Posts Tagged ‘Urology’

Same Day Medical Appointment-Just What the Patient Ordered

June 20, 2014

No one knows for certain what the future holds for American Medicine. What we do know is that reimbursements are going to decrease in the near future. We are challenged to find ways to increase the volume of patients we see in our practices. An even greater way to maintain our incomes is to increase the volume of patients seen but also to increase the income per patient that is seen in our offices. On of the best ways to accomplish both goals is to see more new patients. We all know that seeing a patient in the 90-day global period is not as productive as seeing a new patient who is likely to need a work up, evaluation, and perhaps a surgical procedure. Remember there is no income generated by suture removal! After reading this article you will understand the concept of same day appointments and how to consider implementing this in your practice.

Why are same day appointments important?
SDA is what our patients want. Every patient with menometrorrhagia experiences anxiety about her condition and wants to be seen as soon as possible. Most patients do not wish to wait weeks or months for an appointment regardless of the fame and reputation of the doctor. That medical doctors are in a service industry and it behooves us to cater to our patients needs. If we are honest with ourselves, doctors who have long waiting times from weeks to months to see a new patient are merely stoking their egos.

However, this philosophy and this practice of making patients wait to receive an appointment will not enhance patient satisfaction nor improve a practice’s performance. Patient satisfaction is vital in order to build and maintain a successful practice. You can be the most talented robotic surgeon and have a reputation for doing a laparoscopic hysterectomy in less than one hour with no blood loss, and less than 24 hours hospital stay, but if your patients are not satisfied with your care before and after their surgery you may find large gaps and openings in your schedule and a decrease in the number of surgical procedures you perform.

I see up to 35-40 patients/day, which may include 6-8 new patients! How do I do it? I suggest having a sufficient number of the right staffers with the right attitudes while providing them with the appropriate tools to do their job and accomplish their goals. I am solo practitioner and have 6 FTE employees. This is nearly twice the national average of 3 FTE/provider. However, a robust staff allows me to accommodate SDA in addition to seeing follow-up appointments and performing office procedure. I have motivated my employees to know that accommodating SDA is expected and I am willing to provide them with adequate staff and tools to see the extra patients. My ability to accommodate SDA is assisted by having a highly integrated practice management and electronic medical records system, which I fully exploit, makes my practice truly chartless.

Being able to offer SDA requires the proper attitude, which includes a positive, can-do spirit by the doctor. It starts at the top, i.e., with the doctor. It begins with the doctor arriving and ready to see patients on time. If the patients are to be seen at 9:00, that means patients are placed in the room and the doctor is ready to begin seeing patients at 9:00 and not 9:15 or later. If the doctor is late, you can be sure that the day will contain significant delays and the ability to accommodate SDA will not be possible.

I recommend that physicians leverage technology whenever possible to optimize your workflow. Using his electronic medical records system, he is able to see in real-time which patient has arrived, who has been roomed, and if the patients are running on time. He can see this information anywhere in the office by using his tablet computer. He can better “pace” himself when such information is available.

I suggest that you qualify patients when they call for a new appointment by making certain payer information and appropriate authorizations have been obtained, and that patients know in advance what the estimated cost and co-pay will be and that the fee is going to be collected prior to the visit. This requires a well-coordinated effort by the
front desk and the billing office, as well as having the necessary electronic and web-based resources to accomplish this complex task.

Physicians should not assume the liability of providing care without being compensated. It is a good idea for the demographic information and health questionnaire be completed before patients arrive in the office so as not to delay their visit. The patients are also informed to be on time as they will be seen within a few minutes of their arrival. Before
the patient is placed in the exam room, all the reports, supplies, and equipment needed to see the patient is in the room or already available in the electronic health record/chart.
It is a good idea to anticipate how many additional slots he will need by leaving openings to accommodate new patients. This takes minimal analysis of patient appointment demand patterns. For example, leaving additional slots on Monday afternoons as a few patients seen in the ER will likely be calling Monday morning for follow up appointments.

In the next blog I will describe how to accomplish same day appointments and how you can be the darling of your patients.

If Viagra Doesn’t Work-Prostaglandin Might

April 11, 2010

Erectile dysfunction is a common condition affecting nearly 30 million American men.  It wasn’t long ago that most cases were thought to be do to psychological causes.  Now we know that most men have a physical cause.

Impotence occurs with greater frequency after age 40, although it is not inevitable consequence of aging.  The condition can result from complications of chronic conditions, such as coronary artery disease, high cholesterol levels, high blood pressure, and diabetes mellitus.  Side effects of surgery, medications, and psychological influences are also associated with impotence, as are lifestyle factors such as high-fat diet, drug abuse, excessive alcohol consumption and smoking.

Since July 1995, prostaglandin (Caverject) has been approved by the Federal Drug Administration for the treatment of impotence.  Prostaglandin offers men and their partners hope for a problem for which there was previously no approved medication.

Caverject is administered via a small needle through the skin on the top of the penis.  The drug works by relaxing smooth muscle tissue, which, in turn, enhances the blood flow into the penis, creating an erection.  The drug is used for the treatment of erectile dysfunction, whether the cause is neurological, vascular, or psychological.  Men who choose this treatment option receive an initial injection from their physician to determine the optimum dosing.  Then the patient can administer prostaglandin once he has been trained in the technique of self-injection.

Prostaglandin is only available by prescription.

An erection usually occurs 3-5 minutes after the injection and will last for 30-45 minutes.  Men are able to enjoy orgasm and normal ejaculation using prostaglandin injection.  However, the recommendation is to limit the use to twice a week.  Side effects include slight pain at the site of the injection, occasional bruising, and less than 3 percent will have an erection that requires medication to reverse the drug effect.

The results of using prostaglandin are favorable since more than 80 percent of patients diagnosed with erectile dysfunction who use prostaglandin experience an erection adequate for sexual intimacy.

If you suffer from erectile dysfunction, it is a good idea to see your physician so that the proper diagnosis can be made and the appropriate dose of prostaglandin can be selected.  It is now possible to find an effective treatment for most men who suffer from this common medical problem that significantly impacts a man’s quality of life.

Bottom Line:  If you have tried one of the oral medications for erectile dysfunction and you are not receiving the result you would like, consider self-injection therapy with prostaglandin

Self Care for Women With Urinary Incontinence

March 30, 2010

Incontinence is a condition that results in the involuntary loss of urine without the owners’ permission. It is a condition that affects millions of American men and women. There are many changes that occur in the human body as we get older. Like many other bodily system, the urinary tract undergoes changes with age. These changes make middle age and older men and women more likely to become incontinent of urine as they grow older. It is important to remember that incontinence is not a necessary part of the aging process but it is more common in older men and women. There are a number of actions that women can take to decrease or even limit this embarrassing situation.

The skin around the outside of the vagina in women is called the “vulva”. This area includes the skin around the urethra and the vaginal “lips” or labia. Frequently, in incontinent women this area is red, raw, and sore from urine irritating the skin. If this is a problem for women, these tips may help make women more comfortable and avoid irritation of the bladder, urethra, and surrounding skin.

  • Women who are incontinent should wear cotton underwear instead of underwear made of synthetic material such as nylon. I also suggest that women do not wear synthetic pantyhose, especially not under pants or jeans. Women will also find that the underwear will be less irritating to the vulva if the underwear is washed in pure soap or soap flakes and not in harsh detergents or with the addition of fabric softeners. I suggest that women wash the vulvar area no more than twice a day, using only plan water or mild soap such as Ivory or Dove.
  • Women who are incontinent should avoid bath oils, bubble baths or bath salts. All of these can be very irritating to the already sensitive skin of the vulva. Vaginal deodorants or douches should also be avoided. Tampons should not be used as they may irritate the bladder and the urethra.
  • After bathing, the vulvar area should be gently dried with a towel, and then use a hair dryer on cool or low setting to dry the vulva completely.
  • If you need a powder to help keep the vulvar area dry, I suggest using ordinary cornstarch and not talcum powder.
  • Finally, try drinking pure water as much as possible and avoid caffeinated beverages such as coffee, tea, and cola beverages. Avoid alcohol especially in excess as alcohol may irritate the bladder and the urethra.

Nearly every woman with incontinence can be helped and most can be cured. If this is a problem that is affecting your quality of life, I suggest you contact your physician.

Tick Tock or When Your Biologic Clock Slows Down

March 10, 2010

When the phrase “biologic clock” is mentioned, most think this is in reference to women who experience a loss of hormone production at the time of menopause.  But men also have a clock that starts to slow down around age 35.  It is at this time that men experience decreasing hormone production, decrease in fertility potential, as well as an increase risk of genetic problems in children born to men who are older.

The theory that men go through a change in life, similar to what women experience, could be taking hold. We know for certain that the cause of the slowing of the biologic clock in women is due to a decrease in the production of estrogen.  If less estrogen in women leads to the end of menstruation, moodiness, hot flashes, loss of sexual interest and osteoporosis, couldn’t male versions of these symptoms be caused by less testosterone?

How common is male hormone deficiency?  Currently in the U.S., at least 6 to 10 million men suffer from the effects of extremely low testosterone levels in their bloodstream.  Sadly, only 1 out of 6 of these men will ever receive treatment to resolve this problem.

Infertility and aging

It has been noted that more men, and women, are deferring parenting until they are older, finished their education, and are more financially stable.  As a result the number of children born to fathers older than 35 years has increased considerably in the past few decades.  This creates a problem as there is a decrease in fertility in men with increasing age.  Since it takes longer to achieve a pregnancy in older men, they should be counseled and may consider starting their family sooner before their clock completely winds down.

Since there is evidence of the existence of a male “biological clock,” the likelihood of taking more than a year to conceive doubles when the man is over 35. The implication is that a man’s age should be another factor that is taken into account when looking at the chances of conception in couples who are having difficulty conceiving.

In addition, as men age, the genetic quality of their sperm declines significantly. According to the Centers for Disease Control and Prevention, the number of babies born to parents older than age 35 more than doubled from 1970 to 1999, from 6 percent to 13 percent. This trend has led to the rise in the rates of infertility in the past decade, and to increased miscarriage rates and the possibility of a baby born with Down Syndrome (in addition to other genetic abnormalities).

When testosterone levels drop

In women, menopause generally marks the end of youth, hence the idea of a “mid-life crisis.” Some women get hot flashes, are moody, irritable and/or depressed. Male menopause, or andropause, is not as clearly defined for men as it is for women.  There probably is a syndrome of testosterone deficiency in aging men, and that testosterone deficiency is manifested by a diminished sexual drive, difficulty in getting or maintaining an erection, lack of energy, even irritability and grumpiness.  There are even changes in a man’s height, caused by bone loss and osteoporosis.

If a man is experiencing any of the symptoms of testosterone deficiency, they need to see their physician and undergo an evaluation which includes a blood test to measure the testosterone level.  Not all male mid-life crises are a result of testosterone deficiency.  First, the doctor must be sure that the symptoms are not due to depression.  Many of the issues in testosterone levels could be confused with the effects of depression. If you’ve got symptoms that may be suspicious, the first thing is to have a thorough physical and laboratory work and make sure you rule out other medical conditions such as diabetes, which also affect testosterone levels. Treat those conditions first, before you consider looking at testosterone.

There is also a useful questionnaire, ADAM-Androgen Deficiency in the Aging Male, that is helpful for men to identify testosterone deficiency.

The ADAM questionnaire asks you to check for the following symptoms:

  1. Decrease in sex drive
  1. Lack of energy
  1. Decrease in strength and/or endurance
  1. Lost height
  1. Decreased “enjoyment of life”
  1. Sad and/or grumpy feelings
  1. Erections less strong
  1. Deterioration in sports ability
  1. Falling asleep after dinner
  1. Decreased work performance

Men experiencing Loss of morning erections depression, tiredness, memory loss, decreased muscle mass and increased weight, more fragile bones, or a diminished sex drive might be candidates for testosterone replacement therapy.  Treatment of testosterone deficiency is easily accomplished with injections of testosterone, patches placed on the skin that transmit the medication from the skin to the blood stream, or topical gels applied to the upper arm or lower abdomen can quickly restore a man’s libido and sex drive.

So if you are over 35 and are feeling less than your best, you should talk with your doctor about your symptoms. A complete medical examination that includes laboratory tests can help show whether testosterone supplements might help you feel better. If treatment is suggested, then I encourage men to try it for a period of a few months while keeping track of the changes. If low testosterone is the cause of their symptoms, men will not have to wait long to see the effects of treatment.   Bottom line…men, you may not be able to turn back the clock of time but you certainly can reset your biologic clock with hormone replacement therapy.

Dr. Neil Baum is a urologist at Touro Infirmary.  For more information, contact Dr. Neil Baum at (504) 891-8454 or go to his Website, http://www.neilbaum.com

The Circumcision Decision –The Prime Cut

March 9, 2010

The first concern most men will have about their genital organs occurs right after birth when he undergoes a circumcision….and, unfortunately, the young boy has no part in the decision whether to lop off that precious piece of real estate!

Removal of the foreskin of the penis is one of the oldest surgical procedures known, dating back well over 5000 years. Hieroglyphs picturing ritual circumcision were found in ancient Egypt, and the religious significance of circumcision is described in the Old Testament.

Medical Risks and Benefits

Parents should be assured that the great majority of circumcisions are trouble-free. But circumcision is surgery, and all surgeries run the risk of complications.  The most common complications, which occur in only about 1 percent of circumcisions, are: bleeding, which can easily be controlled with pressure, and minor infection, which can be treated with antibiotics.

The medical benefits of circumcision are small. Uncircumcised boys have a higher risk of developing urinary tract infections (UTIs) than circumcised boys, particularly in the first six months of life  However,  the overall risk of a UTI is still less than 1 percent. Generally, physicians will recommend circumcision for any boy who has two UTIs in the first year of life. A circumcision performed months or years after birth is done surgically under anesthesia, and seems to be associated with fewer complications and less pain and trauma.

Circumcision also has small but measurable benefit in preventing penile cancer, a very rare disease that strikes only about 1 in 100,000 men. Uncircumcised men are three times more likely to develop penile cancer than circumcised men.

Uncircumcised men are also reported to be at greater risk for developing sexually transmitted diseases such as syphilis and HIV infections than circumcised men, but behavioral factors, such as not practicing safe sex, are far more important risk factors.

Overall, the increased risk of developing UTIs, sexually transmitted diseases, or penile cancer is extremely low, regardless of circumcision status.

A Kinder Cut

For those parents who elect to have a circumcision performed on their newborn infant, it is important that the parents select an experienced surgeon to perform the procedure.  The AAP recommends that pain relief with a local anesthetic should be used during the procedure.  Safe and effective forms of analgesia for circumcision are easily accomplished using a local or topical anesthetic consisting of a gel or cream applied to the foreskin before the procedure.  This method has been found to provide adequate pain relief during the 5-10 minute procedure.

Parents considering circumcision should talk with their doctors, and make sure that they are comfortable with whoever will be performing the procedure. Specify in advance what type of anesthesia will be used, and notify the doctor if there are any bleeding disorders in the family.

Parents who choose not to circumcise need to receive instructions on how to care for an uncircumcised penis. The foreskin should never be forced to retract, nor should objects such as swabs or cotton balls be used to clean underneath it. Although most boys will have retractable foreskins by age 3, in some cases, it may take 7 to 10 years. Parents must be patient and allow the process to happen naturally.  All boys who are not circumcised need to be instructed on proper hygiene of the foreskin.  Failure to do so can result in inflammation of the penis and a foreskin that is even more difficult to retract and clean.   Occasionally, this condition, phimosis, or tight foreskin requires a circumcision as an adult.

So if you are considering the “prime cut” for you or your newborn son and have any questions, I suggest you contact your doctor.

Dr. Neil Baum is a urologist and can be reached at 504 891-8454 or on his web site www.neilbaumcom