Ebola

I haven't posted on the subject of Ebola virus, but I am getting a lot of questions about it, so here goes.

As a general matter, I think the world at large has been very slow to respond to this outbreak.  On the other hand, I think the initial panic and furor are abating and cooler heads are prevailing.

When I say that the world response has been slow (excepting Medicins Sans Frontieres or MSF, otherwise known as Doctors Without Borders) I  mean it has taken months for the World Health Organization, Centers for Disease Control, National Health Service or European Union to respond in any way.  The above photo appeared in the March 2014 breaking news coverage by the British Broadcasting Company of Ebola in Conakry.  Notice the suburban homes behind the guys in Personal Protective Equipment.  That's suburban, not rural village.  Ebola outbreaks up until now have occurred 2,000 miles from the African coast, and have been in isolated locations.  Given the lack of medical care in these isolated areas, Ebola patients generally didn't survive long enough to get to cities of any size.

Conakry is the capital of Guinea and has 1.7 million people in it, an international airport serving Western Africa and Europe, and a deep-water port.  It's in Wikipedia- you don't have to be CIA to figure it out. I find it hard to imagine not breaking out in a cold sweat realizing Ebola is in a large port city with an airport, especially if you are in government or public health.  It does rather appear that the world-at-large only sat up and took notice when Westerners got Ebola. (warning: satire.)

At this point, Ebola has spread to adjacent countries but the ground response is more effective.  This is largely due to hard-won lessons in nursing care, social networking and community support.  For example, family members can now see and communicated with sick loved ones (by phone or the other side of a window) and can see workers don or remove PPE and can see the dead before their burial.  Think about it: if this was happening here, how would we react to sick family members being taken into a big white tent or building from which  no one ever comes out alive?  And you never, never see them again?  We are once again reminded that nursing care is critically important, and communication and emotional support are a big part of it.  This New Yorker piece is an excellent history of the earlier ground war against the outbreak.

A big question now exists over quarantine.

Some perspective should be applied over general air travel out of the three affected countries. Last year, those three countries comprised under 0.02% of the world's commercial air travel.  The US received 2% of these passengers, coming in 12th place as destinations from these countries.  Projections suggest a total of 2.8 commercial air passengers per month flying out of these countries for the next year.

Also, bear in mind that this is not an airborne illness like a cold or flu.  The current CDC recommendations that open with 21 day monitoring but not forced close quarantine are reasonable in this light.Similarly, the New England Journal of Medicine advises against forced quarantine of returning health care workers.

It is reassuring to consider that the only people in the US who have contracted Ebola did so through very direct contact.  In fact, consider the Liberian patient who died in Texas.  He slept with his fiancee for days before being hospitalized.  She and her family were in mandatory quarantine in that apartment for close to a week before it was de-contaminated.  None of those folks went on to develop Ebola.

I think it is now time to turn to increased global efforts to address the outbreak in the currently affected West African countries.  Certainly, forcing returning symptom-free health care workers into 3 weeks of restricted quarantine is not the opening move here and neither is blockading travel in or out of those countries.

Aside from humanitarian reasons, impeding any effort from developed countries to flood in to combat the infection with money, personnel and resources is foolish in the extreme.  As General MacArthur is famously quoted as saying regarding the Pacific Theater of Operations in World War II "Would you rather fight in Saipan, or in California?".  Doing everything possible to quell the outbreak while it is still confined to Western Africa is to avoid fighting it in Karachi or Mumbai.

The sparks that have flown to the US and Spain have been well contained.  It should not be assumed that sparks landing in large urban centers in developing countries with marginal health care and political infrastructure will fare as well.  As an example, consider that 40% of the world's supply of generic prescription medication is manufactured in India.  If Ebola were allowed to become pandemic in India, the humanitarian suffering would be unimaginable.  Additionally, the rapid loss of generic medications for the world would have immediate impact on the entire world's population.

So, my $0.02? Don't panic, take reasonable precautions for self-protection, and put the resources where the real fight is before it gets out of control.

Myth: 8 glasses of water a day

I still get asked whether one should drink eight full glasses of water a day for reasons of health, and the short answer is "No.".

It's a bit of a mystery where that meme got started, but it has never been the advice of doctors as a matter of general health. It may have gotten its start in the 1940's around the amount of fluids in both solid foods and beverages in the average diet.

At any rate, if you are becoming a bit dehydrated you will feel thirsty.  Feel free to have some water or any  other fluid.  Certainly most of us are going to be better off drinking water than alcohol  or sweetened drinks.  It is simply not necessary to push  fluids beyond this point.

How often are people late for appointments?

This is an interesting post in which a doctor is vexed by how often his patients are late and asking whether this is the norm.

The post does address this and found a study showing that 7.7% (one in thirteen) patients are late for doctor appointments.

However, it also pointed out that another study shows an average patient wait time of 38 minutes for the doctor. Gulp. Mea culpa maxima.

My own experience and perspective?

• We do encourage the first patient of every morning and afternoon to arrive 10-15 minutes early to make it easy to start out on time.  I do often run late because the first patient is late to arrive and I am then already starting off 15 minutes behind.
• I do spend a lot of time with  each  patient.  It's difficult to arrive at an accurate diagnosis without an extensive understanding of the development and nature of symptoms and a physical examination.  This takes time.  There's good medicine and fast medicine, but no good, fast medicine.
• I gotta admit that because of this I rarely ask patients to re-schedule if they happen to be running late!

How understanding why you don't like certain people can be helpful to you

Here's a neat thought.  We all meet people we just don't like.  It's pretty unusual to like everyone you meet, and it's impossible to be all things to all people.

However, maybe it would be good to pause and reflect on why you don't like that person.  What if the reason is that that person has some characteristic we wish we had more of?  What if the things we don't like in others are often the things we dislike in ourselves?

What if meeting someone you don't like not only affords an opportunity to learn ways to accept if not like them, but also a way to examine and  better yourself?

Changes in prescribing and dispensing hydrocodone

The Food  and Drug Adminstration of the federal government (DEA) has changed hydrocodone to a Schedule II agent.  This is effective as of Monday 10/06/14. Scheduled agents are felt to have varying levels of potential for dependency or abuse. 

This is due to concerns that this narcotic pain-killer which is  the active agent in Vicodin, NorCo and Lortab (as well as a number of other brand names) is over-used and/or over-prescribed.  Certainly, the US, which comprises about 4% of the world's population, is using about 99% of the world's Vicodin and NorCo.  It is unlikely that Americans have 99% of the world's physical pain.

What this means is that doctor offices will no longer be able to prescribe or refill these medications by phone or fax.  Like morphine, Dilaudid or Percocet, any  prescriptions or refills of hydrocodone pain killers will require a hard copy.

If we are prescribing this  to you for the first time, you will be given a physical prescription.  No refills can be written on the original prescription.  The  pharmacy cannot fill the prescription without this physical prescription.  They cannot act on faxing or phoning it in ahead of you.

Any refills will also require a physical prescription.  If you need one, please call my office and allow two full business days to have it ready for you to pick up and take to a pharmacy.  A friend or family member can pick up the prescription and/or the medication.  If we feel we need to see you about this, we will make an appointment for you. 

If you are using pain medication or other scheduled agents regularly, we will want to see you regularly in order to evaluate its effectiveness and safety.

Doctors in California are being encouraged to use the state Department of Justice's Physician Drug Monitoring Program which allows doctors to determine whether patients are being prescribed scheduled agents by other doctors or providers.

If you are using hydrocodone or any other scheduled agent and would like to be able to reduce the amount you take, or stop taking them altogether please feel free to see me about this.

How safe is vaping?

So far, it's hard to say. As this nice summary in Nature points out, marketing and sales of devices is moving faster than science or regulation.

For now, it seems reasonable to say that the safety of vaping is unknown and that the safety of second hand vapor is also unknown.  It is probably best to avoid vaping indoors in public areas and to be aware that no one actually knows whether it could be harmful to you.

A little exercise goes a long way!

The American College of Cardiology (a professional organization of heart specialists) recently found that daily  exercise can lower your risk of heart attack and add years to your life. 

This is scarcely news in itself.  What is interesting was finding that 5 minutes of running at relatively slow speeds (6 mph or less) every day lowered risk of death from heart disease by 30-45% and added 3 years of life expectancy.  This was found to be true of fit adults, and also of overweight smokers.

It is also reasonable to suppose that it is the intensity of the exercise that was so beneficial and not necessarily just running.  Skipping rope or going fast on a stationary bike is probably just as good for you.

If you have thought of going to a gym to exercise (low cost, air-conditioned, you don't have to buy exercise equipment and find room for it...) it can be intimidating to consider it if you feel like you're not in very good shape.  Here are some tips on what you can do if you feel you might be embarassed at a gym.

Also, realize that you may be self-conscious about exercising in public if you feel out of shape or overweight.  However, studies find that other folks at the gym are either focused on their own exercise and not thinking about you or they think it's great that you're improving your health but just shy about saying so!

Drug Advertising and Side-Effect Information

Everyone who watches TV has seen ads for "new" drugs with 10 seconds of why it's the best thing since sliced bread, and 20 seconds of side-effects including-but-not-limited-to death, deathiness and death-like symptoms. Kidding.

This should raise several important questions.

First, why do drug companies keep running these obnoxious ads?  Because they keep working (pdf).  Despite their disagreeable qualities, most patients who see the ads ask for a prescription for the drug and most doctors who are asked to prescribe it will do so.  Why?  Most patients are hopeful that something "new" may help them, and most doctors find it faster and easier to say yes than to explain no.

Also, ads should raise the question of how is this drug "new'?  Depends on how you define it.  Drugs advertised on TV are certainly not generics: they are newly developed and approved drugs that will therefore be expensive.  On the other hand, only 10% of them will be new insofar as being the first ever of their kind, or better than already available drugs that do the same thing (congeners).  The other 90% are what is known in the trade as "me-too" drugs.  They are no better than older generically available drugs, and are being sold in hopes of obtaining market share for the drug company that makes them.

Last and not least, I get the most questions on side-effects.  The questions are basically around what are the side effects, and how bad are they.

Listed side effects are not inevitable.  They are simply a list of possible side effects.  WebMD does a great job in discussing what side effects actually are and how they can occur.

Common side-effects may occur in up to 10% of people who take a medication. This also means that 90% of people who take the medication experience no side effects.  Severe side-effects are far less likely to occur, as the FDA does not permit the sale of medications that are seen to frequently cause severe side-effects.

The tricky bit is trying to find out for yourself what side effects actually can happen with a medication, and also how commonly they actually occur.

The problem is that the information provided by pharmacies or in with the medications is largely provided by lawyers, and not by doctors or pharmacists or nurses.  The PI (Product Insert) is principally designed to prevent class action lawsuits by listing every possible reaction to the medication  to prevent you from being able to sue for failure to disclose ("You didn't tell me that could happen.").

It would be helpful if the PI also told you how often the side effect actually happens, whether it's real or theoretical, whether it happens in humans or only in test animals and whether it happens in patients like you, or only in ICU patients with organ transplants receiving the medication in their iv (not kidding).  Problem is, they don't.  The PI is not written to inform you, it is written to protect drug companies.  The much-vaunted PDR (Physician's Desk Reference) is simply a copy of PI's from all medications.

There is no shortage of information from sites such as drugs.com which do a pretty good job of providing useful information in plain English about medications.  However, I've still never seen one that tells you how common the side effects actually are with numbers.  Sorry, but it matters.  You might be okay with a medication where dizziness occurs in 1 in 10,000 people, but not so much if it were occurring in 10% of people.

Sider 2 is useful in getting that information.  Its A-Z listing shows side effects in color-coded columns from most common to least common and allows you at a glance to see if a side effect is common or rare and also percentage of occurrence by the color coding in the sidebar.

Micromedex is the first (or second) most widely used medication database used by doctors and pharmacists.  It's smartphone app is available for only $2.99/year. It does a superb job in easily presenting drug information including actual occurrence rates of side-effects.  However, it is targeted to doctors and pharmacists.  If you want to use it, you'll need a medical dictionary at your side to translate it.  Sorry, we say rhinorrhea and you say runny nose.

Low FODMAP Diets

Certain types of foods may cause digestive symptoms we commonly associate with Irritable Bowel Syndrome (IBS)  and gluten intolerance.

IBS is a real problem involving heightened sensitivity to digestive system distension or fullness, which can result in abdominal discomfort, nausea, bloating and diarrhea.

Celiac disease (also known as sprue) is a reaction to gluten (a wheat protein) resulting in progressive injury to the absorptive lining of the gut.  Around 1% of people have celiac disease. On the other hand, many more people report chronic abdominal discomfort, bloating or diarrhea which is alleviated by avoidance of gluten, even though they are proved not to have true celiac disease.

Two researchers at Monash University in Australia since 1999 (a dietician and a gastroenterologist) have found that certain types of foods may be fermented and/or poorly absorbed and could be responsible for these sort of non-specific, hard-to-pin-down symptoms.  The term FODMAP is now becoming more widely known as a result of their work.

FODMAP is acronymic for:

• Fermentable
• Oligosaccharides,
• Disaccharides,
• Monosaccharides
• And
• Polyols.

This handout (pdf) from the Canadian Digestive Health Foundation breaks this down, and further describes what these chemicals are very nicely.

Basically, some naturally occurring carbohydrates such as lactose (milk sugar), fructose (fruit sugar), the fructans in onion, garlic and wheat and galactans in beans can be fermented during digestion leading to discomfort, nausea and bloating. 

Additionally, some of these are not readily absorbed and can lead to water being drawn in to the colon before elimination resulting in diarrhea.  This latter is particularly true of synthetic sweetening polyols such as sorbitol or xylitol which are used to artificially sweeten foods, chewing gum and other products.

Mind you, we're talking about naturally-occurring constituents of common foods.  Some foods contain more of these than others.  For example, fructans are more abundant in wheat and rye than in rice or oats.  Similarly, apples and mangos contain more fructose than bananas or berries.

This pamphlet (pdf) from Stanford University Medical Center nicely shows within the FODMAP's, which foods to limit and which are okay.

If you feel that your digestive symptoms may be affected by dietary FODMAP's you can systematically limit dietary FODMAP's one group at a time for a few weeks to determine which group or groups you may wish to limit long-term.

Alternatively, you can limit all six groups at once.  If you notice improvement, you can then de-limit one group at a time to identify culprit groups.

Please note this is quite effective with limiting intake of culpable types of FODMAP's.  Absolute avoidance is not generally necessary.

(Also, we are just discussing food substances resulting in fermentation and poor absorption. 

Other digestive symptoms such as fever, weight loss, appetite loss, stringy bowel movements, blood or mucus in your bowel movements are warning signs of much more significant problems such as infections or cancers.  Please see me for such symptoms as soon as possible, and do not try to treat them with a reduced FODMAP diet.)

Interesting Perspectives on the Changes in Medical Practice and Ethics

Unless you are a close student of history or of a certain age (*cough*), you probably don't fully realize how much the current practice of medicine really dates from the civil rights movements of the 1960's and 1970's, and how different this is from previously.

Until quite recently, the ethical principle of benificence (or paternalism, as it is also known) was the standard.  This meant that the  doctor was understood to be a professional with a deep understanding of a complex body of knowledge whose duty was to make complex decisions for patients with the best interests of the patient in mind.  Please note that the "decider" is the doctor and that the doctor also determined what was in the patient's interests. 

This article by James Hamblin in The Atlantic is an interview with Barron Lerner, whose father was an infectious disease specialist in the 1950's.  The interview is in the setting of a book written by him on the evolution of medical ethics from the reflections of he and his father, both of whom are doctors.

A part of the civil rights and free speech movements was the development of ethical autonomy, in which the doctor and the patient are understood to be shared decision-makers.  The physician is there to provide expert knowledge and experience, and to provide and describe a full range of options to allow the patient to be as fully informed as possible and to be able to decide for him/herself what is the best course of action.

Hamblin's article nicely addresses the intersection of autonomy with real concerns like time and differences of goals or opinions.  I'm sure every doctor has had cases where they have felt that the patient was making a truly bad decision, and I'm equally sure every patient has had visits or encounters where they've simply wished the doctor would just get to the point and tell them what needed to be done.  And time certainly is a factor.  Fully investigating the medical concerns at hand, performing a physical examination (yes, a good directed physical examination is still valuable and helpful in arriving at a diagnosis, but it does take time) and then fully describing the range of diagnostic and treatment options, their upside and downside risks and fully answering all questions and concerns is pretty near impossible to do in fifteen minutes in all but the most straightforward problems or concerns.  This is of course coupled with patient focus-grouping which reveals the importance of completeness and length of time with the doctor.  And also promptness. Doh!  Hello, quality-control triangle!

This article by Brandon Cohen in Medscape talks about the elephant in the exam room.  Can ethical autonomy go to the extreme of consumerism?  Is medicine another service in which customer satisfaction trumps the actual quality of the service?  Are HealthGrades reviews of doctors just like Yelp reviews of restaurants (read closely how many negative restaurant reviews relate to dissatisfaction with wait service and not so much the actual quality of the food which is what restaurants provide)?  Which is more important: that patients get the best care and have the best health, or that they are personally satisfied?  When are these goals mutually exclusive and when are they not?

If it sounds like I have more questions on this than answers, that's because it's true.  I do know that it's not unusual for Canadians to come to the U.S. for knee replacement because it takes longer in Canada to get MRI's or surgery for chronic conditions.  I also know that Canadians live longer than Americans, and can get timely tests and treatment for serious problems.  I know that most patients complain about TV ads for medicines, but I also know that the ads still run because they work.  I know that a bad rating of a hospital may mean the hospital is really bad, but it also may mean they treat a lot of complicated patients with rare conditions that no one else can treat.

Sunscreens: Summer is definitely here!

If you follow the weather reports (or just step outside) you've noticed Summer is definitely on!

The liberal application of sunscreen every two hours can help to prevent sunburn, skin cancer and wrinkling of the skin.  This is especially important in children, since one single blistering sunburn can double the lifetime risk of melanoma.

Melinda Moyer at Slate Magazine covers (no pun) the topic quite nicely.  Briefly;

• Organic sunscreens are called this because they are carbon-based, and absorb UVA which causes cancer, and UVB which causes sunburn.  
• Mineral sunscreens accomplish this by reflecting UVA and UVB.
• SPF 30 blocks 97% of UVB, SPF 50 blocks 98%.  It's probably not necessary to get anything stronger than that.
• Spray-on, or wipe-on sunscreen may not cover your skin as well as lotions.
• Using combined sunscreen + insect repellent may increase the absorption of the chemicals into your bloodstream, which may not be a good idea.

Environmental Working Group (a non-profit organization) has a great website that provides plenty of information and recommendations on sunscreens and their ingredients, safety, quality and cost.

Their iPhone and Android apps, Skin Deep also makes this information accessible on sunscreens and also  cosmetics in a mobile platform.  You can browse by entering sunscreen as a search word, or barcode scan products at the store.

More on the Topic of the Affordable Care Act ("ObamaCare"): The Stealthy, Ugly Growth of Corporatized Medicine

Yves Smith at Naked Capitalism pretty much sums up how the ACA incentivizes corporatization of medical care and presents an existential threat to small practices.

As previously stated, I think some problems can be improved upon by centralization and technology.  However, I don't think medical care is one of them, and I don't think centralization and technology should be the default approach for all complex problems.

Here in our small local pond, I see:

• Marshall Medical buying out so many medical practices it's becoming the company store in the company town.  They are organizing the doctors into a Foundation in the hopes that it will improve "productivity".  The doctors are unhappy with this as it in all likelihood will translate to more work and less pay.  Such is life when you sell your autonomy.
• Hospitals and "healthcare systems" everywhere are cutting costs by replacing receptionists with automated phone systems.  I don't think that's a good idea in what is ultimately a service, but that's where it's going.  I personally hate being on hold, and I definitely don't want it when I'm trying to call my doctor, or my daughter's doctor.  IMHO, the receptionist in my office is the voice on my phone and the first and last person you meet when you come to see me.  I do not regard or compensate this as a rookie position, and have no inclination to replace Carolyn with a robot.  How would my "productivity" improve by making me harder to contact?
• Computerization of medical records takes time away from nurses and doctors: the time it takes to enter notes or orders is time and eye contact not spent with patients.  Additionally, sharing records and keeping medications up to date is worse than ever since those responsibilities are often given to the newest entry-level employees.  The reason I haven't adopted electronic records is because I've used or beta-tested half a dozen of them and use the hospital's system for hospital patients.  At the end of the day, medical care is all about time and eye contact with patients.
• Medical supply vendors like Robinson's are no longer available to us.  Instead, patients have to go into Sacramento to whatever vendor submits the lowest competitive bid to have a virtual monopoly on medical supplies for the greater Sacramento region.  Since when has taking the low-ball bid ever been a smart move?  How are people in Placerville or Somerset or Grizzly better served by getting crutches or a wheelchair in Sacramento?
• Large employers got a reprieve from ACA insurance until next year, but not small businesses.  I guess the best investment a corporation can make is in a US representative.  I have no issue whatsoever with tax credits being available to folks based on their  annual income. It's also good that you enjoy that break in premiums every month if you bought your own insurance.  However, if you're a small business providing insurance to your employees you have to pay the full monte all year and take the tax credit as an end-of-tax-year deduction.  This does not give small business any reason to provide insurance to employees, and over 40% of employees in this country are from small businesses.  I don't think small business owners had much say in this part of the ACA, unless I missed the memo.

As a matter of history or disclaimer, I am a traditionalist.  I am in a family practice by myself, my wife is a registered nurse who works in the office and I take care of my patients in the ER, the ICU and the hospital and in hospice.  I admit I stopped delivering babies after the 500-600th one, because I was never getting any sleep.

At this point in time, remaining a traditionalist requires a level of canniness and responsiveness.  However, I see no reason to stop practicing medicine the way it has been practiced for the last several hundred years just because everyone  is deciding that they can get more sleep and be more "productive" by becoming an employed cog in a corporate machine.  So far so good, and long may it last.  We'll see if it continues to be better to fight on your feet than live on your knees.

For Your Reading Pleasure

The author of this essay turns his thoughts from review of political events to Spring and the protection of young life.  The writing is a sheer joy to read.

Despite the banality of the thought, we have all found it uplifting to see this small confirmation that despite every natural and human challenge and unkindness, life has waged a battle that it has never lost.

John McAfee: crazy? crazy like a FOX? Great Ask-Me-Anything, especially if you are inclined to dodgy business practices in Central and South America.

Remember: 50% of the police who stop you in most Third World countries can’t read. This is a powerful piece of information for the wise.

On Being an Aging Parent

Oh, it's so true!

Slate carried a great piece today written from the perspective of being (rather than caring for) an aging parent.  I had a fit laughing about "the look" when you forget a name or a date.

Don't get me wrong here: I don't think dementia is funny.  I am simply aware that forgetting the names of things is in the Top Five ist of things people see a doctor for, where there is nothing seriously wrong with them.

At the same time, I am sort of surprised that the risk at 85 years of age or older of developing Alzheimer's disease is 50%.  To me, I guess that sounds pretty good considering (1) the average life expectancy is 78-82, and (2) that means there's a 50% chance at that age and older of NOT developing Alzheimer's disease!  I guess I'm more of a glass half-full kind of guy than I thought.

Do remember (no joke intended) that it has been shown that folks at 85 and older who maintain normal short-term memory tend to regularly exercise, socialize and get out of the house.

The Importance of Sleep

The Big Picture linked to a couple of good articles this weekend on sleep.

While we generally feel like missing some sleep here and there is not a big deal, it's turning out that it is a big deal after all.

The New York Times describes some of the current research on sleep's role in not just consoldating memory and maintaining functional neuronal connections, but also in clearing the brain of accumulated metabolic waste products.

The Boston Globe lists some of the adverse effects noted of sleep deprivation on physical and mental health and longevity.

Interesting Reading

Aeon Magazine has a fascinating article on a town in Belgium that has a long history of taking in people from out of town who have psychiatric or learning disabilities.  Apparently, the improvement in their quality of life and function has been a source of interest in the European psychiatric community since the 19th Century.


Scientific American has an excellent examination of the high cost of medications (hint: difficult science is expensive).

The New York Times carries an interesting story of what happens when doctors "Google" their patients.  The author claims just about every doctor does this: I confess the thought had never crossed my mind.

Happy New Year!

Thanks to Medscape for posting this article that really speaks to the root of the doctor-patient relationship, and to Slate for this discussion of the importance of exercise!