The Value of Annual Physicals

I am always surprised to read articles questioning the value of annual physicals. (Such as here or here.)

To be sure, no one is questioning the usefulness of appropriate screening tests for diabetes, high cholesterol, high blood pressure or for breast or colon cancer.  The debate usually is around whether a distinct and separate visit purely for such preventive concerns is absolutely necessary.

Theoretically, nothing specifically keeps doctors from ordering some of these preventive tests during a visit for some other specific reason such as a cold or other illness, or for a follow-up visit for ongoing chronic conditions such as diabetes.

However, in reality this is not so easily accomplished.  There may not be adequate time to discuss such tests in an already complex visit (nausea and weight loss in an elderly demented patient, or recent car accident with neck pain, shoulder pain and suture removal needed are mere examples).  Helpful parts of the screening physical examination may not be called for at that time either (for example, listening for cholesterol build-up in the carotid arteries of the neck in a person being seen for hip and knee pain).

Also, some tests require more time, information or examination.  A normal mammogram is not reassuring if there is actually a breast lump that would be noted on a physical examination.  An acceptable cholesterol result is different for someone with a strong family history of heart disease or stroke than for someone else.

I, and many other doctors, find that the only way to make sure that adequate time and care can be given to the entire range preventive care is to arrange a visit dedicated to this purpose- the annual physical.  I think the fact that people are living longer and having fewer heart attacks and strokes suggests we're on the right track in doing so.

Over the past few years, more and more of my professional time is being spent on issues, concerns or problems that seem to be related to or caused by patients' stress.  I guess I'm not exactly surprised since I see a lot of older patients on fixed incomes, military families with household members on deployments and I practice in an area with a 12% or greater unemployment rate.

Certainly, this can be frustrating as it makes it increasingly difficult to stay on time (never my strong point, I admit), but even more so because I real feel for folks who are just flat out telling me they are physically and emotionally overwhelmed by stress related to financial, employment, medical or family problems or all of the above.

Increasingly, I am coming to view this as part of a big picture with no obvious solution in sight.

Growing up in a strong union heavy manufacturing town (Pittsburgh, PA), I remember what "speed-ups" were about.  This was a short-term increase in work hours that was agreed to by the union in order to complete a big job order for the benefit of both the workers and the company.  Lately, with everyone scrambling like hell to get the same amount of work done by fewer people the whole economy feels like a giant, permanent speed-up.

Added to this is a sense that no matter how hard you work, it's impossible to excel in your work without sacrificing your family life.  Or, vice versa.

Time War is now being coined to describe the conditions over the past 20 or so years that are leaving us all in a sense of continual uncertainty, instability and anxiety for the future.  A bit like the Red Queen in Alice in Wonderland: running as fast as you can just to not fall behind, plus the potential to just sink without a ripple.

As a doctor, I'm also affected by the same forces at play, but a lot less so than many and grateful of it.  Also, I've never been so happy to be self-employed.  At the same time, I agree with the authors of this article that there is a tremendous rush for a quick fix just to cope, just to "take the edge off".  This ranges from antibiotics for viral infections to sleeping pills for what often amounts to overwork.  Agreed: why is everyone on Ambien?

Solution? Hope for the future?  IMHO, I'd be happy to see it agreed that the new "full-time" is 25-30 hours a week.  This seems like a reasonable way for people to have gainful employ and a family life. Companies may have to hire more people to get current workloads accomplished, but that seems reasonable and would certainly employ more people (many of them skilled).  A change in work and/or public school hours would be great, since it's tough to raise children if their pre-school or public school hours are vastly different than work hours.  I see nothing wrong or prohibitive about matching work and school schedules more closely.

In the mean time, healthy ways of reducing or coping with stress include realizing what really makes your life worthwhile, and not stressing over the rest.

Some New Developments in Weight Loss

As you might expect, there is a lot of ongoing study on what causes obesity and how people can successfully reduce total body weight.  Particularly, there is a lot of interest in the role of certain hormones (leptin, for example) in regulating appetite and fat metabolism.

Overall, humans are very well evolved and adapted to be able to withstand famine.  This is a good thing if you get lost in the woods, but in normal day to day life, it can make it challenging to maintain a healthy body  weight.

In the last month or two, several interesting things have come out.

First off, is the confirmation based on large studies that food journals work.  This is not surprising in many respects since keeping a daily record of what you eat and how many calories it amounts to would be very helpful in staying within a calorie budget and also seeing where the most effective improvements could be made.

The problem historically has been that keeping a food journal has been really tedious: booklets, paper records, calculators and so forth.  Admittedly this is also tough to even get started with if you are worried that you are going to see "too much information".

Happily, the Internet can help with this.  Free applications are now widely available which allow you to state your gender, height and current weight, and then develop a daily calorie budget based
on how much you would like to weigh and over what amount of time.

The concept of a calorie budget refers to a daily net calorie intake that should allow you to succeed, based on calories eaten minus calories burned off.

Lose It! and myfitnesspal are both web-based applications that allow you to select from a large variety of fresh and pre-prepared and restaurant foods, and an extensive variety of activities and exercises.  Both of these are free, and both are available as free iPhone and Android apps as well.  Personally, I like Lose It! because it has an exhaustive list of exercises and activities including household walking, vacuuming, housecleaning and about ten different levels of yardwork as well as athletic activities ranging from running to archery to skiing.  My wife prefers myfitnesspal because it has a better selection of fresh foods and scratch meals.

For those of you who find daily fixed work-outs a bit boring, Sworkit is a pretty cool circuit training application that allows you to set up and follow a series of exercises from 5 to 60 minutes  focused on specific body areas or whole body.  It allows you to vary your work-out day to day, and even includes yoga sequences and core strengthening!  This is also available as an iPhone app (I don't happen to know if it's also in the Android Market).

Another big study seems to link low-carb diets with being helpful and keeping weight you've lost from coming back.  (Atkins had a point after all?) Lots of people have had the frustrating experience of working hard to lose weight, and then have it come back over the next months even though they are continuing to diet and exercise regularly.  Apparently, decreasing calorie intake and increasing activity and exercise helps to reduce weight, but your body quickly responds by reducing metabolic rate.  This means your body burns off calories at a lower rate and stores more of it as fat even though you are not doing anything differently.  The study looked at diets where 60%, 40% or 20% of the dietary calories came from carbs and found that the 20% calories as carbs diet was the best at keeping the weight off.  This seems to work by countering the aforementioned down-regulation in metabolic rate. Interestingly, fat intake was not restricted in this study.  The  weight loss apps I described above could also allow you to regulate carb intake for both weight loss and weight maintenance purposes.

Last, but not least, one of three new drugs in the pipeline recently obtained final FDA approval.  Qnexa is actually a combination of low doses of two already existing generically available drugs, phentermine and topiramate.

Phentermine has been used as an appetite suppressant for decades.  Topiramate started as a drug to prevent seizures, has also been found to be highly effective at preventing migraines and its most common side effect has been weight loss.

Please do not hesitate to ask about healthy weight reduction: I am very happy to discuss it and am delighted to see patients succeed in their efforts and also reduce their need for medicines for high blood pressure, heartburn or joint pain!

Interesting Reads

• The Economix blog of the New York Times on the problems with both "trickle-down" and "trickle-up" economics. (Hint: in balance, the money stays where it's accrued.)
• Boing Boing with a story of cow-related fatalities and how it reflects on the way we assess risk. (Why are we afraid of sharks and air travel, when cows and driving your car are clearly so much more dangerous?)
• Xeni Jardin, a blogger under treatment for breast cancer on science-based cancer treatment versus quackery.

Lyme Disease

Hot weather is indeed upon us. It's the season for brush clearing, outdoor activities and also for potential exposure to Lyme Disease.

Fortunately, Lyme Disease is not nearly as common in California as it is in New England and the upper Midwest. Also, even within California it is not very common in El Dorado county. In fact, it only has occurred in 0.9 in 100,000 people in El Dorado county from 2002-2011.

While there are plenty of deer and plenty of deer ticks here, it seems that the Western Fence Lizard helps to keep Lyme Disease itself from being as common as it otherwise could be.  Ticks bite these lizards, but there seems to be something in the lizards' bloodstream that then goes on to kill of the Lyme Disease-causing bacteria in both the lizard and in the tick!

Within El Dorado County, the areas where it is most commonly seen is above Ice House and around Folsom Lake and El Dorado Hills.

It is worth bearing in mind that most Lyme Disease exposures occur in March and April, mainly because that is when the nymph or immature ticks are born. They are the main vector of Lyme Disease in humans.  The nymph is on the right in the photograph: note the significant size difference compared to the adult on the left!

 The best ways to avoid tick bites are:

• Wear shoes, socks, and long pants especially when you are hiking or brush-clearing.
• Wear light colored clothing: it makes ticks easier to see.
• Don't allow leaf litter to accumulate in "border zone" areas of trees near your home: ticks like to live and breed there.

Removing a tick is straightforward.  Use some tweezers to grab the tick as close to your skin as possible.  Pull the tick firmly and straight out.  (Jerking or twisting the tick can cause you to tear off its body, leaving its head still embedded in your skin.  Do not burn or apply noxious substances to the tick; you can injure yourself, and also cause the tick to regurgitate into your bloodstream which is not good.)

Once you have removed the tick, wash your hands and the bite site with soap and water and apply an antiseptic to the bite site.

Please see us if:

• You can't remove the tick, or its head is still embedded.
• You develop a flu-like illness or rash within a month or so of a bite.

Another word on "Obamacare"

I posted the other day on so-called "Obamacare" otherwise known as the Affordable Care Act.

By coincidence, Lifehacker posted on the subject in the form of a concise Q&A which is rather more approachable than my posting.  While I don't agree with all the replies, the comment thread is at least interesting and civilized.

On "ObamaCare"

With the Affordable Care Act ("ObamaCare", as it is also referred to in the news media) back in the news cycle, I have been asked several times a day what I think of it, or how it is affecting me.

So far, I have no sort of problem with it.

• It has improved "doughnut hole" coverage for MediCare patients with Part D plans (medication coverage).  This has been good because I have a lot of MediCare patients and accept new MediCare patients. They are all on fixed incomes, and this has helped to ease the burden of their medication costs.
• It has allowed 18 year olds to stay on their parents' insurance until 26 years old, whether they are in college or employed or not.  This has been very helpful, since the job market out there for people in this age range is very poor.  I can now see these patients in my office, as opposed to them hitting the ER in crisis mode, which is more dire and more expensive to everyone.
• The SCOTUS has ruled in favor of the requirement for all citizens to carry health insurance.  Whether you wish to regard this as a mandate or a tax is irrelevant.  Simple math demonstrates that insurance systems that allow people to opt out will fail.  This is apolitical and simply due to human behavior.  In a system where people can opt out of health insurance, the ones who will carry it are predominantly people with existing conditions (which are expensive).  People without health conditions often opt out.  When they become ill or need care, the cost of their care is then assumed by the taxpayers. In the mean time, the insurance companies have to levy higher premiums because of the disproportionately high percentage of people they cover who are expensive to cover.  This makes relatively healthy people disinclined to carry insurance because of its cost.  And so on, and so on...
• Yes, this assumes that uninsured people needing medical care will nevertheless receive medical care.  That is going to remain the case unless we all accept the idea that doctors and paramedics and nurses are not morally or ethically (let alone legally) required to render care.  Aside from the fact that this would be contrary to the Hippocratic Oath, we should not really want medical professionals to be able to refuse care on the basis of risk that it will not be profitable!
• I received $600 in reimbursement for this year as a small business owner who has provided medical insurance to my employees.  I imagine other small business owners who insure their employees are OK with this, too.  I'm comfortable with this.  Now, if I can also get reimbursement because I also offer dental coverage and retirement...
• I can't see that requiring states to create single websites that make it easy for consumers to comparison shop for health insurance is any problem.  Sounds like Google Shopper or Amazon to me, and insurance companies certainly aren't making it easy to compare coverages and prices on their own.  Hopefully, this will eventually work into a way for individuals and small businesses to combine into larger shared insurance pools, since the premium costs would be much lower.
• Requiring insurances to provide birth control?  Can't see why that's even controversial: undesired pregnancy is expensive to everyone, and there is no requirement of women to take any form of birth control here.
• Insurance companies can no longer refuse to insure you because of already existing medical conditions or pregnancy, and they can no longer look for ways to drop you if you develop a medical condition.  Can't say I see any problem here either, since these behaviors have been scandalous and, in the latter case, illegal and unethical.
• Insurance companies must spend a certain proportion of their expenses on actual medical care.  That would be nice; it's what they're supposed to be doing. Perhaps it will incentivize them to make administration more efficient.  Right now, over 30% of US medical costs are administration and paperwork.

As stated in earlier postings, I welcome any attempt to improve the delivery of medical care in our country which until now is the 47th best in the world, while outspending the top 10 by 300% per capita and committing the most medical errors of the top 19 world economies.  Frankly, I would have preferred an approach like Germany which has a cradle-to-grave basic entitlement insurance and a very active, competitive and strongly regulated commercial insurance industry where anyone can buy as much (or as little) additional health insurance as they wish.

The only things missing or under-utilized in the Affordable Care Act are critical elements that are present in objectively and measurably better healthcare systems; federal regulation of insurance companies, and government-sponsored medical treatment and device testing.  These were discussed, but went largely off the table due to cries of "big government" and "socialism".

I think Germany's approach is sound here: the German government does not permit insurance companies to raise annual premiums by more than 5-6%/year unless they can prove that the increase is warranted due to actuarial costs.  This keeps them from simply increasing premiums for pure profit motives. The lack of this regulatory oversight in the US could result in insurance companies increasing their premiums to defray the costs of changes required by the ACA.

Clearly, it is not good to have a medical research system as we do in the US in which the majority of medical research is funded by drug companies.  It is certainly known that drug companies only fund applied studies that might be to their benefit, and do not publish studies that result in unfavorable findings.  Nor would one expect a publicly traded for-profit corporation to do otherwise. I do not object to drug company sponsored research, but I think it is the role of federal government to fund or perform academic research, and also studies of head-to-head comparisons of different drugs or treatments and to make the findings widely known to doctors and patients.  It is telling that one of the largest US insurance companies (United) routinely sends its doctors such study findings based on UK research and not US research for exactly this reason.

At the individual level, the Obama administration's concerns for primary care doctors and especially rural ones has resulted in a satisfying increase in MediCare payments which I think is only right since rural primary care doctors have been historically the most lowly paid of all doctors in the US.

Have a great weekend!