Back in the Saddle

Yes, I'm back from vacation which was absolutely great (except for the jet lag)!

Many thanks to Drs. Boston, Camisa, Ramos and Young and to Marshall's hospitalists who took care of everyone in my absence.

What about the side effects?

Yes, medicines can have effects on you that are not intended but that you may find obnoxious or may even be dangerous. These would be side-effects, and this is different from the actual desired effects of the medicine such as reducing pain, lowering blood pressure and so forth.

This can occur with prescription medicines, and also over-the-counter ones (OTC's) and also with vitamins, herbs and supplements.

In the case of prescription and OTC medicines (not herbs and supplements, though), the effectiveness and also the safety of the medicines is regulated by the federal government's Food and Drug Administration (FDA).

Believe it or don't, the FDA frowns on medicines that have side-effects that are dangerous. However, if a medicine causes a side-effect that is pretty rare (say, one in 10,000 people who take it), a lot of people are going to have to take it before a pattern of harm from the medication becomes apparent. Drug companies have to do incredible amounts of testing and trials before the FDA will even approve the drug for sale, but it's not realistic to expect them to test 100,000 people before FDA approval to uncover rare side-effects that affect 1 in 10,000 people.

This is not to say that once a drug goes on the open market that that's the end of the story. There is actually ongoing surveillance afterwards to be able to detect rare side-effects as people start to be prescribed the medication in offices by their doctors.

Even so, that's why being prescribed a medicine should involve discussion of what the benefits of taking it are balanced against the risks involved. In this less than perfect world, perfect benefit with absolutely zero side-effect is often not possible. However, as long as the probable good to you far outweighs the potential for serious harm taking a medicine is probably an overall good idea.

Sometimes, this is obvious and sometimes it's not.

For example, it's usually clear that taking an antibiotic for pneumonia is worth risking the antibiotic causing a rash or stomach upset versus letting the pneumonia kill you.

On the extreme opposite end of the spectrum, taking medicines for osteoporosis (low bone density) very clearly reduces your risk of falling and breaking a hip which in itself is known to have a 50% risk of being dead or in a nursing home within the following six months. However, with the TV coverage of jaw necrosis, you would scarcely know that the risk of having jaw necrosis happen to you is literally one in one million. Since the risk of dying in a fall is one in 281, taking the medicine is probably a safe bet. Just goes to show that TV finds bad/scary news sells ad time, but good/calming news doesn't: "if it bleeds, it leads" journalism at work.

So, bottom line:

• Medicines can have side effects, but dangerous ones are rare.
• Make sure that you understand and are comfortable with why you are being asked to take a medicine, what's in it for you, and what is the potential for any down side.
  

Away from the office

Just to let you all know, I'll be out of the office on vacation from the 14th through the 27th of this month.

Amy or Abbie will be in during usual office hours, and will be able to take care of any routine matters.

Otherwise, my colleagues in the community and at the hospital will be available should anything arise that cannot wait for my return!

Can I keep from becoming diabetic?

Short answer; yes.

This doesn't seem to get as much media airplay as it should, but then no one stands to profit much by extolling the virtues of moderate diet and exercise habits.

Becoming diabetic should concern you if you are overweight, and especially if diabetes runs in your family, you have high blood pressure or abnormal cholesterol tests. In fact, it's not so much what the scale says as your waist circumference (at the belly button, not at the hips). Over 40 inches in men and over 35 inches in women predicts folks who are likely to develop diabetes.

The good news?

Losing weight can reduce your odds of becoming diabetic by about 80% or more, and it doesn't take as much as you probably think. Losing 5-7% of your weight will do it. If you weigh 200 pounds, that means losing 10-14 pounds, not the usual 30-50 pounds that people often say if I ask them.

This can be done by limiting your calories to 1,800/day, avoiding any food over 30% calories as fat (check the Nutritional Fact labels) and getting a fast walk in for 30 minutes, 5 days a week. Just enough to break a little sweat will do. Sorry, "being on my feet all day" doesn't help. Yes, just eating smaller portions does help. The problem here is that many people eat up to 3,000 calories a day!

Most folks can lose about 4-6 pounds a month this way. 10 pounds off lowers your blood pressure by 8-10%, which is as good as starting doses of medicines for this. 7% weight loss, and you really cut down your odds of ever seeing me every 3 months for diabetes.

You get a taste for it and want to keep losing weight because you feel better and like what you see in the mirror, well the rest is gravy!

So, what about CalPERS Blue Shield EPO?

Well, that's a good question!

Between the newspapers, phone calls, and conversations with patients I think Blue Shield made real efforts to revise their way of running the EPO here to reduce costs. This was at CalPERS's request back around January. They were so far into this that they were mailing contract offers to doctors, and outlining the specific changes: mainly requiring authorization for CAT scans and more expensive tests, and requiring you to see me first before going to a specialist. The first requirement would have been a minor nuisance, the second not a problem. Heck, that's what we're for is to see you if you don't feel well!

However, I don't believe CalPERS had any intention of accepting any offer Blue Shield could reasonably make. I suspect they have a big wave of retirement coming in, and a lot of financial incentive to funnel people into cost-effective (read: cheap) HMO's. They would arouse too much complaint by simply doing away with everything but Kaiser, so they simply keep eliminating every other choice one at a time and jacking up the price on everything else.

Remember two years ago, when you could have brain or spine surgery and cancer treatment at Sutter? How about just before then when you could also choose HealthNet or PacifiCare?

So, now what?

You've got two choices; stay local, or go down the hill.

The two HMO's are Kaiser and Western Health Advantage. Kaiser is Kaiser, 'nuf said. WHA is an HMO based around UC Davis, which is a good place if you have acute leukemia or need a transplant, but otherwise is Big County in my book. I think there may still be one or two docs up here who take WHA, but maybe not.

In any event, WHA means down the hill for any X-Ray, surgery, or specialist. If you go to Marshall ER, a lot of effort will be taken to transfer you down the hill once you are medically stable because Marshall doesn't have a contract with WHA. WHA will therefore pressure them to send you to a hospital where they do have a contract.

HMO'S are cheaper, but you get what you pay for.

BTW, docs get paid by HMO's on what's called capitation. Meaning, the doc gets a dollar figure per patient per month (PMPM) whether any of them are seen or not. Problem is, that's what your insurance company is supposed to deal with; it's called managing risk. In an HMO, then the doc has to manage risk and decide whether you are too ill (expensive) to keep or take as a new patient, and whether to see you (expensive) or treat you by phone. You have to take on a lot of patients to make this risk a safe bet, which is where the stereotypic HMO experience of packed phone lines, impacted schedules, and "I'm Dr. Smith's patient, but I've never seen Dr. Smith" comes from. Do docs learn to game this system? Only if they want to live.

The remaining alternative would be with Blue Cross as a PPO: PERSChoice or PERSCare. Same as with any other cafeteria plan. The PPO means you can go just about anywhere you want (not many docs or hospitals that don't take Blue Cross), but it's more expensive. How much more? If you are a single employee not covering dependents, PERS Choice (less cost, higher deductibles than PERSCare) would cost you $1.80/day more than WHA. Naturally, it's more if you are covering dependents.

So, what to do?

If your employer is local (like City of Placerville, EID) then raise a stink! Being a local employer with local employees and sending them all down the hill every time they become ill, or need to take a sick child to the doctor is crazy and costly in terms of missed work to boot!

If you're retired, do the same! If you live over 30 miles from Sac, how can you be expected to go there for every medical need or problem?

Otherwise, it's all going to boil down to money- yours. You're going to have to look at the cost of a Blue Cross PPO compared to a cheaper down-hill HMO. I know my medical care is better than theirs, I hope you agree and find the additional cost worth the value.

Up and Running

Good Morning!

I plan to use this site to make information about the practice available on line, and to provide information that affects us. This might be changes in insurances, alerts about illness in our community or frequently asked questions.

The Link List is a list of websites I often mention to patients interested in general medical information, or on specific things like identifying their generic pills, or finding out whether their insurance covers them, or whether their supplements or herbs contain the labelled amount in each pill.

I don't intend, for now, to post absolutely every day (like, in my spare time). Still, come on by regularly and check it out!