Mark Tong, MD

Treating Common Warts With Duct Tape

2012-02-10T08:21:00.000-08:00

Common skin warts are actually caused by a virus. Your immune system will eventually get rid of the virus and allow your skin to return to normal. The catch is that this can take about a year!

If you don't want to wait that long, there are a number of ways to get rid of them. Freezing them with liquid nitrogen or surgically removing them can be done by me in my office. (Unfortunately, that freezing spray that you can buy over the counter is just not cold enough to get rid of warts, and the acid treatment often fails and is kind of painful.) Aldara (generically known as imiquod) is a prescription cream that can work, and does not sting or burn. However, it is very expensive and not covered by most health insurances.

As an intriguing alternative, duct tape may work (this link is for a technical audience and may require free registration) in getting rid of warts. Yes, duct tape: 101 uses, now 102!

There are only three clinical studies on this, though that's kind of interesting since you could imagine there would be none. The effectiveness is not 100%, but it also doesn't seem to be harmful either. The idea is that covering warts with duct tape causes localized inflammation and irritation, which in turn stimulates an immune system response that helps in getting rid of the warts. This is supposed to be how freezing warts works, too.

The treatment with duct tape in clinical studies is:

Cover the wart with a piece of duct tape for seven straight days.
Then, remove the tape for 12 hours overnight.
Repeat Steps 1 and 2 as needed for up to 6-8 weeks.

Again, there are no wart treatments that are 100% effective. However, this method can be helpful and seems otherwise to have no harmful side-effects unless you are simply allergic to duct tape.

Interesting Reads

2012-02-09T09:11:00.000-08:00

Warren Buffet on the risks of bonds assets (ditto from Black Rock): (Bloomberg).

Interesting analysis of the Obama presidency to date,through the lens of the history of modern U.S. Presidents: (Atlantic).

Yves Smith on why the bank bailout sucks: (Naked Capitalism).

Matt Taibbi says "cry me a river" to Wall Street bankers: (Rolling Stone. profanity alert- it's Taibbi)

Could You Pass a U.S. Citizenship Test?

2012-02-08T17:22:00.000-08:00

Just for hoots, try passing this 96 question citizenship exam found posted in that hotbed of communist sympathy the Christian Science Monitor.

All applicants for citizenship must pass a Naturalization Test, scoring at least 60% correct. 92% of applicants do so. Have a go at it!

Why Don't You Use a Computer?

2012-02-07T15:52:00.000-08:00

I get asked every now and again by patients (usually while I'm writing in their chart) whether I plan to go to a computerized medical record.

I find that to be a really interesting question. Generally, I am a very enthusiastic computer user. I create web content, enjoy computer games, am versed in maintaining and securing wireless networks, and am proficient with several operating systems.

However, I have no plans to adopt "Electronic Medical Records" (EMR) unless they become far more useful than they are at present.

First of all, adopting EMR is shockingly expensive. Start up cost of adding new hardware, licensing software, training staff and doctors in their use and scanning existing paper records to EMR is about $50,000 in itself. This does not include future licensing or upgrades to equipment or software. It also does not include the 10-20% losses in income of the first 1-2 years of adoption due to a decrease in the number of patients that can be seen, as the implementation of EMR slows everything for 1-2 years.

Additionally, there is no widely accepted standard code set or open-source code for EMR. This means it is very easy to sink this kind of time and money into EMR for your office or group or hospital and be absolutely unable to use it to share crucial medical information with neighboring physicians simply because they using one of the other 10-20 most popular EMR platforms being marketed.

It should also be realized that EMR is not new, and has been around for a decade or two. It's intended primary use has never been to enhance the quality or consistency of medical care. Rather, it has been marketed as a way to fully document your visits in such a way as to justify your billing to insurance companies.

Unfortunately, EMR has not been fully re-vamped to optimize patient care and reduction of errors. Instead, features have simply been layered over and added on to the pre-existing systems. As a consequence, studies demonstrate that EMR does not result in improved care and actually results in increased error rates.

All of this may explain why the majority of doctors have not adopted EMR. A regular contributor to Kevin, M.D. nicely sums this up. You might not notice this here in Placerville, since Marshall has implemented an EMR system recently which can make it look like everyone now uses EMR.

I find it interesting that when I answer patient questions by saying that I don't plan to computerize my office the response is usually positive.

Most patients have commented that they find the use of a computer by doctors, nurses and physical therapists to be off-putting insofar as it limits conversation and eye-contact, and seems to take up time that would otherwise be spent examining or communicating with patients. I suspect they have a point here.

I'm sure it's possible to use EMR and not lose this human touch, but the current systems just aren't there yet and aren't likely to be there soon. I myself would rather not risk losing this element of human touch and communication with my patients.

A Reverend and His Calling

2011-12-14T13:59:00.000-08:00

The reverend in the picture writes movingly of his experience at the Port of Seattle. The link was forwarded to me by a member of his church. While I've never met the reverend, I have no reason to take his words at anything other than face value. Read his story with an open mind, as his words are very much worth reading.

Choosing a Medicare supplement

2011-12-07T14:16:00.000-08:00

The open enrollment period to join or change a Medicare supplement plan is from 10/15 to 12/7 this year. Selecting the right plan for you does not have to be difficult. Seriously.

If you call an insurance broker to help you in this, you do want to sound very assured and informed about what expensive medications you take (if any) and what extent of coverage and monthly premiums you can afford. Otherwise, a broker is going to be unwilling to spend 1-2 hours with you without being able to sell you a plan.

The website for the Open Enrollment Center has gotten easier and easier to use since the start of the Part D (drug coverage) and Part C (Medicare Advantage) programs years ago.

First, click on the blue bar-shaped button called My Medicare Tools. (Sorry, Windows Vista is not easy to use for screenshots.) This goes to the Resource Locator page.

Next, click on the sidebar element called Drug and Health Plans. This will open the Medicare Plan Finder. Jackpot!

From here, you can use your Zip Code to look for available plans in your area. If you want, you can also do a more personalized search based on your Zip Code, and also your existing Medicare Number and demographic information.

Even using the general search just based on Zip Code alone, you still can indicate whether or not you are already on Medicare and whether or not you have any other help with prescription drug costs (such as Social Security, MediCal, SSI and so forth).

Continuing on the general search with regular Medicare alone, you get a chance to create a list of medicines you take by name. You do not have to do this, but it's useful if there are any medicines you get which seem to be unusually expensive. Usual examples of this would be inhalers for asthma or COPD, and pills for rheumatoid arthritis, chronic colitis, chronic pain and cancer. The vast majority of medicines for heart conditions and diabetes are generically available.

If you wish, you can bypass this by clicking "I don't take any drugs", or "I don't want to add drugs now".

The next screen then allows you to check off the pharmacy or pharmacies that you use. You can select as many from how ever many miles from where you live, or just skip ahead.

At this point, you get a Summary of plans in your area. This list will be limited to only ones that fit your selections if you made any specific selections. Here, you can go on to see an entire list of plans. You can also refine how the list is presented to you before you proceed. For example, you may want to show only Part D drug coverage plans because you already have Part A and Part B Medicare. Or, you may want it to show plans listed in order of monthly premium, or in order of annual deductibles, or ratings by consumers.

The last screen is titled Your Plan Results. This is a list of plans where you live, available to any pharmacies you may have chosen and any other specifics you may have made. You can still use the drop-down menu to change the list to show in order of cost, or ratings, or other choices. You can also check the box to the far left of any plans that interest you, and then click on the orange bar "Compare Plans" to show a head-to-head comparison of just the plans that interest you.

For what it's worth, looking for the most highly consumer-rated Part D plans in the Placerville area shows Medco, Blue Shield and AARP to be the best. Certainly, we've had no problems with any of these and patients do not complain about their coverage with them.

Otherwise, please please please DO NOT choose any plan that "takes over for Medicare" or makes Medicare your secondary insurance (this includes Part C Medicare Advantage plans). This will immediately result in a smaller pool of available specialists, more restrictions on medications, and long delays in getting authorization for any tests. If you don't like "the Canadian health care system", then don't pick any plan like this!

Be very suspicious of the nicely dressed, helpful young men and women with the tables set up at the grocery or drugstore. Plans they offer may be cheaper in the short run, but you will definitely be getting what you pay for here. Remember; if it's to good to be true, it is!

Emergency Contraception- the "Morning-After Pill"

2011-11-09T14:23:00.000-08:00

"To err is human, to forgive is divine."

Despite best efforts, accidents can happen. In this case, we are talking about unprotected sexual intercourse and the possibility of undesired pregnancy. This could involve teens and young singles, and also married couples who do not yet want to have children or do not want to have more children.

Medication is available that can really lower the likelihood of pregnancy occurring in this event. Higher than normal doses of birth control pills can prevent a fertilized egg from becoming a fetus.

Specifically, these medications can keep an egg (or ovum) which has been fertilized by sperm from being able to implant (stick to) the inside of the uterus, and hence from eventually going on to become a fetus.

Mind you, if you feel or believe that preventing a fertilized egg from sticking to the inside of your uterus (womb) would be something that you feel wrong in doing then by all means do not do so. However, most people who feel strongly about "right to life" issues do not define this as abortion.

Plan B is the brand name of a medication you can buy over-the-counter, and use in case of emergency. It can cost about $45.

It is important to realize that time is of the essence in such a situation as missed birth control pills, condom rupture or unprotected sex. If Plan B is taken within 12 hours, it has a 95% chance of preventing undesired pregnancy. By 2 and 1/2 days later, the chance falls to 72%. Sooner is definitely better! It is probably best to simply buy some and have it ready to use if you ever need it. Twelve hours can go by very quickly when stores are closed on a weekend night.

Plan B was actually based on the known doses of birth control pills needed to prevent undesired pregnancy. It is simply packaged in a form that is easy to use.

This link from Princeton University provides useful guidance in how to use 19 different commonly used birth control pills as emergency contraception.

Life Line ultrasound screening- Meh.

2011-11-09T13:58:00.000-08:00

I get asked about this test periodically, whenever Life Line scans come to town.

Do I recommend them? No.

Why doesn't my insurance cover them? Because they are proved not to be helpful.

The tests include ultrasound examinations of the carotid arteries which carry blood supply up to your brain, the abdominal aorta which carries blood supply to the abdomen, and also the circulation in your legs.

These are all standard diagnostic tests which can be ordered by doctors and are covered by insurances. The problem is, they are not useful as screening tests applied to patients who have no concerning symptoms. These tests have only been shown to be useful in preventing strokes, aneurysm rupture or worsening leg circulation in the presence of symptoms or abnormal physical exam findings.

In the absence of such, we find that applying these tests does not prevent these problems and simply exposes healthy people to further and riskier tests in the event of minor abnormalities being found.

Mind you, this is one of the reasons to be seen annually for wellness examinations or physicals. An important part of the exam is checking for findings that would suggest circulatory problems or aneurysms. Happily, the physical exam is quite sensitive in finding these problems and can guide further testing and treatment. When I am listening to your neck and abdomen and feeling pulses in your feet, that is exactly what I am doing!

Effectiveness of Prostate Cancer Screening

2011-10-11T13:05:00.001-07:00

If you have been following the news in the last week, you will see that the United States Preventive Services Task Force (USPSTF) has recommended that doctors not routinely screen for prostate cancer in men. A separate and independent review panel agrees with this recommendation.

Mind you, both groups are composed of doctors and analysts who have no ties to government employment or drug companies. Also, their recommendations are based on how well screening and preventive efforts work without regard to their cost. In other words, recommendations are not made on the basis of cost to the system or rationing.

PSA blood testing and rectal examination have to some extent seemed to doctors to be tools that are not the "sharpest tools in the shed", but the only tools available. It was hoped that over time, their use in screening for prostate cancer would have a positive impact on outcomes; that is, keep men from dying of prostate cancer.

The problem here, is that these tests do not seem to end up saving lives. In fact, it may be that they cause more anxiety, suffering and painful and unnecessary tests and surgeries than benefits.

A major difficulty here is that prostate cancer is common, yet dying of it is not.

Cancer cells start to appear in a normal, healthy man's prostate gland as a pure correlate of aging. By the time you are 50 years old, the chance of having cancer cells in your prostate gland is 50%. At 65 years old, the chance is 60% and by 75 years old it is 75%.

Yet, out of 17 men with cancer cells in their prostate, only one will die. The other 16 will go on to die of natural causes or other conditions without any sign of prostate cancer.

The problem is, that we do not have a way of determining who is that 1 guy out of the 17, so we end up treating all of them as if they will go on to die of prostate cancer without treatment.I

In addition to this not very good statistic, the number of men every year who die of prostate cancer is staying the same over time. In other words, we are not saving lives by doing routine annual rectal exams and PSA blood tests.

Faced with this, it seems that it would be better if we simply stopped doing such routine screening until we can develop a way to determine who's prostate cancer should be aggressively treated, and who's can simply be watched.

Mind you, this does not apply where there are symptoms present that raise a concern of prostate cancer- that's not screening, it's diagnosis. It also may not apply to men with a concerning family history of prostate cancer in their fathers or brothers.

This is certainly a discussion that can be had face to face in the office. I just think patients should have all the information at hand to make decisions that they feel are right for them.

For my part, being a man over 50 with no history of prostate cancer in my family, I do not intend to have prostate cancer screening tests done as part of my annual physicals.

Advance Directives- Pre-Hospital DNR, or AND

2011-09-21T16:56:00.000-07:00

The idea around decisions or orders to Allow Natural Death (AND), or Do Not Resuscitate (DNR) is to address your preferences or personal wishes in the event of a sudden and immediately life-threatening loss of heartbeat and/or ability to breathe.

In previous posts, we discussed directives you can make which speak to your wishes on matters affecting your medical care.

This post specifically discusses sudden, unexpected and potentially immediately fatal events occurring outside the setting of a hospital or ER, and your wishes in such an event. More particularly, this pertains to a sudden loss of heartbeat and ability to breathe such as might occur in a massive heart attack.

This may be ultimately expected in a terminal illness such as advanced cancer, or may be entirely unexpected.

Doctors generally ask about your preferences since we do not wish to withhold care from you that you want, but we also do not wish to perform heroic or even desperate procedures on you that you actually do not want.

Certainly, you should realize that a decision by you to allow a natural death or not to resuscitate does not affect your care in other matters such as your cancer, pneumonia or hip fracture. As our nursing colleagues rightly point out, "no resuscitation does not mean no care"!

Something to be mindful of in your decision-making is what is occurring during a loss of breathing and pulse and during CPR.

A sudden loss of breathing and pulse can occur for a variety of reasons, but while it is occurring, there is a significant loss of oxygen supply and blood flow to your brain. CPR is an attempt to maintain circulation of blood to the brain while awaiting definitive attempts to restore normal heart rhythm by delivering an electrical shock. This is known as defibrillation (or "shock paddles", as seen on TV). Medicines given if this occurs in a hospital are largely given in order to maximize blood flow to the brain. It is ultimately timely defibrillation that can restore normal heart rhythm with intact brain function.

Note the emphasis on the intact brain function part.

The tricky part here is that your brain can only go for 5 minutes without good blood supply before permanent brain damage starts to occur. Past this limit, the longer the duration of sub-optimal blood flow the more extensive the damage. For a worst-case scenario, think Terri Schiavo.

Even in the best of circumstances where this occurs in a hospital, the odds of going home alive and with an intact brain are about 15%.

If this occurs outside a hospital (such as at home, a friend's house, a movie, a restaurant, etc.) the lack of immediate access to a defibrillator makes an enormous difference.

If you survive long enough to make it to an ER, and survive long enough to actually be admitted to the hospital, your odds of eventually going home alive and with an intact brain are only 2-8%. This is because your valuable 5 minute window of opportunity is already gone by the time paramedics can arrive even if someone has immediately called 911.

Once paramedics arrive, they are legally required to initiate CPR and resuscitative efforts. If, given the aforementioned discussion, you would wish for them to do so, you do not need to take any action at all.

On the other hand, if you would NOT want them to do so, you need a signed order from a doctor instructing them not to start resuscitative efforts.

This handout and sample form can be used if you feel that you would not want paramedics to start resuscitation for such an event in your home. It only requires your signature (or your caregiver's) and your doctor's signature.

(Paramedics will still come to your home and provide the usual help in all other matters! Signing this does not mean that they will not come to your home, or help you if you have fallen down or have a medical problem.)

Advance Directives- POLST

2011-09-06T16:47:00.000-07:00

In 2009, a new sort of advance directive became available. It is called Physician Orders for Life-Sustaining Treatment (POLST). It is not meant to replace an Advance Directive for Health Care, but rather to amplify on it in a clear and easily read manner. Also, it can be used even if there is no formal Advance Directive.

Additionally, the POLST form takes the form of a physician order and does not require notarization or witness co-signatures as does the Advance Directive. It addresses your wishes around heroic resuscitation or cardio-pulmonary resuscitation (CPR), as well as your preferences in terms of how intense or aggressive you wish your medical care to be in the event of a serious medical problem.

This is a very helpful list of frequently asked questions from the California Hospice Foundation.

This .pdf document is the actual POLST form itself for your use.

Advance Directives- An Introduction

2011-08-31T14:12:00.000-07:00

Advance Directives are important legal documents, but are sometimes misunderstood. Generally speaking, advance directives designate another person or persons to make decisions or take actions on your behalf should you be unable to do so for yourself. They can also be designed to state your own wishes and preferences.

Many people have such directives around legal and/or financial matters. For example, they may have a will or a living trust or they may have a document authorizing their spouse to gain access to financial accounts or pay bills or sell assets if they were to become unable to do so themselves or jointly.

Advance Directives for Medical Care (so-called "Living Wills") make your wishes known about medical care and designate people to make medical decisions for you if you become unable to state them for yourself. For example, you will typically be asked to state a preference around organ donation and around prolonging life in the event that you are in a coma or persistent vegetative state ("brain dead") or some terminally ill condition.

Please be aware that your wishes around artificially prolonging your life only become applicable when you are already brain dead or in a coma or terminal condition. Advance Directives generally do not address your preferences or wishes around scenarios that could lead up to being terminally ill or brain dead.

For example, you may have strong feelings about the roles of interventions or procedures such as dialysis or emergency brain surgery in dire emergencies where you are already so sick that cannot discuss them for yourself. It is okay to add these wishes to your Advance Directive.

Advance Directives allow extra space for the addition of any further statements that you may care to make. In California, they do not require an attorney to draft. They simply require your signature and either a notary public or the signatures of two persons who know who you are.

However, you may wish to enlist the aid of an attorney if such a directive seems complicated or unclear.

This site has state-specific free downloads of Advance Directive forms.

Five Wishes (produced by the non-profit Aging With Dignity) is an advance directive that more fully addresses your feelings around comfort and is a bit more specific around examples of life-sustaining interventions or procedures and allows you to address them as you see fit. The document costs $5, but can be previewed for free as a .pdf document.

This form from the Attorney General's office of the State of California is also freely available.

We also have a handout on this subject and sample forms from the California Hospital Association for your use. Feel free to ask for one next time you are in the office!

Pharmacokinetics: What happens to the medicines I take?

2011-08-29T08:35:00.000-07:00

Folks often ask questions about their medicines (whether over-the-counter or prescription) that have to do with how long they last, or how long it will be before they take effect, or how long until side-effects may go away or for the medicine to be out of circulation.

A handy principle or "rule of thumb" has to do with what happens to medicines after you take them; this is known as pharmacokinetics. (On the other hand, what they do after you take them is called pharmacodynamics.) Mind you, this rule of thumb only applies when a medicine is being taken regularly and as directed. This means that it is being taken in the instructed amount and frequency and not "as needed" or "now and again". However, this rule of thumb applies to nearly any medicine by any route (swallowed, injected, i.v., etc.).

How much of a medicine (dosage) and how often it needs to be taken (frequency) has to do with how quickly your body metabolizes or breaks it down, and then how quickly it is excreted out of your body. For the vast majority of medicines, the liver breaks them down, and then they are excreted in your urine.

When taken at the directed dose and frequency, a medicine does not stay at a fairly constant and effective level in your blood stream until after the 4th dose. This is called steady state.

For example, if today you start taking a pill for pain that is supposed to be taken three times every day, then a steady and pain-relieving amount will start to be maintained in your system by later tomorrow. On the other hand, if you start one that is a once a day pain pill, it will not reach a steady level until five days from now.

Similarly, if you are taking a medicine regularly and feel that it is causing troublesome side effects it will not be entirely gone until after the fourth missed dose.

FDA Concerns About Zocor/simvastatin in the 80 mg dose

2011-06-09T08:17:00.000-07:00

The Food and Drug Administration (FDA) announced concerns yesterday about the risk of muscle injury specifically around Zocor or generic simvastatin in the 80 mg dose.

Statins have been widely used since the 1980's for reduction of cholesterol and reduction in the occurrence of sudden deaths from cardiac arrest, heart attacks and strokes. Muscle injury is known to be an uncommon side-effect of the statins and is proportional to the potency ("strength") and dosage ("size") of the particular statin.

Simvastatin is the most potent of the generically available statins, and the 80 mg dose is the highest dose made for it.

The FDA is concerned (this link is technically worded) that the risk of muscle injury with 80 mg a day of simvastatin is higher than for comparable doses of other statins. Specifically, they are recommending that doctors not start patients on this dose, or increase patients already on lower doses to this dose.

This concern is based on a recently completed medical study comparing the effects of simvastatin in 20 mg and 80 mg doses with and without supplemental Vitamin B12 and folic acid after heart attack.

One of the findings from this study was that the risk of muscle injury with the 80 mg dose was 0.9%, and 0.02% with the 20 mg dose. Prior to this test, the risk with the 80 mg dose had been reported as 0.53%. Hence, the warning.

Please note that if you already are on simvastatin at 80 mg a day for a year or more and not having side effects (such as persistent muscle or joint pain, or weakness), there is no need of concern.

News announcements suggest switching to other medicines that are as effective as 80 mg of simvastatin. The problem with this is that the only medicines that are equally effective are Lipitor 40 mg and Crestor 20 mg. Neither of these is generic, so they are often much more expensive.

If you would like us to switch you to one of these, let us know. Please check your insurance formulary to see which of these you would prefer so you can let us know which one to switch you to.

Can I split this pill?

2011-06-08T08:16:00.000-07:00

We often get asked whether it's okay to split or crush a pill. This might come up because of a need to reduce the dose, or because of difficulty swallowing the pill whole (think sulfa antibiotic or potassium replacement).

Generally, pills that have a score or line imprinted into them are intended by the manufacturer to be safely and easily splittable. Also, pharmacies will put an easily visible sticker on the bottle telling you not to crush or split the medication if this is an issue.

Pill splitting devices are easily and cheaply obtained at supermarkets, drug stores and pharmacies and are much easier to use than using a kitchen knife on the counter-tops!

If it interests you to know why some pills should not be crushed or split, there are a number of reasons (h/t Art Gonzalez, Pharm.D., Marshall Hospital Pharmacy Department):

Crushing pills meant to dissolve under the tongue (sub-lingual) such as nitroglycerin for chest pain or angina can cause them not to work.
Extended-release formulations of medicines often are designed to have an outer coating that allows the medicine inside to be slowly absorbed into your bloodstream over a long period of time. Spitting or crushing these can allow 12-24 hours worth of that medicine to get into you in a few hours: this would not be good. Often, these medicines have abbreviations after their names such as CR, LA, SR, XL, XR, CD, etc.
Crushing or splitting pills with potential to be cancer-causing (carcinogenic) or birth-defect causing (teratogenic) can cause the medicine to be released into the air and can be positively dangerous to patients and their family members. Examples would include chemotherapy pills and hormonal pills.
Sometimes the pill bottle will be labelled not to crush or split the pills because they are fragile, taste bitter, or might stain your teeth or irritate your throat.

Is there a link between cell phone use and cancer (v. 2.0)?

2011-06-01T17:07:00.000-07:00

I posted on this topic a few months back, and noted that there was no compelling evidence to suggest that cell phone use was linked to brain cancers. Certainly, the occurrence of the types of brain cancer in question (gliomas and acoustic neuromas) has remained pretty much the same over the last decade or two, even though cell phone use has escalated very rapidly.

The World Health Organization (WHO) announced concerns of a potential risk in heavy cell phone use for developing gliomas and acoustic neuromas.

If you've been looking for a good excuse to stop answering your cell phone or to spend money on hands-free headsets, then now's the time!

However, if you are wondering how safe or unsafe cell phone use may be from the standpoint of brain cancer risk it's worth noting that the WHO's findings are far from conclusive.

The level of risk is not new compared to earlier studies, and is assigned a level of 2B. This means a possible risk of cancer in humans, but with very limited evidence.
Note that other possible carcinogens in the 2B category include carpentry, coffee and pickles.
Even if this finding is taken at full face value, we are still talking about an uncommon form of cancer which means that the risk in any individual of developing a brain cancer from using a cell phone regularly is still very low.

To me, this is also interesting as telecom industry studies show that cell phone users are using there phones less for actual voice phone calls and more for texting, email and data transmission such as smart phone apps.

Until I am convinced otherwise I plan to continue to use my cell phone, start off my day with a mug of coffee, and eat pickles or kim-chee when the mood strikes me. However, I will continue to defer carpentry to my wife since she is far better at it than me!

Travel Preparations

2011-05-24T18:09:00.000-07:00

Summer is fast approaching, and we often get questions about travel abroad.

The idea here is to have a great time, but also be able to avoid or deal with health-related problems that may arise.

First, don't forget the basics.

Bring things you already use such as spare glasses or contact lenses, sunglasses and prescription medicines you normally take. I suggest you bring controlled substances such as sedatives and pain-killers in the original pharmacy-issued containers. You might also want to make sure that such medicines are legal to possess on entering the countries in which you will be traveling.
Bring normal first aid supplies such as lip balm, insect repellent, eye drops, band-aids, athlete's foot cream, Neosporin, and Tylenol or Advil.
Pack for the kind of activities you will be doing. Rick Steves has a lot of great advice on this!

Feel free to see us if you have further questions or concerns. Also, we can help you with specific medical needs such as:

Hepatitis shots
prescription medicines to prevent malaria
Tetanus shots
prescription medicines in case of travelers' diarrhea
prescription medicines for "jet lag"
prescription medicines for flying-related panic attacks

Travel Med is a good resource for those unusual immunizations that doctor offices and public health departments do not carry, such as yellow fever vaccine. They have a Sacramento location at:
4250 H Street, Suite 4
Sacramento, CA 95819
916/254-2100

The Centers for Disease Control (CDC) have a lot of information for travelers, including specific concerns about your destination.

Also, don't forget to check the U.S. Department of State for information on travel such as passport requirements and crisis situations in your destination.

Bon Voyage!

Preventing Kidney Stones

2011-05-04T14:43:00.000-07:00

Kidney stones are a relatively common problem, and a very painful one to have.

Lifetime risk of ever having one in both men and women is 5%. Fortunately, the risk isn't higher since passing a stone can be more painful than childbirth (or so every female patient who has had both has told me).

80% of stones contain calcium. Out of these, 80% are made of a chemical called calcium oxalate.

Happily, these kinds of stones may be prevented by some dietary suggestions:

avoid high protein, high salt diets
avoid Pepsi, Coca-Cola, tea and iced tea
avoid excessive cheese and dairy products in your diet
drink lemonade regularly (or, 8-10 ounces of lemon juice in 64 ounces of water)
drink "reverse osmosis" water such as Aquafina, Dasari, or Alhambra instead of tap or well water
if you take calcium supplements, use the ones that contain calcium citrate and not calcium carbonate (such as TUMS, RolAids or "natural" calcium)

(h/t Dr. Kash Desai, a local urologist)

Discount Prescription Drug Program

2011-05-04T13:56:00.000-07:00

While the rest of California is participating in the economic recovery (jobs, home prices; that sort of thing), unfortunately the Sacramento area is not.

A patient recommended this website for a California discount drug card. He tells me it's pretty much as billed: no application or registration, and accepted in many local pharmacies.

Check it out if you'd like to pay less for prescription medications.

Do Cell Phones Cause Cancer? (No, not likely.)

2011-04-15T13:49:00.000-07:00

Certainly, holding an emitter of electromagnetic radiation close to your head frequently should raise some question as to whether this could be harmful. However, cancers that could be caused by such EMR are occurring less frequently even as cell phone use is becoming more and more common. The best medical studies to date do not show a link, either.

This article (h/t New York Times) does an elegant job of bringing together the concerns and the most reliable information to date. For those avoiding the NYT paywall, this article (h/t BoingBoing) summarizes it quite nicely.

A Couple of Interesting Notes

2011-04-12T13:17:00.000-07:00

Are lucky people really lucky, or just more flexible and open to opportunity? (h/t to Lifehacker)

It's pretty shocking to put the recommended evacuation areas around the Fukushima reactor near Tokyo into perspective. Gizmodo provides some maps of the same sized zones around reactors in L.A. (and also New York and Chicago). Ouch.

A Few Interesting Reads

2011-04-07T14:21:00.000-07:00

From Wired magazine, an interesting re-do on the famous Milgram experiments from back in the day. If asked, do you think you would deliver electrical shocks to a stranger for money? If actually offered money and provided with a real person, would you still?
In Vanity Fair, a famous economist writes on the effects on our country of having 40% of the country's wealth in the control of 1% of its people.
Ted Rall's cartoon: Terrorist Plots We Could Really Use.

Why did some pills suddenly get so expensive?

2011-03-29T09:06:00.000-07:00

Well, I had been wondering that myself.

It appears that the FDA is trying to eliminate very old drugs that are widely used in conditions for which they were actually never proved to be safe and effective.

This in itself is not a bad idea. For example, a look into whether childrens' over-the-counter cough and cold formulas really help or not has shown not only that they don't help to relieve cold symptoms in children, they can also cause serious side-effects such as seizures. This has led to efforts by family doctors and pediatricians to let parents know this and to use more supportive home treatment than over-the-counter medicines.

On the other hand, this has led drug companies to respond in unfortunately predictable ways. This story explains why colchicine (used for decades to relieve or prevent severe gout pain) went suddenly from 10 cents/pill to $5/pill.

It is also probably why you can't get quinine pills for leg cramps anymore. It was never actually tested for any condition but malaria. My guess is that the companies that make it don't want to go through the trouble and expense of testing it for leg cramps and simply withdrew it.

Radiation Exposure

2011-03-16T18:48:00.000-07:00

While I trust that the fax from Grandpa's Pharmacy offering to sell me and my office staff much-sought-after potassium iodide at the bargain rate of $60 is well intended, I doubt that it will be necessary. Apparently, there's been a run on the supply in the US, especially on the West Coast.

Potassium iodide can help to displace radioactive iodine from being taken up by the thyroid gland in the event of exposure to it, but would have to be taken at least 6 hours before exposure. Even given the US NRC recommending US citizens in Japan evacuate from within 50 miles of the troubled reactor, the exposure levels on the US mainland over 5,000 miles away is going to be just about nil. Overall, the smart money in avoiding exposure to radioactive iodine will be avoiding drinking milk from northeast Japan.

Some interesting reading on the subject:

ProPublica has a nice reading list from a variety of news sources covering basic background, up-to-the-minute liveblogs and twitter feeds, and the public health aspects of radiation exposure.
MSNBC (h/t to Boing Boing) shows a ranking of US nuclear power plants at risk for quake damage causing a core meltdown. (Hint: the most at-risk are not in California)
For those concerned about TEOTWAWKI (the end of the world as we know it), Medscape has a very technical discussion of nuclear and radiologic decontamination including a discussion of potassium iodide. Who knew Mylanta and Maalox can help to reduce absorption of strontium and radium? (Dose: 100cc by mouth ASAP upon exposure)
For an interesting and lighter side note, Slate discusses why there is so little looting going on in Japan right now.

2011-03-06T13:27:00.000-08:00

Interesting conversation over breakfast with my daughter this morning about how to decide on your livelihood. She is a high school freshman who wants to contribute to the world, have a comfortable salary, have a family, travel and enjoy what she does for a living. Indeed, don't we all?

Interesting she should ask (and believe me, I'm glad she's asking), since there have been some interesting reads in the news on this very subject.

This article in the Harvard Business Review questions the practice of "business as usual" and re-frames the question for the future as "Does what you do have a point- one that matters to people, society, nature and the future?"

The next people to be displaced by computerization (not so much by off-shoring) are attorneys. Wow. Just wow.

Staying cool under pressure is somewhat genetic, but more so environmental. And the good news is, it can be taught!

Here's a handy way to estimate portion sizes.

2011-02-17T13:56:00.000-08:00

For those who struggle with trying to visualize diet recommendations such as "1 cup of pasta",

3 ounces of meat is the size of a deck of cards
1 and 1/2 ounces of cheese is the size of 4 dice
1 cup of cooked cereal or pasta is the size of a baseball.

(h/t to Consumer Reports magazine!)

A Clinician's Perspective on the Question of Violent Language in the Public Media

2011-01-13T13:45:00.000-08:00

I agree with the author of this article (a practicing psychiatrist) that the link between violent acts and violent language used on TV and in talk radio cannot be so easily dismissed.

This is much discussed in the setting of the shootings in Tuscon by Jared Loughner; it is reasonable to suppose that Mr. Loughner did not get the idea to shoot Representative Giffords simply because he follows Sarah Palin's website. However, I'd say that it's hasty to say that no connection exists between his actions and the general tone of Ms. Palin and others like her. "Don't retreat: Reload" is not a peaceful or reasoned exhortation.

An Alternative to Coumadin (warfarin)

2011-01-06T08:52:00.000-08:00

As many of you already seem to be aware, the FDA approved a medicine called Pradaxa in late October, 2010.

Currently, it is for use in patients who have a very common arrhythmia called atrial fibrillation (AFib) without any heart valve disease along with it. The purpose of the medication is to act as a "blood thinner" to prevent stroke due to the AFib.

Up until this time, the only way to do this was with a pill called Coumadin (warfarin). Aside from the 2% per year risk of serious bleeding due to the medication, it also requires frequent lab testing to be sure that the dose is adjusted correctly. Dose adjustments are common because many, many common foods and medicines can interfere with the metabolism of Coumadin.

The deal with Pradaxa, is that it works just as well as Coumadin in preventing AFib-related stroke, and is about the same in terms of side-effects and bleeding risks. However, the dose is largely the same for all patients, and does not require lab testing. Pradaxa can be used as a first medication, or as a change from Coumadin.

Currently, the cost of this medicine is about $200/month since no insurance plans cover it (the exception to this is the military's TriCARE insurance which covers all but a $20/month co-payment). Depending on you financial state of affairs and the value you place on your time and co-pays for lab testing, you may still find this worthwhile.

News on the MediCare front

2010-12-16T14:48:00.001-08:00

Thanks to everyone who read this or my letter to the editor of the Mountain Democrat, and especially if you contacted your senators to express concern!

At this time, a bipartisan bill has been passed that puts off a 25-30% reduction in reimbursement to doctors taking care of MediCare and TriCare patients until 1/1/2012. It awaits President Obama's signature, which he has said will be forthcoming.

In the meantime, please keep the pressure on Congress and Senators Boxer and Feinstein to use this time to find a different way for MediCare to determine physician reimbursement.

The current formula (the so-called Sustainable Growth Rate, or SGR) has been used for a decade or more, and ties physician reimbursement to various measures of cost including the rate of inflation. While I am fine with MediCare expenditures being contained, the problem here is that the costs of running a practice (payroll, insurance, rent, supplies) has steadily increased far faster than the rate of inflation). This results every year in the potential for a steep reduction in physician reimbursement. Congress has annually passed a last-minute measure putting it off until the next year.

By now, this has snowballed into a potential rate cut of 25-30%, which you have to admit is mighty steep. If this were to happen, older Americans and military patients would be depending on doctors wanting to take on the care for patients for whom they would be getting 70 cents or less on the dollar; all this while still trying to pay their employees generously and provide them with benefits during the worst economy since the Great Depression. Bit challenging, that.

Please keep Congress working on a better solution for this problem!

A Way to Track Your Blood Pressure

2010-12-03T14:31:00.000-08:00

A patient recently gave me the link for a free on-line program for tracking and graphing your blood pressure over time.

I was seeing her over a concern for her blood pressure, and she showed me a graph of 6 months worth of averaged blood pressure measurements! This made it very easy to discuss her blood pressure, address concerns over it and come up with an agreeable plan of treatment and follow-up (diet, exercise and weight reduction, as it so happened).

Check it out!

Impending MediCare crisis!

2010-11-17T13:47:00.000-08:00

This is a letter submitted to the editor of the Mountain Democrat. 'nuf said.

Dear Editor,

As a family doctor serving our community for the past 13 years, I want people to be aware that doctors who see MediCare and TriCare patients (the disabled, the elderly and the military and their families) face a 30% reduction in payment for their care to be phased in on December 1 and January 1.

To be clear, this is not related to recent health care reform legislation but rather to a payment method that MediCare has been using for years now called the Sustainable Growth Rate. This is supposed to reign in spending by MediCare (and TriCare, which is linked to it) by scaling payment to doctors based on local population and cost of running a business. This has typically been deferred at the last minute by Congress in order to avoid cuts to doctors and their patients.

Unfortunately, the currently convened "lame duck" session must act now to defer these cuts and hopefully to devise a better system of payment. If they do not, every doctor who sees disabled, older or military patients faces a loss of 30% in professional services given in service to these patients.

Speaking for myself, I do not plan to stop seeing patients with these insurances because I feel it is a duty and responsibility of doctors to see these patients who have given so much to our community. However, such large reductions in payment would certainly affect how many patients with these insurances I could see and would certainly have a stifling effect on the ability of elderly and military patients to find medical care.

If this concerns you, please urgently contact Senators Boxer and Feinstein to urge them to act now!

Yours truly,

Mark Tong, MD

Office of U.S. Senator Barbara Boxer
501 I Street, Suite 7-600
Sacramento, CA 95814
(916) 448-2787
(202) 228-3865 fax

Office of U.S. Senator Dianne Feinstein
One Post Street, Suite 2450
San Francisco, CA 94104
Phone: (415) 393-0707
Fax: (415) 393-0710

A Word on Whole-Body Scans (this time in airports)

2010-11-16T08:27:00.000-08:00

I find it ironic at just the time that renewed concern is being expressed by both doctors and patients about radiation exposure in medical tests such as CT's and heart scans, we are evidently willing to accept what amounts to radiation exposure with unknown health risks in the interests of a virtual strip search to get on a plane. Given the way that medicines and tests often only reveal side-effects after widespread use, I hope that we don't see a rash of "problems" in pilots, flight crews and business travelers in the intermediate future.

I must say, I do find myself in agreement with Captain Smith that our response to the terrorist actions between 1985-89 was much more calm, determined and measured and less self-defeating.

Favorite Doctors of 2010

2010-10-11T13:59:00.000-07:00

Hey, I'm very honored!

Thanks to everyone who voted for me in the Foothills Style magazine as among our communities favorite doctors. My staff and I do everything we can to give you excellent medical care and service, and look forward to continuing to do so for the future!

"How Doctors Think"- a good book

2010-09-24T13:17:00.000-07:00

I recently finished reading this book after a really interesting discussion with some friends-of-friends who happened to work in publishing and in clinical psychology.

It was quite the best seller when it was first published in 2007, and was discussed as a book written by a doctor to a target audience of laypersons with the intent of helping to understand how their doctors may think, and thereby how to get the most out of their appointments.

Certainly it is that, but is worthwhile for anyone to read and particularly for doctors.

Dr. Groopman is systematically examining the way in which doctors are trained and practice. He is also looking at how some specific specialties (such as primary care, surgery and radiology) may be prone to certain types of predictable errors due to their training or practice settings.

The book is not an indictment of medical error, but rather a study in technical and human limitation with suggestions for recognizing and remedying such problems.

It is therefore a fascinating book for the patient and family, but should offer reflection and self-inspection for any doctor.

Back to School Special: A Different Way to Rank the Best Schools

2010-09-07T12:53:00.000-07:00

We've all seen the U.S. News and World R eport annual ranking of top schools since it was first published in 1983. Many students and parents avidly look to see where their university, college, or graduate school falls within the top 100.

It's worth noting that the rankings are based largely on entrance examination scores, amount of funding received for research, and the subjective impression by educators of the overall prestige of the institution.

There has been real interest in looking at the ranking of schools in a different way which is based more on desired outcomes.

For instance, what if the focus was more on how well institutions of higher learning fulfilled their stated missions to graduate enrolled students, prepare them for further education or social service, and to attract and maintain high caliber faculty as well as to do research?

The Washington Monthly did exactly such a ranking which examined research funding, but also successful graduation rates, transition to graduate study, involvement of Pell grants, ROTC and Peace Corps and also the membership of faculty in national academies as recipients of significant awards.

Some rankings based on these criteria are not surprising; Stanford is highly ranked at #4, though really Stanford has always claimed to be serious in the societal aspects of its mission statement.

On the other hand, Harvard placed a lowly #9, while UC San Diego was #1! Not only did UCSD spend more on research than Harvard, but UCSD also surpassed Harvard in successfully graduating students, and in student community service. (Disclosure: my alma mater UC Davis was #6).

A recent study published in the Annals of Internal Medicine similarly looked at the ranking of medical schools in a different light. Rather than ranking med schools based on MCAT scores and what percentage of applicants were turned down, this study ranks by the number of graduates who go on to practice primary care medicine, and particularly under-represented minority graduates and practice in rural or under-served parts of the country. The assumption being made here is that the ultimate goal of a medical school is to produce doctors who will be of the most benefit to the health of our country.

Interestingly, the rankings based on these criteria are nearly opposite the classic rankings based on elite status.

I guess the implication of both these rankings is that students, their families and also the populace in general and our government should consider thinking differently about how we think of our institutions of higher learning and how we want to act on this.

A Wonky Look at the Development of U.S. Obesity

2010-08-31T14:37:00.001-07:00

We've all heard that obesity in our country is virtually pandemic. Indeed, 70% of the adult population is clinically overweight or frankly obese as defined by calculation of body mass index (BMI) which looks at your weight in relationship to your height.

This study looks at obesity since the mid-1800's and how it develops in the same people over time.

The conclusion is that the development of present levels of obesity did not just suddenly develop in the late 1980's, but rather has developed more slowly and steadily throughout the entire 20th century.

As this study points out,

The lifestyle changes of the 20th century affected the four groups under study somewhat differently. Identifying the deep causes of the long-run trends is outside of the scope of this study, but the “creeping” nature of the epidemic, as well as its persistence, does suggest that its roots are embedded deep in the social fabric and are nourished by a network of disparate slowly changing sources as the 20^th-century US population responded to a vast array of irresistible and impersonal socio-economic and technological forces.

The most obviously persistent among these were:

the major labour-saving technological changes of the 20th century,
the industrial processing of food and with it the spread of fast-food eateries (To illustrate the spread of fast food culture, consider that White Castle, the first drive-in restaurant, was founded in 1921. McDonald started operation in the late 1940s, Kentucky Fried Chicken in 1952, Burger King in 1954, Pizza Hut in 1958, Taco Bell in 1962, and Subway in 1962.),
the associated culture of consumption,
the rise of an automobile-based way of life,
the introduction of radio and television broadcasting,
the increasing participation of women in the work force, and
the IT revolution.
These elements – taken together – virtually defined American society in the 20^th century.

Health Care Reform Should Not Write Off Small Medical Practices

2010-08-30T11:01:00.000-07:00

While I've generally been of an optimistic wait-and-see approach to the recently enacted health care reform legislation, I have been concerned to note that a fair amount of it seems optimized to large medical organizations.

For example, the billions to be spent to create incentives for doctors to use electronic medical records (EMR) does nothing to require uniform code standards so that various EMR products would still be able to communicate and share data with each other. I hesitate to spend up to $40,000 in start-up costs alone, only to find that my EMR system can't share data with other offices or hospitals.

Also, the use of medical practice data for statistics gathering is not useful in small office practices because of the smaller number of patients. This really presupposes medical groups with tens of thousands of patients like Kaiser or the VA.

This article reports on a meeting with two White House officials basically stating that doctors should get ready to enjoy a life in Big Medicine. Frankly, if I enjoyed working for Kaiser or the VA, I'd already be doing that.

I do find it unfortunate that the present administration's approach to stimulating businesses and propping up banks similarly seems to almost solely be directed to enterprise-scale businesses and large banks and not the small "mom and pop" businesses and local credit unions.

As far as I'm concerned, entrepreneurship is what makes America great!

ALERT: Billing Issue with Marshall Lab

2010-08-26T13:12:00.000-07:00

If you are a MediCare or MediCal patient, you have already noticed that Marshall Lab has been using computer software that can generate a paper for you to sign anytime you come in with a test ordered where MediCare has a possible restriction on how often they can be done. I posted on this on 11/30/09, as patients were becoming concerned about being billed for tests that were ordered by their doctor.

Evidently, a problem has arisen where you sign this paperwork even though MediCare should be covering the test. This should be OK, because all the form states is that you are aware that you MAY (not will or shall) be billed. However, MediCare seems to be taking this as blanket acceptance for them to refuse to pay on the tests.

This is not at all how this is supposed to work. We have been in touch with Chris, who is a woman who does billing for Marshall. She is advising patients not to pay in these situations, and is re-billing MediCare. She has given us permission to give out her name and also her phone number to use in case you are in this predicament.

Her number is 626-2770, ext. 2588#.

A Really Interesting Letter on the End of Life

2010-08-24T10:52:00.000-07:00

Some of you may remember Marty Welsh; he was a family practice doc here, but retired a few years ago after he was diagnosed with ALS (otherwise known as Lou Gehrig's disease).

This was a real tragedy as this is known to be a slowly progressive, debilitating and ultimately fatal and untreatable illness, and also because Marty is a fantastic guy and a model doctor.

About a year ago, he wrote a letter to the opinion pages of the LA Times which is his hometown paper. This letter has been very widely read, posted and cited. It is a very clear and heartfelt letter written my a person dying of ALS, and also from the point of view of a doctor who is now a patient who knows what will happen to himself over the course of the illness.

Sorry it's taken a while to link to it, but better late than never. It's certainly a worthwhile reflection on the meaning of quality of life.

Weight Loss Apps

2010-07-17T16:42:00.000-07:00

For those of you with both a desire to lose weight and a smartphone, here is some interesting information on useful (and often free!) apps for weight loss.

Personally, I use Lose It!, as I find it simple and fun to use to track calorie intake as well as energy expenditure against a daily budget for weight management.

Colon Cancer Screening

2010-07-17T15:56:00.000-07:00

Colon cancer screening is something I used to have to bring up at annual physicals, but ever since Katie Couric ran video from her own colonoscopy on her morning show in 2000 there has been increasing acceptance of colon cancer screening as a do-able and worthwhile preventive measure.

For most people, colon cancer screening should start at 50 years of age since colon cancer before this age is very uncommon. Certainly, if you have a history in your family of colon cancer or other high-risk conditions you should consider starting screening at 5-10 years prior to the age of cancer diagnosis in your relatives.

For people at higher risk to have colon cancer (such as family history of colon cancer, personal history of Crohn's disease), colonoscopy is a good choice of screening test. This allows a doctor to visually inspect the inside of your colon, and biopsy any abnormal lesions to determine whether they are at risk to become cancers and to determine the frequency of interval screening colonoscopies.

For most people, the are a number of different tests that could be chosen for screening. While Ms. Couric's educational efforts spurred people to ask about screening, it also seems to have led many people to assume that colonoscopy is the best or even the only good screening test. This is not correct.

Admittedly, out of all the tests that require bowel prep (a regimen of laxatives that cleanses out the colon for inspection) colonoscopy is the only one that inspects the entire colon and in which biopsy can be performed at the same time on any polyps or lesions that may be seen.

However, most polyps seen are benign, or only have a 3-5% chance of possibly becoming cancerous over the following 5-10 years necessitating repeat colonoscopies for surveillance.

This would be great if colonoscopy was proved to find cancers early enough to save lives. However, it has not.

In fact, only one type of test has actually been shown to reduce the actual number of yearly deaths from colon cancer. This test involves test for blood in your bowel movements. If done annually, and if a positive test result (blood shown in bowel movement) is followed by colonoscopy this type of screening has been shown repeatedly over the years to be the only screening method that actually reduces the risk of dying of colon cancer as the cause of death.

Such tests used to require three separate specimens and used a chemical that would turn blue in contact with iron. Since iron is in hemoglobin which is what red blood cells use to carry oxygen, this test could be an indicator of bleeding from a very small, early colon cancer. Unfortunately, due to the nature of the test a positive result could come from rare meat, dental work or taking aspirin.

A more recent test now in use is superior and widely available and covered by insurances. This test is called FIT (fecal immunochemical test) uses antibodies that link only to human hemoglobin that has not been exposed to stomach acids. Thus, the test is both more accurate and less apt to cause false alarms. Also, it does not require any change in diet or medications, only needs one specimen and the specimen can be mailed back to the lab.

This newer test is so sensitive that it has been found to detect colon cancers over two years before a colonoscopy would find them, even in people at high risk for colon cancer.

Certainly, if I am seeing you for a physical and you are quite convinced that you need a colonoscopy for screening I will be happy to refer you to a good specialist for this. However, in most cases I recommend the FIT test annually as my preference is for the only life-saving test we have to offer.

Sorry, but we have no choice but to limit taking new MediCare and TriCARE patients

2010-06-17T20:09:00.000-07:00

It shocks and saddens me to see that Senate Republicans have successfully blocked passage of a bill that would have prevented a cut by 21% in the reimbursement that doctors receive for seeing seniors and the military. This is apparently all in the name of not adding to the federal deficit at a time when seniors and the military are among the hardest hit in the present state of the economy, and when many feel that the payments from these insurances are already barely adequate for the complexity of care rendered.

I have freely seen patients with MediCare and TriCARE since I was a medical student, and I have always considered it an honor to serve my community, my country and my profession by treating our seniors, active duty and former military service members and their families.

However, I also have staff to pay, a mortgage and a child to put through college.

It is with the deepest regret that I will have to limit the number of new patients with these insurances that I can accept. Certainly, I will happily continue to care for my present patients with these insurances or as they become eligible for them by "growing into them".

These links to MedScape/WebMD and the Senior Journal provide more information on this issue.

With all love and respect,

Mark L. Tong, MD

UPDATE:
Apparently, the Senate has put of MediCare and TriCARE cuts for 6 months. I certainly hope they use the time to come up with a better solution than the present one. The House is expected to pass this on Monday. Yeah.

Should I get the shingles vaccine?

2010-06-17T15:38:00.000-07:00

Short answer: Sure- why not?

Shingles is a reactivation of chicken pox virus. When you get chicken pox as a child, you get over the pox illness. However, the virus remains dormant in your nervous system. For some reason, it can flare up in later adulthood.

The shot is one shot for life, and is recommended at over 60 years of age.

It is a live, attenuated virus which means that you should not take it if you have a condition that impairs your immune system such as AIDS, leukemia, lymphoma or bone marrow cancer. Also, you should not take it if you are on medication that suppresses your immune system such as chemotherapy or organ transplant medications.

Mind you, the vaccine probably prevents shingles about 70% of the time. However, it's probably still worthwhile since it's likely that if you get shingles even though you got the shot the outbreak will be much milder than it otherwise would have been.

Got to this link, if you'd like an explanation for why doctor offices don't give this vaccine.

Sexual Intercourse After a Heart Attack

2010-05-24T08:37:00.000-07:00

Evidently, this is an issue that often goes unaddressed with patients (not by me, I think).

Patients who have had a heart attack are usually and rightly concerned about what they can safely do, and how hard they can push their own bodies without harm. Their partners and family may be equally concerned about whether physical activity including sexual intercourse could be dangerous or harmful.

For most patients, sexual activity is perfectly safe within the few weeks after going home from the hospital assuming you feel generally up to it.

This frequently asked question list is helpful and reasonably specific, and notes that sexual activity (in terms of demand on your heart) is moderate and falls in between showering and gardening in terms of metabolic demand.

[Do note that if you use medication for erectile dysfunction (Viagra, Levitra, Cialis) you should not use them with nitroglycerin- containing heart medications (such as Imdur, IsMo, sub-lingual nitroglycerin) because sudden decreases in your blood pressure could result.]

Allergies

2010-05-20T13:01:00.000-07:00

'Tis the season!

If the last few weeks of yellow-green pollen on everything has also been marked by itchy watery eyes, itchy runny nose and sneezing then you are very likely allergic to it. This is often referred to as "hay fever" and is technically known as seasonal allergic rhinitis.

If you notice this all year 'round, you may also be allergic to other things such as molds, dusts or animal danders.

Happily, there are a lot of things you can do to improve your symptoms.

First, try to avoid pollens by wearing a mask for mowing or brush clearing. Wash your face and hands when you're done. Try to sleep with the windows closed.

Over the counter medicines can be very helpful .

Anti-histamines such as Benadryl, Zyrtec and Claritin help by blocking the effects of histamine released in the allergic reaction. Remember, the more it works for allergy, the more potential there is for drowsiness. You may have to try different ones to strike the best and safest balance.

Decongestants such as Coracedin and Sudafed can help but can also raise your blood pressure. If you already have high blood pressure or take medication for that you should at least check your blood pressure after taking decongestants. If it's higher than your usual, you probably should avoid these.

Be careful of decongestant nose sprays such as Afrin and Neo-Synephrine. They are very effective, but addictive if used for over 3-5 days in a row.

Prescription nose sprays such as Flonase and Nasonex are easy to use, well tolerated and the single most effective kind of medication for relieving symptoms. If you are using them, remember that they have to be taken every day in order to prevent allergy symptoms.

Hopefully, this will help relieve the bothersome symptoms of hay fever for the season. If not, let us know so we can work on this with you.

Chicken Pox outbreak

2010-05-18T08:19:00.000-07:00

We are seeing chicken pox within the last week or two here in El Dorado county, as also noted in the Friday 5/14/10 Mountain Democrat (sorry, their website is subscription only).

This is a common viral illness that generally shows up as a mild illness with feeling generally ill, itching, and fever up to 102 degrees for up to 2-3 days. More severe disease can result in pneumonia or other complications.

People at moderately higher risk of more severe disease includes:

people 13 years old or older
people with chronic skin disease such as eczema or psoriasis
chronic lung disease
patients who take steroids chronically as inhalers or pills

Folks at higher risk of severe disease include:

newborns
pregnant women
patients on steroid pills daily
patients with supressed immune systems (HIV/AIDS, chemotherapy, organ transplant medicines)

Mind you, if you've already had chicken pox before you are extremely unlikely to get it again.

For the most part, the illness is treated supportively with soothing compresses, rest and over the counter medicines such as Tylenol. It generally goes away in a week or two. As it can easily spread through touching pox lesions and/or coughing or sneezing we generally recommend staying at home and avoiding school or work or social gatherings until the pox lesions have scabbed and the scabs have come off and there is no more coughing or sneezing. It is not necessary to see us in the office for this, as risk of spread to other patients is high.

Certainly, feel free to call if you are concerned about more severe illness or risk for severe illness.

The chicken pox vaccine has, over the past decade or more, been a routine part of childhood vaccinations and is generally given at 15-18 months of age. More recently, a second dose has been recommended for better vaccine response. Please contact the county department of public health about this if you feel you may need a second vaccine.

High Deductible Health Insurance Plans

2010-05-12T08:17:00.000-07:00

The impact of the recession on our local economy has been severe, especially considering the number of folks who have been affected by the loss of jobs in construction,and the number of state employees affected by furlough programs.

I think one of the tough choices folks are having to make is in choosing health plans that are lower in monthly premiums, but leave a lot of out-of-pocket costs to the patient in terms of annual deductibles, coverage only of generic medicines and/or coverage only of preventive care (or everything but - such as only ER and hospitalizations).

These high-deductible plans (so called "crash and burn" or catastrophic coverage plans) are attractive insofar as the monthly cost in premiums is lower or at least manageable.

The problem is that these plans were never really geared for families or for patients over about 30- 35 years old. These plans have been around for quite a while, but the target market was always young healthy employees just out of school and off their parents' insurance who rarely got sick and would typically just need annual Pap smears and coverage of emergencies or catastrophes such as car accidents and traumatic injuries, or unexpected severe illnesses needing hospitalization.

These plans were never really intended for folks living in what the insurance industry calls "elephant country"- the age at which you are actually increasingly likely to need the insurance for sudden problems like heart attacks, strokes or cancers, or for chronic problems like high blood pressure or diabetes. For families or for patients over 30- 35, you can actually end up either spending more money out of pocket in a year than you would have by having a more comprehensive insurance plan, or you can find yourself doing without necessary medical care. Or both.

Please look closely at these kinds of health insurance plans; it's really important to look beyond the monthly premium and also look at the possible costs to you of medicines, physicals, appointments or tests over the year and whether you have the reserves to handle the cost of these or not. The situation you'd like to avoid is where you use the catastrophic coverage for a medical catastrophe that could have been avoided or prevented.

Otherwise, please let us know if you have such a plan. We are happy to work with you in any way we can in order to provide the best medical care, but we have no way to know whether anything we prescribe for you or recommend to you represents a problem for you unless you let us know!

Wandering in Dementia Patients

2010-05-05T08:21:00.000-07:00

As our population ages, dementia (the gradual loss of higher brain functions such as memory, orientation and attention) will be an increasing problem.

Wandering away from home is one of the most frustrating and potentially dangerous problems family and caregivers can face. Institutions such as nursing homes have secured doors and staff to prevent this. In your own home, this can be much more difficult.

Evidently, searching for wandering dementia patients is very difficult and very different from usual search and rescue since the demented person may not act logically and may actually try to evade rescuers.

Fortunately, there are some simple things you can do to prevent this in the above link, and also here.

Osteoporosis

2010-04-14T08:14:00.000-07:00

Osteoporosis falls into one of those medical conditions in which you don't feel anything wrong until there's a problem, but if you develop a problem it's serious and already too late. On the other hand, it's happily also detectable and preventable.

Also known as "brittle bone disease", osteoporosis refers to a loss of bone strength. This does not cause pain in its own right, but it does mean that a simple fall to the ground can result in painful or disabling fractures. We are especially concerned about hip fractures because even though they can be surgically repaired, half of patients who sustain a hip fracture have died or are permanent nursing home residents within the following six months.

On the positive side, there's a lot that can be done to detect osteoporosis early on, and to prevent it from harming you.

Testing can easily be done to detect osteoporosis before fractures or loss of height occur. Indicators of higher risk to have low bone density include:

smokers
body weight under 154 pounds
family history of osteoporosis
physical inactivity
alcohol use
post-menopausal women older than 65, or older than 60 with another risk factor

The most accurate and reliable test for osteoporosis is the DXA (dual X-ray absorptimetry) test. Heel ultrasound is not accurate, and should not be used as the only basis to rule in or rule out osteoporosis. Save your money, if this is offered as part of a low-cost "health screening". (When's the last time you heard of a doctor or ER talk about ordering a bone ultrasound?)

The arm emits a low-dose beam of X-rays through several specific sites such as the wrists, spine and hips. The table can detect how much of that known amount of X-ray is getting through to the table. The more dense your bones are, the less makes it through to the table. Then, a detailed result can be generated showing density of your bones at these various points in comparison to other patients of your age.

Long story short, if your bone density is among the lowest ranking it does actually relate to markedly higher risk of a simple fall resulting in a serious fracture.

If this is the case, then it's a good idea to get proactive about maintaining or improving your bone density in the interests of not sustaining a fracture as well as avoiding loss of height or a humped curvature of the spine (the so-called "widows' hump").

Exercise does help:

High-impact exercises that involve gravity help to stimulate bone formation (lack of this is why young healthy astronauts develop loss of bone density within a matter of a few weeks in orbit). This would mean running, walking and treadmill as examples. While water aerobics and elliptical trainers are excellent for cardiovascular conditioning, they do not increase bone density.
Exercise that promotes balance can prevent falls (no fall, no fracture). Tai Chi, yoga and dance are particularly beneficial.

Look at your home:

Most falls occur in your home; it's were you are most of the time.
Address things that can result in falls, such as loose carpeting or throw rugs, exposed electrical cords, poor lighting or lack of grab bars in the bathroom.

Make sure you are getting adequate calcium and vitamin D by supplementing. This does not increase bone density once you are over 35 years old, but it does ensure that you are getting enough to maintain normal bone metabolism.

Calcium carbonate, 600 mg, twice a day
Vitamin D, 400 International Units, twice a day

Prescription medicines do have a role if your bone density is already in the osteoporotic range, since they not only improve bone density but also reduce the occurrence of fractures. The most effective are the bisphosphonates.

Fosamax and Alendronate are conveniently once a week.
Fosamax is now generically available as alendronate.
Unfortunately, the absorption of once a month and once a year treatments such as Boniva is poor and limits their effectiveness.

Allergy Season. Again.

2010-03-29T08:07:00.000-07:00

Great skiing this weekend, but allergy season is gearing up even as the ski season winds down.

If you are chronically a hay fever or allergy patient, now's the time to prepare.

Sleep with your windows closed, if possible. Wash your hands after coming inside from being outdoors. If possible, avoid being out and about in mid-day since this is when pollen counts are at their highest.

If you usually take a medication that works well for you, don't wait until you're sneezing and weeping continuously to start taking it. Now is a good time to start. Once everything is covered with green pollen, you're already behind the 8-ball.

Remember that as far as pills are concerned, the more effectively they work as anti-histamines, the more likely they are to produce drowsiness.

Over-the-counter Claritin is a pretty good balance of effectiveness versus drowsiness. Zyrtec is "stonger", but more likely to make you feel sleepy and Benadryl even more so.

Avoid decongestant nose sprays such as Afrin, 4-Way or Neo-Synephrine. Use of these for over 3 days in a row can be addictive.

Prescription nose sprays such as Nasonex or generic Flonase are actually more effective than pills alone. However, you have to use them daily for the duration of the allergy season. Otherwise, they are not so effective.

Please see me if you are having allergy symptoms despite such treatment, or if you also have a lot of coughing, wheezing, chest tightness or shortness of breath. This could mean you have asthma and not just simple hay fever.

Health Care Reform

2010-03-24T14:33:00.000-07:00

So, I'm getting a lot of folks asking how I feel about the passage of the health care reform bill (H.R. 3590- the Patient Protection and Affordable Care Act), and how I think it's going to affect me and other doctors.

Mind you, these are my opinions based on following these issues for years as a doctor.

If you want to read the actual documents of this bill and of the bill that will proceed through the Senate for the President's signature (H.R. 4872- the Health Care and Education Affordability Reconciliation Act of 2010), this article provides links to the full source documents.

More manageable, plain English 20+ page summaries of these bills (pdf) can be found here and here. This and this are for folks who like FAQ lists.

Generally, I like what I see.

I think it's great that the first things on the table that should occur in the next months include extending coverage for young folks to 26 years old on their parents' insurance, setting up insurance pools for people with pre-existing medical conditions, closing the Part D "donut hole" and covering preventive care for MediCare patients, and doing away with insurance company practices of capping coverage, refusing to insure patients with medical conditions, and stopping your insurance when you become ill.

Do I agree with requiring people to have insurance?
Do. The. Math. Or, consider whether you really feel okay about your taxes and premiums paying for the medical care of a healthy 20 or 30 year old who decided not to pay for insurance and then develops diabetes or has an accident. Did requiring drivers to have insurance cause premiums to go so high that you can't afford to drive? Or, is it better that if you get in an accident and the other guy is at fault that his insurance covers it because he has to have it?

Do I think it's going to bankrupt health care?
No. I believe the Congressional Budget Office.

Will it "cut down on Medicare"?
No. Remember the closing the donut hole part?

Is it okay to pay for this with taxes?
Please. We're talking tax hikes of 3.8% on unearned income of people filing over $200,000/year, or couples filing jointly over a quarter million dollars a year. People in these tax brackets have seen a 300% increase in their earnings in the past 10 years. The rest of the country (adjusted for inflation) has stayed flat over this time. I believe the super-rich can and should afford it.

But, what about my own insurance?
No downside. There's nothing in this law to keep you from staying on your present insurance if you like it. However, you might find it reassuring not to have a $1-3 million dollar lifetime cap on it if you develop and expensive problem like a cancer or a bad car accident. Also, formation of risk-sharing pools in each state should make it possible for you to get your own affordable insurance if you get fired, go to part-time, retire before 65, decide to go into business for yourself, or just don't want to go to Kaiser if the boss decides to change everyone to Kaiser. Bummer.

The government? Involved in health care?
The government already is involved; MediCare, MediCal and the VA. As far as I can tell, the private sector insurances have otherwise had free reign since World War II. I am as frustrated as any doctor with run ins with Medicare, but I also have run its with Kaiser, Blue Cross and Blue Shield. I am perfectly happy to let the government have a go at it. Heck, the seem to do just fine with having a military, enforcing the law and putting out fires. I also must say I've never had a letter or parcel lost by the Post Office.

How do I think it will affect me and my practice?
Dunno, but I remain optimistic. I look forward to not losing patients because they lose their jobs or their boss goes cheap (Kaiser). I look forward to seeing my college students and recent grads without the burden of them having to pay out of pocket. Hey, there's a good chance my own insurance rates will go down and/or that I could more easily retire before 65! Having an influx of available new patients who now have insurance? Sounds good.

Next? More jobs!

The Physical Examination

2010-03-21T17:16:00.000-07:00

The physical examination dates back to antiquity, and is useful in assessing a number of clinical findings that can help to establish diagnosis. In other words, examination of a patient's body can help to determine what is happening and what to do.

As I was taught it, examination followed a detailed history-taking which consists of detailed questions and answers about health, symptoms and recent or past events.
I was lucky to attend a medical school (the University of Pittsburgh School of Medicine). This is a very large teaching campus serving half Pennsylvania and also Ohio and West Virginia and had dedicated hospitals for veterans, children, women, ear nose and throat surgeries, eye surgeries and psychiatric patients. As the only medical students in Pittsburgh, we had the entire run of the place to ourselves. Also, the population there is the oldest in the U.S., so you do see a lot of folks. Additionally, the faculty included doctors who were very experienced and gained their experience when good history taking and physical examination skills were nearly all you had. This was before ultrasound, CT's and MRI's. Laparoscopic surgery a new technology at my time.

There are times when the physical exam is not so useful (such as discussing a new diagnosis of high cholesterol or diabetes based on abnormal screening blood tests) and other times where it is crucial (such as sore throat, abdominal pain or shortness of breath).

Unlike in days gone by when doctors rarely asked questions of their patients (such as the 1800's), I find that my teachers were correct: the majority of helping patients relies on accurate diagnosis, and the majority of diagnosis relies on history taking and a targeted examination. I continue to find it useful to elicit a full story, give patients adequate time to explain it and then ask what patients think is actually going on. Not, I admit, great for my schedule but it does help to get it right the first time whenever possible.

I see (h/t to Kevin, MD) this remains a topic of debate amongst doctors, which is not surprising in the context of advances in technology and increasing constraints on time.

This author's reflections on how technological advancement has changed medicine including the social aspects of it really resonates with me, as I see fewer and fewer of my colleagues in the hospital at all due to the trend towards doctors going fully into hospitals or fully into offices and clinics, but no longer both.

I regret that more and more we seem to distrust our eyes (and almost all of dermatology for example relies on observation, as do a myriad of other diagnoses); we distrust our ears (and the tale the patient might tell us if we only listen long enough) and we distrust our senses. We are putting far too much emphasis on "test results" to tell us what to do next.
We see too little of our radiology colleagues because we don't go down there as much as we used to. It's a loss--it was great to show them a CAT scan or MRI and give them the clinical context, and then hear their opinion.
I miss the nurses' station with the chart racks which used to be the social center of each floor of the hospital. Since you can write your note from anywhere (including from Starbucks), we we wind up "talking" to each other through the medical record. We don't develop relationships that are good for coordinated patient care.
I bemoan the fact that the art of bedside diagnosis is in danger of extinction. The people who invented these skills (beginning a hundred and fifty or more years ago) had to wait for an autopsy to reconcile what they saw or felt or heard on the outside of the body with what was actually going on inside. Now, we can make those correlations in real time; it should have made us superb at the bedside. Instead I worry we will get to a point where if you are missing a finger and show up in a hospital, no one will believe you till they get an MRI, CAT scan and an orthopedic consult.

I think this writer sums up nicely the use of a guided examination in arriving at an accurate diagnosis, which not only allows effective treatment to be started without delay, but also avoids unnecessary tests, radiation exposure and cost to the patient.

We believe that the truth is somewhere in between. We arguethat clinicians who are skilled at the bedside examination makebetter use of diagnostic tests and order fewer unnecessary tests.If, for example, you recognise that the patient’s chestpain is confined to a dermatome and is associated with hyperaesthesia,and if you spot a few early vesicles looking like dew dropson rose petals, you have diagnosed varicella zoster and sparedthe patient the electrocardiography, measurement of cardiacenzymes, chest radiography, spiral computed tomography, andthe use of contrast that might otherwise be inevitable. Andso many clinical signs, such as rebound tenderness, lid lag,tremor, clubbing, or hemiparesis cannot be discerned by anyimaging test.

Health Care Reform

2010-03-21T16:38:00.000-07:00

On the eve of a vote on health care reform in the House, this link shows a brief summary of the bill's content.

For those with a yen for source documentation, this link is to a pdf file that shows the entire content of the bill.

Sex and the Insulin Pump

2010-03-10T13:13:00.000-08:00

This is a well-written article by a professional teacher and writer about the impact of having an insulin pump for Type I diabetes on her feelings of sexuality and self-worth.

The article is of general interest about how chronic illness and particularly medical equipment can affect not just your health, but also sexuality.

As a doctor, it is also a reminder that medical conditions and also their treatments can affect life and also quality of life, which includes sexuality. I admit that I had not considered this in the insulin pump, though the subject often comes up in the setting of arthritis, heart attacks and cancers of the breast and prostate. "Will I spread the cancer by touching her?" "Will "being with him' cause his heart to over-work itself?" These kind of questions may be hard to ask, but they're real questions. They reflect concerns based on anxiety, love and compassion. Nothin' more real than that.

(H/t to boing boing for this link.)

Telemergency Alert Device

2010-03-05T08:28:00.000-08:00

A patient's daughter recommended this alert device, based on her use of it for her father who is medically frail and lives alone.

(Disclaimer: this is useful information being passed on, not a product endorsement.)

The idea with alert devices is for elderly folks to have a quick and easy way to summon help if needed (think: Help! I've fallen down and I can't get up!)

The device costs about $148 (see this Amazon link) as a single purchase. Otherwise, there is no installation fee or monthly subscription fee.

You can set up to 5 numbers (including 911 if you wish) that the device will automatically dial in succession if a button is pushed on the base or on a wireless pendant. If no one answers on call #1, the device goes next to call #2, and so on. Thus, you can opt to call family or neighbors as opposed to every call out summoning the fire department.

The only potential drawbacks that have been pointed out are that the button can be activated fairly easily (as in rolling onto it in sleep), and that the device will leave a message on a message machine and stop calling further numbers. Perhaps setting calls to go to cell phones is better.

Popular Health Supplements

2010-02-25T16:07:00.001-08:00

Hmmm, this looks interesting.

This link is to a graphic representation of data around health supplements as a "bubble race". The higher the bubble, the stronger the evidence showing that it works. The bigger the bubble, the more popular it is (in terms of Google searches).

Hormone Replacement Therapy: better to wean slowly or stop cold turkey?

2010-02-05T08:22:00.000-08:00

Ever since the publication of the findings of the Womens' Health Initiative earlier in the last decade,
it has generally been appreciated that hormone replacement should be reserved for alleviation of intractable menopausal symptoms and only for as long as necessary to do so.

On the other hand, it has been unclear whether stopping hormone replacement can be sudden or whether it should be done gradually.

A recent medical study suggests that there may not be much difference between the two approaches.

Women who suddenly stopped taking hormone replacement had the same number and severity of hot flashes as women who took their usual doses every other day for a month and then stopped.

Interestingly, almost half the women went back on to hormone replacement because of the severity of hot flashes within a year of going off them.

I think the take-home message is that hormone replacement is reasonable to use to alleviate significant hot flashes and menopausal symptoms. In order to establish whether you still need to be on them, it's okay to just stop them and consider restarting them if the symptoms return and are not tolerable. Remember that the earliest signs of harm from use of hormone replacement took over 5 years to manifest in the Womens' Health Initiative study, and also that there are alternatives to hormone replacement that you may prefer.

An Inspiration in Tough Economic Times

2010-02-05T08:08:00.000-08:00

Ralph Bakshi is a cartoonist and cartoon animator (remember Fritz the Cat, Wizards, Lord of the Rings?) who in this YouTube video is responding to a question at a comics convention as to advice for young up-and-comers in a tough industry during this economic downturn.

His answer is like Babe Ruth taking it out of the park.

The answer addresses the opportunities in times of crisis for animators, but really speaks to anyone with some creative talent, a marketable idea and the drive to take the entrepreneurial bull by the horns.

This is recommended viewing for anyone considering making a go of a long cherished idea that has been on the back burner until now.

Kidney Stones

2010-02-01T08:13:00.000-08:00

Kidney stones are a relatively common, and potentially quite painful problem.

They occur through the formation of crystals from dissolved chemicals in the urine. These form in the kidneys, and can be passed down through the ureters to the bladder. If they are small enough to get out of the bladder, but big enough to get stuck partway down (4-6 mm across) that's when the problem gets very painful. Painful as in more painful than childbirth (so says every female patient I have ever had who has a basis for comparison).

Kidney stones have a 10-15% chance of occurring in any given person's lifetime, though this varies with a number of factors:

Stones are 2-3 times more likely to occur in men than in women.
Whites have more stones than Hispanics, Blacks and Asians.
Stones are uncommon in people under 20 years old, and the occurrence peaks between 50-70.
Stones are more common in hot, dry climates. Also, heat exposure and dehydration are risks.

80% of stones are made of calcium (which happily means that they show up on plain old X-Rays), and 80% of these calcium stones are made up of a chemical called calcium oxalate.

So, for the good news- there are things you can do in order to prevent these stones. (h/t to my urology colleague Dr. Kash Desai for many of these):

Hydration: drink 6-8 glasses of water a day, avoid sodas, salt and caffeine from your diet.
Avoid high-protein and high-salt diets.
Avoid excessive cheese and dairy intake.
Lemonade is good: 8-10 ounces of lemon juice in 64 ounces of "reverse osmosis" water such as Aquafina, Dasani or Alhambra.
Orange juice, or any other citrus juice is good. (Remember, you should not drink grapefruit juice at all if you take a statin cholesterol medication.)
Vitamin B-6, 50 mg a day.
Calcium supplements are OK, but should be calcium citrate with Vitamin D and magnesium (and not calcium carbonate such as Tums, Rolaids or "natural" calcium).

Sports Injuries in Girls

2010-01-30T11:36:00.000-08:00

3 million girls now participate in high school sports. This is a 940% increase since the Title IX Equal Opportunity in Education Act was passed in 1972; how cool is that?

A recent study reveals some very interesting findings about injuries in our young female athletes.

The bottom line of the study is that girls have a higher risk of certain specific types of injuries than boys, but a lower overall injury rate than boys.

Specifically,

The most popular high-school girls' sports are basketball, track, volleyball, softball and soccer.
Overall, girls had half the injury rate of boys.
In girls, injury rates were highest in soccer.
The most common injuries were knee and ankle. These comprised 60% of all injuries in young female athletes (which is to say 99 injuries/100,000 athletes).
This was a 30% higher rate of knee injury than in boys. ACL (anterior cruciate ligament) ruptures were seen to be three times more frequent in girl soccer and basketball players than in their boy counterparts. Girls also had higher rates of surgical repair than boys.

On the other hand,

Traumatic brain injury involved only 11/100,000 girl athletes: a much lower rate than in boys.
Basketball had the highest rate of concussion in girls, at a rate topped only by boy's football and boy's soccer. (Girl's track and girl's soccer were next highest.)

Interestingly, cheer-leading had the highest rate of catastrophic injury in girls. I guess I don't find this completely surprising as I do a lot of sports physicals for our local athletes.

Overall,

There is no "injury epidemic" in girls' sports.
The increased number of injuries seen corresponds to the greater number of girls competing.
Other studies show that knee and ankle injury rates in girls improve with specific warm-up exercises and use of protective gear such as knee pads.

(Ed. If you are proud of your athletic potential-sports-scholarship daughter, niece, grand-daughter or neighbor, thank the federal government for Title IX.)

Discussing End of Life Care With Your Doctor

2010-01-24T14:14:00.000-08:00

This article in the L.A. Times is pretty interesting, insofar as it's one of those studies where you would think the result would be obvious. Not.

The study, published online Jan. 11 in the journal Cancer, surveyed 4,188 physicians about how they would talk to a hypothetical cancer patient with four to six months to live. A majority of respondents (65%) said they would discuss prognosis, but only a minority said they would discuss do-not-resuscitate status (44%), hospice (26%) or preferred site of death (21%) at that time. Rather, they would wait until symptoms were present or until there were no more treatments to offer.

I must say, I'm pretty surprised about this. I think the time to have this discussion is before a crisis, and not at the time of crisis. Admittedly, these kinds of discussions are incredibly time-consuming but they are also necessary in order for everyone involved to have a chance to think and talk about what is wanted and what is not. Certainly, the time has to be right for the discussion. It's just that the right time is not at the end of the line.

For that matter, a cancer diagnosis is not the only kind of medical problem where this issue is relevant. It applies equally where a medical problem is very likely to be fatal in the near future, and where it is best for patients and their families to discuss their own preferences and choices for the future.

Does losing weight help with my blood pressure?

2010-01-13T17:11:00.000-08:00

Yes; yes it does!

This is particularly nice to know at this time of the year when many people gain 7-8 pounds over the holidays. The trick is to lose this rather than gaining 7-8 pounds every year that you never lose.

On average, losing 10 pounds (no matter how much you presently weigh) results on an 8-10% reduction in you blood pressure.

This may not sound like much, but it's about what you would see with starting doses of prescription blood pressure pills.

Take home message: losing 10 pounds is as helpful as starting a blood pressure medication. Which one sounds better?

Holiday Schedule

2010-01-01T21:19:00.000-08:00

We will be out of the office spending the holidays with our families during Thanksgiving (11/26 and 11/27), on Christamas (12/24 and 12/25) and on New Year (12/31 and 1/1)!

These happen to fall on Thursdays and Fridays, so we will be enjoying a few well-deserved long weekends during this season.

Please plan accordingly, particularly with respect to any medication refills or prescriptions you may need.

We wish you and your loved ones the best for the season and the new year!

Avoiding Snow Sport Injuries

2009-12-20T13:35:00.001-08:00

Well, we've got a pretty good start to the skiing and boarding season! (To say nothing of some pretty sorely needed precipitation.)

This article relates some pretty interesting findings in sports-related medicine and may help to prevent avoidable injuries.

Surprise (sorta) findings:

Average age of injured skier: 40. Mostly men, and mostly at low speeds.
Contrary to popular stereotype, snowboarders were not found to be slamming into skiers; skiers were found to be sliding downhill into snowboarders during failed attempts to stop.
Wearing a helmet helps to reduce head and brain injuries in low-speed accidents.
Buying boots big enough for your child to "grow into them" increased injuries in children. This is because the binding release mechanism doesn't release as well when there's a lot of leeway for foot movement within the boot.

Not a surprise finding:

Drug use while on the slopes increased injury.
Wearing a helmet while hitting a tree at 30 mph did not save heads. The idea is wear a helmet, but don't hit a tree.
Improved bindings reduced shinbone fractures.

Do I need to drink 6-8 glasses of water a day for my health?

2009-12-18T13:22:00.001-08:00

Short answer; no.

It's actually not known how the idea started that drinking 6-8 glasses of water every day is absolutely essential for good health, but it certainly has gained a lot of traction over the years.

Generally, when your body is becoming depleted in fluid volume an involuntary thirst reflex engages which makes you feel thirsty. This results in you getting something to drink so you no longer feel thirsty. In other words, natural mechanisms keep you from becoming unknowingly dehydrated so that it isn't necessary to drink fluids constantly to prevent dehydration.

Mind you, this assumes general circumstances. Certainly, if you are trying to lose weight it helps to feel full on no-calorie water instead of food.

Also, very elderly people can lose some of the thirst reflex and not realize that they are mildly low on fluids.

Also, this does not apply in special circumstances where you may be losing more fluids than usual or where access to fluid is restricted, such as strenuous work outdoors or diarrheal illness (or desert combat operations for those of you in the military). Here, you want to be mindful to replenish fluids often enough to urinate every 2 hours and for your urine to look clear or light yellow. Also, be sure to use sport drinks or eat food to replace lost sodium.

If you are concerned about dehydration, the first sign of this is a decrease in urine production and/or dark colored urine. Improvement in this is a good sign of adequate rehydration.

Snow Days

2009-12-08T16:20:00.001-08:00

We have been closed for the past two days due to the unusual snowstorm to low elevations and loss of electrical power(which includes lights and phones).

At this time, we have power, lights, heating and roads back and should be back in the office as usual tomorrow (Weds. 12/9/09) morning!

We hope you all have been safe and well.

GERD, medicines, and Rebound Effect

2009-12-04T13:52:00.000-08:00

GERD, or gastro-esophageal reflux disease, is a common condition in which acid stomach contents go "upstream" (reflux) from the stomach into the esophagus. The symptoms of upset stomach and burning up through you chest were probably why it used to be called "heartburn".

Medicines such as Zantac, Tagamet, Pepcid and Axid help by causing your stomach to produce less acid. Newer ones such as Prilosec, Nexium, Prevacid, Aciphex and Protonix do so even more powerfully.

Doctors are realizing within the last 6-12 months that these medicines can cause what we call tachyphylaxis, or rebound effect.

In other words if you have taken these medicines for over 3-4 weeks, your condition may be adequately treated. However, when you stop taking the pills your stomach starts to re-produce normal acids. In fact, for the first week or two it may temporarily over-produce them before coming back down to normal.

When "heartburn" symptoms returned after you stopped the pills, we used to think this meant you just had to stay on the pills for life. Now, we are concerned that for many patients this might simply be a side-effect of long-time use of the drug.

If you have been on such a medication for over 3-4 weeks and the "heartburn" comes right back within 1-3 days of stopping the medication, use Tums or Rolaids freely for a week or two if needed. These are acid buffering agents, and do not cause the same sort of rebound effect. However, they can keep your "heartburn" symptoms under control for the week or two it may take for this to subside.

Remember also that tobacco products, alcoholic beverages and anti-inflammatory pain relievers can cause or contribute to GERD. Tylenol is not such a medication, and is safe to take.

Note that this does NOT apply to patients with other conditions where life-long treatment with powerful acid reducers is entirely appropriate such as hiatal hernia, Barrett's esophagitis or GERD that does not tolerate cessation of the medications.

Also, you should seek urgent medical attention for symptoms that could represent bleeding or cancer such as obstruction to swallowing, feeling full all the time, loss of weight or appetite, rectal bleeding or black sticky bowel movements.

H1N1 Update

2009-12-04T13:40:00.000-08:00

We have received an ample supply of H1N1 shots, and have started contacting patients who are at high risk and in most need of receiving the shot. (I posted earlier on who those groups of patients might be, and why.)

We probably have more than enough, and can provide some for folks who would simply like one.

Please call so we can arrange a time when you can come in to get one, if you'd like.

Also, the Public Health Department will be holding a completely open shot clinic to give free H1N1 shots to anyone who would like one on Monday 12/14 at the Fairgrounds, from 1PM- 4PM at the Organ Room.

H1N1 flu shot clinic

2009-12-03T15:30:00.000-08:00

The county Public Health Department will be announcing a free flu shot clinic for anyone who needs or wants an H1N1 shot.

This clinic is to be on Monday 12/14/09 at the Fairgrounds. The time and more particulars are to be announced by Public Health. Their phone number is 621-6100.

How much is OK to drink?

2009-12-03T15:14:00.000-08:00

Well, that depends.

Unlike with tobacco products where there really is no safe amount at all, for many folks there is a safe level of alcohol intake.

Potentially harmful drinking is defined as over 7 drinks/week or over 3 drinks/occasion for women, and as over 14 drinks/week or over 4 drinks/occasion for men. The reason for the gender difference is the generally greater muscle mass in men than in women.

A drink is defined as a 12-ounce beer, a 6-ounce glass of wine or 1 1/2 ounces of liquor.

When we say that exceeding these limits can be harmful, we mean that we start to see a real increase in both medical and social problems at these levels.

Social problems can involve DUI's, loss of drivers' license, job loss, absenteeism or divorce.

Medical problems that can occur as a direct result of drinking include depression, heart failure, liver failure, cirrhosis, bleeding ulcers, anemias, malnutrition, nerve damage and sexual dysfunction.

On the up side, safe levels of alcohol consumption are seen to lower risks of having a heart attack. This is, for some reason, particularly true of red wine.

Mind you, if you do not ordinarily drink there is no medical reason to start. Also, if you have problems with alcohol, it may be better to abstain entirely.

Being (possibly) billed for lab tests at Marshall

2009-11-30T13:12:00.000-08:00

When you go to lab to get blood tests done and you are asked to sign a paper you are NOT being told that you WILL be billed.

Marshall recently bought new billing computer software that automatically prints out a form called an Advance Beneficiary Notice (ABN) whenever a doctor orders a test that has a limit on how often it might be done or has often been not reimbursed to Marshall.

This form tells you that:

Your doctor feels you need this test.
If your insurance, for some reason, refuses to pay Marshall for doing the test, Marshall may bill you for it.

Problem is, Marshall's billing people are not involved in tell you about this or helping to determine whether or not you actually will get a bill or not. The lab people are just being asked to have you sign the paper whenever the computer prints one out.

You won't get a bill for:

annual screening tests done at least a year after the last one
diabetic glycohemoglobin tests (HbA1c) at any frequency at all for out of control diabetes
tests often ordered for screening but ordered for non-screening purposes, such as a mammogram for an abnormal screening mammogram, or a PSA test for an enlarged prostate.

Genes and Medicine

2009-11-30T12:59:00.001-08:00

This article is fascinating (in a real science geek, wonky kind of way) about ongoing study into the genes that different diseases and diagnoses may have in common.

The study itself is interesting, but so are the implications of different, seemingly unrelated illnesses having a common genetic link. The ramifications for future ways of thinking about and treating or preventing disease is profound.

Also, the graphic is cool!

Swine Flu Shots

2009-11-25T08:48:00.000-08:00

Update: we have, indeed, ordered swine flu vaccines about 2 months ago. We have not yet received them, though are told we may get them within the next few weeks.

News coverage of problems in both production and distribution are not grossly exaggerated.

We have been keeping a list of patients at high risk to call when we receive vaccine.

Widowed Persons Association of California

2009-11-24T08:23:00.000-08:00

A patient recently informed me that the Widowed Persons Association of California has a local chapter here in Placerville.

This group is a non-profit and non-denominational organization, and I gather that the local chapter is a social group with entirely voluntary attendance and participation.

The November calendar shows a couple of Sunday events such as a dance and a cards & games potluck, and also breakfasts or dinners at local restaurants 3-4 days each week.

From what I've been told, support is there for you but the events are generally social affairs and not ongoing grief counseling. For many , this is just "what the doctor ordered".

CHAPTER # 10
Placerville
P.O. BOX 2440
Placerville, Ca. 95667-2440
(530) 642-2511

Constipation

2009-11-23T08:21:00.000-08:00

OK, not your most glamorous topic. It is, however, one I get a lot of questions about.

Constipation refers to bowel movements (BM's) that are dry, pebbly looking and hard to expel. Dehydrated, in a word.

Your BM's are made of undigested plant fibers (roughage), bacteria and bile pigments. The roughage comes from fruits, vegetables and whole grains in your diet. The bacteria are a normal part of the bacterial flora in your digestive system (there are more normal bacteria on/in a human body than actual human tissue cells!). The brown color is from bile which is made by your liver, stored in your gall bladder and secreted into your small intestine to help you to dissolve and absorb essential fats in your diet.

Problem is, your colon and rectum work to re-absorb water from your bowels so you don't lose a lot of water in your BM's and become dehydrated. When your colon can't do that, it's called diarrhea.

Constipation can occur if you don't eat enough fruits and vegetables. This will mean you lack the necessary bulk to fill your rectum. Filling the rectum stretches nerve endings in it which signal your brain that you need to go to the bathroom. As this goes on, too much water gets drawn from the contents of your rectum. The end result is dry, pebbly, hard BM's. Constipation!

Please note that normal does not mean having a BM every day- it means having soft normally formed BM's.

Treatment of constipation starts with increasing dietary fiber.

Eat more fruits and vegetables; five servings every day would be good not only for constipation, but also in reducing many kinds of cancer.
Metamucil, Citrucel, bran or flax seeds taken every morning can also help and is safe.

If this is not sufficient, other medicines can be used daily and will not produce dependency on them.

Stool softeners such as DSS simply make your BM's softer and easier to pass.
Natural cathartic agents gently stimulate a BM, such as Senakot, prunes or prune juice.

If constipation has been going on for a long time, your rectum can become so conditioned to feel full that it can no longer signal an urge to defecate to your brain. This neurogenic bowel problem can get to the point of needing strong laxatives just to have a BM.

In such a case, you may need to do all of the above plus use Milk of Magnesia or a Dulcolax suppository every 2-3 days as needed.

Constipation with fever, abdominal pain or rectal bleeding may represent an emergency for which you should be seen as soon as possible by a doctor.

All the medicines mentioned above are easily available over the counter. Please feel free to see me about constipation. It's a very common and obnoxious problem that can be helped!

MediCare Part D Open Enrollment

2009-11-20T14:37:00.000-08:00

It's that time of the year again! From now through 12/31/09 you can change your Part D plan, which covers your prescriptions. If you haven't been happy with coverage or the donut hole, now's the time to choose something better. If you have been happy with it, now's the time to make sure no changes are going to be made for next year that you wouldn't like.

The Centers for Medicare and Medicaid Services (CMS) has a website for open enrollment.

Here is a table summarizing the 60 different plans available for El Dorado County.

This is a pdf file that you can print off as a worksheet to help you sort out your options on-line or with an insurance broker.

Things to keep in mind:

Relax. You've got to the end of the year!
Focus on looking for plans that specifically cover your expensive medications. The inexpensive ones will be covered by any plan.
Think about whether you might be better off paying more in monthly premiums for donut hole coverage than not being able to afford your medications by the end of the Summer.
Don't be fooled into picking a plan where you make MediCare your secondary insurance! This does not turn out to save you money and seriously limits your heath care!

Cancer Screening

2009-11-20T13:47:00.000-08:00

There has been a great deal in the news just in the past month about new studies and recommendations regarding cancer screening. This is all very interesting, but also pretty complicated.

First off, these stories are based on findings of the New England Journal of Medicine, the U.S. Preventive Services Task Force, and the American College of Obstetrics and Gynecology. The have yet not been widely adopted by other organizations such as the American Cancer Society and medical insurance companies or MediCare. Also, the are not related to present Congressional legislation on health care reform and addressed clinical effectiveness not cost. In other words, it's about the outcomes not the money.

Also, these findings related to people at average risk for cancer, and not to persons at high risk due to family history or other factors.

First, the study in the New England Journal pointed out that screening for breast and prostate cancer was associated with an increase in early detection of localized cancers, but not with a decrease in more advanced cancer.

This is concerning because the idea of screening is to find cancer early, before they have a chance to spread. If that is what is actually happening with breast and prostate cancer screening then we should be seeing a rise in early cancers and a resulting decrease in later stage ones. Which we're not.

What this seems to mean is that there are two types of such cancers. One kind is very slow growing and it may be that a wait and see approach may be as reasonable as biopsies and surgery. The other kind is so aggressive that it may become detectable between screening test intervals.

The thrust of this article is that we need to do more research in tumor biology so that we can identify which tumors should be aggressively treated, and which can be watched over time.

Coming hard on the heels of this, the U.S. Preventive Services Task Force (which has been around for decades) is recommending that breast cancer screening not be started until 50, the to be performed by breast examination and mammography every other year until 70-75 and then discontinued. They have also found that monthly breast self-examination is not generally helpful.

Much of the concern is over the naturally fibrous nature of female breast tissue up to age 50, and therefore the potential of self-examination and mammography to both miss cancers and also to over-call benign nodules and cysts.

The same recommendation stresses that individual patients may wish to proceed with screening between 40-50 based on personal preference, and that the recommendation does not apply to high risk patients such as those with family members with breast or ovarian cancer or positive genetic testing of BRCA mutation which increases risk of developing breast cancer.

The American Cancer Society has strongly disputed this recommendation.

Just this morning, the American College of OB/G announced a recommendation that cervical cancer screening (Pap smears) should not start until 21 years of age regardless of sexual activity prior that age due to the very low rates of cervical cancer in such young women. Further they recommend Pap smears every other year up to 30, then every third year to 70. This assumes no abnormal Pap smears are found.

This is probably based on the already established observation that it takes about 10 years to go from normal Pap smear to cancer and is a best effort at conservative screening without over-kill.

So, there you go: all the news on cancer screening! For now, anyways.

Nasal Saline solution

2009-11-20T13:42:00.000-08:00

Many patients use nasal saline to irrigate their nasal purposes for allergy problems, chronic sinus inflammation and for relief of cold and flu symptoms.

If you make up the solution for yourself, it's important that the finished solution is exactly the same degree of saltiness (salinity) as your bloodstream. Otherwise, this can make irrigation painful and counter-productive.

The recipe is:

4 cups of clean tap water
2 teaspoons of regular table salt

Use real kitchen measuring cups and spoons, and discard the solution after 2 days.

Health Care Reform Bill HR 3962

2009-11-08T10:16:00.000-08:00

Patients have been asking me what I think of the government's efforts at reforming our health care system.

I've posted once or twice in this before covering the general principles and how US health care stacks up in terms of cost, administration and quality compared world-wide.

More recent patient inquiries were more along the lines of how I, as a doctor, feel about the specific proposals and how I see it affecting me and my patients. Up to now, there hasn't been much I could specifically say since the reform bill before the US House of Representatives was a work in progress. That is, until last night when it passed the House. Reform must now be approved by the US Senate, so it's quite likely that it will be different than the present House Bill before it is presented to the President of the United States for signature into law.

At present, HR 3962:

Would take effect by 2013
Would require Americans to purchase medical insurance or pay a penalty of 2.5% of income, subject to exemption due to hardship
Would expand Medicaid/MediCal to be able to cover about 30 million Americans who currently are too poor to buy private insurance, but too "rich" to be eligible for Medicaid or MediCal (MediCal is the California version of Medicaid, which is a Federal program providing insurance to people close to the poverty line)
Would close MediCare's "donut hole" in Part D drug coverage, and change incentives in the currently scandal-prone MediCare Advantage insurance products
Would lift the exemption of health insurance companies from anti-trust laws, which up to now have kept them from being investigated for their practices
Would forbid insurance companies from denying insurance based on gender or pre-existing medical conditions
Would forbid insurance companies from the practice of rescission, in which they investigate you background upon receiving expensive claims to find ways to retroactively deny your coverage
Would create a governmentally sponsored "public option" for those who choose it over privately available insurance.
Would forbid covering the cost of abortions except in cases of rape, incest or threat to the health of the pregnant woman using Federal funds rendered to insurance products
Would, according to the Congressional Budget Office, be cost neutral
Would be partially funded through a 5.4% income surtax on couples filing jointly over $1Million in income, or individuals filing over $500,000 in income
Would also be funded by changes in the existing MediCare and Medicaid programs, details of which are unclear at the time of this writing (the bill is about 2,000 pages long)
Would help to fund continuing medical education for doctors and nurses

Personal politics aside, I think this is a step in a good direction. I cannot see a problem with a cost-neutral program that would make affordable health insurance available to over 96% of our fellow Americans.

Requiring everyone to have health insurance is common sense. Otherwise, healthy people skip insurance leaving sick people as the main insurance participants which results in continually increasing costs. This gets passed on as increasing premiums in a system that still has to fully and publicly absorb the costs of the healthy uninsureds when the get ill or injured. It makes as much sense as requiring auto insurance, which protects every driver against the possibility of having to pay out of your own insurance even though the other driver was at fault but has no insurance.

As to the carve-out of Federal funds to public and private insurances in the coverage of abortion, from a purely pragmatic point of view that's going to be a real accounting nightmare. From an ethical point of view, I think it's pretty silly since everyone pays taxes that pay for things that one may not use or like. That's just the nature of taxation, government and shared resources in a democratic (as opposed to theocratic or dictatorial) society.

I do hope that some provisions for enforcement are made; it's one thing to illegalize price-fixing and rescission by insurance companies, and quite another to enforce it.

I still remember receiving my settlement checks from several major insurance companies a few years ago in which the were sued in class action filings under RICO statutes and chose to settle rather than undergo a public trial during the heydays of the HMO's. It's not good when every single one of the country's biggest health insurance companies are basically willing to admit that their business practices are indistinguishable from the Mafia.

I also look forward to the day that I don't lose patients from my practice because of a change in their employment or their boss's choice of insurance.

Frankly, I also look to the possibility of lower insurance costs without lower insurance quality for my practice.

I don't know how this will effect my bottom line, though if the "public option" were to reimburse at MediCare rates plus 5%, that would be just fine. The days are long gone when insurances paid much above flat MediCare rates unless you were the biggest fish in the pond. MediCare+5 along with MediCare (independently of the Reform Bill) considering lowering reimbursement of expensive procedures in order to increase payments to primary care services would be mighty welcome to little guys in the trenches like me!

Better Sleep

2009-11-05T14:34:00.000-08:00

It's not surprising to me that patients often relate problems sleeping.

Lots of things can help with getting a handle on better sleep, bearing in mind that persistent problems with sleep may represent bigger issues that merit further evaluation and discussion.

First, avoid things that can make it harder to fall asleep or stay asleep.

Avoid exercise, caffeine or alcohol within two hours of bedtime.
Avoid leaving unresolved problems or tasks. Keep a "To Do" list next to the bedside so you can jot down a quick note rather than stay up trying not to forget it.
Avoid using your bedroom as an office or for watching TV.
Make sure your bedroom is dark and quiet; use ear plugs and a sleep mask if you need to.

If you can't fall asleep, don't make it harder.

Go to bed and get up at the same times, no matter how poorly you've slept, every day of the week.
If you're having trouble sleeping, go to another room to read or listen to some music. Don't watch TV or use your computer; the light can cause you to become more awake!
Avoid naps, or at least don't nap for over 20-30 minutes.

As far as sleep aids go,

You shouldn't have persistent trouble sleeping for over two weeks. This may be a sign of other problems such as untreated pain, asthma, heart failure, restless legs syndrome, sleep apnea or depression and should be managed as such.
Herbs such as valerian and chamomile can help.
Warm milk does help, due to the serotonin release that it can produce.
Melatonin is safe and effective; just realize that it has to be taken about an hour and a half before lights-out to work!
Benadryl can be used for sleep, as long as it doesn't make you feel groggy when you wake up.
Prescription medicines such as Ambien/CR and Lunesta should be regarded with great caution. They may not be as safe and non-habit forming as believed.

UPDATE: further changes to hospital care

2009-09-13T15:03:00.001-07:00

So, since the last discussion of this back in June, the number of primary care doctors in our community who are available to see patients in the ER and in the hospital is no longer 7. It's down to 2. That's right, two.

I will continue in my arrangement with the hospital doctors to be available most, but not all of the time. It is simply not possible for me to be on call 24/7/365.

If you call the office after hours, you can leave a message. Naturally, if you feel you may be having a medical emergency, you should call 911. Otherwise, we will continue to return any phone messages early on the next business day.

Child Abduction: How Likely?

2009-09-13T11:57:00.000-07:00

Sorry, but I think I'm suffering Garrido overload.

As a dad, I wonder how likely it is that my daughter could be kidnapped by a complete stranger . I certainly remember my own childhood in which we all walked to and from school, got together afterwards to play ball, or went hunting for snakes and crayfish in the woods. I'm sad to see that few kids are allowed to have this sort of independence anymore, and wonder how dangerous coming home from school by yourself really is.

Well...

115
number of children in the U.S. kidnapped in a single year

71,900,000
number of children in the U.S. in that same year

The year in question is 1999, the most recent nationwide statistic I could find on the number of U.S. children who were abducted by strangers (not family members) with intent to keep, harm or hold them for ransom. I'm not sure where the 40 million U.S. children figure comes from in that same source link. The 40 million link goes to a demographic display on Nation Master. The link I have provided is much more specific and accurate.

Note that this figure includes all children under 18 years of age, not just 6-17 year olds.

So, doing the math...

1 in 625,217
Odds of a child in the U.S. being abducted by a stranger

0.00016%
Probability of the same

For sake of comparison,

1 in 84
Odds of dying in a car accident

1 in 5,051
Odds of dying in a plane crash

1 in 340,733
Odds of being killed in a fireworks accident

So, it looks like my daughter's twice as unlikely to be kidnapped by a stranger as being killed in a freak fireworks accident. Maybe the Free Range Kids people are on to something here!

Disclaimer: I am not advocating doing clearly ill-advised or criminal things, such as leaving your children at home alone while you go on a vacation. Only you can ultimately decide what seems good for your children.

Flu Shot Clinics for El Dorado County

2009-09-13T11:53:00.000-07:00

Here is a link to flu shot clinics for our county. It also includes a list of frequently asked questions such as who should get them and how much they cost.

Where do I get a flu shot?

2009-09-01T08:19:00.000-07:00

Regular seasonal flu shots are available, and I have not heard of any supply problems or shortages.

Safeway stores are already giving them.

The Public Health Department also has a Flu Hotline that you can call to find other locations for flu shots. The number is 621-6188.

Actually, the best time to get a flu shot is between Hallowe'en and Thanksgiving. This results in your immune system response to flu to be at its highest at the time we normally start to see flu which is December through February.

Perspective on Health Care

2009-08-26T13:46:00.000-07:00

This link is to a well written op-ed from the Washington Post and is worth a read. It's fairly brief, to the point and quickly summarizes the similarities and differences in structure, cost and quality of health care in various industrialized nations compared to the U.S.

It certainly reflects the data on the subject, and also my experience of health care in other countries as experience by me, my family or as related by my patients.

Current H1N1 flu vaccine recommendations by the CDC

2009-08-26T08:34:00.001-07:00

I understand through an email update from the California Medical Association, that vaccine for the novel H1N1 flu ("swine flu") is to be available along with the standard seasonal Autumn flu shots.

Realize that the H1H1 vaccine is separate from this, and is likely to require two shots in series.

The word is that access and supply are not going to be a problem, but in the event that it is, the CDC is recommending that certain groups get first access. Mind you, other sources such as WebMD had news coverage less than a week ago of production delays. It is important to remember that researching, developing and producing vaccines and other biologicals is extremely difficult. The flu vaccines are matured on chicken embryos for gosh sakes!

At any rate, the current recommendations for novel H1N1 flu vaccination in the event of inadequate supply is as follows:

First:

Pregnant women
Children 6 months to 4 years old
Children 5 to 18 years old with chronic medical conditions
health care workers with direct patient contact
people living with or caring for children under 6 months old

Second:

19-24 year olds
25-64 year olds with chronic illnesses

Third:

25-64 year olds without chronic illnesses

Last:

all persons 65 and older

Note that the reason for "seniors" to get H1N1 vaccine last is because they are at very low risk to even get the swine flu. This probably means that if you are 65 or older, you got a flu back when you were younger that was similar and gives you partial immunity to the swine flu. Younger folks don't have this response because they weren't around yet!

Remember, this is different than the usual annual flu shots. Those are available and plentiful and should be received between Hallowe'en and Thanksgiving for best effect.

Novel H1N1 Flu- Update

2009-08-18T09:35:00.000-07:00

The novel H1N1 influenza ("swine flu") is still being seen, including the unfortunate death of a local 52 year-old woman who apparently had chronic medical conditions as well.

Folks who are at higher risk for severe infection are those with chronic conditions (such as chronic lung disease) and also morbid obesity with a Body Mass Index over 35. The reason for this latter is not clear. Body Mass Index is calculated as follows: Weight/Height x Height and then multiply by 703.

Unfortunately, swab tests for detecting flu are not very accurate, and may detect flu only 50% of the time!

Otherwise, the H1N1 flu is similar to usual winter-time flu insofar as:

Symptoms are different than a common cold, since body aching and sense of weakness and illness is more severe.
Medications for treating this flu are the same, and should be started within the first 2-3 days to be effective.
You should cover your mouth when you cough, or wear a mask.
Wash your hands frequently.
You may return to work or school 24 hours after the fever has gone.

To Grizzly Flats

2009-08-13T08:26:00.000-07:00

The death of two neighbors and friends in a single day is a deep loss and sorrow. Patient privacy forbids me to name them, but we know who we're talking about here.

I've known and doctored both fellows for years, and their deaths are painful to me as the loss of two patients whom I've known, liked and respected for a long time.

For your community, I'm sure this sadness runs very deep. I have always, and will continue to be truly impressed by the genuine sense of mutual support and real neighborliness in your community.

With love and respect,

Mark Tong, MD

How your pharmacy works

2009-08-04T13:23:00.000-07:00

Much of what happens when you have a prescription occurs behind the scenes.

When you bring in a prescription, or if we call or fax it for you, the medication is labeled, placed in a secure bottle and checked against other medicines you obtain through that pharmacy to be sure that it is safe with your other medicines. The pharmacy also provides verbal and written instructions and precautions about the medicine.

When you need a refill, they provide this by phone and in many cases on-line through a dedicated website.

Even when the bottle says that there are no further refills, a call to the pharmacy will take care of this.

What happens is that they will fax me a request to okay any refills. We respond by faxing them back within 4 hours or less of receiving the request.

Mind you, we may also contact you if we notice that you are overdue for an annual physical or a follow-up appointment for a chronic medical condition. We may also wish to see you first if you are requesting a refill on a medicine that was prescribed a long time ago (such as a pain pill for a condition that went away a few years ago).

Because of the contracts that pharmacies have with commercial insurances (such as Blue Shield, Anthem, United, etc.) they can only fill prescriptions for 30 days at a time. I'm sure they'd be happy to be able to fill more at once, but if they do the insurance won't pay them for the medicines.

The reason for this is that the insurance companies have out-sourced discount contracts for medicines to Pharmacy Benefit Managers (PBM's) or "the mail order pharmacies" such as MedCo and Express Scrips. These companies are contracted with your insurance to contract with drug companies to provide discounted prices for large-volume buyers. In other words, your insurance saves money on medication costs by getting discount rates and requiring you to use them if you want to get more than a month's supply of medicines at a time.

You may use your insurances PBM by looking through the materials they send you every year, or by calling them at the toll-free number on your insurance card. They will provide you with any necessary paperwork. We can provide a 90 day prescription with up to a year's worth of refills if you ask. When this is sent in, they will mail 90 days at a time for up to a year to your address.

Do realize that you probably should not use the 90 day option for a new pill or a change in the dose, until we know it's working well and not causing you any problems.

Also, be aware that the military (CHAMPUS, TriCARE) operates differently. If you have no insurance, WalMart will fill many prescriptions for $4/month or $10/90 days. Just let us know which one you need when asking for a prescription.

Upcoming Vacation

2009-08-04T13:20:00.000-07:00

I will be away from the office catching a bit of beach time from Thursday through Monday!

Cindy will be here, so the office will be staffed to help you.

UFCW patients: yes we take your new insurance!

2009-07-29T13:22:00.000-07:00

Effective 9/1/09, UFCW & Employers Benefit Trust (UEBT) and UFCW Northern California and Drug Employers Health and Welfare Trust Fund (Valley Drug Fund) will change from Anthem Blue Cross PPO to Blue Shield of California PPO.

We accept both of these insurances, so this change will not effect your health care at our office. All we ask is that you let us make a copy of your new card whenever we next see you.

The Influence of Health Insurance Companies on Health Care Reform

2009-07-12T14:41:00.000-07:00

This is a link to a fascinating interview by Bill Moyer of Wendell Potter. Mr. Potter was employed as a Vice-President of Public Relations for Cigna, which is one of the largest health insurance companies in the US. Was, that is, until a bit of an eye-opener when he was back in Tennessee visiting family.

...we shouldn't fear government involvement in our health care system. That there is an appropriate role for government, and it's been proven in the countries that were in that movie.
You know, we have more people who are uninsured in this country than the entire population of Canada. And that if you include the people who are underinsured, more people than in the United Kingdom. We have huge numbers of people who are also just a lay-off away from joining the ranks of the uninsured, or being purged by their insurance company, and winding up there.

BILL MOYERS: You told Congress that the industry has hijacked our health care system and turned it into a giant ATM for Wall Street. You said, "I saw how they confuse their customers and dump the sick, all so they can satisfy their Wall Street investors." How do they satisfy their Wall Street investors?
WENDELL POTTER: Well, there's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.
So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.
I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

The link is to a video, and also to a viewable and printable full transcript.

Check it out, if you are interested to understand how commercial insurance companies influence the discussion and the political process around the reform of our health care system.

Tylenol, Vicodin and Percocet safety

2009-07-08T14:04:00.000-07:00

If you follow the news much, you will be noting that an advisory panel to the Food and Drug Administration (FDA) is expressing concerns about the safety of two commonly prescribed narcotic "pain-killers" Vicodin and Percocet, and also about the safe dosing levels for Tylenol (generically known as acetaminophen).

Just to clarify, the issue is not so much about the maximum safe doses of acetaminophen so much the fact that it's in a number of prescription and over-the-counter medications and that it may be easy for people to accidentally take too much as they may not realize how much they are actually taking.

Acetaminophen is in "non-aspirin pain relievers" over the counter, and in Tylenol as regular,
Extra-Strength and Arthritis. It is also in a large number of generic and Tylenol brand cough and cold formulas, allergy medicines and sleep aids.

In addition to this, it is a component of Vicodin and Percocet which are prescription medicines for pain.

You can start to see where it might be easier than you suppose to get more acetaminophen into you than you thought. This Q&A rather sums it up:

People think that if it’s a safe drug and I have this pain, it works better if I take more,” said Cesar Alaniz, a clinical associate professor at the University of Michigan College of Pharmacy.

How Do Drugs Get Tested?

2009-07-07T09:00:00.000-07:00

The recent news about over-the-counter (OTC) Zicam causing a loss of sense of smell in over 300 people raises a few eyebrows. Frankly, Bextra being withdrawn in 2005 for being linked to causing an increase in heart attack risk raised quite a few eyebrows, too.

It's important to make a distinction between pharmaceuticals and supplements.

Pharmaceuticals are regulated and approved by the Food and Drug Administration (FDA) and must be proved to be safe as well as effective in treating the condition for which approval is being sought.

Supplements, herbs and vitamins are marketed as nutritional or dietary supplements and therefore are not required to meet any such standards. Let the buyer beware!

By the time a pharmaceutical has received FDA approval to be sold, it has been researched and extensively tested in labs and then in humans for both safety and effectiveness. The testing in humans usually involves several thousands of folks, half of whom receive the tested drug and the other half a placebo.

This is done in such a way that the doctor giving the drug doesn't know whether the person will receive an active drug or a placebo. This is called randomized, double-blind placebo/control study, and is intended to keep people from reporting or not reporting side-effects because they know beforehand whether they got drug or placebo. Also, it is done this way so the doctor cannot reveal whether they are getting drug or placebo, either.

Granted, this assumes that the drug manufacturer is conducting the research in accordance with standards, and isn't "massaging the data". It also assumes that the directorship of the FDA is aggressively pursuing its mandate on behalf of the public.

In the case of Bextra, the drug company reported 11 months of heart attack data as a full year, thereby under-reporting the incidence of heart attacks related to the drug to the FDA.

Also note that the burden of proof of effectiveness and safety is on the company, and not the FDA. This is as it should be from the point of view that the costs of such proof should be on the company which stands to profit from FDA approval, and should not be upon the consumers and taxpayers.

Also, it is important to realize that if a drug as a rare side-effect and perhaps only occurs in one out of 10,000 or 50,000 people who take it, this is not going to become evident until several million people have taken it. This is neither a failure of the drug company, nor the FDA. This is simply a fact of life, which is why there are processes for reporting potential rare but serious side-effects with medicines. An example of this is the current investigation of psychiatric side-effects with the new smoking cessation drug Chantix.

Bottom Line:

Supplements and herbs differ from pharmaceutical drugs significantly in that they are not required to be proven to be safe or effective, nor to be tested for interactions with medicines or foods, nor for truth in labelling.

This does not mean that they do not work or should never be taken, but it does mean that a reasonable degree of skepticism in the literal sense should be exercised.

A trial period of changes in hospital coverage: and now for something completely different!

2009-07-05T13:26:00.000-07:00

Short story:

Starting Monday July 13th, for a trial period through the end of October, my call group will have patients admitted and cared for by the hospital's hospital-based doctors for 3 weeks on and 3 weeks off. We will care for our patients for 3 weeks off and 3 weeks on, alternating with the hospital-based docs.

At the end of this trial period, we'll see how it's been working out for everyone, including our patients to see if we all want to continue on in this 3 weeks on/3weeks off cycle.

Long story:

Physicians used to be on-call for the needs of their patients 24/7/365. Naturally, that gets old pretty quickly since you can never be away from a phone our out of the area.

A few decades ago, a common practice developed where different doctors would agree to share coverage on evenings, weekends and holidays. When you are on-call you're on for the group, but when you're off you're all the way off (as in you can go fishing or skiing, leave town, catch a movie with your kids...).

In the past 5 or so years, a nationwide trend which Marshall adopted is one in which family doctors only see patients in the office, and the hospital hires doctors who only see patients in the hospital (such doctors are referred to as hospitalists). Supposedly, the patients get better care as they are seen by doctors who only ever treat hospitalizably ill people. Also, supposedly this is more profitable for both the family docs and the hospital.

So far, no one including Marshall can demonstrate a difference in hospitalist versus family doctor care in terms of the complexity of the patients, how well they do and how long they have to stay in the hospital.

Unfortunately, one outcome of this is that there are only 7 primary care docs in Western El Dorado County who still see patients in the office and also in the ER and in the hospital. Marshall's own doctors backed out of the hospital about 5 years ago and can't come back.

I share call with Drs. Keith Boston, Leanne Camisa and Dave Ramos. This means if you have to be in the hospital after hours, one of us will be admitting you and I will see you first thing in the morning (or on Monday AM, if it's a weekend).

Thing is, Camisa and Ramos are married and have two young children. As you can imagine, they are finding it increasingly difficult for one or the other of them to be on-call literally half of their lives.

Bottom Line:

For my call group to continue to function, we needed to come up with some form of relief.

We still feel the best care you are going to get if you get really sick is going to come from a doctor who already knows you well.

We think the hospital docs are excellent docs, but would prefer to take care of our own patients because it's important to us.

However, the times are changing around us and there aren't many of us left doing the full range of practice.

So, we want to try out a system where we're each on-call every fourth night and weekend for 3 weeks in a row, and then 3 weeks off.

During this 3-week off period, the hospital docs will be informed as to your medical history, surgeries and your medications.

Please let me know how you feel about this, and please let me know if you are in the hospital but feel that you would rather that I was seeing you there.

Again, this is a trial period from mid-July for about 3 months. At the end of it, we'll be seeing how it's working out for everyone involved especially our patients.

Happy July 4th!

2009-07-04T12:47:00.001-07:00

Have a happy holiday celebrating our nation's independence with your friends and family.

In case it interests you, this link comments on a plain English contemporary reading of the Declaration of Independence. This link is a how-to on photographing fireworks displays.

Remember, that long stick coming out of the rocket is for staking it into the ground; it's not a handle... :-)

Samsung Jitterbug- nice idea for older folks who live alone

2009-06-10T14:31:00.000-07:00

A patient who is in her 80's and lives alone, while her son lives nearby in town showed me this last week. (Sorry, tried to upload a photo of it- drat this Blogger!)

Basically, it's a cell phone that you can get through the usual cell phone vendors that is well designed and intended for older folks (especially ones living alone).

It's large and soft enough to be held easily, but is only slightly larger than most cell phones. It opens like a clamshell phone, so the keyboard is protected from damage or accidental activation.

The keys and display are large enough to read and to use easily, even by folks with less than 20/20 vision or "arthur-itis".

A special model of this has three keys colored green, yellow and red. One calls Operator, one calls Help (such as a friend, relative or neighbor) and one calls 911.

My patient liked this over the usual LifeLine pendant ("Help! I've fallen and I can't get up!"), because it works outside the home, and she can also call her son instead of every distress call resulting in an EMT/fire department response.

Working With Your Hands

2009-06-01T18:29:00.000-07:00

This is a really nicely written article by a guy with a Ph.D. in political philosophy who is very happily and fully self-employed repairing motorcycles.

The trades suffer from low prestige, and I believe this is based on a simple mistake. Because the work is dirty, many people assume it is also stupid. This is not my experience. I have a small business as a motorcycle mechanic in Richmond, Va., which I started in 2002. I work on Japanese and European motorcycles, mostly older bikes with some “vintage” cachet that makes people willing to spend money on them. I have found the satisfactions of the work to be very much bound up with the intellectual challenges it presents. And yet my decision to go into this line of work is a choice that seems to perplex many people.

I was very impressed by the kind of thinking that goes into how this guy solves problems.

In fixing motorcycles you come up with several imagined trains of cause and effect for manifest symptoms, and you judge their likelihood before tearing anything down. This imagining relies on a mental library that you develop. An internal combustion engine can work in any number of ways, and different manufacturers have tried different approaches. Each has its own proclivities for failure. You also develop a library of sounds and smells and feels. For example, the backfire of a too-lean fuel mixture is subtly different from an ignition backfire.

Hmmm. Sounds like a day in my life...

Swine Flu- Update

2009-05-05T14:51:00.000-07:00

Yes, there has been a confirmed case of H1N1 ("swine") flu in a student at Camino School. The school has decided to close for a week to diminish the chances for spread within our community. The virus is known to be contagious for 7 days after the onset of illness.

The good news is that the virus shows none of the markers for severe disease, and is not resulting in illness any more severe than a usual seasonal flu!

Swine Flu- An Historical Perspective

2009-04-29T14:35:00.000-07:00

Most folks have heard that the Spanish Flu pandemic at the close of World War I killed millions of people, and was a shocking illness that left memories of it for generations afterwards. This is certainly true.

However, in the context of the current early stages of this influenza outbreak, it is useful to look back at the Big One in a more statistical light.

As many as 2.5% of people who got the flu died.

This does not mean that 2.5% of the world's people died, it means that 2.5% of those who got the flu died.

In fact, only 28% of the world's entire population got the flu at all. 97.5% of them survived.

In other words, in the world's worst flu pandemic in history to date your odds of not getting the flu at all were 7 out of 10, and if you did get it your chances of survival were better than 9 to 1.

And this was before advanced emergency medical care, advanced hospital care and before antiviral and antibiotic medicines.