Dr. Thompson's Blog

How to get Good Medical Care in an HMO

It is possible to find good physicians and get good care in an HMO,  but only if you demand it. An HMO prefers to have  only healthy, young adults in their care. If you have a medical problem, trouble can be ahead. Each physician gets a report card periodically about how many tests they have ordered and how many referrals to specialists they have made. Their salaries are affected if they order too many. Most HMOs also have a limit on the amount of time to be spent with  each patient. I would last in an HMO about 10 minutes. There is no way I would tolerate these rules. Some patients take a while to really get to the bottom of their problems. Getting to know your patients as a physician is one of the true joys of practicing medicine. You become a very important part of a patient's life and a long term relationship brings many rewards, not financial, but very special. 

Before you enroll in an HMO it is important to answer a lot of questions and also carefully read anything you are given to sign. You want to be sure of which tests are allowed for you and your children. You also want to know if they will pay for emergency care in another hospital if you are traveling. For your children, does the plan pay for immunizations, yearly physicals, lab work and ER care? Also, who will see your children? Will it be a pediatrician or a nurse practitioner? I saw a two- year-old one day with a severe degenerating disorder. The parents said their child was  seen at the local big Kaiser.I asked the name of their pediatrician, so I could send him or her a report of my examination. The  parents said they had never had a pediatrician or M.D. but the child was seen by a nurse practitioner. The  little boy had a progressive, life threatening disorder and I was appalled. I met the CEO of a  large Kaiser on an airplane and told him about the boy. He said not having an M.D.was  impossible. He gave me his card and when the child died a few months later I tried to locate  him, but he had moved. I will never forget  that little boy.  

Senior Medical Care When Traveling in the U.S.

If you are traveling in the U.S.by yourself or other seniors there are some precautions to take. As an older person, you want to be sure you carry a prescription for your glasses if you need them. Glasses do get broken. You also want to be sure you have refills  for any prescriptions you take. If you become ill on an airplane there may not be a physician on board. The airlines are somewhat better in the past about training their staff about what to do if someone becomes ill. I hope they are better, too, about having more medications available for physicians to use than they did in the past. I have responded to calls for a physician several times when I was flying.  One time it was necessary for me to have the pilots land the airplane mid-way across the country because there was no medication I could use to stop a man from  having seizures. From his luggage, we decided that he was using a stimulant and had been traveling for several days. I was accustomed to treating seizures in children, but there was nothing in the airplane medical chest  I could use. 

Most, and I hope all airlines  have defibrillators on board. I am told the staff are trained to use these. I  have found that some of the flight attendants in the past were quite difficult. One flight attendant insisted I show her my medical license. Would she had done that for a male doctor? Another one asked me if I wanted a glass of wine as I was listening to a person's chest and taking his blood pressure. Amazing!

My other concern, if you are traveling by car or bus, and become ill is about using urgent care facilities. Not all have a physician on-call. I have seen seen some grave mistakes happen when a non-physician tries to treat a patient. One teenager who had muscular dystrophy, was told he had diabetes and the nurse wanted to give him insulin. The parents called me and traveled for several hours so I could see the youth. A chest X-ray showed he had lobar pneumonia! He did well with the right antibiotics.

Medical Care for Seniors

A woman called me about the concerns she had  regarding her eighty-year-old husband. She said he now always seemed very tired. I knew the couple received their medical care in an HMO. The  accounts she had told me previously about their internist were disturbing.  The doctor said anyone in their eighties who had a problem was "just getting older". He seemed to discount they might have an actual medical problem.  I asked the wife when her husband had last had a complete physical examination,  chest X-ray, pulmonary function tests,  EKG and a blood panel. None of those had been done recently or ever!

I don't know how  any doctor can dismiss an older patient's concerns without doing a physical examination and some tests. What patients in HMOs may not know is that each test costs the doctor money. HMOs really just want healthy,young patients who don't cost them any money. No matter how hard I try to keep people, who can afford good medical care, to get it, I often fail. To me the best medical  care can made the difference between life and death or a life that has no fun or quality to it. 

The other problem I have found with many HMOs is that they have nurse practitioners who see patients without any oversight by a physician. A brilliant man in his fifties who did book editing for me died with terrible medical care in an HMO. He did not see any doctors but a nurse practitioner. I am sure there are some excellent nurse practitioners in areas where no physician wants to practice and they fill an important need. Now too many doctors are choosing specialties that make them a lot of money. Family doctors, pediatricians and psychiatrists are at the bottom of the pay scale. Some psychiatrists will just accept cash payments, so they may do very well. So I would urge family members who have an elderly spouse or parents insist that an elderly person receive the best medical care possible and not in an HMO.

When Doctors Don't Refer to Specialists or Ask for Advice

I was reading an article recently about a pediatrician who was loved by the family because he was very involved in getting them the help they needed for their two sons. Both boys were said to have weak muscles. The diagnosis of cerebral palsy was raised, as well as some form of muscle disease. The doctor ordered various genetic tests but at no place in the article did I see that a neuromuscular specialist had been consulted or the boys sent to see one. I thought about this and wondered if it was the doctor's ego or just lack of training. Few general doctors or pediatricians receive any neuromuscular training. Orthopedic surgeons who see children with muscle problems also receive almost no neuromusuclar training. I was married to an orthopedic surgeon who had wonderful surgical training but he learned about muscle disorders from me. 

I had one parent who told me of her experience with an orthopedist. He examined the child, watched him walk and told the mother, "Your boy has Duchenne muscular dystrophy. I would take him home and let him die." As it turned out the boy had treatable dermatomyositis. With the prednisone treatment I ordered he has lived a long a productive life.

Sadly. if a general doctor tries to have a muscle biopsy done, most are worthless. Pathologists generally do not have training in reviewing muscle biopsies. I  have seen biopsy slides from across the country. They were so poorly put together by the lab technicians that they were unreadable.  Yet many were signed out as muscular dystrophy. I have always reviewed my own biopsies and if I had a question would send them to Dr. Caroline Sewry in London. She is the world's expert in these and the author of the  main muscle biopsy books.   She is working on a new revision at this time.

 

Trump is Trying Again to Undo Obamacare

An excellent article on 8/15/18 in the New York Times by two law professors notes how Trump continues to try and sabotage healthcare. First he promised he would see to the repeal of the law that has helped millions of people. When that didn't work he has tried to whittle off pieces bit by bit. His newest ploy is to announce that insurance companies can sell "junk" insurance. Of course, he didn't call it that. He  just said that the policies can last for 364 days and be renewed for up to three years. These policies do not have to abide by caring for those with  pre-existing conditions and long-term medical care can be denied, as well as other things that ensure Americans will  have adequate healthcare coverage. Of course, Trump and his family have excellent coverage, so his wife could stay in the hospital as long as she desired, which she did, and not suffer any financial penalty.

I was glad to read that a lawsuit has been filled by several cities against this newest attempt to destroy parts of Obamacare. Trump, when he took the oath of office as President, said he would uphold the nation's laws! He certainly is not doing that. Instead he is lashing out at anything President Obama did. As the presidential historian, Douglass Brinkley said recently, "Trump has soiled the presidency." 

I think as Americans, we  must  stand up to these ongoing and devious ways to destroy our healthcare system and our country. How sad that a man can only care about destroying everything President Obama did. I wonder how he will be viewed by historians?

Caring for Elderly Parents or Family Members

As our population ages, many of us  have had to be caretakers for elderly family members.  For some reason the job always seems to be given to the same person. Fighting with health insurance problems is only part of the problem but a big one. Recently, I been helping a family member get a special piece of medical equipment and I cannot believe the amount of time, telephone calls, and Internet searches it has taken. If you are dealing with an HMO that is even worse. The companies spend extraordinary amounts of money in an attempt to keep patients from getting  good care. Recently, in talking with a friend, she was amazed to hear that the U.S. is far down the list of countries providing  the best health care. The last I checked, the top two were France and England. 

You  have to be very tenacious to get good care whether it is from an insurance company, an HMO or a nursing home. Often Medicaid patients and those in Veterans' hospitals get the worst care. One woman told me the Veterans' hospital where her father was sent was dirty and his care was bad. Even with good insurance some of the care for elderly patients is below standard. Few physicians seem to want to spend time talking with patients. A wealthy friend in San Francisco told me that eight different doctors came into her room over several days but none of them came closer than the foot of her bed. I was amazed. 

Some family caretakers may not know about hospitalists but they can be a nightmare. The one I dealt with in Las Vegas came in mid-morning, wrote a few notes in the patients' charts and then was gone. Hospitalists make large salaries and should spend time talking to family members, studying patients' medical records and giving good care. Even in two medical schools,I know about, the hospitalists are terrible. So don't give up, because your tenacity will usually pay off. 

Helpful Websites for Medicare Recipients, Veterans, and Patients with Disabilities

Now that Trump and his wealthy Republicans in Congress are trying to get rid of Medicare, Social Security, and Medicaid, there are some agencies and groups that can help if you have problems with different benefits. 

The first group is the Patient Advocate Foundation. Their website is www.paf.org and the telephone number is 1-800-532-5274. The Center for Medicare Advocacy can also be helpful. Their website is www.medicareadvocacy.org and the telephone number is 1-860-456-7790. Medicare is 1-800-633-4227

If you are disabled at any age, a wonderful group to help is Protection and Advocacy. They have lawyers on the staff and if they feel they can help there is no better group. They  have helped many patients for me, both children and adults.

For veterans there is a Veterans Crisis line at 1-800-273-TALK. It is shameful that the U.S. does such a very bad  job  of helping men and women who have put their lives on line to serve in the military. I know of this first hand. My brother was in the Air force in the second World War and served in India. As he was flying home the plane crashed in the Mediterranean and he was one of eight survivors. Keith recovered and professionally he did a fine job as a hospital administrator. His personal life was not happy and his social life changed dramatically. He had been an outstanding student, stage manager, and  leader. He became reclusive and was not happy. I tried hard in his later years, when I saw more of him, to get him some counseling, but the VA did nothing. He died several years ago.After the second World War he was not the big brother I had known as a little girl. 

Misdiagnosis of Childhood Diseases

Because so many older doctors have retired or are retiring because of the difficulty in  practicing, childhood diseases are not something that most younger doctors have seen. Immunizations have been wonderful in protecting children unless the parents refuse them.(We owe Dr. Salk and Dr. Sabin and the others who have developed vaccines a great thanks for their work.)

When I was a resident in pediatrics, I was  married and had two children. Both children had had measles and mumps, because vaccines were not available. I was on ward rounds with an attending staff doctor who specialized in developmental problems. One little boy looked quite ill and to my eye had had regular measles or rubeola. The attending doctor said he though it was an allergic dermatitis. The child  had a fever and all the signs of rubeola. I spoke up and said I thought he had regular measles.  The child was on an open ward, so it was important that he be moved and treated for the disease. The attending doctor was upset with me but agreed to call the infectious disease doctor. That doctor agreed with my diagnosis and I was never the attending doctor's favorite after that.

When I had my own pediatric practice, a mother brought her child in and said she had been diagnosed as having mumps. The location of the swelling didn't seem right to me and I suspected the child  had an abscess in one of  her teeth. The mother immediately contacted the child's dentist and the abscess was treated. The "mumps"  was cured. 

Another time when I was consulting in a Navy muscle disease clinic, I was presented with a child the resident doctor diagnosed as having muscular dystrophy. The muscle weakness was not symmetrical, as occurs in muscular dystrophy.  I asked the parents if cases of polio had occurred when the child became weak. They said "Yes" and the boy had also had a fever. The diagnosis was polio, not muscular dystrophy. So a second opinion is often a very wise thing to get, particularly from an older physician. 

 

 

Is Dental Care Deteriorating as Much as Medical Care?

A good friend developed some white patches in her mouth and on her tongue. Her dentist watched them for a while and then referred her to various dental specialists. She ended up being told it was mostly likely cancer. A biopsy was done which was reported to be inconclusive. Despite this she was referred to a radiologist who advised that six to eight teeth be removed before radiation was started. The woman was also referred to a cancer nurse and another biopsy was done. This, too, was inconclusive.

Having always reviewed the muscle biopsies of my intramuscular patients, I knew how really bad and inconclusive many of them could be. Some were unreadable, even from major medical schools and hospitals. I asked if I could call the pathologist at the University of the  Pacific Dental School in San Francisco. They had seen many patients for me and were outstanding. The pathologist there said he would be glad to review the biopsies. When his report and the last  one were sent to me, I was amazed at what I read. Both reports noted some fungal elements. The San Francisco report urged that anti-fungal oral treatment be given. This had never been done. When I was in practice and seeing newborn babies quite a few had thrush, which is due to a fungus. We treated the babies with oral drops and they did well.

In checking the Internet, I saw pictures of small white patches in the mouth and it was noted that these occurred more readily in patients with diabetes. My friend has diabetes! 

It took some strong urging from my friend and myself but she is now on oral anti-fungal treatment. Hopefully, this will cure the lesions and no teeth will need to be removed and no radiation or chemotherapy will be needed. 

 

 

Suicide Rate Continues to Increase

We've heard for a long time that 22 veterans commit suicide each day and yet veteran medical and psychiatric care seems to get worse and worse. An article in the 6/8/18/ New York Times by Benedict Carey noted that the rate of suicides has "climbed 25%." This past week alone, there were 16,000 suicides. In 2016, according to the article "nearly 45,000 Americans aged 10 or older died" by suicides.  Suicide is now the tenth leading cause of death in the U.S. Males commit suicide more than females and guns are usually their weapons of choice.  Now that  physicians spend less and less time with their patients how can they  know when a patient needs to talk or needs help and  they don't  have or take the time to listen?  They probably don't even offer the number for the Suicide Hotline which is 1-800-273-8255.

In the past, when I was in private pediatric practice, I knew my families well and if there was a problem with depression, anger, medical problems or other reasons of concern I heard about them. House calls were a wonderful way to see how a family operated. I still hear from family members who were patients over 40 years ago. They know if they have a problem, I will still listen and find a way to help. This is one of the great joys of medicine. Young doctors are having trouble with depression and also far too many commit suicide. I don't understand what we are doing as a nation that money and the need for power have  taken over when compassion, caring and taking care of each other were formerly so important. 

Many medical schools are grooming their young doctors to be research scientists instead of caring physicians. They are far more interested in  having a Nobel prize winner than a doctor who is loved and offers wonderful care to his or her patients.