News on the MediCare front

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

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!

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)

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

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

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

We've all seen the U.S. News and World Report 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

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

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

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

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

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

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

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?

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

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

'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

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

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

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

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.

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

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

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 argue that clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test.

Health Care Reform

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

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

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

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?

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

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

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

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

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?

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

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!