By Val Jones. It is estimated that as many as 10 million U.S. adults have ADHD (Attention-Deficit/Hyperactivity Disorder).  A recent research study (publication-pending) suggests that the economic burden of ADHD on America could be as high as $250 billion annually. I attended a recent briefing on Capitol Hill and interviewed one of the study’s co-authors: Tufts economist, Dr. Peter Neumann as well as congressman (and psychologist) Tim Murphy about ADHD in America.

I learned from Dr. Neumann that cost these high cost estimates are most strongly influenced by reduced productivity in adult workers with ADHD rather than direct costs of treating children with the disorder. Productivity costs include absenteeism, and reduced work output due to difficulty focusing. Dr. Neumann explained that ADHD has many “spill over effects” in that it impacts the educational system, the justice system, the healthcare system, and our work environments. Please check out our interview video for the full story.

Congressman Tim Murphy is a clinical psychologist with three decades of experience in treating people with ADHD. He is also Co-chair of the Mental Health Caucus and GOP Doctors Caucus where he regularly works to raise awareness of healthcare accessibility needs. I had the chance to interview him also at the event.

I learned from Rep. Murphy that the costs of ADHD multiply when patients are untreated.  Getting the correct diagnosis is critical, because impulsivity and problems with focusing are not always caused by ADHD. These symptoms can be caused by lead poisoning, damage to the limbic system of the brain, metabolic disorders, or even sleep apnea. Children who are inattentive should not be put on medications for ADHD without first confirming the diagnosis by ruling out other possible causes.

Rep. Murphy recommends a team approach to the management and treatment of ADHD and he believes that costs related to ADHD are escalating because some physicians are not managing children holistically, but resorting to prescribing medications without involving counselors and family directly. He sees lack of health insurance coverage for behavioral health services as a threat to comprehensive and effective ADHD treatment.

Please watch the video for the full interview with congressman Murphy.

This post originally ran on the Better Health blog on December 14th.

By Val Jones. There aren’t too many grandmothers developing mobile health apps these days, but I met a charming one (Jill Campbell) at the mHealth Summityesterday. Jill is a 60 year-old woman from Texas who has been actively concerned for the safety of herself and her daughter over the years.

“My daughter took a self-defense class,” Jill explained, “And she was taught the ‘fight or flight’ response to escape harm. I’m 60 years old. I’m not good at fighting and not very fast at fleeing. So what’s my third option?” Jill created the WatchMe 911 app to provide the solution.

“I first started thinking about a personal alarm system before smart phones even existed. I saw that there were car alarms and house alarms, and wondered why there weren’t personal alarms. At the time I imagined that the personal alarm would go through an answering service system, but since smart phones were created, it can all be tied together in an app format.”

Jill demonstrated the WatchMe 911 app to me during our interview. It contains features such as a panic button that can be armed in advance. Two taps on the smart phone screen and a circle of friends and 9-1-1 are contacted immediately with your GPS location and an alert message. The panic button is a favorite for women who are concerned for their safety when walking late at night or in dimly lit parking lots or alleys.

The “Monitor Me” feature allows the user to schedule messages to friends in advance of a potentially dangerous situation. The message will be sent at a specific time unless disarmed by the user. This is helpful in situations where, for example, a user is out for a run without their phone and might become injured or threatened. They can set the alarm to send out a call for help to friends, with a pre-programmed description of the trail that they’re on. This feature is also popular during blind dates when users would like their friends to check in with them at a certain time. (more…)

By Val Jones. In a recent interview with the president of the American Optometric Association (AOA), Dr. Dori Carlson, I learned the surprising statistic that about 1 in 4 school age children have an undetected or undiagnosed vision problem. School vision screenings, while helpful, still miss more than 75% of these problems. And for those kids who are discovered to have a vision problem during a school screening, upwards of 40% receive no follow up after the diagnosis. Clearly, we need to do better at diagnosing and treating childhood visual deficits. My full conversation with Dr. Carlson can be listened to here.

Dr. Carlson told me that the solution involves comprehensive eye exams – a full medical eye exam performed by an eye doctor. During a comprehensive eye exam, the optometrist will check the health of the eye tissues, including the eye muscles, cornea, conjunctiva, tear ducts, pupils, lens, and retina, as well as the patient’s ability to track objects, to see at different distances, and to focus adequately.

Vision correction is important at the youngest age possible because learning is greatly impacted by vision. Children who can’t see the chalk board, or who can’t read a computer screen or book, may lag behind in school or have attention challenges. In fact, it’s likely that some visually impaired children are misdiagnosed with ADHD (Attention Deficit Hyperactivity Disorder) as their interest in lessons fade since they can’t participate well without seeing what’s going on. (more…)

By Val Jones. I’ve often heard physicians say that “the history is 90% of the diagnosis.” In other words, they can usually determine the underlying cause of a patient’s problem just by listening to their account of how it evolved. The physical exam is merely to confirm the diagnosis, and is often cursory, limited, or ignored.

I believe that the physical exam is far more important than it seems – and I learned this during my recent oral medical specialty board examination. Although I have been sworn to secrecy regarding the content of the test questions, I will share an epiphany that I had during the exam.

The examiners’ job is to describe a patient and then ask the examinee what else she’d like to know and what she’d do next. With each description, I found myself struggling to visualize the patient – wishing I could see their face and hear their tone of their voice as they described their condition. I hadn’t realized that so much of my clinical judgement was based on laying eyes on a patient – I needed to see if they were in pain, if they were straining to breathe, if their skin was pasty or pale, if they were disconnected and potentially drug-seeking, if they were fidgety, if they were articulate, forgetful, or well-groomed. All of these subtle cues were gone.  I was left staring at the examiner – who himself couldn’t describe the patient more fully because he was to stick to the script, reading verbatim from a prepared list of signs and symptoms.

And then something interesting happened – based on the short description of an imaginary patient’s complaint, I began to go down an inappropriate (and expensive) diagnostic pathway. Since I couldn’t see the patient, and some of the symptoms could have been life-threatening, I suggested some pretty aggressive measures. I would not have ordered any of these tests had I been able to see the patient in-person, because I would have been able to see what was actually wrong quite quickly.

I realized that when two doctors plan for the care of a patient they’ve never met, all manner of inappropriate and expensive testing and treatment can occur. So I wondered to myself: what will happen to our healthcare system if we continue to divorce ourselves from patient contact? When diagnostic algorithms become even more rigid, and patients are pressed into diagnostic code categories with pre-determined courses of action prescribed for them long in advance? It’s going to become easier and easier for people to be locked in to an incorrect diagnosis, and subjected to a battery of expensive, and unnecessary tests and procedures… when all that was needed was a pair of human eyes and a thoughtful exam at the very beginning.

I’m pleased to report that I passed my specialty board exam, and I’m now certified in Physical Medicine and Rehabilitation. However, as I consider my clinical future – I know that to be a good diagnostician, I must spend time with my patients in-person… and I’m looking forward to it.

By Val Jones.  You probably see your primary care physician once a year, and your dentist twice a year. But how often do you see your eye doctor? Vision is the most valued of the 5 senses, and yet Americans don’t seem to be making regular eye exams a priority. A recent CDC survey suggests that as many as 34.6% of adults over the age of 40 (with moderate to severe visual impairment) believe that they don’t need regular eye exams. About 39.8% of the respondents said that they didn’t get regular exams because they were too costly, or because their health insurance didn’t cover the expense.

Although cost may play a role in peoples’ thinking, a comprehensive eye exam costs as little as $45-50 at retail outlets. I suspect that the real reason why people don’t get regular eye exams is because they incorrectly believe that if their vision is stable, their eyes are healthy.

A comprehensive eye exam is a type of medical check up – it is not just a vision assessment. Eye care professionals can diagnose everything from glaucoma and cataracts to high cholesterol, diabetes, high blood pressure, and even neurologic conditions such as brain tumors and multiple sclerosis. The eyes are more than a “window to the soul” but a window to general physical health. And the good news is that exams are relatively inexpensive and painless – so please consider making them part of your yearly health maintenance routine.

And to my primary care friends – don’t forget to encourage your patients to get annual eye exams. As the CDC notes:

Recommendations from primary-care providers can influence patients to receive eye-care services; persons who had visual screening during routine physical examinations had better eye health because of reminders to visit eye specialists. Public health interventions aimed at heightening awareness among both adults aged ≥65 years and health-care providers might increase utilization rates among persons with age-related eye diseases or chronic diseases that affect vision such as diabetes.

I myself have had an unexpected diagnosis during an eye exam, and feel passionate about the importance of preventive screening. In fact, I’ll be the upcoming host of a new eye health education initiative – a radio show called, “Healthy Vision with Dr. Val Jones” supported by ACUVUE brand contact lenses. The first show will be released here today, and it’s also available at Blog Talk Radio. (more…)

By Val Jones. I received this press release today and was depressed by the prevalence of meritless lawsuits in this country. Most physicians (95%) are sued at some point in their careers, and as many as 90% of these suits are found to be meritless. If that doesn’t make you want to quit practicing medicine, I don’t know what does.

This kind of litigious climate definitely adds to my stress levels — and makes me fearful of caring for very sick and fragile patients who are likely to have poor outcomes, regardless of what I do. Many of my colleagues practice medicine with one eye always looking over their shoulder, wondering when that one bad apple will take them to court in an attempt at a financial windfall.

In Canada, those who bring frivolous lawsuits to court are responsible for all legal costs. I’d be in favor of having a similar process here to chill the medical malpractice frenzy that’s raising costs and driving physicians out of clinical medicine. Cases of true medical malpractice should be punished and patients’ rights protected — but when 90% of lawsuits are bogus, it’s time to fight back.

Here’s the AMA’s press release:

WASHINGTON – A new report from the American Medical Association (AMA) paints a bleak picture of physicians’ experiences with medical liability claims and bolsters the case for national and state level reform. A key finding from the report is that, among physicians surveyed by the AMA, there was an average of 95 medical liability claims filed for every 100 physicians, almost one per physician.

The report has data not available anywhere else, including information on medical liability claims’ impact by age, gender and practice arrangement for physicians. Highlights in the report include:

- Nearly 61 percent of physicians age 55 and over have been sued.There is wide variation in the impact of liability claims between specialties. 

- The number of claims per 100 physicians was more than five times greater for general surgeons and obstetricians/gynecologists than it was for pediatricians and psychiatrists.

- Before they reach the age of 40, more than 50 percent of obstetricians/gynecologists have already been sued.

- Ninety percent of general surgeons age 55 and over have been sued.

“Even though the vast majority of claims are dropped or decided in favor of physicians, the understandable fear of meritless lawsuits can influence what specialty of medicine physicians practice, where they practice and when they retire,” said AMA Immediate Past-President J. James Rohack, M.D. “This litigious climate hurts patients’ access to physician care at a time when the nation is working to reduce unnecessary health care costs.”

The number of medical liability claims is not an indication of the frequency of medical error, as the physician prevails 90 percent of the time in cases that go to trial. While 65 percent of claims are dropped or dismissed, they are not cost-free. Average defense costs per claim range from a low of over $22,000 among claims that are dropped or dismissed to a high of over $100,000 for cases that go to trial. This leads to increased costs for physicians and patients.

“The AMA supports proven medical liability reforms to lower health care costs and keep physicians caring for patients,” said Dr. Rohack. “The findings in this report validate the need for national and state medical liability reform to rein in our out-of-control system where lawsuits are a matter of when, not if, for physicians.”

The report includes data from the AMA’s 2007-2008 Physician Practice Information survey of patient care physicians and other sources.

Originally posted on Better Health  by Disruptive Women Val Jones on August 3rd.

The following interview with Dr. Jan Gurley, a board-certified internist physician, was recently featured on the Better Health blog.

Dr. Jan Gurley just returned from a mission trip to Haiti, 5 weeks after the earthquake hit. In this audio clip, she relays a horrific first-hand account of the current realities of life in Port Au Prince. With no running water, bathrooms, or place to shelter – and packed into a field with 100,000 people – some young women are choosing to stop drinking water in an effort to commit suicide.

Dr. Gurley describes the loss of human dignity associated with the crisis in Haiti, including a near stampede when sanitary napkins were offered in a crowd of women. She explains that the place is becoming dangerous – and the screams of women being raped in the night fill the dark air. In the day time, people huddle together for safety while the stench of rotting corpses surrounds them. With the rainy season approaching, and tent cities perched precariously on land-slide prone hills, Dr. Gurley predicts a second wave of disease, violence, despair, and death in Haiti.

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Ever wonder why your physician only spends 5-10 rushed minutes with you during your office visit? You may think it’s because there are simply too many patients vying for her time, but that’s not the real reason. The root cause is that health insurance companies are stealing time from your visit by requiring excessive documentation from your doctor. She can’t give you the time you need, because doing so would put her out of business.

In a special report on the administrative burden of healthcare, MedPage Today revealed that PCPs spend about one third of their income on documentation required by health insurers. Because they run a business with thin margins, they must increase the volume of patients they treat in order to cover the salaries of the staff required to manage this “paper weight.”

About 49% of all physicians have said that they are considering retiring or quitting medicine in the next two years (the rate is lower for specialists), largely because of increasing documentation requirements and decreasing reimbursement.

Primary care is hardest hit by costs of coding and billing requirements, since they charge relatively little for their individual services. Imagine the difference in complexity between freezing a wart versus removing an appendix. Yet the number of people required to document, code, and process the paperwork for those two procedures are similar. The reimbursement, however, can differ by thousands of dollars.

The average PCP requires 4.5 staff to manage the administrative challenges associated with practicing medicine. If you consider that the average annual income for a PCP is $149,200, then it’s easy to see why a PCP’s income barely covers staff salaries, let alone the overhead associated with office space, supplies, and computer technology.

How can family physicians survive in this hostile reimbursement environment? There are really only two choices: to work in large group practices or to cease accepting insurance. (Of course, I’m leaving out the third option: to choose a different career).

I have decided to join an insurance-free practice. Now, before you assume that this means “concierge medicine” with exorbitant membership fees – let me tell you that it’s not what you think. DocTalker Family Medicine simply charges an hourly rate for my time – and I do whatever is appropriate for the patient, whether it’s a house call, an office visit, an email, or a phone call. There is no membership fee, people can pay with their credit card, cash, check or PayPal, and once we’ve met in-person and a full history and physical is performed, much of their care can be accomplished remotely.

So what does that cost? The average patient in our practice spends $25/month on their primary care needs. Isn’t that amazing? We can charge reasonable rates because we’ve reduced office staff from 4.5 to 0.5 people/provider and we pass on the savings to patients. We answer our own phones, we see almost all patients within 24 hours, and we’re available 24/7 by phone and email. And you know what? We’re happy to do it because we find meaning in every interaction. We aren’t being crushed by a paper weight.

As healthcare reform moves forward, and new ways are sought to wring money out of a crazy and convoluted system, it might just make sense for some of us to opt out and get back to basics: a doctor or nurse available 24/7 for your primary care needs at a price you can afford. No red tape, no unnecessary office visits, no insurance company hassles.

Anderson Cooper sent a reporter to our practice to see for herself what hassle-free medicine actually looks like. I hope you enjoy the segment… and if you’re in the DC or Virginia area, please check us out for yourself!

This post was originally published at Better Health.