessity are considered self-evident. Also a given is the need for saturation to be 90% or above. It's a nice round number, and we're taught early on it's the tipping point on the sigmoidal hemoglobin curve. No one wants to be caught on the steep portion. So, the floor nurse sneaks a nasal cannula onto your patient at night, and the intern walks them wearing a pulse-ox before discharge. At $2 billion per year for oxygen, we have a problem. JAMA recently published a 'patient-centered' oxygen review. It's excellent reading. Table 1 summarizes studies of patient and caregiver feedback on oxygen use, and Box 1 provides an individual patient narrative. The described experience and related complaints are painfully familiar to anyone caring for a patient on oxygen. There isn't any 'news' here, and others have called for oxygen reform. The review highlights the evidence — or lack thereof — and is notable for its practical depiction of oxygen devices, durable medical equipment (DME) companies, and overall oxygen logistics. I regularly receive emails from the American Thoracic Society (ATS) oxygen interest group asking for feedback to help support passage of the Supplemental Oxygen Access Reform Act. I can't speak to the substance of the act, but — per its proponents — it's designed to achieve what the JAMA review advocates: oxygen reimbursement and supply tailored to individual patient needs. Great. There are things we healthcare providers can do now, though. De-implementation (or deprescribing) is critical to cost efficiency, but it's a distant second to not ordering oxygen at all. Outside of the mortality benefit for those with resting hypoxia, outcomes from oxygen prescriptions range from inconsistent to nonexistent. So, to start, if your patient does not have resting hypoxia, think twice (or perhaps three times) before walking them or doing an exercise test. This brings us to the walk-of-life prior to hospital discharge. The resulting ambulatory oxygen prescription is meant to be 'short-term,' but it is rarely so. More often, it's a gateway drug, driving long-term prescriptions and patient dependence. This is well recognized, and both the ATS and CHEST College list deprescription as part of the their 'Choosing Wisely' campaign. Therapeutic overconfidence and time constraints, along with psychological patient dependence, conspire to prevent it. Discharge is typically handled by general medicine clinicians, house staff, or advanced practice healthcare providers, none of whom are comfortable withholding therapy from someone who desaturates with ambulation. However, to quote an old adage from The House of God , 'if you don't take a temperature, you can't find a fever.' If you don't walk your patient before discharge… I'd take the same approach to nocturnal hypoxia. The Centers for Medicare & Medicaid Services (CMS) reimbursement for desaturation at night is a modern-day medical mystery. The data isn't there and there aren't guidelines recommending it. Past reviews have argued against screening or prescribing. Anecdotally, I see this less now; but again, if you eliminate reimbursement. I'm confident it won't be seen at all. Lastly, there's oxygen education to improve health literacy. This is critical but it's a heavy lift. It takes time and resources, and both are in short supply. The JAMA review recommends an oxygen specialist to shepherd the anaerobe through the DME gauntlet. If only the authors could help me pay for one. Maybe I can negotiate with CMS myself. I'll stop ordering nocturnal and ambulatory oxygen supplementation. With the savings generated, CMS will pay for a respiratory therapist to do deprescription and DME navigation. Now that's choosing wisely.
CBC
5 days ago
- Health
- CBC
Virtual doctors to help keep ER open in Hay River, N.W.T., until next week
New 'Limited' physician coverage at health centre until next Thursday, says local health authority Remote doctors will help provide care at the health centre in Hay River, N.W.T., until late next week to keep the emergency department open amid a shortage of on-site physicians, says the Hay River Health and Social Services Authority. In an update posted to Facebook Thursday afternoon, the authority said it would keep the emergency department open from July 17 to 24, with "limited" physician coverage and support from nurses and virtual doctors. The authority described virtual doctors in its release as licensed health-care professionals who provide remote care and can do things like carry out assessments and give prescriptions. "They work closely with on-site staff to ensure continuity of care," the authority said. "Residents are asked to be mindful that wait times may vary depending on physician availability and patient volumes." People are still asked to call 911 if they have an emergency. This is not the first time the authority is relying on virtual doctors. In April, it said it would go without an on-site doctor at the health centre for nearly a week. At the time, it said patients needing a doctor would be connected to one virtually or they would be medevaced to Yellowknife or Edmonton if needed.
Medscape
5 days ago
- Health
- Medscape
On Retiring From the Practice of Medicine
Last week, I retired from practicing medicine. My medical work stopped 3 years ago, but now retirement is official. To retire, all I had to do was submit a one-page form to my state medical licensing board: name, address, email, and two boxes to check. One said that my patient records would remain accessible. The other affirmed, 'I am not aware of any open or reasonably anticipated complaints to the Board against me.' (Complaints about any physician can be submitted by email, so the most a doctor can promise is that nothing is 'reasonably anticipated.') I had decided not to renew my license this year, to avoid fees and continuing education requirements. My first medical license was issued over 50 years ago, when I was an intern. For 42 of those years, I practiced medicine in my own office. The end of my office work was sudden. I had already cut back working hours when COVID struck. On Friday, March 13, 2020, I left my office and never came back. At first, I stayed in touch with staff by phone and saw patients online a few hours a week. That was frustrating and almost useless. Remote technology back then was poor, and the visits achieved little. Some professionals who retire wonder whether doing so will cause them to lose their identity. I have found that what identity I had seems to still be there. Practicing medicine was a great privilege. Being able to help, guide, or reassure people in their times of need struck me then, and strikes me now, as a most worthy way to spend one's working life. I regret none of it. I just don't want to do it anymore. Consulting with patients, I met many people I would never have otherwise come across. They hailed from towns nearby and from countries around the world. Many shared stories I had never heard, some of which I could not have imagined. In this way, I got to know my patients, at least a bit. Over time, I grew to know some of their children, even their grandchildren. There were times when getting to know them, what they did, how they thought, had a direct impact on managing their medical condition. Most often it did not. Still, it always seemed to me that caring for people is better done if you know them, at least to some extent. Through the years, nothing changed my mind about this. Throughout, I remained grateful for the efforts patients had to make to see me. They fought traffic, scrounged parking, struggled with officialdom over referrals, sat in my waiting room, all for the honor of hearing what I had to say. To the end, I never stopped wondering whether what I had to offer was worth their effort. I would like to think that, at least for many, it was. Looking back, the practice of dermatology, and of medicine in general, has of course changed a great deal. The big change in dermatology has been the emphasis on cosmetic work, which was not part of what dermatologists did when I started out. Lasers and cosmetics have lent our profession more glamour, and for many who practice it, a different emphasis. Cosmetic clients ask different questions and have different expectations from patients with purely medical concerns. I got involved a bit with cosmetic dermatology before I really understood what it entailed, but my heart was never in it. Cosmetics remained a small part of what I did. The big change in medical practice in general is the ubiquity of electronic medical records (EMRs). The advantage these offer dermatology is the ease with which photographs and other visual records can be incorporated into visit notes. These offer much-needed precision in identifying and following lesions that was unavailable in the old days of scribbled paper charts. EMRs have of course also changed the texture of practice life, demanding hours of record-keeping drudgery, much of it in the service of recording data of dubious significance. The third change worth mentioning is the acceptance, by the medical profession and the public, of mid-level providers, nurse practitioners and physician assistants (PAs). I worked with PAs for 20 years. Their competence, and interest in traditional medical dermatology, was a source of much professional satisfaction for me and of great value to my patients. Retirees I met, among my friends and patients, sometimes told me they were unhappy, not because they missed their work but because they missed the people they had worked with. In medicine, those are staff and colleagues. They share an intimate knowledge of the small charms and frustrations that fill working days: the cranky gent who sends the staff flowers; the insurer who will not cooperate; the regular patient who cannot manage to show up on time, or at all. As I mentioned, many of my own colleagues were PAs whom I trained myself and worked alongside for years or decades. All were capable; one was extraordinary. At times, she and I shared a heart-to-heart about the work we did together and how we felt about it, what it was like to live with a sense of unending responsibility, challenged at times by spasms of self-doubt. What if we had not offered advice in a way the patient could accept? What if well-laid plans did not turn out well, or if our suggestions seemed on reflection to be ill-advised or just wrong? Life offers few chances to have fully honest talks like those, with someone who truly understands, on matters that cut to the core of the soul. I will cherish with gratitude the memory of those discussions. Some people who think about retiring worry about needing to endure going-away parties. Along with food and drink and perhaps a parting gift or memento come speeches and sentiment, which may spill over into sentimentality. If such are the rites of passage for leaving an office, what must they be like for leaving a profession? While recall is fresh, I can share my own experience. The acceptance of my application for retirement status came by email:
Russia Today
5 days ago
- Health
- Russia Today
White House explains Trump's swollen ankles and bruised hand
The White House has released a memo from President Donald Trump's physician explaining recent visible changes in his limbs, which some observers had taken as indicators of a serious health condition. In a memo issued Thursday, Dr. Sean P. Barbabella said Trump has been diagnosed with chronic venous insufficiency, a condition he described as 'benign' and common among people over the age of 70. Trump, 79, was recently seen with swelling in his legs, which Dr. Barbabella attributed to the condition. Chronic venous insufficiency is typically age-related and involves malfunctioning of one-way valves in the veins, which are responsible for returning blood to the heart. The legs are often affected because the veins there must work harder against gravity. People who spend extended periods standing are more susceptible to the disorder. According to the statement, no signs of more serious vascular conditions – such as deep vein thrombosis – were found. Barbabella also explained that recurring bruising on the back of Trump's right hand was the result of 'soft tissue irritation from frequent handshaking' and preventive aspirin use. Swollen ankles at the World CupBruised hand at today's press availability. Is the Trump administration hiding the President's health? Where is @jaketapper? While swelling in Trump's ankles gained attention last week, the bruises on his hand have been visible since at least October, fueling speculation that he was undergoing intravenous treatment. Trump and his staff have repeatedly said the marks are due to vigorous handshaking. Many senior US officials are of advanced age. Critics argue that the country's political system favors seniority and has effectively turned into a gerontocracy. President Joe Biden's age became a major campaign issue during last year's presidential election. His aides were accused of hiding signs of cognitive decline to keep him in the race. Biden dropped out of the campaign less than four months before Election Day after a disastrous debate performance against Trump.
Irish Times
5 days ago
- Health
- Irish Times
What is chronic venous insufficiency? Donald Trump diagnosed with condition
Donald Trump was diagnosed with chronic venous insufficiency, the White House said on Thursday, after he noticed swelling in his legs. The White House released a memo from the president's physician, Sean Barbabella, who said a medical examination revealed no evidence of a more serious condition such as deep vein thrombosis. 'The president underwent a comprehensive examination, including diagnostic vascular studies. Bilateral lower extremity venous Doppler ultrasounds were performed and revealed chronic venous insufficiency, a benign and common condition, particularly in individuals over the age of 70,' the memo said. It is a fairly common condition among older adults, but requires a thorough check-up to rule out more serious causes of swelling in the legs. Here are some things to know. READ MORE Chronic venous insufficiency, or CVI, happens when veins in the legs cannot properly carry blood back to the heart. That can lead to blood pooling in the lower legs. In addition to swelling, usually around the feet and ankles, symptoms can include legs that are achy, heavy-feeling or tingly, and varicose veins. Severe cases could trigger leg sores known as ulcers. Overcoming gravity to pump blood from the feet all the way up to the heart is a challenge, especially when someone is standing or sitting for long periods. So legs veins are lined with one-way valves that keep blood from sliding backward on that journey. Anything that damages those valves can lead to chronic venous insufficiency. Risk factors can include blood clots, vein inflammation known as phlebitis or being overweight. Doctors must rule out serious causes of leg swelling, such as heart problems, kidney disease or blood clots. Ultrasound exams of the leg veins can help confirm chronic venous insufficiency. According to the Cleveland Clinic, treatment can include wearing compression stockings, elevating the legs and achieving a healthy weight. Also exercise, especially walking, is recommended – because strong leg muscles can squeeze veins in a way that helps them pump blood. Medications and medical procedures are available for more advanced cases.
