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.
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.
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!
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.
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.
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.
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.
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.
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.
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.
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".
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!
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!
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.
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.
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!
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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... :-)
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.
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.
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!
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.
Swine flu is a flu virus (Type A H1N1) which has been identified in Mexico where it caused 20 deaths, and also in the US, Canada, and possibly New Zealand and Spain where it has caused no deaths.
The reason that the federal government declared a national public health emergency in the face of a new strain of flu is to be able to rapidly move flu medicines from a national stockpile to places it is needed as quickly as possible.
With the exceptions of the deaths in Mexico, Swine Flu is like having the flu: fever, aches, congestion, cough and sometimes vomiting and diarrhea.
It should be treated like the flu:
stay home
cover your mouth when you cough or sneeze, discard the tissues in the gargage.
use Tylenol for fever or aches
use medicines such as Coracedin, NyQuil or Robitussin DM for cough and congestion
use Benadryl for nausea or vomiting
use Imodium/AD for diarrhea
Seeking emergency medical attention is reasonable for unusual symptoms such as:
chest pain
difficulty breathing
unremitting vomiting
To avoid getting the flu,
Wash your hands frequently with regular soap or waterless hand cleaner.
Avoid touching your eyes, nose or mouth.
Avoid visiting ill people, if possible.
Consider using an N95 respirator mask. These filter out viruses and bacteria from the air you breathe, and can be bought at hardware stores where they are used for sawing and grinding work. These are fiber and semi-disposable, not the big rubber ones with large filter cartridges!
Hearing aids, technology and the Baby Boom have finally come together in a "perfect storm" with the happy outcome of really good hearing aids for not much more than the older funkier ones.
The technology around small audio devices, high fidelity, good micro-circuits and batteries has been around for a few years, but the demand has not. Not until recently, that is. With the Baby Boomers finally hitting AARP and MediCare age, there are millions of potential customers for hearing aids that "ain't your fathers hearing aids".
Especially for folks with the most common kind of high-tone hearing loss (more loss at pitches around human speech than at lower pitches), the newer "open-ear" devices are a perfect fit. They are nearly invisible, work well, and don't squeal with feedback even when you use a phone, wear ear protectors, or use a helmet or a hat.
These often cost around $4,000 a pair which is not much above the older clunkier ones. MediCare may cover up to about $500 of this. Make sure the vendor has a reputation for seeing you after the sale for any further fittings and fine adjustments.
I am very impressed that I have had several patients in the past few months absolutely ecstatic over their new hearing aids and the quality of service from their vendors. In fifteen years, I have never heard anyone go on about how happy they were with their hearing aids!
The patients in question had obtained them at All American Hearing in Cameron Park, and the Costco in Folsom. As a disclaimer, I have absolutely no financial ties to either organization and receive no compensation or "kick-backs" from them. (I am, however, a Costco member and am impressed by the quality of the meat and produce selections.)
I have heard every objection to getting hearing aids that there is. Think about it in the same way you would think about LASIK vision correction or a remodel on your home. If the money involved would be worth it in terms of quality (hearing really, really well in this case), then the time to spend that money is when you will be able to enjoy it for a long time. This may also mean while you are still relatively young and still working, since you are still bringing in a paycheck. This is easier than after you retire and are living on a fixed income, and certainly better than waiting until you are so old that you may not get to enjoy them for long.
Hearing what's going on around you, not feeling irritated by having to ask people to repeat themselves and being able to fully enjoy a conversation, a party, music or a dance are not at all over-rated!
70% Percentage of doctor offices dropping EMR within 2 years of buying one
$65 Billion Amount of money being budgeted towards national implementation of EMR
I guess I'm not too hot on the concept of electronic medical records.
As a preamble, let me say that I own several computers, have installed my own wireless networks, enjoy using computers, have tried voice recognition software, and have beta-tested several EMR systems.
Bottom line, they do not save me time or make me more money. In fact, they can cost up to $40,000 to implement and take me longer to document what I do. They do not pay for themselves, and they do not help me to render better medical care than simply keeping and paying attention to a well-organized paper record. Plus, the paper record can still be used even if the power goes out, or the scheduling computer doesn't work.
I also note, that the EMR produced notes from many of my specialist colleagues that are often up to 4-5 pages of not much more useful information than I can get out of one page of well-organized well-written manuscripted notes.
As EMR systems become for comprehensive, they can actually start to make the job harder: for example, not permitting me to list a strong family history of breast cancer on the master Problem List. Like many other features of medical care, a system created by non-doctors and non-nurses may not be particularly effective or easy to use by doctors and nurses.
Also, there is no agreed upon code standards, so none of these expensive systems is capable of interfacing with other systems.
Believe me, I would enthusiastically embrace a system that allowed me to do my work faster, better and more efficiently that was affordable and as universally used as Microsoft Windows. I doesn't yet exist.
Ambien was a hot new drug for sleep back in the early 1990's, and went generic as zolipedem in the last year or so. If you watch TV or read magazines you would have noticed because you have been blitzed with ads for the competion: Ambien CR, Lunesta, Sonata and Rozerem all sound like the greatest thing since sliced bread. At least, they do on TV.
Granted, older sedatives often taken for sleep (such as Valium, Ativan, Restoril, Serax, etc.) create problems because they render you unconscious, not asleep. This is crucially different, since you are losing up to half of the really deep, restorative sleep and dream sleep when you take these. When this happens for over three nights in a row, daytime problems will follow; such as forgetfulness, irritability, tiredness, depression, moodiness or difficulty concentrating.
When Ambien first came out, it seemed to be the best of both worlds: helping people to sleep, but without the loss of deep sleep and dream sleep.
Unfortunately, it may be that Ambien and the other newer sleeping pills may not help you sleep any better, they may just keep you from remembering your sleep. This may be why some people who take it have been seen to cook, eat or even drive at night without remembering doing so.
Basically, people get needed sleep. Insomnia is often a symptom of another problem such as stress, depression, sleep apnea, pain,urinary problems, drinking or long-established bad sleep habits. The treatment then is to treat the underlying problem, not to be drugged into unconsciousness every night.
To make it easier to sleep well,
Go to bed and get up at the same time every day, including weekends, vacations and holidays.
Don't eat or have alcohol or exercise within two hours of bedtime.
Don't watch TV in your bedroom.
If you can't sleep, go to another room and read or listen to some music. Do not watch TV or use your computer! The light from the screens stimulates your brain and wakes you up.
Try taking 2-3 mg of over-the-counter melatonin about 1-2 hours before your bedtime.
Tylenol PM is OK to use for sleep, unless you find that it causes side-effects or makes you feel groggy in the morning.
Methicillin-resistant Staphylococcus aureus(MRSA) simply refers to the development of antibiotic resistance by a common skin bacteria over the last several decades.
"If it bleeds, it leads" news coverage to the contrary, MRSA is not new, not invariably fatal and not incurable or untreatable.
Staph (as Staphylococcus aureus) is commonly known, is one of the common bacteria found in the environment and on any normal, healthy person's skin. Because it is always on your skin, it is one of the most common bacteria to cause skin infection when you get a scrape, cut or some other break in the skin's surface.
Antibiotics used to treat skin infections can lead to the development of antibiotic resistance in surviving strains Staph. Slowly and steadily over the past few decades, strains that resist common antibiotics have become more and more common. This is an expected evolutionary result of antibiotic use.
At this point, MRSA has become a common cause of skin infections. Fortunately, many antibiotics that are inexpensive, safe and generically available work against MRSA (such as Bactrim and Cleocin). This does mean that if doctors suspect MRSA, they may want to use these instead of the usual ones like Keflex or Amoxicillin.
Otherwise, it is not unusual for normal healthy people to spontaneously carry MRSA, and to also spontaneously stop carrying it. Eradication of MRSA from your home and body is technically possible, but really not practical (industrial-strength showers three times a day for a month, anyone?).
"Statins" are the most commonly prescribed cholesterol lowering medications, and have been around since the 1980's. The first four are now available generically, and were originally developed based on naturally occurring plant-based compounds. Lipitor was ground-breaking in the mid-1990's because it was more potent ("stronger") and mainly because it was completely synthetic in origin. Crestor followed in the same manner.
They are called "statins" because the chemical names all end in -statin: lovastatin, atorvostatin, pravastatin, etc., etc.
Concerns about rare but severe side-effects in news and magazines fail to make clear the extent of any risks and benefits in taking statins.
Downsides:
Flatulence (passing gas) is actually the most common side-effect. Not harmful, not associated with diarrhea; just more passing gas. I have, so far, never had anyone stop taking a statin because of this.
Liver injury. Turns out, increased liver function blood tests turn out to be from the effect that lowering your cholesterol has on allowing solidified fats in your liver to dissolve and return to normal. (so called "fatty liver") This is not a toxic effect on your liver. Unfortunately, warnings that go on drug labels rarely ever go off them.
Muscle injury. Actual toxic injury to muscle is rare with statins. Rare as in 10-25 times per 10,000,000 (10 million) prescriptions written. That's 1-2.5 in a million. Your chances of being struck dead by lightning are about 1 in 5,000. Please, let's put that in perspective.
Muscle aching. Here, were talking achiness that is not harmful, and goes away within a few days of stopping the medication. This occurs in about 4% of folks. Mind you, this comes from studies showing 21% of people taking a statin complain of achiness, but 17% of people taking a sugar pill (placebo) do, too. The human mind is a funny thing...
Upsides:
Reduced risk of heart attack or cardiac arrest by about 31-34%.
Similarly reduced risk of stroke.
Reduced risk of Alzheimer's dementia.
Reduced risk of colon cancer.
Reduced risk of osteoporosis.
Short story:
Statins can make you pass gas more often, but can't hurt your liver. Muscle aching is uncommon and actual muscle injury is extremely rare.
They do reduce you risk of heart attack, stroke, Alzheimer's, colon cancer and osteoporosis.
As you may know from prior postings on this subject or as a matter of common knowledge, last January Wal-Mart started offering deep discounts on hundreds of commonly used generic prescription medicines at $4/month or $8/3 months.
As of this January, the following changes have been made:
3-month (90-day) prescriptions are $10.
New prescriptions have been added at $9/month or $24/90 days:
Ventolin HFA, the asthma inhaler
bupropion ER, the equivalent of Zyban for stopping smoking
alendronate/Fosamax, the osteoporosis weekly pill
tamoxifen, the breast cancer chemotherapy pill
several birth control pills
Otherwise, the other medicines are still $4/month.
As previously mentioned, I'm not a big Wally World fan. However, I have to say these prices on hundreds of the most widely used medicines are probably saving lives in a time when lots of folks have to make food/medicines/housing/heating decisions all the time.
The increase from $8 to $10 for 90 days worth is still an unbelievably good deal; particularly with the addition of the aforementioned medicines!
I imagine the reason they continue to offer these discounts is that folks spend an average of $35 whenever they walk in. If you don't want to buy anything else, then don't. But that's a pretty unbeatable deal on medicines if you need them.
I am borrowing this picture from a newspaper article that talked about something I haven't really seen in print as much as I would expect, which is patients having to not see a doctor because of cost or insurance problems.
Patients canceling, re-scheduling or failing to appear for appointments should not surprise anyone in a full year of the worst economic downturn since the Great Depression with no end in sight.
This article touches on some of the decision-making folks have to face, and also some approaches and resources to stay as healthy as possible.
Certainly, if cost is a problem with medications we are prescribing or tests that we order, do not hesitate to ask. (Believe me, you may find it slightly embarrassing, but you're far from alone.).
If you need to re-schedule a physical or visit due to financial problems, just give us a call in advance. If you are unsure whether this is prudent, it's okay to ask.
We want to see you as often as is in keeping with good preventive health care and treatment of emergencies or with chronic medical conditions. However, the world is presently far from perfect, so let us know if you are having difficulties.
Well, we've got a pretty good start to the skiing and boarding season! (To say nothing of some pretty sorely needed precipitation.)
