Health Care Reform

So, I'm getting a lot of folks asking how I feel about the passage of the health care reform bill (H.R. 3590- the Patient Protection and Affordable Care Act), and how I think it's going to affect me and other doctors.

Mind you, these are my opinions based on following these issues for years as a doctor.

If you want to read the actual documents of this bill and of the bill that will proceed through the Senate for the President's signature (H.R. 4872- the Health Care and Education Affordability Reconciliation Act of 2010), this article provides links to the full source documents.

More manageable, plain English 20+ page summaries of these bills (pdf) can be found here and here. This and this are for folks who like FAQ lists.

Generally, I like what I see.

I think it's great that the first things on the table that should occur in the next months include extending coverage for young folks to 26 years old on their parents' insurance, setting up insurance pools for people with pre-existing medical conditions, closing the Part D "donut hole" and covering preventive care for MediCare patients, and doing away with insurance company practices of capping coverage, refusing to insure patients with medical conditions, and stopping your insurance when you become ill.

Do I agree with requiring people to have insurance?
Do. The. Math. Or, consider whether you really feel okay about your taxes and premiums paying for the medical care of a healthy 20 or 30 year old who decided not to pay for insurance and then develops diabetes or has an accident. Did requiring drivers to have insurance cause premiums to go so high that you can't afford to drive? Or, is it better that if you get in an accident and the other guy is at fault that his insurance covers it because he has to have it?

Do I think it's going to bankrupt health care?
No. I believe the Congressional Budget Office.

Will it "cut down on Medicare"?
No. Remember the closing the donut hole part?

Is it okay to pay for this with taxes?
Please. We're talking tax hikes of 3.8% on unearned income of people filing over $200,000/year, or couples filing jointly over a quarter million dollars a year. People in these tax brackets have seen a 300% increase in their earnings in the past 10 years. The rest of the country (adjusted for inflation) has stayed flat over this time. I believe the super-rich can and should afford it.

But, what about my own insurance?
No downside. There's nothing in this law to keep you from staying on your present insurance if you like it. However, you might find it reassuring not to have a $1-3 million dollar lifetime cap on it if you develop and expensive problem like a cancer or a bad car accident. Also, formation of risk-sharing pools in each state should make it possible for you to get your own affordable insurance if you get fired, go to part-time, retire before 65, decide to go into business for yourself, or just don't want to go to Kaiser if the boss decides to change everyone to Kaiser. Bummer.

The government? Involved in health care?
The government already is involved; MediCare, MediCal and the VA. As far as I can tell, the private sector insurances have otherwise had free reign since World War II. I am as frustrated as any doctor with run ins with Medicare, but I also have run its with Kaiser, Blue Cross and Blue Shield. I am perfectly happy to let the government have a go at it. Heck, the seem to do just fine with having a military, enforcing the law and putting out fires. I also must say I've never had a letter or parcel lost by the Post Office.

How do I think it will affect me and my practice?
Dunno, but I remain optimistic. I look forward to not losing patients because they lose their jobs or their boss goes cheap (Kaiser). I look forward to seeing my college students and recent grads without the burden of them having to pay out of pocket. Hey, there's a good chance my own insurance rates will go down and/or that I could more easily retire before 65! Having an influx of available new patients who now have insurance? Sounds good.

Next? More jobs!

The Physical Examination

The physical examination dates back to antiquity, and is useful in assessing a number of clinical findings that can help to establish diagnosis. In other words, examination of a patient's body can help to determine what is happening and what to do.

As I was taught it, examination followed a detailed history-taking which consists of detailed questions and answers about health, symptoms and recent or past events.
I was lucky to attend a medical school (the University of Pittsburgh School of Medicine). This is a very large teaching campus serving half Pennsylvania and also Ohio and West Virginia and had dedicated hospitals for veterans, children, women, ear nose and throat surgeries, eye surgeries and psychiatric patients. As the only medical students in Pittsburgh, we had the entire run of the place to ourselves. Also, the population there is the oldest in the U.S., so you do see a lot of folks. Additionally, the faculty included doctors who were very experienced and gained their experience when good history taking and physical examination skills were nearly all you had. This was before ultrasound, CT's and MRI's. Laparoscopic surgery a new technology at my time.

There are times when the physical exam is not so useful (such as discussing a new diagnosis of high cholesterol or diabetes based on abnormal screening blood tests) and other times where it is crucial (such as sore throat, abdominal pain or shortness of breath).

Unlike in days gone by when doctors rarely asked questions of their patients (such as the 1800's), I find that my teachers were correct: the majority of helping patients relies on accurate diagnosis, and the majority of diagnosis relies on history taking and a targeted examination. I continue to find it useful to elicit a full story, give patients adequate time to explain it and then ask what patients think is actually going on. Not, I admit, great for my schedule but it does help to get it right the first time whenever possible.

I see (h/t to Kevin, MD) this remains a topic of debate amongst doctors, which is not surprising in the context of advances in technology and increasing constraints on time.

This author's reflections on how technological advancement has changed medicine including the social aspects of it really resonates with me, as I see fewer and fewer of my colleagues in the hospital at all due to the trend towards doctors going fully into hospitals or fully into offices and clinics, but no longer both.

• I regret that more and more we seem to distrust our eyes (and almost all of dermatology for example relies on observation, as do a myriad of other diagnoses); we distrust our ears (and the tale the patient might tell us if we only listen long enough) and we distrust our senses. We are putting far too much emphasis on "test results" to tell us what to do next.

• We see too little of our radiology colleagues because we don't go down there as much as we used to. It's a loss--it was great to show them a CAT scan or MRI and give them the clinical context, and then hear their opinion.

• I miss the nurses' station with the chart racks which used to be the social center of each floor of the hospital. Since you can write your note from anywhere (including from Starbucks), we we wind up "talking" to each other through the medical record. We don't develop relationships that are good for coordinated patient care.

• I bemoan the fact that the art of bedside diagnosis is in danger of extinction. The people who invented these skills (beginning a hundred and fifty or more years ago) had to wait for an autopsy to reconcile what they saw or felt or heard on the outside of the body with what was actually going on inside. Now, we can make those correlations in real time; it should have made us superb at the bedside. Instead I worry we will get to a point where if you are missing a finger and show up in a hospital, no one will believe you till they get an MRI, CAT scan and an orthopedic consult.

I think this writer sums up nicely the use of a guided examination in arriving at an accurate diagnosis, which not only allows effective treatment to be started without delay, but also avoids unnecessary tests, radiation exposure and cost to the patient.

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

Health Care Reform

On the eve of a vote on health care reform in the House, this link shows a brief summary of the bill's content.



For those with a yen for source documentation, this link is to a pdf file that shows the entire content of the bill.

Sex and the Insulin Pump

This is a well-written article by a professional teacher and writer about the impact of having an insulin pump for Type I diabetes on her feelings of sexuality and self-worth.

The article is of general interest about how chronic illness and particularly medical equipment can affect not just your health, but also sexuality.

As a doctor, it is also a reminder that medical conditions and also their treatments can affect life and also quality of life, which includes sexuality. I admit that I had not considered this in the insulin pump, though the subject often comes up in the setting of arthritis, heart attacks and cancers of the breast and prostate. "Will I spread the cancer by touching her?" "Will "being with him' cause his heart to over-work itself?" These kind of questions may be hard to ask, but they're real questions. They reflect concerns based on anxiety, love and compassion. Nothin' more real than that.

(H/t to boing boing for this link.)

Telemergency Alert Device

A patient's daughter recommended this alert device, based on her use of it for her father who is medically frail and lives alone.

(Disclaimer: this is useful information being passed on, not a product endorsement.)

The idea with alert devices is for elderly folks to have a quick and easy way to summon help if needed (think: Help! I've fallen down and I can't get up!)

The device costs about $148 (see this Amazon link) as a single purchase. Otherwise, there is no installation fee or monthly subscription fee.

You can set up to 5 numbers (including 911 if you wish) that the device will automatically dial in succession if a button is pushed on the base or on a wireless pendant. If no one answers on call #1, the device goes next to call #2, and so on. Thus, you can opt to call family or neighbors as opposed to every call out summoning the fire department.

The only potential drawbacks that have been pointed out are that the button can be activated fairly easily (as in rolling onto it in sleep), and that the device will leave a message on a message machine and stop calling further numbers. Perhaps setting calls to go to cell phones is better.

Popular Health Supplements

Hmmm, this looks interesting.

This link is to a graphic representation of data around health supplements as a "bubble race". The higher the bubble, the stronger the evidence showing that it works. The bigger the bubble, the more popular it is (in terms of Google searches).

Hormone Replacement Therapy: better to wean slowly or stop cold turkey?

Ever since the publication of the findings of the Womens' Health Initiative earlier in the last decade,
it has generally been appreciated that hormone replacement should be reserved for alleviation of intractable menopausal symptoms and only for as long as necessary to do so.

On the other hand, it has been unclear whether stopping hormone replacement can be sudden or whether it should be done gradually.

A recent medical study suggests that there may not be much difference between the two approaches.

Women who suddenly stopped taking hormone replacement had the same number and severity of hot flashes as women who took their usual doses every other day for a month and then stopped.

Interestingly, almost half the women went back on to hormone replacement because of the severity of hot flashes within a year of going off them.

I think the take-home message is that hormone replacement is reasonable to use to alleviate significant hot flashes and menopausal symptoms. In order to establish whether you still need to be on them, it's okay to just stop them and consider restarting them if the symptoms return and are not tolerable. Remember that the earliest signs of harm from use of hormone replacement took over 5 years to manifest in the Womens' Health Initiative study, and also that there are alternatives to hormone replacement that you may prefer.

An Inspiration in Tough Economic Times

Ralph Bakshi is a cartoonist and cartoon animator (remember Fritz the Cat, Wizards, Lord of the Rings?) who in this YouTube video is responding to a question at a comics convention as to advice for young up-and-comers in a tough industry during this economic downturn.

His answer is like Babe Ruth taking it out of the park.

The answer addresses the opportunities in times of crisis for animators, but really speaks to anyone with some creative talent, a marketable idea and the drive to take the entrepreneurial bull by the horns.

This is recommended viewing for anyone considering making a go of a long cherished idea that has been on the back burner until now.

Kidney Stones

Kidney stones are a relatively common, and potentially quite painful problem.

They occur through the formation of crystals from dissolved chemicals in the urine. These form in the kidneys, and can be passed down through the ureters to the bladder. If they are small enough to get out of the bladder, but big enough to get stuck partway down (4-6 mm across) that's when the problem gets very painful. Painful as in more painful than childbirth (so says every female patient I have ever had who has a basis for comparison).

Kidney stones have a 10-15% chance of occurring in any given person's lifetime, though this varies with a number of factors:

• Stones are 2-3 times more likely to occur in men than in women.
• Whites have more stones than Hispanics, Blacks and Asians.
• Stones are uncommon in people under 20 years old, and the occurrence peaks between 50-70.
• Stones are more common in hot, dry climates. Also, heat exposure and dehydration are risks.

80% of stones are made of calcium (which happily means that they show up on plain old X-Rays), and 80% of these calcium stones are made up of a chemical called calcium oxalate.

So, for the good news- there are things you can do in order to prevent these stones. (h/t to my urology colleague Dr. Kash Desai for many of these):

• Hydration: drink 6-8 glasses of water a day, avoid sodas, salt and caffeine from your diet.
• Avoid high-protein and high-salt diets.
• Avoid excessive cheese and dairy intake.
• Lemonade is good: 8-10 ounces of lemon juice in 64 ounces of "reverse osmosis" water such as Aquafina, Dasani or Alhambra.
• Orange juice, or any other citrus juice is good. (Remember, you should not drink grapefruit juice at all if you take a statin cholesterol medication.)
• Vitamin B-6, 50 mg a day.
• Calcium supplements are OK, but should be calcium citrate with Vitamin D and magnesium (and not calcium carbonate such as Tums, Rolaids or "natural" calcium).
  

Sports Injuries in Girls

3 million girls now participate in high school sports. This is a 940% increase since the Title IX Equal Opportunity in Education Act was passed in 1972; how cool is that?

A recent study reveals some very interesting findings about injuries in our young female athletes.

The bottom line of the study is that girls have a higher risk of certain specific types of injuries than boys, but a lower overall injury rate than boys.

Specifically,

• The most popular high-school girls' sports are basketball, track, volleyball, softball and soccer.
• Overall, girls had half the injury rate of boys.
• In girls, injury rates were highest in soccer.
• The most common injuries were knee and ankle. These comprised 60% of all injuries in young female athletes (which is to say 99 injuries/100,000 athletes).
• This was a 30% higher rate of knee injury than in boys. ACL (anterior cruciate ligament) ruptures were seen to be three times more frequent in girl soccer and basketball players than in their boy counterparts. Girls also had higher rates of surgical repair than boys.

On the other hand,

• Traumatic brain injury involved only 11/100,000 girl athletes: a much lower rate than in boys.
• Basketball had the highest rate of concussion in girls, at a rate topped only by boy's football and boy's soccer. (Girl's track and girl's soccer were next highest.)

Interestingly, cheer-leading had the highest rate of catastrophic injury in girls. I guess I don't find this completely surprising as I do a lot of sports physicals for our local athletes.

Overall,

• There is no "injury epidemic" in girls' sports.
• The increased number of injuries seen corresponds to the greater number of girls competing.
• Other studies show that knee and ankle injury rates in girls improve with specific warm-up exercises and use of protective gear such as knee pads.

(Ed. If you are proud of your athletic potential-sports-scholarship daughter, niece, grand-daughter or neighbor, thank the federal government for Title IX.)

Discussing End of Life Care With Your Doctor

This article in the L.A. Times is pretty interesting, insofar as it's one of those studies where you would think the result would be obvious. Not.

The study, published online Jan. 11 in the journal Cancer, surveyed 4,188 physicians about how they would talk to a hypothetical cancer patient with four to six months to live. A majority of respondents (65%) said they would discuss prognosis, but only a minority said they would discuss do-not-resuscitate status (44%), hospice (26%) or preferred site of death (21%) at that time. Rather, they would wait until symptoms were present or until there were no more treatments to offer.

I must say, I'm pretty surprised about this. I think the time to have this discussion is before a crisis, and not at the time of crisis. Admittedly, these kinds of discussions are incredibly time-consuming but they are also necessary in order for everyone involved to have a chance to think and talk about what is wanted and what is not. Certainly, the time has to be right for the discussion. It's just that the right time is not at the end of the line.

For that matter, a cancer diagnosis is not the only kind of medical problem where this issue is relevant. It applies equally where a medical problem is very likely to be fatal in the near future, and where it is best for patients and their families to discuss their own preferences and choices for the future.

Does losing weight help with my blood pressure?

Yes; yes it does!

This is particularly nice to know at this time of the year when many people gain 7-8 pounds over the holidays. The trick is to lose this rather than gaining 7-8 pounds every year that you never lose.

On average, losing 10 pounds (no matter how much you presently weigh) results on an 8-10% reduction in you blood pressure.

This may not sound like much, but it's about what you would see with starting doses of prescription blood pressure pills.

Take home message: losing 10 pounds is as helpful as starting a blood pressure medication. Which one sounds better?

Holiday Schedule

We will be out of the office spending the holidays with our families during Thanksgiving (11/26 and 11/27), on Christamas (12/24 and 12/25) and on New Year (12/31 and 1/1)!

These happen to fall on Thursdays and Fridays, so we will be enjoying a few well-deserved long weekends during this season.

Please plan accordingly, particularly with respect to any medication refills or prescriptions you may need.

We wish you and your loved ones the best for the season and the new year!

Avoiding Snow Sport Injuries

Well, we've got a pretty good start to the skiing and boarding season! (To say nothing of some pretty sorely needed precipitation.)

This article relates some pretty interesting findings in sports-related medicine and may help to prevent avoidable injuries.

Surprise (sorta) findings:

• Average age of injured skier: 40. Mostly men, and mostly at low speeds.
• Contrary to popular stereotype, snowboarders were not found to be slamming into skiers; skiers were found to be sliding downhill into snowboarders during failed attempts to stop.
• Wearing a helmet helps to reduce head and brain injuries in low-speed accidents.
• Buying boots big enough for your child to "grow into them" increased injuries in children. This is because the binding release mechanism doesn't release as well when there's a lot of leeway for foot movement within the boot.
  

Not a surprise finding:

• Drug use while on the slopes increased injury.
  
• Wearing a helmet while hitting a tree at 30 mph did not save heads. The idea is wear a helmet, but don't hit a tree.
• Improved bindings reduced shinbone fractures.
  

Do I need to drink 6-8 glasses of water a day for my health?

Short answer; no.

It's actually not known how the idea started that drinking 6-8 glasses of water every day is absolutely essential for good health, but it certainly has gained a lot of traction over the years.

Generally, when your body is becoming depleted in fluid volume an involuntary thirst reflex engages which makes you feel thirsty. This results in you getting something to drink so you no longer feel thirsty. In other words, natural mechanisms keep you from becoming unknowingly dehydrated so that it isn't necessary to drink fluids constantly to prevent dehydration.

Mind you, this assumes general circumstances. Certainly, if you are trying to lose weight it helps to feel full on no-calorie water instead of food.

Also, very elderly people can lose some of the thirst reflex and not realize that they are mildly low on fluids.

Also, this does not apply in special circumstances where you may be losing more fluids than usual or where access to fluid is restricted, such as strenuous work outdoors or diarrheal illness (or desert combat operations for those of you in the military). Here, you want to be mindful to replenish fluids often enough to urinate every 2 hours and for your urine to look clear or light yellow. Also, be sure to use sport drinks or eat food to replace lost sodium.

If you are concerned about dehydration, the first sign of this is a decrease in urine production and/or dark colored urine. Improvement in this is a good sign of adequate rehydration.

Snow Days

We have been closed for the past two days due to the unusual snowstorm to low elevations and loss of electrical power(which includes lights and phones).

At this time, we have power, lights, heating and roads back and should be back in the office as usual tomorrow (Weds. 12/9/09) morning!

We hope you all have been safe and well.

GERD, medicines, and Rebound Effect

GERD, or gastro-esophageal reflux disease, is a common condition in which acid stomach contents go "upstream" (reflux) from the stomach into the esophagus. The symptoms of upset stomach and burning up through you chest were probably why it used to be called "heartburn".

Medicines such as Zantac, Tagamet, Pepcid and Axid help by causing your stomach to produce less acid. Newer ones such as Prilosec, Nexium, Prevacid, Aciphex and Protonix do so even more powerfully.

Doctors are realizing within the last 6-12 months that these medicines can cause what we call tachyphylaxis, or rebound effect.

In other words if you have taken these medicines for over 3-4 weeks, your condition may be adequately treated. However, when you stop taking the pills your stomach starts to re-produce normal acids. In fact, for the first week or two it may temporarily over-produce them before coming back down to normal.

When "heartburn" symptoms returned after you stopped the pills, we used to think this meant you just had to stay on the pills for life. Now, we are concerned that for many patients this might simply be a side-effect of long-time use of the drug.

If you have been on such a medication for over 3-4 weeks and the "heartburn" comes right back within 1-3 days of stopping the medication, use Tums or Rolaids freely for a week or two if needed. These are acid buffering agents, and do not cause the same sort of rebound effect. However, they can keep your "heartburn" symptoms under control for the week or two it may take for this to subside.

Remember also that tobacco products, alcoholic beverages and anti-inflammatory pain relievers can cause or contribute to GERD. Tylenol is not such a medication, and is safe to take.

Note that this does NOT apply to patients with other conditions where life-long treatment with powerful acid reducers is entirely appropriate such as hiatal hernia, Barrett's esophagitis or GERD that does not tolerate cessation of the medications.

Also, you should seek urgent medical attention for symptoms that could represent bleeding or cancer such as obstruction to swallowing, feeling full all the time, loss of weight or appetite, rectal bleeding or black sticky bowel movements.

H1N1 Update

We have received an ample supply of H1N1 shots, and have started contacting patients who are at high risk and in most need of receiving the shot. (I posted earlier on who those groups of patients might be, and why.)

We probably have more than enough, and can provide some for folks who would simply like one.

Please call so we can arrange a time when you can come in to get one, if you'd like.

Also, the Public Health Department will be holding a completely open shot clinic to give free H1N1 shots to anyone who would like one on Monday 12/14 at the Fairgrounds, from 1PM- 4PM at the Organ Room.

H1N1 flu shot clinic

The county Public Health Department will be announcing a free flu shot clinic for anyone who needs or wants an H1N1 shot.

This clinic is to be on Monday 12/14/09 at the Fairgrounds. The time and more particulars are to be announced by Public Health. Their phone number is 621-6100.

How much is OK to drink?

Well, that depends.

Unlike with tobacco products where there really is no safe amount at all, for many folks there is a safe level of alcohol intake.

Potentially harmful drinking is defined as over 7 drinks/week or over 3 drinks/occasion for women, and as over 14 drinks/week or over 4 drinks/occasion for men. The reason for the gender difference is the generally greater muscle mass in men than in women.

A drink is defined as a 12-ounce beer, a 6-ounce glass of wine or 1 1/2 ounces of liquor.

When we say that exceeding these limits can be harmful, we mean that we start to see a real increase in both medical and social problems at these levels.

Social problems can involve DUI's, loss of drivers' license, job loss, absenteeism or divorce.

Medical problems that can occur as a direct result of drinking include depression, heart failure, liver failure, cirrhosis, bleeding ulcers, anemias, malnutrition, nerve damage and sexual dysfunction.

On the up side, safe levels of alcohol consumption are seen to lower risks of having a heart attack. This is, for some reason, particularly true of red wine.

Mind you, if you do not ordinarily drink there is no medical reason to start. Also, if you have problems with alcohol, it may be better to abstain entirely.