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Clinical Issues

The Top 8 Jobs with the Highest Injury Rates

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Four of the top eight are medical workers: orderlies, nursing assistants, personal care aids, and registered nurses.

According to the Bureau of Labor Statistics, more than 35,000 nursing employees are injured each year severely enough that they miss work.

Some hospitals have report that they have reduced lifting injuries among nursing staff by up to 80 percent — using an approach often called “safe patient handling.” They use special machinery to lift patients, similar to motorized hoists that factory workers use to move heavy parts. The hospitals also conduct intensive training among the staff.

Yet the majority of the nation’s hospitals have not taken similar action. The injuries are often so severe that they’re career-ending, a problem compounded by the fact that many of those injured are relatively young. To help address the problem, on Jan. 1, 2012, the Hospital Patient and Health Care Worker Injury Protection Act went into effect in California. This NPR article follows several injured medical workers and their stories.

New Year’s Resolution: Don’t Have an Annual Physical

It may sound a little odd to suggest not going to the doctor. But this editorial does just that. About 45 million American adults have a basic annual check-up. However, a study has indicated that those check-ups for adults — with no specific symptoms to discuss — are not particularly useful. In fact, the Canadian guidelines have recommended against these exams since 1979.

In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years. Their findings? Regardless of which screenings and tests were administered, studies of annual health exams dating from 1963 to 1999 show that the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease.

There are many reasons why the annual physical is not productive; it does little to avert death or disability from acute problems; it does little for chronic conditions without significantly useful interventions; and, sadly, an early diagnosis might extend the time patients know they have cancer but is unlikely to extend their lives.

This is not to suggest skipping doctor visits altogether: get your flu shots, stay up-to-date on vaccines, discuss symptoms with your doctor.

But consider this from Dr. Ezekiel J. Emanuel, oncologist and vice provost at U. Penn: Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won’t include an annual exam. That will free up countless hours of doctors’ time for patients who really do have a medical problem, helping to ensure there is no doctor shortage as more Americans get health insurance.

Dr. Oz: Only a Third of Claims Backed by "Believable" Evidence?

His credentials are impressive: Vice-Chairman, Department of Surgery, Columbia University College of Physicians and Surgery; he has a long list of publications; and he holds three degrees from Ivy League Colleges. He’s also won a few Emmys and was one of the Time 100, The World’s 100 Most Influential People, in 2008.

Yet Dr. Oz, host of The Doctor Oz Show  since 2009 and The Doctors doesn’t do so well when it comes to fact checking. Following a June 2014 Senate subcommittee hearing in which he was taken to task for unsubstantiated claims made on his show, a group of Canadian researchers and physicians fact checked many claims he has made on his shows.

Researchers randomly selected 80 claims from each show and looked to see what evidence, if any, could back them up. Two team members conducted independent searches, spending up to an hour on each one. “In an attempt to be as fair as possible” to the shows, they wrote, they “used a relatively broad definition of support.” Still, only 21% of the recommendations on “The Dr. Oz Show” could be supported by what the researchers considered “believable” evidence. Another 11% were supported by “somewhat believable” evidence. Given that his shows’ viewership averages just under 3 million people per day, that’s a lot of people being exposed to a lot of apparently unsubstantiated medical advice.

Medicine still requires the vignette

In an era of systematic clinical research, medicine still requires the vignette, as explored in this opinion piece. The multiple comments are interesting as well, many with strong opinions which provide illumination into why patient stories are (still) so important and how they fit with a sound scientific approach to better treatment:

In addition to reminding us of the real and human part of practicing medicine, stories are great hypothesis generators. Evidence-based medicine is important, but no real evidence can be generated until a testable hypothesis is created. This is where vignettes play an important role. When we see an outcome, especially if it’s unexpected, it forces us to ask questions, which in turn lead to hypotheses.

$1,600 for a Diaper Rash Treatment?

Alarmed by a rapid increase in spending on compounded drugs, like a $1,600 baby balm, insurers and others are acting to control their use.

Drug compounding involves a pharmacist making medicines for a patient who cannot be helped by mass-manufactured drugs. Compounded drugs do not require FDA approval, though Congress recently has moved to enact regulatory legislation. They might be used when a patients is allergic to an ingredient in a commercial product, or a patient needs a liquid formulation of a medication rather than it being in pill form.

Pharmacy benefit managers say there is scant evidence that these combinations of ingredients are safe or any more effective than conventional drugs. Express Scripts, the largest PMB, has said it will stop paying for more than 1,000 ingredients used in compounding, cutting spending by its health plan clients on such medicines by 95 percent. It said such spending had grown to $171 million in the first quarter of this year from $28 million in the first quarter of 2012.

Vaccinations: The Soaring Price of Prevention

MCNTalk has long taken on the vaccination story and has advocated rational and life saving public health policies that promote vaccination.

As this article demonstrates, the dark side of vaccinations is not the overstated risk of side effects, but the predatory cost escalation. The short answer to why the manufacturers are driving up prices is because they can.

This is further enabled by the requirements that some vaccinations be administered for school admission and other public good.

Also the lack of marketplace pressures since the cost is generally borne by government and insurance carriers promotes insensitivity and indifference among those who benefit from them. Finally, monopolies granted via patents and regulations do nothing to induce competition among manufacturers.

Sixteen years into the vaccination/autism myth

In 1998 Andrew Wakefield published a paper claiming a link between the measles-mumps-rubella (MMR) vaccination and autism – reporting on a total of eight children who developed symptoms of autism within a month of receiving the vaccine.

In the past sixteen years there have been multiple studies – at least 14 worldwide – and books published debunking the paper, which was initially rejected by four of the six reviewers who were asked to judge it. And yet the myth continues to have tragic effects worldwide as more deaths are reported from outbreaks of preventable these diseases here in the United States and abroad. Why? In part thanks to celebrities like Jenny McCarthy, actress, Playboy centerfold, co-host of The View, and since 2005 anti-vaccine activist. Read more…

A Clinical Story Worth Sharing

Most IMEs answer straight-forward questions on known issues. But there are those rare but important moments where we are reminded that things are not always as they seem, and that an examination can have extraordinary and unexpected value and impact on peoples’ lives. Allow me to share such a story.

Recently MCN conducted an IME on a 46-year-old woman who had back pain complaints in a workers’ compensation claim. The physicians who evaluated her found her to not be fixed and stable, and elected to order an MRI of the spine. It should be noted that the doctors felt that the findings they observed did not wholly fit with the injury claim but that they were significant. Typically an MRI would not be ordered for a low back pain complaint.

Five days after the evaluation she underwent the study. That same day MCN received a call from the radiologist who reviewed the film, calling our attention to unexpected findings of a mixed signal intensity mass involving the lower pole of the right kidney, approximately 4.5 by 4.4 centimeter. He noted that this may represent a renal cyst, but that a renal cell neoplasm could not be ruled out.

We informed the examining doctors who saw the claimant about these findings as well as the claims manager. As Medical Director, my priority at MCN changed in part from processing a report for her claim to doing right clinically by the claimant and ensuring that she was aware of these findings. I called her and told her that we had found something unexpected and explained to her the importance of prompt follow-up, and forwarded her the radiology report along with this email:

It was nice speaking to you this evening. As I mentioned, I am the Medical Director of MCN where you were seen for an IME on November 9, 2013 for your workplace injury. The report is in draft form at this point in time and when completed, will be sent to the department. I do note that the doctors who evaluated you did not regard you as fixed and stable and that you warrant either further treatment or evaluation.

As part of your evaluation, you underwent an MRI on November 14, 2013. The report is attached to this email.

As you can see, the radiologist reading this study noted an unusual mass that caused them to call our office, and it thus came to my attention. We will be letting the examining doctors know about this as well.

While I do not wish to alarm you, it is most important that you seek evaluation for this finding. It is possible that some of the symptoms you experience may be related to this rather than the injury. Regardless, it should be assessed to determine if it is of significance and warrants treatment.

I would recommend that you present these findings to your personal physician and work with them to investigate and follow up as appropriate.

I would appreciate any follow-up that you wish to offer and hope that the findings turn out to be insignificant and that you recover nicely from your injury.

Please let me know if you have any questions or if we can be of further assistance.

Thank you for your attention.

Brian L. Grant, MD

One week later I was surprised and touched by the following text:

Hi, this is (name withheld). I found out yesterday at the mass on my kidney is cancer. Will know more on Monday. Seeing oncologists and urologist. Thank you and please please please thank the two wonderful doctors that ordered the MRI and for taking my complaints seriously. Bless you all.

Several weeks later she underwent a partial nephrectomy at a large University medical center in the region. The subsequent weeks were rocky emotionally for her but in the end she was relieved to learn that she had a clear cell renal carcinoma and that the surgery was able to completely remove the tumor with all margins clear for carcinoma.

And by the way, her claim was also processed with an impairment rating relative to the back findings, and a settlement from the carrier.

My point in sharing this is that the work we do has impact, sometimes in ways we would never anticipate. In this case we identified a tumor causing back symptoms and took the necessary steps to help this patient get the right care in a timeframe that perhaps contributed to a great outcome. I am proud of all involved in this case and we all wish the claimant the best outcome.

Brian L. Grant, MD

Chronic Pain: Back in Control

Brian L. Grant, MD
My friend and colleague David Hanscom MD recently appeared on Dr. Oz discussing his experience and research on chronic pain, and the tragedy of operating on basically normal backs, on people in pain. He has published a book that anyone considering back surgery might consider reading first.

Sadly, common sense and good care as represented by Dr. Hanscom does not pay. No expensive back implants are sold, no surgical fees generated and no hospital stays take place. And for those who were not truly injured but underwent the knife for symptoms and not true pathology, they decidedly have an injury afterwards. This is tragic.

Common Surgery May Not Actually Help

The most common orthopedic procedure in the United States appeared to be no more helpful for some patients than a completely simulated surgery, according to an unusual Finnish study.

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the United States, performed, the study said, about 700,000 times a year at an estimated cost of $4 billion. Read more…