Merry Christmas, Happy Holidays and a great New Year for all!

My Christmas wish list to Santa:

• Global energy independence from fossil fuels and nuclear energy over the next 20 years using existing capital, real estate and technologies.  Sounds like a great public works project that would employ a lot of laborers, construction workers and engineers.
• The tech sector should start realizing their job is often to put other people out of jobs.
• National legalization of marijuana: tax and regulate it, and spend the money we spend on criminalizing it on something more useful.  Like Pat Robertson says.
• An end of poverty: a universal basic income equivalent to poverty line income, no strings attached, funded by a combination of a household carbon tax of no more than $100/year and   de-funding organizations helping those in poverty (because no one would techinically qualify anymore).  See reasoned discussions from those flaming commies at Business Insider and Forbes Magazine.

For all of us who's celebration no longer includes family or friends who are no longer with us, may you please find love and hope this season and be consoled that they are not forgotten.

So, what do you think about "Obamacare"?

I got asked this a lot when the Affordable Care Act (a/k/a "Obamacare") got passed, and I'm asked that a lot with the rollout of insurance markets.  I gotta say, my viewpoints on this are complicated.  

For one thing, I have from the beginning been in entire agreement with former Secretary of State Colin Powell that we should have a single-payer health insurance like all the other industrialized countries in the G20.  Yes, that means taxpayer money is spent on providing a basic health insurance from cradle to grave for all US citizens: MediCare for All, if you will. I'd certainly prefer this over a series of "tweaks" that fully involved drug companies and insurance companies in the decision making.  I don't see any of those monied interests allowing a solution that would impact their revenue stream.

Is this a real departure from the status quo? Yes. Why do it?  Because all the other industrialized countries are successfully doing so, with longer life expectancies than the US, lower medical error rates, and at 1/3 of what we pay per capita. (Feel free to see earlier posts for links on these figures.)  I happen to like Germany's system as a model.  The German government provides a basic insurance from birth.  If you want and can afford more extensive insurance, you can buy all you want from the very active and competitive private insurance companies.  If you don't want to, you don't have to but at least you're not a hospitalization or accident away from personal bankruptcy. 

What keeps the insurance companies in line is  that annual increases in premiums of over 6% per annum are not permitted unless the insurance company can prove to the government that it is necessary due to medical costs incurred and not just profit motive. 

What keeps doctors and hospitals in line is that the government routinely does comparison tests head-to-head of medicines, surgeries and devices and then publicizes the results so everyone involved knows what works and what doesn't.

Sounds good to me: I've never heard anyone characterize the German government as being soft-headed or given to wild over-spending.

Otherwise, I have to admit that Covered California (California's insurance website) is pretty impressive.  It runs smoothly and the rates offered look very attractive and the tax credits for individuals or small businesses are generous and not just for the wealthiest or most impoverished but really benefit middle class individuals and businesses with fewer than 25 employees.

I agree with requiring health insurance of all citizens.  Just simple math here: insurance risk pools fail if "healthy" people can opt out but everyone still has to pay if they get sick or hurt.  Arguing that you shouldn't have to carry insurance because you won't get sick is like saying you won't wear seat belts because you've never been in an accident.

On the other hand, my biggest concern with "Obamacare" is its underlying assumption that bigger and more centralized has to be better.  This is my principle objection to other trends in government, services and business.  The ability to shop Amazon from your smartphone and receive your goods two days later at prices lower than in your town is all very well and good (unless you have a small business in your town), but applying this model and philosophy to everything as a default model to every complex system is flawed.

The widespread application of computers, robots and out-sourcing has, in my opinion, resulted in a massive and tacitly accepted exchange of more expensive but higher quality for cheaper and good-enough.  Remember when you could buy a tool or appliance that you'd hand down to your kids?  Bought anything that good lately?

Many aspects of the Affordable Care Act incentivize doctors and hospitals to coalesce into larger more centralized organizations under the assumption that this will reduce costs and improve the quality of medical care.  In my experience, sometimes this helps, and other times it doesn't.

However, to seek to change the great majority of medical care in the US to a smaller number of much larger and centrally controlled organizations is to risk losing its personal qualities.  What do people like about Kaiser?  Everything under one roof: see mid-level, draw blood, pick up medications all in one visit to one place.  What do people not like about Kaiser?  Never see same doctor, doctors rushing to see patients in 8 minutes, hard to get to see specialists.

I happen to believe that the practice of medicine has a deeply and inherently personal quality to it.  It takes time to ask enough questions to arrive at a correct diagnosis.  It takes time to build a trusting, respectful relationship that is mutual between patient and doctor.  I think and see that it does matter that the doctor who sees you in the hospital already knows you well as a patient and as a person.

So, I guess what I think about "Obamacare" is that it is at least a reasoned and good-faith effort to fix something that is really in need of improving.  However, the long term impact is going to make medicine more like corporate businesses: bigger with more "economies of scale" (uck) that will provide medical care in a way that is less expensive, possibly more efficient (depending on how that's defined) but increasingly impersonal and detached.

Happy Hallowe'en!

• Why it's probably okay to let your kids eat lots of Hallowe'en candy 
•  Pictures of people freakin' out in a haunted house.
• .Fourth annual Evil Week on Lifehacker.

Spider Bites

I agree with this article on spider bites, particularly in California.

Happily for us, brown recluse spiders are native to the Southeast US.  For us on the other side of North America, this means a bite from this highly venomous spider is not going to happen unless the spider arrived in some furniture being moved from the South.  Admittedly, this has been known to happen- it's just that this is not normally brown recluse territory.

Black widow spiders have a more powerful venom than other local spiders, but they are not roamers.  They build webs in secluded areas and wait for insects to get caught it the web.  The best way to avoid black widow bites is to avoid putting your hands or feet where you can't see them (such as when you are moving a wood pile, cleaning a shed, remodeling a basement...)  That being said, black widow venom is fairly powerful and can in some cases cause tissue break-down and infection requiring antibiotics.  On the other hand, if you are bitten by one, you're going to notice it!  This is not one of those cases where you just wake up with a tender red bump.

Smaller spiders are just not that venomous around here.  If you happen to roll over one in your sleep, they can bite hard enough to break skin but their venom is not going to cause serious tissue damage.  Mind you, any break in the surface of your skin  can cause infection, but generally keeping the break clean with soap and water, and protected with Neosporin and a bandage is your best means of preventing infection from occurring.

What's an HMO and what's a PPO?

These are both forms of health insurance that are popular in the U.S.  PPO's (preferred provider organizations) have been around the longest.  HMO's (health maintenance organizations) were first developed in the 1980's, went out of favor for a while, and are back on an upswing due to the economic recession.

PPO's are the more traditional insurance which is provided by a company (such as Blue Shield, HealthNet, Anthem/Blue Cross and so on), and it is typically paid for by your employer with costs to you in terms of deductibles and co-payments.  The PPO is made up of doctors and offices and hospitals that are willing to take your insurance and have a contract with your insurance company.  When doctors who accept your insurance see you, they send a claim (or bill) to your insurance.  If your insurance allows it, you may at some point later get a bill from the doctor, lab or hospital for the balance of what they billed but your insurance didn't cover.  Mind you, some insurances do not permit such "balance billing".

In other words, in a PPO your doctor gets reimbursed to treat you and does not get reimbursed to not treat you.  It therefore means that PPO doctors have an incentive to do the most they can to keep you healthy and also happy with the office and your care.  Admittedly, there is an element of trust that when your PPO doctor wants to see you back or get some tests done, it is in your best interest and not because it's profitable.

HMO's were invented in the 1980's as an alternative designed to reduce costs of health insurance.  Insurance companies offer doctors "capitation" contracts.  In such an agreement, instead of a doctor agreeing to accept certain amounts of money for certain services provided, the agreement is to accept a certain amount of money every month for every HMO member who has selected him or her as their primary doctor (PMPM = per member/per month).

HMO's take a variety of forms.  In some, they are almost like socialized medicine insofar as the health insurer directly employs all the doctors and owns all the facilities.  Kaiser is an example of this.  In others, the HMO is a collection of doctors, groups and hospitals willing to accept capitated payment contracts.  Western Health Advantage and Anthem/Blue Cross HMO are examples of this.

In any of these forms, the HMO offers real trade-offs compared to traditional PPO's.  HMO's are usually a bit cheaper in terms of monthly premiums and also in terms of exposure to deductibles and co-payments.  On the other hand, you are required to receive your care from a restricted panel of doctors and hospitals and there is no option to receive care outside the HMO.  To be sure, seeing a doctor not in your PPO costs you more money, but it is an option which is helpful when you need a second opinion or a surgery that is not performed at your local or preferred hospital.

From the doctors' point of view, HMO's are radically different from PPO's.  The actuarial risk; the risk of losing money on sick patients requiring expensive care, is on the insurance company in a PPO.  If they take on a lot of sick people, or pay too much to doctors, or run their business poorly they lose money.  In an HMO, that financial risk is now taken on by the doctor.  If the doctor takes on too few HMO patients, a few HMO patients getting sick can cause the doctor to lose money.  In order to hedge against this, the doctor has to take on a LOT of HMO patients.  Remember, in an HMO the doctor is paid monthly to be your primary doctor even if the two of you have never met!

This shift in who carries  the financial risk has some impacts that are important to the patient.  In an HMO, the element of trust now is that if the doctor does not need to see you, it is in your best interest and not because seeing you causes your doctor to lose money.  Also, it shifts the party who is most concerned about the money from the provider of your health insurance to the provider of your actual health care.  I would not go so far as to say this is immoral, but it does require patients to be aware of and comfortable with this arrangement and its implications.

In short, PPO's are usually more expensive, but optimize choice on the part of the patient as to where they can go.  They also do not require you to go to your primary doctor to get to a specialist, unless you prefer to or the specialist happens to prefer it.

In comparison, HMO's are often cheaper, but you are fully limited to being able to see only the doctors or hospitals in the HMO.  You must see your primary care doctor in order to be referred to a specialist.

In a PPO, the financial risk is on the insurance company.  Since your doctors only gets paid to see you, you are trusting that they are not over-seeing or over-testing you in order to make money.

By contrast, in an HMO, the financial risk is on doctors.  Since your doctor gets paid every month for having you as a patient even if you have never met, you are trusting that your doctors are not under-treating you to save money.

Personally, I have trained or worked in both HMO's and PPO's, and I have had both kinds as my insurance.  I definitely prefer PPO's for their focus on choices provided to me and my family. 

I mistrust HMO's because I know that the doctors who work in them are under an enormous amount or pressure to take on large numbers of patients to make the HMO arrangement financially viable to them.

Long story short, you get what you pay for with health insurance!

MediCare Open Enrollment is now until 12/7/13

As many of you recollect, the opportunity to shop for or consider changing MediCare Part D coverage is every year at this time, from mid-October until December 7th.

For those of you who are new to MediCare, a bit of back story.

MediCare is a federal entitlement program written into legislation by the Johnson ("LBJ") adminstration, in response to commercial insurance companies dropping coverage of seniors due to their likelihood of needing medical care or treatment.  Part A covers hospital based (inpatient) expenses such as surgery and hospitalization.  Part B covers office  based (outpatient) care such as doctor visits, labs or XRays.

Part D was enacted during the George W. Bush administration to help to provide MediCare coverage of prescription drugs: until then, it was cash-and-carry unless you had pension benefits that provided such coverage.  Part of the Affordable Care Act under the Obama administration involves reducing the so-called "donut hole".  This is an amount of money you have to pony up if you spend a lot of money on medications before the end of the calendar year.  The donut hole will gradually close to zero over the next decade.

This Medicare Plan Finder link allows you to start comparison shopping Part D plans starting with your zip code so that you are only looking at plans offered where you live.  You can also (if you want to) search out plans that cover the medicines you take by entering each medicine by name.  If you want, you can also narrow the search to specific amounts you want for premiums, by strength of patient reviews and a number of other factors.  :You can then examine all the plans that fit your selection criteria and check them out further if you like.  You can also enroll from this site.

All in all, selecting a Part D plan or deciding whether you want to change yours or not is made pretty straightforward and the format is not much different than shopping on Amazon.

A few tips:

• Medicare has nothing to do with Covered California which is an online insurance market under the Affordable Care Act for California for people not on Medicare.
• If a medicine you take doesn't seem to be covered, see if other medicines that are in the same class are.  Medicines in the same class work the same way, and can generally be substituted without any problems.
• Most drugs are generically available.  Only 10% of new drugs are really a new kind, or superior to older less expensive drugs of the same class.  Don't let cost get in the way without asking us if you have lower cost options to choose from.
• These tips are especially important if you use inhalers or injectable medicines since they are often very expensive.

Secure Horizons HMO Part D plan has gotten much smoother to work with over the last two years, so we are accepting it as a Part D plan.  Specialist offices have also gotten a lot smoother at working with them which makes this a much better option than when it first rolled out.

Please don't hesitate to ask if we can help you!

Effects of the Government Shutdown on Medical Care

In the event you were wondering what effect the "government shutdown" has on US medical care, the New England Journal of Medicine (not known as a hotbed of knee-jerk hysteria) informs us that at this time:

Regular inspections and lab research by the FDA (Food and Drug Administration) are on hold.  Emergency work involving human safety (high-risk drug recalls and law enforcement) are ongoing.

CDC (Centers for Disease Control)  tracking of infectious diseases including flu is on hold.

CDC publication of a weekly bulletin advising doctors of medical and infectious disease trends or developments (Morbidity and Mortality Weekly Report) is on hold.

NIH (National Institutes of Health) enrollment of new patients for ongoing clinical trials is on hold.  Yes, this includes children in pediatric cancer studies.

Federally administered health insurance marketplaces under the Affordable Care Act are not affected, as they rely on different funding sources.  The reason some of them appeared to be unresponsive was due to the large numbers of people using them.

California Affordable Care Act insurance marketplace is up and running on schedule!

As of this morning, websites for state-based health insurance comparison shopping are operational.

The Patient Protection and Affordable Care Act, ACA for short, (or "Obamacare" or "Romneycare version 2.0" if you wish) to date has:
-made it illegal for your health insurance to refuse to continue to insure you if you become ill
-required your health insurance to allow you to keep your children on your policy until they are 26
-made it illegal for insurance companies to refuse to cover you because of pre-existing medical       conditions
-provided rebates to employers who already provide health plans
-has reduced the Part D drug coverage "donut hole"(this will be gradually reduced to zero by 2020)

Regardless of one's political leanings, I have yet to talk with a patient who didn't think these were good ideas.  And hey, Congress passed the ACA and it was signed into law by the President.

The next stage has involved states (or the Federal government, if a state declines providing patients and small businesses (50 or fewer employees) with a single website that allows them to compare coverage and pricing for more affordable health insurance with coverage of outpatient care, hospital care, surgery, preventive care, and healthcare of pregnancy, newborns and children.

And now, it's here.  In California, the program is called Covered California.  Check it out for yourself.  Even if you already have insurance through work, it's nice to comparison shop.  I'm already pleasantly surprised that the cost of insuring my family through Covered California with Blue Shield compares very favorably to the Blue Shield I provide at my office.  My next step will be to see whether I can come up with a small business plan for my office that's better than what I currently have.

Mind you, if you already have insurance you are perfectly happy with, "Obamacare" doesn't affect you.  On the other hand, if you have no insurance or aren't happy with what you've got this may be the solution to your problem.

We are contracted with Covered California Blue Cross and Blue Shield.

We are optimistic about the potential for this program to keep people with no insurance or really high deductible plans from falling through the cracks.

Not All Medicines Are Created Equal

When doctors refer to a "class" of medications or drugs, we are referring to a group of drugs that are chemically similar (but not identical), that are used to treat the same conditions, and work the same way (so-called mechanism of action).

Often, medical studies showing some benefit or risk of a single drug are understood to mean that this benefit or risk may or may not accrue to every other drug in its class.

As more study and research occurs, we are coming to realize that in some cases different drugs in the same class can vary significantly in terms of their effectiveness or safety.

For example, Avandia (a diabetes drug) was taken off the market by the FDA several years ago due to heart disease risks with the drug.  Actos (in the same drug class) was not.

Just a few years ago, head-to-head tests showed that two of the SSRI's (serotonin-specific re-uptake inhibitors, commonly used in the treatment of depression and anxiety) were both more effective and lower in side-effects than the others.  Those two are Zoloft/sertraline and Lexapro/escitalopram.

More recently, we find that while the statins are all effective in lowering cholesterol and preventing heart attacks and strokes, two of them are particularly lower in side-effects and drug reactions.  These two are Pravachol/pravastatin and Zocor/simvastatin (in doses of 40 mg a day, or less).

On the positive side, the so-called ACE inhibitors (a class of blood pressure lowering drugs that are particularly beneficial in diabetics) are known to prevent heart attacks and strokes.  Additionally, several are also seen to reduce your risk of memory loss and Alzheimer's dementia due to there ability to positively affect circulation in the brain.  These are Altace/ramapril, Tarka/trandolapril, Capoten/captopril, fosinopril, and Zestril/lisinopril.

Immunizations (or, shots)

Retail pharmacies are already providing annual flu shots.  There is no shortage, so no need to hurry.  Getting a flu shot before late November can help to prevent getting the flu, or giving it to others.

Many retailers also offer pneumonia immunizations.  These are covered once in your life under MediCare and prevent the one kind of bacterial pneumonia that is the most common single kind and also the most deadly.  It doesn't keep you from getting colds or every possible kind of pneumonia, but it does protect you against the worst one!

Shingles shots are also once in your lifetime and covered by MediCare.  Shingles comes about from having had chicken pox as a child.  I think ads on TV make shingles out to far more severe than it is for most folks, but on the other hand it's not something you'd like to get if you could avoid it.  If you've never had chicken pox, then you should definitely get the shingles shot since it will act as immunization against getting chicken pox as an adult, which is a very serious and unpleasant problem.

Preventing Dizziness When You Get Up Quickly

Getting dizzy and light-headed when you stand up quickly is not unusual, but it can be a serious problem if it is bad enough to cause falls or injuries or loss of consciousness (syncope).

The problem is referred to as orthostatic or postural hypotension.  This means your blood pressure drops when you get up after being seated or laying down for some time.  This is similar to the occasional news story of kids at a parade or soldiers at boot camp passing out after they've been standing and not moving for a long time.  In fact, anyone will black out if they can't or don't move for a long enough period of time.

Please be aware that an actual sense of spinning is called vertigo, and is really an entirely different problem with different causes for the symptoms.

Your heart pumps blood out under pressure in your arteries to get blood all the way out to your hands and feet, and uphill against gravity to get to your brain.  This is the blood pressure we measure when you come to the office, or that you measure for yourself with an automated blood pressure cuff.  On the other hand, the blood getting back to your heart in your veins is under very little pressure and relies on you using your leg muscles to squeeze the veins in your legs, forcing blood up and back to your heart.

So if you've been asleep or laying down for a while, or sitting using a computer or watching TV for some time, 2-3 units of blood can "pool in your legs" as this blood is not being actively returned to your heart because you're not using your legs.  Generally, as you get up and start walking, this blood gets pumped back into circulation by you using your leg muscles.  However, under some circumstances this mechanism may not work properly, and then you get really dizzy and light-headed when you get up too quickly.  If you actually pass out, then your head gets to the same level as your heart, and blood flow to your brain is restored and you wake up.  This is why you can only donate one unit of blood at a time!

Things that can make this problem worse include dehydration, illness, medication side-effects, Parkinson's disease and aging.

If you are experiencing this problem, please let us know.  If you are concerned that it is due to medications, definitely let us know!

You can help to prevent this dizziness by flexing your leg muscles several times before you stand up.  If your balance when sitting is not so good, flexing your leg muscles when you are laying down in bed also helps!

Sunscreen's Best Kept Secret

Sunscreen is important in preventing eventual development of skin cancers from accumulated sun exposure to your skin over the years.

However, applying it daily can also prevent aging and wrinkling of your skin even if you don't plan on going outside.  An Australian medical study demonstrated that daily application of SPF 15 sunscreen year 'round in patients up to 55 years old helped to prevent sun-damaged wrinkling of the skin and led to younger looking skin by *cough* middle age!

New Study on Gun Violence

The Centers for Disease Control (CDC) was asked after the shooting at Sandy Hook Elementary School to review existing studies on guns and violence carried out with guns.

They have now published the results and made them available to the public.  The report brief is available as a pdf or html document.

The brief is worth a read for anyone interested in looking past the politically charged exchanges to see what the facts actually show.  Interestingly, the findings have just as much in them to appeal to gun control advocates as they do to the NRA.  Slate magazine does a pretty good job of summing up the high points.

Biggest news of the Summer!

Annals of Internal Medicine published an Australian medical study involving 900 middle-aged adults up to 55 years old (average age was 39) over a 4.5 year period of time to test the effects of sunscreen on slowing aging of the skin due to sun exposure.

People who applied SPF 15 sunscreen every day had significantly less wrinkling and aging of the skin.

This is important, since sun related wrinkling of the skin is related to risk for skin cancer.

It's also great news because the bottom line is:

PUT SOME SPF 15 SUNSCREEN ON EVERY DAY (WHETHER SUMMER OR NOT, GOING OUT OR NOT) AND YOUR SKIN WILL LOOK YOUNGER!

Drowning Doesn't Look Like Drowning (as seen on TV)

Slate has an excellent article to check out as we are fully in to Summer and school is out.

Many of us picture a drowning person as seen on TV or movies: arms thrashing, gurgling and yelling for help.  In reality, drowning is typically a very quiet affair.  It is sobering that over half of drownings happen within 25 yards of parents or other responsible adults.

Please read this article for how you can effectively recognize a drowning person so that you can help effectively.

One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.

Chronic Strains

We are realizing that chronic strains, sprains and tendinitis ("pulled ligaments") are different than acute ones, and respond differently to different kinds of treatment.

Common examples of these include strains of the forearm tendons ("tennis elbow"), the ligament below the kneecap, or subpatellar tendon ("jumper's knee) and shoulder or rotator cuff strains ("pitcher's shoulder").  By acute, we mean new.  By chronic, we mean that the pain has been going on for 6-8 weeks or longer.

When you overwork or suddenly strain a tendon, tendon fibers are actually torn and damaged at a microscopic level.  (Injuries in which the tendon is actually torn through or completely ruptured would be a totally different discussion.)  Your body responds to this injury by increasing blood flow to the area to prevent infection and by shortening the muscle and tendon ("spasming") to prevent further injury.

This is why when an injury is new, it helps to put ice on it (this reduces blood flow to the area, and thus reduces swelling and inflammation) and to take anti-inflammatory pain relievers such as ibuprofen or naproxen (because they reduce pain, and also reduce inflammation which  causes pain).  Avoiding painful activity also helps here, because you are allowing the injured area to rest and heal.

On the other hand (sorry, no pun), when the pain has been present for over 6-8 weeks, it turns out that this model is no longer accurate.

We used to think that this was how tendinitis worked all the way through its course.  However, it turns out that as time goes on, inflammation and swelling  are replaced by separation of collagen or connective tissue fibers and development of new blood vessels (neovascularization).  This explains why you can reach a point where anti-inflammatory pain medicines, cortisone injections and surgeries no longer help to relieve the pain.

Happily, this is where physical therapy really comes into its own.  A professional physical therapist can help you to re-stretch the injured tendons and re-strengthen muscles that support it.  While it's more time consuming than taking pills or getting a shot, it works better than any other treatment including surgery for tendon strains of over 6-8 weeks in duration.

We are very fortunate here to have plenty of highly skilled and effective physical therapists in a wide variety of locations near most people's home or work.

So, bear in mind that if your strained your shoulder or your elbow and it won't seem to go away and medication stopped helping, it may be time to re-assess the situation and consider getting a physical therapist involved in getting you back  to form!

Re-thinking some of the cholesterol drugs

When you get your cholesterol tested (a full fasting lipid panel), you are getting a lab test for several sorts of naturally produced complex chemicals that affect your health, and your risk of having a heart attack or a stroke.

Most of the cholesterols in your blood are actually produced by your liver.  Ultimately, they are used to make certain sorts of hormones and also the myelin sheath of your nerve cells which seems to act as a natural insulation.

When we look at your total cholesterol, we are mainly interested in two kinds: the LDL (low-density  lipoproteins) or "bad cholesterol", and the HDL (high-density lipoprotein) or "good cholesterol". Also, we are measuring another kind of cholesterol-like class of chemicals called triglycerides (TG for short).  The optimal levels of these depend strongly on each individual, and can be affected by diet and exercise and medications.

We have known for decades that people who have high LDL levels have more heart attacks and strokes, and that (if necessary) using 'statin cholesterol-lowering drugs reduces the number of heart attacks and strokes that actually occur.  As long as the 'statin is not harming you, we feel pretty good about you not having a heart attack or a stroke!

We have also known that people with high TG levels and/or low HDL levels also have more heart attacks and stokes.  Therefore, we reasoned that (if  necessary) using medications to lower TG levels and/or raise HDL levels would also reduce the occurrence of heart attacks and strokes.  Prescription medicines of this sort include NiaSpan, Lopid, TriCor and WelChol.  Over-the-counter ones include niacin and Omega-3 fish oils.

Well, not so much.

It turns out that using medicines to lower TG levels or raise HDL levels improves your lab test results, but not your actual likelihood of having a heart attack or a stroke.  This is one of those examples of science in action.  Seems like a good idea based on scientific understanding;
try it out, but if further study fails to show that it doesn't actually help, then stop doing it.  Thus, many medical journals are encouraging doctors to stop using these medicines in their patients.

Mind you, 'statin drugs are still clearly shown to reduce heart attack and stroke risks as well as lowering LDL levels.  The 'statins seem not only to reduce the LDL levels, but also reduce inflammation in the microscopic inner lining of blood vessels (the endothelium).  This latter property helps to keep cholesterol plaques from suddenly rupturing and forming a blood clot in blood vessels going to your heart or brain.  This would explain why the 'statins are beneficial and other types of medication are not.

Bottom Line:

Prescription and over-the-counter medicines for your cholesterol are not a substitute for making good choices about your diet, and exercising regularly.

The 'statin drugs have been found to lower your risk of heart attack or stroke.

Other drugs have been found to improve your lab test results, but not your health. 

Marijuana Use

I was reading this article in Slate magazine a few weeks ago which commented on the increased potency of cultivated marijuana over the past couple of decades.  The article is serious, though the author takes a slightly tongue in cheek tone in suggesting that growers should be interested in the rich target market of well-to-do boomers who want to get a mild buzz, but not get completely stoned.  This blogger and comedy writer seems to have read the same article, initially scoffed at it, but found it to be a convincing argument after all!

From my professional point of view, I have wondered about what the options are for patients with nausea or glaucoma who are not regular recreational users.  How, after all, do you treat the nausea or elevated eye pressure if you don't actually also want to get high?

It turns out that this is an already well established ongoing concern and area of research (h/t one of my patients). There is a specific class of chemicals called cannabidiols (CBD) have most of the medicinal properties in marijuana. The tetra-hydrocannabilnols (THC) have most of the euphoriant properties (the high).  So, plant breeders are quite interested and active in trying to breed plants with higher CBD content and lower THC content to optimize medicinal value and moderate the buzz in available products.

Of course, specific evidence around the medicinal value of marijuana is somewhat limited at present.  Normally, the most statistically powerful kind of medical studies are so-called randomized double-blind placebo-control studies.  This means you gather a large number of people who are medically similar, sort them into two groups, then test a medication or procedure versus a placebo on the two groups in such a way that the patients in the study do not know which they are receiving, and neither do the doctors in the study.  This is difficult to do in testing marijuana since the federal government and many state governments regard marijuana use as a crime.  It is considered unethical to perform medical studies in which the participants are required to commit crimes.

Nonetheless, certain inferences can be gained.  For example, existing evidence does suggest that marijuana smoking does not cause lung damage or lung cancer, and may have a protective effect on lung health.  This is based on lung function and cancer statistics in surfers (who tend to smoke marijuana but not tobacco) and in Rastafarians (who tend to smoke both).

Public opinion polls reflect a majority of Americans support legalization of marijuana for recreational, let alone medicinal, use.  I think we will eventually see this happen, and am interested to be able to know more about marijuana's medicinal value.

Lowering the risk of memory loss and weakness

Because it often happens that as we age our bodies slow down and our short-term memory fades, it is often assumed that this is an inevitable consequence of getting older.  How often do we hear "getting old ain't for sissies!", or "my get up and go got up and went", or "I've got CRS".

It turns out that significant losses of muscle strength, reflexes, speed and memory are not necessarily inevitable.

Up to age 50, if you don't use your muscles they just don't get bigger or stronger.  After 50, if you don't use them they get smaller and weaker.  Use it or lose it, pretty much.  On the other hand, we are just as capable of maintaining strength if we keep fit and active.  For example, we have seen that for people who compete in running, swimming or bicycling there is no significant loss of performance times between 30 and 70 years of age.  Sure, no one's talking about mixed martial arts here or competing against teenagers, but it's interesting to see that 70 year olds can compete with 30 year olds on a level playing field.

By the way, that old saw about how women can't develop upper body strength also turns out not to be true.  Nor is it a good idea not to have upper body strength as you age!  Nobody's suggesting women over 50 need to look like professional body builders (unless they happen to be pro body builders), but exercising your arms as well as legs and heart is a good idea.

All too often, I am saddened to see a patient go to the ER due to an accident resulting in an injury such as an ankle fracture.  Broken bones are painful, but generally an ankle fracture is usually treated by splinting or casting, pain medicines and keeping weight off it for a few weeks.  This can be done as an outpatient with follow up with your regular doctor.  However, if your loss of upper body strength or fitness is such that you can't use crutches or a walker then this problem winds up as 3 days in the hospital followed by up to 2 months in a nursing home simply waiting for the injury to fully heal.  I must say, it would be better to keep your arms strong that have to spend 2 months in a nursing home.

It also turns out that the use-it-or-lose-it principle also relates to your brain.  Memory loss happens as we age, but it is not as inevitable as we thought.

First off, Alzheimer's dementia may be a circulation problem involving small blood vessels in the brain.  We see that people who develop this dementia often have risk factors for other circulation or cardiovascular problems such as smoking, high blood pressure, diabetes or high cholesterol.  Also, we see less dementia in people who happen to be on 'statin cholesterol-lowering medicines than in people who don't take them.

In other words, what's good for your heart is also good for your brain.  Don't smoke, and keep your blood pressure, cholesterol, blood sugar and weight under control.

Also, there actually are quite a few folks who live into their 80's who maintain perfectly normal memory and brain function.  When you compare them to folks the same age with memory loss, several patterns emerge.

People who retain their memory into their 80's tend to exercise regularly, stay socially  active and get out of the house regularly. Regularity was key here.  Exercise and social activity did not have to be daily or intense, just regularly occurring.  Similarly, leaving the house a couple of times a week to shop was far better than staying at home for a month at a time.

So, the short story:

You don't have  to get slow, weak and forgetful as you get older.

Use it or lose it!

Don't smoke.  Get your blood pressure, blood sugar and cholesterol checked yearly.

Exercise regularly, get out of the house regularly, and stay socially active with your family, friends and neighbors!

Getting Viagra (the little blue pill) on-line

In a bold move, Pfizer (the maker of Viagra and the second largest pharmaceutical manufacturer in the world) has announced that they plan to allow patients with a prescription for Viagra to fill it on their website and have it dispensed at any CVS pharmacy.

This is a new approach, as generally the drug companies have sold pills wholesale to drugstores for distribution and not retail to individual patients.  Their stated concern is for patients who do not feel comfortable bringing in a prescription to their friendly neighborhood pharmacist.  Kindly note that the retail price here is $25/pill (yes, twenty-five dollars a pill) which  is double the cost at places like Costco or Sam's Club, and you still pick it up at a CVS pharmacy.

Other drug companies will be watching, since there are other medicines that patients may want to get in this way, such as other E.D. drugs, weight loss drugs and birth control medications. 

This article also points out that another concern of Pfizer's part is the wide availability of counterfeit medications, especially Viagra.  When  patients have a poor response to a counterfeit, it reflects poorly on their product.

This is certainly a valid concern.  If a legitimate on-line pharmacy is defined as one that requires a real prescription, is based in the U.S., only sells FDA-approved medications and has a secure server for credit card transactions, then only 2.5% of on-line pharmacies are legitimate, and the rest are shady at best.  At worst, you can get contaminated fakes that are stamped out in a garage in a developing country.

Sandy Hook Elementary, Boston Marathon, ricin in the President's mail...

Boston PD dispatch responds quickly, professionally and efficiently. By 8-10 minutes into the first response, they are coordinating with social media and additional agencies (Kit Up!).

Hospital disaster training pays off in treating mass casualty incidents (Boston Globe).

Lessons learned in combat apply: early use of tourniquets, using felt pens to write vital signs on the chest, team decision-making in the OR...(New York Times).

Shrapnel removed in the OR may become physical evidence (MedPage Today).

If we allow terrorists to make us give up liberty for safety or to respond in fear or panic, then the terrorists win (Atlantic).

Fallin' Down Funny

Scientific American's Brainwaves blog posts a series of Dear Evolution letters from various animal species: fan mail from a few, but mostly gripes.

In Memoriam, Roger Ebert

This link was originally re-posted by one of the many who eulogized Roger Ebert since he died of cancer late last week.  He is pictured here with his wife Chaz.  There were so many memories and tributes written I have forgotten who exactly re-posted this.

"My name is Roger, and I'm an alcoholic" was written by Ebert, and posted on his blog in 2009.  It is one of the best descriptions of Alcoholics Anonymous I have ever read, and like everything else Ebert wrote it is direct, compassionate and rings true whether you agree with him or not.

Hospitals get dinged on re-admissions

As part of the Affordable Care Act, hospitals are now subject to financial penalties if MediCare patients have to go back to the hospital within 30 days of going back home. 

On the face of it, this is not a bad idea.  It creates a disincentive for patients to be sent home before they're entirely stable, and also creates an incentive for hospital-based systems to co-ordinate follow-up care.

However, this penalty does not recognize that in many cases the causes of re-admission may be economic and not medical.  For example, patients may not be able to afford new medications, co-payments for follow-up visits, or may not have reliable transportation.  Additionally, it puts hospitals that admit a lot of poor or elderly patients at higher risk due to the complexity of medical conditions that they treat, and the additional economic and logistical problems their patients may have.

As one healthcare policy expert put it, we’re using a proxy because it’s a convenient proxy — it’s just not a very accurate proxy.

For my own part, I think 30 days after going home is an unreasonably long duration of time.  A lot can happen in a month after going home that may be unfortunate, but is no fault of the doctors or the hospital.

This article also talks about the elephant in the room, which is patient responsibility.  Is it really reasonable to expect hospitals to make appointments for patients, or to arrange transport or pharmacy deliveries?  At what point does the patient become responsible for being pro-active in their own health?

Don't Buy Your Medications at Big Chain Drugstores and Save Yourself a Lot of Money

Big chain drugstores like CVS and Rite Aid make most of their profits on prescriptions.  On the other hand, wholesalers like Costco and Sam's Club use the pharmacy as a way to get people into the store.  Note that you don't have to be a Costco member to use a Costco pharmacy. Independent pharmacies are in between.

A few years ago, the price on pills at Rite Aid and Long's was 500-600% above MSRP (manufacturer's suggested retail price), whereas it was cost + 2-3% at WalMart.  At this point, the price difference can amount to about $780 a year for the average patient.

h/t AlterNet, Consumer Reports


 

It's The Prices, Stupid

Uwe Reinhardt, one of the foremost economists focusing on US healthcare, points out that the reason that the US spends so much on healthcare per capita compared to other countries is not because US citizens use more healthcare resources (in fact, it's the opposite), but rather because the price of healthcare in the US is far higher than in other countries.

This article is worth reading and opening the numerous links if you've ever wondered why it's so hard to find out how much a medical visit, test or procedure is going to cost you before it's done.  Gotta agree: our healthcare system is like getting a pair of pants at two different stores with prices that are 10-fold different.  Stores that don't have price tags, that is.

So, for all those patients who think I've been kidding about those exoskeletons...

Slate has a great article on developments in medical exoskeletons.  The fellow in the picture is paraplegic since an industrial accident.  Now he can walk (but not fly).

Why do so many people do a gluten free diet?

Slate has a pretty good article on this question.

Long story short, it fall into a category of medical problems where a true medical condition is not common, but not rare either (celiac disease or gluten enteropathy affects 1% of the population and is not that hard to definitively diagnose). However, symptoms can occur that mimic the condition leading to potential for over-diagnosis and/or self-diagnosis (gluten intolerance may be "real" in a third of people who describe symptoms after gluten ingestion).  In other words, if 25% of the population is on or has been on a gluten free diet, and only 1% of the population has celiac disease, there's a lot of people who are either mis-labeled with celiac disease, or just prefer not to eat gluten for a variety of reasons.

Anyhow, the Slate article is very comprehensive without rushing to judge.

More on the subject of the high cost of hospital care

Uwe Reinhardt, a well-known economist who is particularly knowledgeable in the area of medical care, responds in an economics blog to Steven Brill's brilliant article on the high cost of hospital care in the U.S. (I posted on this last week and linked to the article).

In his response, he praises the thoroughness of the article though also points out that this is not the first news coverage on the subject, and that the news media silence and general public unawareness of this over the last ten years is surprising.

Additionally, he responds to Mr. Brill's list of proposed improvements by pointing out an already existing law in New Jersey that caps billing of uninsured patients by hospitals as a percent of MediCare reimbursement plus X.

Sounds reasonable to me: Mr. Reinhardt provides a link to the assembly bill in question for those who are interested.

Why is Junk Food so addictive?

Why is it that even though we all know that carbs, grease and salt are not good for you, they are so irresistable?  Why do some junk foods (Cheetos, I'm talking to you) just beg you to eat more of them?  Why do others seem perfectly designed to make you feel okay about eating them (pita chips, ahem)?

It turns out this is not coincidental, but rather the result of decades of research on the science of producing foods with these characteristics and on the marketing of them to consumers.

This article looks at the history since the early 1990's when it was starting to be recognized that obesity was becoming pandemic of the food industry's efforts to head off possible lawsuits or governmental regulations.  To their credit, there was serious discussion and effort at producing healthier snack foods.  In many cases these failed compared to less healthier options.  At the same time, the snack food makers were pouring millions of dollars into devising ways to make their products literally irresistible.

Interviews with some of the people involved over the years are also revealing of motivations and conflicts both at the corporate and personal levels. The last interview about the successful marketing of plain baby carrots by selling them like junk food (but not as junk food) is worth the read.

Avoiding unecessary medical tests and procedures

If you follow the news, you noticed on Thursday that a group representing 17 major medical professional bodies (such as family physicians, pediatricians, heart specialists and radiologists) published a list of 90 overused medications, tests and procedures.

This is actually an initiative called Choosing Widely which is a joint effort of the American Board of Internal Medicine Foundation and Consumer Reports magazine for a couple of years now.

The idea is to come to agreement about medical treatments or tests that are often overused, and to try to educate both doctors and patients about them.  Clearly this could help to reduce the cost of medical care, but the focus of this is also on trying to avoid treatments and tests that often entail costs to patients, radiation exposure or invasive procedures or surgeries.

Choosing Wisely provides lists of its recommendations in both professional and patient-friendly language, so check it out!

Why are medical bills so high?

This lengthy read in Time magazine should be a candidate for this year's Pulitzer.

If you've ever gotten an Explanation of Benefits (EOB) let alone a bill for a $108 application of NeoSporin to a cut in an ER, then this is an article you want to read from beginning to end.  Ditto if you a two day hospitalization for chest pain, even if it turns out that your heart is fine, could wipe you out or cost you your home.

The author, Steven Brill, takes a very thorough trip through several patient experiences with astronomical and unpayable debt due to medical encounters from an investigative "follow the money" approach.

His summary and suggestions for resolving this problem are worth reading even if you don't read the entire piece.  I agree that cost transparency is a reasonable expectation, that lowering MediCare age in many ways makes more sense than raising it and that the time for nation-wide tort reform is long overdue.  (Yes, I am quite aware that I am agreeing with both the Democrats and Republicans on this. And why not?  Any good ideas that can improve health care in our country without bankrupting its citizens should be welcome.)

How helpful is the medical history and physical examination?

Hint: Very.

It is interesting to reflect that the advent of sophisticated laboratory testing and imaging studies ("blood-work and X-Rays") is recent in the history of medicine which is one of the world's oldest professions.  Just to put things in perspective, the stethoscope was first invented (by Courvoisier, if I remember correctly) in the late 1700's.  The widespread medical application of MRI did not occur until the 1980's.

Physicians up until recently had to be able to establish an accurate diagnosis purely on the basis of extended questions and answers (history taking) and a directed bediside exam (physical examination), as ultrasounds and scanners were not yet invented.

With sophisticated technology now at our disposal, it  becomes reasonable to wonder whether all the questions and answers and exams couldn't simply be foregone in favor of just jumping right to extensive lab testing and CT scans.

Well, someone did more than wonder.  They studied how over 400 patients were admitted through the emergency department at a large teaching hospital over the course of a little less than two months.  Specifically, they looked at whether the diagnoses were correct, and how correct diagnoses were made.

Reading about it so you don't have to, Dr. Gregory Rutecki reports that senior doctors arrived at a correct diagnosis in the ER over 84% of the time (residents, about 80% of the time).  As to the breakdown in how these correct diagnoses were made:

• History alone: 19.8% and 19.3%.
• Physical examination alone: 0.8% and 0.5%.
• Basic tests (complete blood cell count, chemistry panel, urinalysis, ECG, chest radiograph) alone: 1.1% and 1.3%.
• History and physical examination in combination: 39.5% and 38.6%.
• History plus basic tests: 14.7% and 14.7%.
• History, physical examination, and basic tests in combination: 16.9% and 18.5%.
• Imaging studies: 6.5% and 6.1%.

While physical examination all by itself is not helpful, history plus examination becomes the sharpest tool in the shed by double.  Note history taking alone is second.  Adding a few basic tests was in some cases helpful.  Note that "imaging studies" (here, scans and more sophisticated tests than just a basic X-Ray) was diagnostic only 6-6.5% of the time: less than half the accuracy of just history taking all by itself.

From what I was taught and what I continue to learn in practice, this finding is not surprising.  The history is telling you what's being experienced by the patient, and the examination can help to establish the basis for what's causing the problems being discussed.  Tests and studies can help to confirm your impression or exclude things that you would not like to delay in identifying.  However, you have to know where to look or what you're looking for to know what tests or studies to do.

When you think a bit about it, this sounds a lot like other areas in life.  A good mechanic wants to ask whether your car sounds like this all the time, or just on hills.  A technician will just hook your car up to the shop's computer, replace any/everything that doesn't green-light and bill you for it.  A good restaurant offers  a menu based on a thorough understanding of its clientele.  Mediocre ones offer lots of carbs/grease/salt for cheap.

Coming to a refined and accurate conclusion or diagnosis is based on a thorough (albeit time-consuming) comprehension of the problem or issue at hand.

h/t KevinMD

Myths About Obesity

The New England Journal of Medicine just published a really interesting article on myths regarding obesity.  It's available to subscribers only on-line, though can be read in full on its iPhone app.

By myths, the authors refer to strongly held ideas put forth by the public media and/or the medical community that are not actually based on testing or any actual evidence.

The article is worth a read for its discussion of the basis for some of these myths, but in summary:

#1: Small sustained changes in diet or exercise will result in large, long-term weight loss.
      Unfortunately, this generally results in about a 10 pound weight loss over 5 years.

#2: Realistic weight loss goals are important, and prevent frustration and failure.
      Actually, some studies show significant weight loss in patients with ambitious goals.

#3: Slow gradual weight loss is better than large rapid weight loss.
      Actually, if you look at weight loss sustained for over a year, both methods can work well.

#4: Readiness is crucial.
      It appears that even people who are at least minimally ready to try to lose weight have a good        chance of success.

#5: Physical Education classes are important in reducing or preventing childhood obesity.
      At least as it is currently taught, PE classes don't seem to affect childhood obesity rates.

#6: Breast feeding is protective against obesity.
      While children who are breast fed enjoy a number of health benefits, preventing obesity is not one of them.

#7: Sex can burn off 100-300 calories.
      Um, actually more like 14 calories.