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It was only a matter of time until health costs in the U.S. rose so high that we would outsource health care. That time is here.

WellPoint, the nation’s largest health benefits company has announced a new product that allows its patients to travel to India to receive care. Starting in January, 2009, “members planning to undergo certain procedures can enjoy access to an extended network of respected hospitals and health care providers in India. By electing to use the international benefit, members can receive care at accredited facilities at lower out- of- pocket costs that could result in thousands of dollars of savings.”

They go on to say a dedicated case manager will coordinate all medical arrangements, including scheduling and concierge travel services. All travel arrangements are booked and paid for, for both the member and a traveling companion. The case manager also arranges any post operative follow up care.

Certain medical tourism facilities in India and Thailand have quality outcomes that rival the United States. Their doctors are trained at fine institutions like Harvard and Johns Hopkins.
The facilities are accredited (without all of the unnecessary United States bureaucracy that drives up costs).

How do they do it? They have less government interference, practically no lawsuits, lower cost structures, no unions, low wages and better customer service.

You may not like it, but that is a fact.

How about a vacation and a knee replacement?

My daughter purchases her own insurance. As a healthy young lady she spends $560/month (up from $375 in 2007) for a policy with $8000 deductible a year. She has already fulfilled her deductible this year (paid the first $8K) and had good coverage for her recent pregnancy and childbirth.

She understood the baby was covered for the first 30 days under the mom’s policy. Well…yes the baby is covered but there is another $2500 deductible for the baby as well as $7500 annual co-pay before the baby is covered for hospitalization. That adds up to $10K for the baby to be covered for the first 30 days.

After 30 days, the premium will be $995/month for healthy mother and baby.

Enough said?

Anyone who reads EverythingHealth or many other health blogs (Kevinmd, Maggie Maher, Dr. Rob, Dr. Val, Happy Hospitalist to name a few) knows that primary care physicians are a dying breed. Everyone talks about the money (painfully low reimbursement) as the cause, but equally annoying is the LACK OF RESPECT for the specialty.

Repeatedly I run across doctors who have no training in Family Medicine or Internal Medicine who say “Oh, I’ll just be a primary care doctor.” One doctor is an 86 year old surgeon who was denied operating privileges so he’s going to “be a primary care doctor.” He did surgery training in 1948.

Another doctor hasn’t ever seen a live patient and he originally trained in Pathology and has done only laboratory work. He is moving to Hawaii to be a “primary care doctor.”

Another has been a hospital administrator for years but want’s to “see patients again” so he is going to do “primary care 1/2 day a week.”

Give me a break! This is not a specialty you can drop in and out of as a hobby.

There is a severe lack of understanding about primary care medicine and the medical specialties of Family Medicine and General Internal Medicine. Each of these specialties requires years of residency after internship and continued medical education and exams for board certification status.

A tremendous body of knowledge is needed to be a primary care physician. One must have diagnostic acumen, know all treatment modalities, have skills in psychology, inherent common sense, knowledge of medical economics, a vast knowledge of pharmacology and hundreds of drug interactions. Primary care physicians must keep up with all of the medical literature and current evidence to be at the top of their game.

I’ve practiced non-stop for over 20 years and I am still challenged by patient care. Even though I could probably deliver a baby or remove an appendix or even amputate a limb if I were stranded on a desert island, I would never be so bold as to think I could drop in and out of those specialties and render good patient care.

Unfortunately the shortage of REAL primary care doctors means the field is wide open to anyone who wants to hang out a shingle and give it a try.

Britney Spears two-year-old son, Jayden, was rushed to the hospital with an allergic reaction yesterday. The tot was admitted for an overnight stay and observation after he developed hives, itchy skin and irritability. A rep for the family reported, “Doctors concluded he had a reaction to something he ingested”. He was released from the hospital in good condition today.

Most of the time, in food related allergic reactions, it is difficult to pinpoint the causative agent without further testing. The most common symptom is a flushed feeling, accompanied by a hive like rash (urticaria), tingling redness of the skin and palpitations and anxiety. Most reactions are self-limited and resolve by themselves or with the addition of anti-histamine medication.

Rarely a serious reaction can cause anaphylaxis and individuals who have asthma in addition to food allergies may be at increased risk for having a life-threatening anaphylactic reaction to food.

Signs of anaphylaxis include skin symptoms or swollen lips accompanied by difficulty breathing or reduced blood pressure. Abdominal cramps or vomiting, accompanied by difficulty breathing or wheezing can be signs of anaphylaxis and the patient should have immediate medical attention. Common causes of anaphylaxis include food, medication, insect stings or latex.

There are eight foods that account for 90% of all food allergy reactions. They are: milk, egg, peanut, tree nut (walnut, cashews etc), fish, shellfish, soy and wheat. True food allergies cause an immune response in the body, which is different than food intolerance. It is estimated that only 2-5% of the population have a food allergy.

Most food allergies begin in the first or second year of life, like in the case of little Jayden Federline. Many children outgrow their allergies (unlike adults), especially allergies to milk or soy formula. The most important diagnostic tool is a good history. What was eaten? What was the timing of the reaction? Did anyone else get sick and how much did the child eat? Skin testing can usually cinch the diagnosis.

Despite the problems Britney Spears has had in her young life, if her son has a food allergy it is not her fault. Getting him to the hospital for treatment and diagnosis was the right thing to do and avoiding the offending food is the treatment going forward.

The world is dancing in the street at the election of Barack Obama. His every word is news and everyone wants to know what he will do next. During his victory speech he announced he will be getting a new family dog for the white house and animal lovers everywhere are weighing in on the best pet for the first family. The blogosphere is buzzing with names, breeds and advice for this major decision.

President Obama (I love those two words stung together) has now related that their new pet needs to be hypoallergenic and they would love to get a dog from a shelter. First of all, the fact that we have a leader that can say “hypoallergenic” is so amazing, I am just giddy.

And the fact that he understands the best dogs are rescue dogs is also to my liking. My pets have always come from the humane society or a rescue society and, I swear, these animals have a special sense about their place in the world.

Nothing is worse than being allergic to the family pet. I have had many sad family counseling sessions with patients to deal with this subject.

So, President Obama, may I present a few breeds for your consideration? This choice will outlast your presidency, and your ability to take your time and not rush into decisions will serve you well in this decision as well.

Best breeds for allergy sufferers:

• Basenji (Came from Africa. Would make a nice statement)
• Bedlington Terrier (I had one as a child. Fabulous dog and fur like a lamb)
• Bichon Frise (Cute but I bet not found at a shelter. Too pricey)
• Cairn Terrier (Good with children and small enough to take on world tours)
• Chinese Crested (A status symbol..probably not right for the Obamas)
• Coton de Tulear (Improve relations with France)
• Fox Terrier (Improve relations with Fox News)
• Havanese (Improve relations with Cuba. They have genetic health issues and you have enough problems with Health Care in the U.S.)
• Irish Water Spaniel (Improve relations with Ireland)
• Kerry blue Terrier (Impressive head, just like Obama)
• Maltese (Improve relations with Malta)
• Poodle (Tried and true success and very smart)
• Portuguese Water Dog (Is there a pond at the white house?)
• Schnauzer (Improve relations with Germany. My mom has this type. Very smart)
• Shih Tzu (Improve relations with China. Doubt available in a shelter)
• Soft coated Wheaten Terrier (They are so cute)
• Yorkshire Terrier (Improve relations with the UK)

Good luck, Mr. President. If you need any advice on Health Care reform, you know where to find me.

Prostate cancer is the most common nonskin cancer in men in the United States and 1 in 6 men will receive this diagnosis in their lifetime. The Prostate-specific antigen (PSA) test was approved by the FDA as a screening test for prostate cancer in 1986 and its use has increased since that time. Most male patients are aware of the test and ask for it at their annual exam.

What is little known by patients, is that the PSA test is not specific for prostate cancer. Men can have an elevated level for no disease reason, or it can be elevated for other common conditions like benign prostatic hypertrophy or prostatitis.

In 2002, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for prostate cancer. They found inconclusive evidence that screening and early detection improved health outcomes.

A new study was conducted by the same task force this year and published in the Annals of Internal Medicine. The researchers looked at the PSA test and asked three new key questions that were not asked in 2002:

1. Does screening for prostate cancer with PSA as a single test, or multiple tests over time decrease morbidity or mortality?
2. What are the harms associated with PSA?
3. What is the natural history of PSA-detected, non palpable, localized prostate cancer?

Their recommendations remain the same as 2002. They do not recommend routine PSA testing in men as a screen for prostate cancer. They state it is associated with psychological harm, possibility of erectile dysfunction, urinary incontinence, bowel dysfunction even death if treated. And its potential benefit remains uncertain. They recommend against testing any man over age 75 years.

So, there you have it. Evidence based medicine. The major medical associations like the American Academy of Family Physicians, the American College of Preventive Medicine, The AMA and The American College of Physicians recommend discussing the “risks and benefits” with patients and consider the patients’ preference.

It is no surprise that the American Urological Association recommends offering PSA and digital rectal examination to men annually beginning at age 50. The urologists benefit from elevated PSA levels.

I would bet that there are very few physicians who will take the time to try and explain this study to their male patients. Every patient I have ever had believes if a test is available that “might” detect cancer…they want it.

With the escalating cost of health care, out out of control malpractice lawsuits and the bankrupt Medicare system , we are going to need to tackle these thorny issues of everything for everyone. There are so many unproven tests and treatments in Medicine and we have not had the will or the leadership to say “no” when there is no proven benefit.

“Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek.”
Barack Obama

“Focusing your life solely on making a buck shows a certain poverty of ambition. It asks too little of yourself. Because it’s only when you hitch your wagon to something larger than yourself that you realize your true potential. “
Barack Obama

“If you’re walking down the right path and you’re willing to keep walking, eventually you’ll make progress.”
Barack Obama

“There is not a liberal America and a conservative America - there is the United States of America. There is not a black America and a white America and latino America and asian America - there’s the United States of America. “
Barack Obama

“Today we are engaged in a deadly global struggle for those who would intimidate, torture, and murder people for exercising the most basic freedoms. If we are to win this struggle and spread those freedoms, we must keep our own moral compass pointed in a true direction.”
Barack Obama

“What Washington needs is adult supervision.”
Barack Obama

It is always kind of a shock when I find out that the way we physicians “have always done things” is not supported by the evidence. When studies prove us wrong, we need to make changes. Here are some new evidence based ways to care for wounds and lacerations:

• Tap water is as effective as sterile water for wound irrigation and does not cause more infection. (In my prior Emergency Department days, the mantra was “irrigate the wound copiously” and we always used liters of sterile water. We should save a lot of money by using tap water.)

• White petroleum jelly is as effective as topical antibiotics in preventing infection. (Vaseline? My mom used to use it. Who knew?)

• For scalp lacerations, hair twisted across the wound and fixed with tissue adhesive is as effective as sutures. (sutures are needed for wounds across joints or areas that flex)

• Keep the wound dry for 12 hours. (We used to make patients keep it dry for 24 hours)

That’s the most updated information we have for wound care. Remember, washing with soap and (tap) water is the most effective thing you can do to prevent infection.