I assumed Cassell was a Florida native with a scarlet neck until I heard him speak during an interview. His distinct Northeast accent grabbed my attention and I quickly reviewed his credentials on the Florida Board of Medicine website. He is now hailed as a great “American patriot” but wasn’t smart enough to attend an American medical school. He subsequently graduated from St. George’s University School of Medicine on the island of Grenada where people look like President Obama. Oh, would I love to review his medical school application to determine the reasons for his rejection.

After leaving Grenada, he began both an internship and surgical residency with the UMDNJ Hospital in Newark, New Jersey, again, training on indigent people.  And from the inner city of Newark, he found his way to Gainesville, Florida to begin a urologic oncology (cancer) fellowship. The greatest numbers of prostate cancer patients are African American men.

Cassell now has a private practice and does not accept Medicaid. He is well ensconced in the American Dream. He has no further need to interact with the indigent and uninsured. He has become the poster boy for Fox News and Rush Limbaugh.  Blonde coquettes show up at his office bearing gifts. He has violated the AMA’s Code of Ethics #9.012 that states “under no circumstances should physicians allow their differences with patients or their families about political matter s to interfere with the delivery of high-quality professional care” but his inflammatory sign regarding President Obama will remain.

Perhaps it’s time for Dr. Cassell to stop practicing medicine. When political views obscure common sense; it’s time for the Board of Medicine to step in.

It is a well known fact that most hospital costs are over-inflated yet no one calls them to task. Premature babies may cost $26 billion dollars per year but how much money has been spent on prevention? We’ve done a lousy job in reducing the occurrence of premature labor or making pregnant moms aware of its dire consequences. For example:

 • Back pain should not be ignored (because it could be a sign of early labor)

 • Patients should be discouraged from drinking soda because they contribute to urinary tract infections

 • Urinary tract infections should be treated aggressively because it can be a precursor to premature labor

 • The cervix of  pregnant women should be automatically measured after 14 weeks by ultrasound imaging to determine if it’s short (2.5 cm or less increases the incidence of preterm labor).

• Complaints of vaginal discharges should not be ignored (especially from lower socioeconomic women) because it could represent an sexually transmitted infection (another risk factor for premature labor)

 • Pregnant women in stressful occupations (professional women included) should be given a leave of absence so their bodies are allowed to rest

• Steroids should be administered to women with preterm labor so their babies will be able to breathe

And the list could go on infinitum. The May 18th 2009 edition of People Magazine had a fabulous article about six amazing college students who were all born premature at less than 27 weeks. Their story not only brought me to tears but also inspired a blog, (see Miraculous Babies). The most premature baby of the group was born at 23 weeks and weighed 1.8 pounds. She is also a college student today.

So, unless you’ve worked as a nurse or a physician, please keep your untrained hands off the destinies our preemies. The “cost-benefits” of their future is priceless.

 Louisiana Senator Mary Landrieu received an additional 100 to 300 million dollars for Medicaid, Nebraska Senator Ben Nelson cut a deal that guaranteed federal Medicaid payment for life (although this is now being challenged by several State Attorney Generals) and Connecticut Senator Joe Lieberman killed a public option because of his wife’s affiliation as a consultant and lobbyist to pharmaceutical and insurance companies.  Hadassah Lieberman was a consultant for Pfizer, who is one of the largest U.S. pharmaceutical companies and recently ordered by the U.S. Department of Justice to pay a $2.3 billion dollar lawsuit for healthcare fraud. Government lawyers settle $2.3 billion dollar Pfizer fraud lawsuit.

On Christmas Eve, the US Senate’s version of HR 3200, aka America’s Affordable Health Choices Act of 2009 passed. The House of Representative and Senate bills must now converge into one bill. The dynamics of that process will be interesting and we will need to watch our backs.

I challenged Doctors for America, an organization of approximately 16,000 physicians to answer the following questions regarding HR3200:

1.  Will the premiums for people with pre-existing conditions be higher and by how much?
2. Will there be some outside regulatory agency to govern the insurance companies in the event of misdeeds?
3. Will there by co-pays and deductibles and by how much?
4. Will there be a limit of services provided by these so-called state regulated insurance plans, i.e., will the poor receive less services based on the type of insurance they have?
5. How much assistance will poor people receive regarding insurance premium payments? 10%, 20%, or 30%?
6. Is there a cap on how much an insurance CEO can earn?
7. Will there be reductions in payments of Medicare and Medicaid to physicians?
8. Will these plans be taxed to people who earn above a predetermined income?

To the organization’s credit, they provided the following answers:

         1.   Older people will have to pay higher premiums at a ratio of 2:1 in the House bill and 3:1 in the     Senate bill. This means that as an “older” person, my premiums will either double or triple           based on the new “reform”. If you are a smoker, be prepared to pay higher premiums as well     and no, you can’t conceal your habits because they can do urine and blood tests in search of        nicotine.

          2.  Insurance companies will be required to report to the government on their performance, profits,  etc. A health insurance’s ability to participate in the Exchanges will depend on its performance.   If an insurance company increases its premiums prior to the Bill’s final approval, they will be  excluded as a candidate for the exchange.

        3.    Yes, there WILL be co-pays but there will allegedly be no more lifetime or annual limits on how  much an insurance company can pay on your behalf.                                       

         4.   Allegedly, there’s a minimum benefits plan on the Exchanges, and then several levels of plans above that. The minimum benefits plan provides “significantly” more benefits than the average individual plan today.

         5.   People earning 400% below the poverty line will have their insurance premiums subsidized.       Who are these people? Any individual who earns $43,000 or less and families of four who earn  less than $88,000. The table listed below illustrates provides an example of a subsidy.                                

         6.   At present there is no cap on the earnings of insurance CEOs but allegedly companies must spend between 80 to 85% of their revenues on medical care. They are also required to report profits annually and pay dividends to their customers if their profits exceed the cap.

         7.   Allegedly, there will be no cuts to either Medicare or Medicaid physician payments.

          8.  There is allegedly going to be an “excise” tax on “Cadillac” plans described as plans that cost  individuals more than $8500 per year or families more than $23,000 per year. Individuals  earning more than $200,000 and families earning more than $250,000 per year will pay 2.35%  more in Medicare payroll tax.    

                What does HR 3200 offer small business owners? Small business, with payrolls less than $250,000 per year will be exempt from the employer responsibility requirement. Allegedly, new small business tax credit will be available for companies who want, but can’t afford to provide their employees with healthcare insurance.

 As a physician, my main concern is patient care and safety both which have declined under an insurance-driven market. Have no doubt about it folks, the insurance companies are running the show and “old-school” physicians like me are growing weary of fighting near-impossible battles.  With the demise of the public option, who’s going to ensure that insurance companies play by the rules? Proposing that states assume that responsibility as suggested by the Senate Bill is unrealistic. The federal government had to enforce the Civil Rights Act back in 1964 and the same principle applies now. Without federal intervention, state governments will do nothing and insurance companies will conduct business as usual.

President Obama admitted that members of the US Senate and Congress have the best health insurance plans in our country. Why should WE settle for anything less?

I wish pregnant moms had time to bond with their babies before being booted out of a hospital. And I didn’t have to threaten billing clerks for not admitting my patients for emergency tests because they didn’t have the “right” insurance.

I wish the ob hospitalists hadn’t sent a patient home inappropriately with low fluid and no further follow-up. The patient thought everything was “okay”, traveled to another state on vacation and had to be tracked down. She was advised to go the nearest hospital where she had an emergency c/section that saved her baby’s life.

I wish I could have avoided the hassle with a local hospital when I attempted to send a patient for a diagnostic test and they said they were “too full and too busy.” I ultimately sent the patient to a specialty hospital that was further away where she immediately had a cesarean section because the baby had stopped growing at 33-weeks. Both mom and baby are fine.

I wish the triage department at a local hospital had performed an ultrasound on a patient who complained of bleeding at 27-weeks. They listened to the baby’s heartbeat, said everything was fine and sent her home. When I sent her for an ultrasound, the radiologist contacted me emergently. The patient’s placenta completely covered the opening to her womb and there was a cord wrapped around the baby’s neck three times. I referred the patient to a specialty hospital where she remained for the next nine weeks until she delivered her baby with the cord still wrapped around its neck. However, both mom and baby are fine.

I wish I could run interference for ALL pregnant moms when somebody drops the proverbial ball . . . but I can’t. So I wrote The Smart Mother’s Guide to a Better Pregnancy instead.

“A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.”

A few months ago, a patient in her early third trimester came for a routine prenatal visit. Her vital signs were good, the baby’s heart rate was normal and as I handed her an appointment slip, I asked whether she felt her baby move during the past two hours.  She said no, she had not felt the baby move all day. Despite hearing the baby’s heartbeat, my antennas immediately went up and I referred her to the labor room to have further diagnostic tests.

A few weeks later, my assistant said, “Dr. Galloway, you’ve done it again.” I asked what was she talking about and she explained that our patient was seen in a follow-up clinic for the removal of her staples. The same day I sent her to the hospital, she had an emergency C-Section because her tests were extremely abnormal. Her baby was in trouble. When the on-call obstetrician delivered the baby, he noted an umbilical cord wrapped around its neck five times and once around its body. However, the baby did well and was eventually sent home in stable condition.

My most gratifying moment occurred when I saw the baby for the first time. “She’s my miracle, Dr. Galloway” said the patient, and of course, I agreed. “She was channeling me the night before I came to see you.” “What do you mean?” I asked. “The night before I had her, I dreamt that she had died but because you sent me to the hospital, she’s alive. She’s my miracle.” Tears swelled in my eyes as I struggled to maintain my composure.  The miracle of life never ceases to amaze me.

Do Insurers Discriminate Against Women?

 The ABC story, Pregnancy and Discrimination, was repulsive. A previous cesarean section is now considered a pre-existing condition that prevents women from receiving insurance. Women must pay higher premiums or have a mandatory sterilization if they choose to be insured. No, you didn’t misread the statement. The Golden Rule Insurance Company had the temerity to become “Big Brother.” What a blasphemous name.

Contrary to misinformation and propaganda, there are very few cesarean sections that are done based on maternal request. Most are done because of fetal distress when the baby is not receiving adequate oxygen and faces the possibility of death. Once an emergency is detected, the physician has thirty precious minutes to perform the procedure in order to save the baby’s life.

Do you recall the miraculous landing of US Air Flight 1549 on the Hudson River in New York City? We commended Captain “Sulley” for his heroic feat without hesitation. However, would his passengers now have a “pre-existing condition” because they were involved in an airline emergency? Of course not. Why so for women? Why are women charged up to 48 percent more for insurance than men?

According to ABC, there are only eleven states that prohibit health insurers from gender discrimination regarding the cost of premiums. The remaining thirty-nine states are fair game for continued exploitation. Healthcare reform is not a lofty ideal with a partisan agenda. The future of our humanity lies within sacred wombs.

After the ABC interview and article became public, The Golden Rule Insurance Company changed their ruling and will now insure women with previous cesarean sections.

Thank you, Senators John Kerry and Barbara Miluski for not only bring this issue to the forefront but for introducing legislature to bring these egregious practices to a screeching halt. Let’s keep beating the drums and greasing the wheels. Sometimes when the volume is turned up high, people eventually listen.

I witnessed the side effects of obesity through the eyes of my late mother. Social isolation, discrimination and low self-esteem were an everyday occurrence. Behind every obese woman is often an untold story.

According to medical statistics, 66% of Americans are either “overweight” or obese. This includes ten to thirty-six percent of pregnant women. Obesity is discussed using the Basal Metabolic Index (or BMI) and is calculated based upon a patient’s weight and height. A BMI of thirty (200 pounds) or greater is reason for concern.

Ideally, obese pregnant women should seek the professional care of a high-risk obstetrician who is also known as a maternal fetal medicine specialist. Obese women are at an increased risk of gestational diabetes, high blood pressure, cesarean delivery, increased post-operative complications and stillbirths. There is also an increased risk of birth defects but it is not known why. Because obese women have a greater chance of having twins, an early ultrasound should be obtained.

How much weight should an obese woman gain during her pregnancy? No more than 11 to 20 pounds according to the Institute of Medicine. And pregnancy is not the ideal time to lose weight. The body requires a daily minimum of 300 additional calories. And it’s the quality of the food that’s important. Not the quantity.

Obese women should seek the services of a clinical nutritionist during their pregnancy and maintain a daily food diary. Every state offers the WIC (Women, Infants & Children) program that has a nutritionist or dietician on staff. I strongly encourage pregnant women to take advantage of their services.

Although obesity poses additional challenges, with proper support and guidance, the outcomes for most women are safe deliveries and healthy babies.

http://www.fns.usda.gov/wic/

http://www.smartmothersguide.com

In recognition of September as the National Infant Mortality Awareness Month, I’d like to share some SMART tips to pregnant women:

S = Seek prenatal care early.  Problems in pregnancy cannot be fixed at the last minute. Tests for genetic problems can only be detected in the early first and second trimesters.  A first trimester ultrasound is also the MOST accurate in terms of a due date. 

M = Mention all high-risk factors such as family history of diabetes, high blood pressure or bleeding. Do not omit information such as smoking or “recreational” drugs.  It will come back to haunt you.

A= Ask to have your cervix measured during your ultrasound if there is a previous history of premature contractions or delivery.  A cervical length of 2.5 centimeters or less is a risk factor for preterm labor. 

R= Research your hospital and prospective physician or midwife carefully.  Is the physician or midwife skilled in managing high-risk conditions?  Will they continue to see you even if you lose your insurance?  Has the hospital had any recent outbreaks of antibiotic-resistant – infections in the newborn nursery?  Is there 24-hour anesthesia? 

T= Test for potential problems such as Gestational Diabetes, Sickle Cell Trait or sexually transmitted infections.

The U.S. is one of the most industrialized countries in the world, yet we rank below Cuba and Taiwan, with respect to our national infant mortality rate.  The health of a nation is judged by its national infant mortality rate. We can do better.  We must do better.  The health of our future generation is depending on it.

An ultrasound report came across my desk the other day that made me scratch my head. On the first page, the fetus was listed as head down and on the second page it was listed as breech (feet first).  Well, what was it?  The patient was almost ready to have her baby and I needed accurate information in order to make a clinical decision.   It wasn’t the first time I had received a conflicting report of that nature and I was becoming highly annoyed.

A few days later I received two PAP reports printed in large font that included an apology for the “discrepancy” of the original reports.  A technician had originally read them as “normal”, but after they were re-read by a physician, they were in fact, abnormal.  I had the unpleasant duty of reporting to my patients that they were now at risk for developing cancer.

In an effort to “cut costs”, professional standards are cast to the wind.  The radiology department in question reverted to a voice-recognition system, eliminating transcriptionist jobs.  Because the computer can’t recognize certain words the ultrasound reports are often riddled with mistakes.   The problem is further compounded by a revolving door of radiologists who are hired as temps and read the reports remotely (outside of the hospital).  As a result of an absence of physician leadership, the radiology technicians have inadvertently “taken over.”

Yes, you can nickel-and-dime health care services, but you will also get what you pay for.    Voice-recognition software can never replace qualified human beings and neither can improperly trained technicians replace pathologists.  Physicians love to scream about tort reform, however how about putting some of these hospitals in check?  I wish my colleagues would get their complacent heads out of the sand and DO SOMETHING to promote patient safety.

 I’m tired of fighting this battle alone.

Yesterday was my birthday, but I wasn’t in the mood to celebrate.  The deeper I get into the fifth decade of my life, the more reflective I become.

My cousin, Pearl (“Paulie”) Ford Colon left us on August 8^th and to say that I’m devastated is an understatement.  She was not only my cousin, but one of my dearest friends. 

Paulie and I were considered the “good” daughters in our extended family.  The daughters who never gave their parents grief; that played by the rules even when others didn’t; who finished college  got the “good” job and was the family support (both financially and emotionally) in the midst of a crisis.  We both walked the perennial tight-rope in corporate America while maintaining our family culture and traditions.  Paulie was my greatest cheerleader and “in-house” comedian.   How I lived for her e-mails that made me howl!

We were scheduled to meet in New York this week so that she could finally meet my children.  We both held the undesired distinction of being childless until the adoption of my sons last year.  Paulie was previously married and had miscarriages.  If only I had been in practice during the time of her pregnancies. 

Paulie briefly mentioned that she was having foot surgery but I never gave it a second thought.  In retrospect, I wish I had.  She ultimately had two foot surgeries within a two-week period although the first surgery allegedly had not healed. 

The smell of smoke alerted her neighbors who called NYPD on that fateful night.  Upon forced entry, a frying pan burning on the stove was discovered along with her lifeless body.    The cause of death was a blood clot to the lungs and I have a million unanswered questions for her podiatrist.  Did he obtain medical clearance from her family physician?  Did he prescribed anticoagulants (blood thinners) upon her discharge and did he have to do the second surgery so soon?

The “business” of healthcare has claimed yet another victim.   When is it going to stop?