Presidential Candidate Health Care Reform Proposals

The New England Journal of Medicine in its October 16th issue provides a review of Senator McCain and Senator Obama's proposals for improving health care in our country.

This journal is one of the most widely read, well-researched and respected professional medical journals in the world and these reviews are presented for an audience of physicians and other medical professionals.

They are well worth reading as they are understandable to a broader audience which would include anyone with an interest in the opinion of one of the most prestigious medical journals in the country.

To summarize,

Early in his campaign, Obama recognized that the success of health care reform rests on the plan's ability to slow spending growth and make health care affordable for everyone. His plan would reorganize the health-insurance market — but not change the basic financial incentives in the system that drive up spending. Although the plan would significantly increase the number of Americans with health insurance, it remains to be seen whether that would come at a price Americans would be willing to pay.

The choice facing health care professionals, like all Americans, is basic: Who deserves to be trusted with the stewardship of America's health care system? The McCain proposal violates the bedrock principle that major health policy reforms should first do no harm. It would risk the viability of employer-sponsored insurance and the welfare of chronically ill Americans in pell-mell pursuit of a radical vision of consumer-driven health care. Senator McCain's plan does not demonstrate the kind of judgment needed in a potential commander in chief of our health care system.

Alli- over the counter weight loss medication

Alli (R) is the over-the-counter equivalent of prescription Xenical (R), and is approved as safe and effective in weight reduction by the Food and Drug Administration.

It is safe to take with other medicines except for Coumadin (R) or warfarin the prescription blood-thinner, and organ transplant medicines.

When taken with meals, it keeps about 20% of the fat in the meal from being absorbed into your bloodstream and then being deposited into fat cells. This 20% then is excreted in your bowel movements, which may make them oily looking.

Yes, that's right. No meal is absolutely zero fat. A fifth of the fat in your meals isn't going to your belly or thighs, but is excreted out of your body. That's the point!

Alli is capable of working as well as any other medication, assuming that you change how you eat in order to minimize this side-effect rather than not taking the pills when you plan to eat pizza or ice cream.

The oily bowel movements are not intended to be punishment; it's probably better than all the fat in meals being fully absorbed and deposited in your fat cells. However it can lead to improved eating habits, too.

This mechanism of action of this medicine is particularly of interest to folks at risk for diabetes, since the growth of abdominal fat cells is what ultimately causes diabetes in the first place!

Disclaimer: I have no financial or other interest in Alli, Xenical or its manufacturers. I am only interested in helping my patients to lose weight safely and effectively.

Weight Loss Recipes

Successful and sustained weight loss requires all three of the following:

1. Reduction in total calorie (fuel) intake: eating less, reducing size of portions, avoiding snacks.
2. Reducing calorie density (richness): not buying or eating foods over 30% calories from fat (the upper left corner of any nutritional fact label), such as "junk" foods, "fast" foods, sweets and so forth.
3. Increasing calorie expenditure (exercise): walking, bicycling, sports, swimming, treadmill, elliptical trainer...

The problem is that human physiology is fantastic for surviving starvation. This is great if the food runs out, but not so great if food is abundant.

I get a lot of questions about healthy food choices and specifically suggestions or recipes, so here are some useful links to healthy recipes that range from simple to complex, basic to elegant:

New York Times: Recipes for Health
Recipe Source: Diabetic Recipes
All Recipes: Healthy Cooking Recipes
Epicurious: Healthy Food Recipes

Bon appetit!

Causes of Death: a bit of perspective

Here's an interesting graphic from National Geographic, which handily illustrates likelihood of causes of death in US citizens.

By all means, look over these and draw your own conclusions. Please note the enormous risks of dying of heart disease, cancer and stroke compared to everything else and consider how much can be done to reduce their risk of occurring: not smoking, taking a baby aspirin a day, improving your weight, blood pressure or cholesterol without "waiting until my body tells me something is wrong". (Your body telling you something is wrong is you having a heart attack, stroke or cancer.)

Also, consider that risks of seriously harmful side-effects often discussed in papers or on TV (bone disease with Fosamax, muscle toxicity with cholesterol pills...) may be as low as 1 in 10,000 to 1 in a million: that is about the likelihood of you dying by accidental electrocution to 3 times less likely than dying through a fireworks accident.

Should kind of make you go Hmmm....

Change in our Immunization ("shots") policy

Sorry to say it, but due to the increasing cost of buying immunizations, the poor reimbursement from insurance companies and their short shelf-life we can no longer afford to give many rountine immunizations. In many cases, we are actually losing $50-100 apiece on shots.

Happily, the Public Health department administers all routine shots at low cost on an appointment basis.

We are more than happy to continue to see you or your family for:

• Well Child check-ups
• Female and Male annual physicals
• DMV exams
• employment physicals
• injuries
• consultations about travel

We still give shots for:

• Adult tetanus
• Adult Hepatitis A, Hepatitis B
• Pneumonia vaccine
  

Sixth Grade Immunizations ("Shots")

The county department of public health is doing their IZ Xtreme program again at middle schools this October. This is available to all 6th graders, and also any 7th and 8th graders who have not received this immunizations.

The immunizations are the standard ones for this age group, and prevent tetanus, pertussis, meningitis, influenza and genital warts virus.

If you believe in preventing fatal or crippling infections in our children and our community, this is a fantastic program that provides over $56o in immunizations to each child free of charge at their school.

IMHO, one of the best uses of taxpayer money I've ever seen!

Health Care Reform

So, I'm going to break team here a little and post on a directly political issue (as opposed to clinical or regulatory/insurance concerns).

This is not intended to be a personal soap box on politics in general; I am simply getting a lot of questions on this lately, and I presume it is due to the national-level debate in the setting of the upcoming Presidential elections in November.

What is Health Care Reform?

That being said, let's clarify some terms. Part of the problem is the overuse, misuse or misunderstanding of some words used in public debate on health care in our country.

"Socialized Medicine"

Right off the bat, no one is proposing "socialized" medicine. Period. If we accept the definition of socialism here as advocating government ownership and administration of the means of providing medical services, then you may notice that no one in our debate is suggesting that the federal government should outright own all the hospitals and medical practices and that all doctors should be employees of the federal government. This would approximate the National Health Service in the U.K.

So: throw away "socialized medicine". No one. Repeat, no one is suggesting this. The motives of politicians using this term to stifle debate, or arouse anxiety or anger should be questioned.

"Universal Health Care"

"Universal health care" is a nebulous catch-all phrase that has no specific definition, save that it is meant to mean all things to all people. Generally, the term is used where improving the availability of health insurance and decreasing the number of people in our country who have no insurance is intended.

While no one could reasonably object to any genuine effort to make health insurance more available to more people, you may notice that any such proposal typically includes specific actions like tax credits for purchasing medical insurance, negotiating with health insurance companies at the table, or offering more incentives to HMO's.

Unfortunately, none of these ideas really addresses the underlying causes of our problems with insurance costs or health care costs. Certainly, including insurance companies as equal partners in any planning is like including the foxes in round-table discussions concerning the security of the chicken coop.

The insurance companies are the only interested party who is satisfied with the status quo, because they are the only interested party who is making serious profits at this, and are the only ones who are distinctly for-profit only in their fullest intent and by definition. (Yes, doctors make a profit. We do have bills to pay, kids to put through college and such. However, the ethical and professional mission of the doctor or hospital or clinic is to provide the best possible medical care for its patients.) Patients, doctors, hospitals and politicians all want substantial change.

So: IMHO, any "universal coverage" plan that includes the insurance companies as equal partners and tries to keep their role as close to the status quo as possible without upsetting their apple cart is doomed from the outset to represent little to nothing in the way or substantial and meaningful improvement and change.

"Single Payer"

"Single-payer insurance" or "national health insurance", or "MediCare for all" is advocated by many (disclaimer: including me- more on that later). This would approximate France or Germany's (or. to a lesser extent Canada's) style of health care. Actually, it would approximate the way health care is administered in virtually every developed nation on the planet except ours.

This would mean that all citizens are entitled by right (and not by bought privilege) to a basic level of health insurance from birth to death. This would typically be through a single large insurance pool composed of all citizens and administered by a single large insurer, which is usually the federal government. The State of Oregon has a roughly similar State administered health plan.

"MediCare for all" is a term used to mean the same thing, but in a way that may convey more meaning than the technically accurate but confusing "single payer". Let's face it, the only folks who use the term "payer" here are medical professionals, insurance people and policy wonks. Average folks think "insurance company". MediCare provides for doctor visits, annual exams, cancer screening, care of acute and chronic medical problems, labs, tests, ER, hospitalization and surgery. If you want and can afford more coverage, then you are free to buy it from whoever you choose. Thus, "MediCare for all" is meant to convey the idea of such insurance being extended by the federal government to all citizens, and not just those who are over 65 or disabled.

As is already practiced in many of the other developed countries of the world, the federal government could administer a publicly funded or supported health insurance that would cover the same things that MediCare covers (as described above) and extended to such care appropriate for children, as well. Insurance companies (through employer-based means or otherwise) would fill the niche in the marketplace for those who want to buy more coverage such as improved drug, durable medical equipment or long-term care coverage, or perhaps as specific riders in the same way you can buy homeowners insurance riders on your cameras or jewelry or computers if their value exceeds the basic plan coverage.

So, what do you think about health care reform?

Again, I get asked this a lot by patients in my office, hence this post. I have tried to define all terms as accurately as possible though I'm sure it's evident that I feel the best plan would be for our government to adopt a single-payer model that mirrors every other developed country in the world.

I see no sense in doing so just because everyone else is doing it. I feel we should do so because of the following facts (repeat, facts: not opinions, facts):

• We do not have the world's best medical system, we have the world's 37th best medical system.
• We do moderately well in terms of measurable health quality (24th best), but
• we do very poorly in terms of being able to care for all our people (55th best), though
• we excel (1st best) in emergency care.
• We spend twice as much money per person for this level of performance.
• Unfortunately, one must wonder whether this translates as follows: we have the best emergency care in the world because we have to, since so many people have no other way to get medical care they go to the ER for it or wait until they're crashing and burning to show up, and thus our overall levels of infant death, lifespan and disease occurrence and care suffer for it.
• Economic models prove that having health insurance where you split the pool of people who are insured as we do will lead to exactly the problems we face where people often find that no one will insure them, or they cannot afford available insurance. (Harford, T. 2006. The Undercover Economist, Oxford University Press, pp. 109-110, 113-16, 119-23.)

Additionally, I myself have moral and ethical qualms with the status quo.

• I think it is wrong to have to change doctors because of your insurance or your job.
  
• I think it's stupid to put the entire choice of your insurance in the hands of your boss (not because your boss is necessarily mean, but because your boss has the most incentive of any player in the game to keep the cost as low as possible).
• I think it's wrong for 47 million fellow Americans to have no health insurance. That's 16% of our entire country! That's 1 of every 6 men, women and children! Note that this doesn't even count people who are on MedicAid or MediCal which has so few doctors who will accept it you may as well be uninsured in many respects (these folks are referred to as "under-insured").
• I think it's wrong for the most common cause of personal bankruptcy in our country to be unpayable medical bills. Half of all personal BK's are because of this, and 76% of these BK's involved households that already had medical insurance at the time of the illness.
• I think it makes bad business sense to not significantly change a business model that costs twice as much as other businesses in the marketplace, and in which you are the 37th best producer. Personally, I aim to be the best and not settle for Top 40. Let's stop saying "Thank goodness for Slovenia (#38)!" No offense to Slovenia, I just expect better for the amount of money we're spending.
  
• I think adequate medical care should be a right, and not a privilege that you have to purchase. I do not believe that it is acceptable for those of us who are less wealthy to be left to die younger. ("[i]nasmuch as you did it to one of the least of these My brethren, you did it to Me", if I may make so bold.)
  
• Yes, I put my money where my mouth is. MediCare, TriCARE, MediCal, Workers' Comp and union commercial insurers typically pay quite poorly. However, I have patients on all these insurances because I think you should have a doctor and get medical care regardless of whether or not you are old, a veteran, poor, injured on the job, or are a labor union member. (Mea culpa. If I were a baseball fan, I guess I wouldn't be a Yankees fan. Besides, I'm from Pittsburgh. I still remember Roberto Clemente!)

So, frankly I hope to eventually see a single health insurance in our country that covers all our citizens from cradle to grave and still has doctors and hospitals in the private sector where competition will still create incentives to do the best possible job of providing professional medical care.

Even though some of my previous posts reflect some apprehension on my part with the federal government administering the insurance, it really makes the most sense for them to do so. At least, it makes as much sense as calling the police and the police responding as an arm of the state, and not as the result of several calls to local and competing privately owned security companies.

Even if a 10% increase in income taxes had to occur to fund this (tax is to government as income is to your household), would you still be ahead? Certainly, I would. Given the cost to me of insuring my family and my employees I'd still be cash ahead. That doesn't even begin to include the other costs and savings in not having to pay a billing service and freeing up my registered nurse to work with patients and not dicker with their insurances.

Mind you, some proposals suggest this level of tax increase. Others propose that the costs of providing a national health insurance would be more than offset by savings in doing so (The Physicians' Working Group for Single-Payer National Health Insurance, 2003. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance, Journal of the American Medical Association, 200 (6). 798.).

What about you? Run the numbers, do the math. Compare an increase in 10% on your income tax against the costs of your health insurance premiums or deductions from your pay for this, the amount you spend on deductibles and co-pays. Heck, add in the lost income and vehicle maintenance and fuel costs of going to Folsom or Sac for this if you have Kaiser or some HMO. If those costs are higher than a 10% income tax increase for you, let me know.

But, also add in other factors and hidden costs.

What if...

• Every neighborhood had an after hours clinic that would even do house calls?
• You got pregnant and didn't get refused health insurance because your pregancy is a pre-existing medical condition? Hey, what if actually your insurance included more maternity and paternity leave and home care after the delivery?
• What if when you were diagnosed with a really serious disease like cancer, it meant that your insurance stepped up and covered more of the costs when you most needed it?
• What if everyone had insurance, but it didn't affect your choice?
  
• Would it mean maybe we could do better at preventing deaths that are preventable with good medical care? That would be nice, since right now we are 19th best in this out of all 19 major industrialized countries.
• Hey, for that matter, what if better coverage didn't come with higher taxes?

Just sayin'...

Passage of the Genetic Information Nondiscrimination Act

After a year of political wrangling, despite widespread political support, the president has signed the Genetic Information Nondiscrimination Act (GINA).

Health insurance provisions will go into effect in a year, and employment provisions in 18 months.

Basically, this means that health insurances will be forbidden by federal law from using genetic information (such as genetic testing results for conditions like breast cancer genes or cystic fibrosis) for determining whether you can be insured or for setting premium rates. Employers will be forbidden from using this information for decisions such as hiring, firing, job assignments or promotions.

This is important since over 1,200 genetic tests are presently available to help diagnose or determine possible risk for a wide range of medical conditions. Many patients are interested in getting the tests performed, but also concerned about how the results could potentially be used against them (for example, being dropped by health or life insurances or being fired from their jobs).

Also, many medical studies rely on volunteer participants to be willing to undergo genetic testing and waivers have had to include the possibility of prejudicial use of the test results by third parties. This has certainly made research into genetic diseases more difficult than it already is.

New Problem with MediCare billing: should be worked out soon.

Just to let you know, we have become aware of a problem with MediCare which should be ironed out soon.

If you have recently been told that I do not have a contract with MediCare this is not true.

Long story:
MediCare is a Federal program that sub-contracts its billing to big companies.

It has also recently made requirements that doctors accept automated deposits of MediCare payments to their bank accounts, and also that doctors must bill under newly issued unique identifiers (NPI's) which must be flawlessly and seamlessly linked to doctor names, tax ID numbers and legacy MediCare numbers.

These last two requirements became enforceable just in the last month or so.

At the same time, NHIC (the big billing company that has been doing MediCare billing for California, Hawaii, Idaho and Nevada for years) lost the contract to Palmetto GBA (a different big company that has been doing MediCare billing in the Atlantic seaboard states for years), effective now.

So, basically a perfect storm of conditions, changes in business structure and entities and agencies auditing the process and performing due diligence has resulted in 75% of the doctors in these states suddenly not receiving MediCare payments and their patients being told that their doctors are not MediCare contracted doctors.

Short story:
MediCare screwed up again.

Solution:
We and our local billing company (Data Management Services, or DMSCO) are working with MediCare to clearly link my name and practice with all necessary unique identifiers in accordance with instructions from MediCare, and should have this straightened out ASAP.

In other words, sit tight, don't worry, it'll get worked out.

MediCare

Now, those of you who are over 65 should already know this. This posting is mainly for those who are coming up on MediCare eligibility and are having some difficulty sorting it out (the MediCare part, not the becoming 65 part).

Where can I read more about MediCare?

Why, at that fount of all knowledge, the Internet! Or, more specifically, their website.

When do I go on MediCare?

For the most part, when you turn 65, or are found to be permanently disabled. This is usually after you've already consigned yourself to senior discounts, AARP membership, being called Sir/Ma'am, and have long forgotten those unsolicited mail offers of low-cost life insurance.

What is MediCare?

MediCare is a federal entitlement program that was legislated into being in the early 197o's during the Johnson administration. It was intended to provide medical care for seniors then, and still does.

If you get a paycheck, a part of your pay is deducted and goes toward a number of programs including Social Security, state disability and MediCare. This is probably good for everyone including oneself unless you plan to work right up until you die without an injury. If not, these programs protect you from having to do so.

Basically, MediCare covers all procedures and treatments that are proven to be safe and effective and beneficial. This means things that it doesn't cover are either not proved to be so, or have been proved to be more harmful than helpful. So, when you take it on yourself to pay for a medical treatment where the provider or vendor has told you that insurance won't pay for it you are probably spending your money and time on unproven treatment. But hey, it's a free country.

What does MediCare cover?

MediCare has an annual deductible that rolls over every January 1st. It's pretty nominal (about $150), after which Part A picks up hospital care and Part B picks up outpatient care including doctor visits. An overview of benefits gives more detail; you will need Adobe Acrobat to read it.

Specifically, this includes cancer screening and routine monitoring such as diabetes tests. However, when they say every year they mean no more frequently than every 365 days midnight to midnight.

What does MediCare NOT cover?

Aye, there's the rub.

MediCare does cover medicines but as a separate supplemental Part D. This is covered in detail in earlier postings.

It does not cover in-home care or skilled nursing home care after 90 days of rehabilitation (such as following a stroke). You may wish to look at Long Term Care Insurance; this was also addressed in an earlier posting.

What happens to my regular health insurance?

Well, that depends.

If you've been busting hump at a poorly paying McJob just for the insurance or the money to buy it, you may decide to just let it go and go with MediCare Part A and Part B. You may want to get Part D for drug coverage; the average premiums are around $50/month.

If you have medical insurance through your retirement benefits you may want to look at it's coverage and costs and decide whether it's to your advantage to keep it, especially if it becomes your secondary insurance which is usually the case. Some folks find that they're better off letting it go though many don't as they're simply apprehensive about this.

So what's all this about MediCare becoming insolvent?

Dunno. It's a bit like the way the health care system has been on the verge of collapse for over 40 years without just flat-out collapsing.

Seriously, the issues are that first of all, the MediCare program was signed into legislation when the average life expectancy in the US was about 67-68 years and not 80 years which it is at present. Doh!

Also, the distribution of ages in our population means that where there used to be 5-6 workers contributing part of their paychecks for each senior, now its about 2-3.

Personally and IMHO, I think at some point the US Congress is simply going to have to grab the third rail and decide to increase the age of MediCare eligibility or come up with a way to extend a MediCare like insurance to all citizens with an income tax hike to leverage it.

I hope it doesn't turn into a Catch-22 situation where you get to be 67, and then the age for eligibility gets bumped to 69, and so on and so on. (Yossarian, you still have to fly 5 more missions...)

Corns

Corns are basically calluses on your feet. Nothing more, nothing less. They result from pressure on your toes and feet from day to day activity, and are therefore treatable but not permanently curable. Or, at least no more curable than calluses on the palms of your hands.

Invasive or surgical treatment is rarely needed.

Home treatment is effective, but takes weeks to resolve a corn.

First, keep pressure off it by wearing a doughnut-shaped corn pad around it. It should be soft, but high enough so that when you walk you don't feel your other toes or the shoe against the corn. You may need to stack several pads to do this. You don't need to wear one at night, but you should wear one every day until the corn goes away.

Also, you can buff them off slowly. After every bath or shower, while the corn is still a little softer you can painlessly take a little off with a pumice stone, nail file or emery board.

Feel free to see me if you have one so large that you feel it needs to be pared down a bit. This is painless and does not bleed, since corns are dead skin and have no blood vessels or nerve endings!

MediCare coverage of lab tests

A number of folks (especially diabetics) have expressed concerns that Marshall Lab is saying that routine lab tests are not covered. I have discussed the matter with the Lab Services Director there, and have the following comments to make by way of clarification:

1. MediCare has always, and continues to cover medically needed lab tests.
2. Medically needed with respect to glyco-hemoglobin tests in diabetics (quarterly average blood sugar tests) are:
1. Every 90 days, if stable/well-controlled
2. As often as ordered by doctor if not well-controlled, doctor defines not well-controlled.

So, what's the to-do and what are all those threatening-sounding forms about?

1. Marshall got tired of being burned on lab tests.
2. They got a computer software program that automatically generates a form warning you that MediCare may not pay for a test for any and every test where MediCare defines a time limit.
3. This form is generated for the front-desk people at the lab, who will ask that you sign it whether you are at the time limit or not.
4. This is not meant to say that you will be billed, it is a CYA measure in case MediCare doesn't pay them.
5. The front-desk people have not been educated in the finer points of law and insurance regulations, they are "just following orders".

BOTTOM LINE:

If it concerns you, do "every 3 month" diabetes labs a 90 days or more apart.

If you have been asked to do labs at closer time intervals, don't worry about it. We are careful to complete the paperwork in such a way that it will be covered.

Sunscreen

Gardening season is definitely here, even for those who don't dare to plant before Mother's Day (which is this weekend!).

The active ingredient is the key factor in a good sunscreen, more so than the Solar Protection Factor (SPF).

Micronized zinc as the active ingredient (read the fine print on the container) is overall the best in preventing sunburns and also preventing skin cancer. It lasts longer and is less expensive than other agents, and goes on just like any other sunscreen.

Remember that any sunscreen will oxidize and will need to be replenished every 3-4 hours!

SPF 15 is good for most days, SPF 30 if you will be near snow or water (which reflect sunlight) or at higher elevations. SPF 45 is more expensive, but no more effective than SPF 30.

As an extra bonus, applying micronized zinc oxide once a day (even if you are not going outdoors) can reduce the number of age-related skin spots on your skin by half within a year.

Allergy Medicines

'Tis the season!

Prescription nasal steroid sprays such as fluticasone or Nasonex are the most effective single medication in relieving allergy symptoms. The absorption into bloodstream is so low (about 0.03%) that long-term adverse effects do not occur. However, they therefore have to be used every day during allergy season and can take a week or two to start working.

Antihistamine pills work by blocking allergy reactions. Benadryl works very well, but makes most people feel drowsy. As a rule, the more effectively an antihistamine works in relieving symptoms, the more likely it is to cause drowsiness. That being said, over-the-counter Zyrtec is stronger than Claritin.

Decongestants such as phenylephrine and pseudoephedrine may also help, and they are often added to over-the-counter remedies so check the labeling carefully! Some people have an elevation in blood pressure with them, so use with caution if you have heart disease.

Do not use decongestant nose sprays (Afrin, Neo-Synephrine, 4-Way, etc.) for over 3-5 days. Rebound is common with these, which means you can develop dependency on it because you get more congested every time you stop using it.

NasalCrom nose spray is very safe and effective if used 3-4 times a day every day for mild allergic nose symptoms.

Naphcon-A eye drops are a great anti-allergy eye drop for itchy watery eyes, and went over-the-counter a few years ago.

Allergy de-sensitization shots improve allergy in around 30% of folks who go through the every 2-4 week shots for about 2-3 years.

Using the Internet for Medical Questions

According to folks who study this sort of thing, up to 40% of internet searches are about medical or health questions or topics. That seems about right to me!

I get a lot of questions regarding the interface between medicine and net based information. I used to give patients a list of specific websites, but it became impossible for me to keep it up to date.

Generally, you should not feel abashed about researching on the internet or asking about your findings. There can't be anything wrong with being seriously interested in your own body and your own health!

At the same time, you should be just as critical or inquiring of internet based sources of information as you would for any other medium such as TV, books, magazines, newspaper or word of mouth. In other words, don't judge a book by its cover. Anyone with a modest level of computer skills can produce a very polished looking responsive website. Do not assume that a finished appearing website with a fast server is necessarily a good source of information.

Websites representing professional medical opinion should reflect this, while those representing personal opinions or chat rooms should be distinctly so. In other words, the Mayo Clinic's website very clearly represents a professional institution while the website of a person who has a specific condition such as M.S. will be representing their personal outlook and experiences. Both may be useful to you, but should be read with the author's background and point of view in mind.

It is difficult to use the internet deductively rather than inductively. That is, looking up a specific known diagnosis such as iron deficiency anemia will yield a wealth of information on that subject. Searching a collection of symptoms such as tiredness and fatigue and dizziness can lead to an overwhelming list of possible diagnoses which could include iron deficiency anemia, but also brain cancer, lupus, syphilis and diabetes.

In other words, trying to diagnose using the internet is difficult. But then, if it was easy medicine would not be defined as a profession!

Do I Have Arthur-itis?

Ahh, arthritis. A common lament.

Actually, arthritis is not a specific diagnosis. It is a symptom that describes pain in your joints.

Any initial evaluation of arthritis should consider uncommon but potentially disabling forms of arthritis in which your immune system is actually attacking your own joints. Yes this can happen, often runs in families and can be treated very well by a rheumatologist with medications that can alleviate pain and prevent crippling deformity. Examples of these kinds of arthritis include rheumatoid arthritis and systemic lupus erythematosus (lupus).

By far, the most common kind of arthritis is simply related to day-to-day, year-to-year wear and tear on the cartilage that lines your joints. Most folks call this age-related or wear-and-tear arthritis. It is technically called degenerative joint disease or osteoarthritis.

This will affect load-bearing joints such as shoulders, back, hips and knees and also frequently used joints such as the fingers. It differs from the nastier ones described earlier by typically being worse as the day goes on, and not being at its worst first thing in the morning.

What to do for it?

First, stay active. Avoiding absolutely everything that hurts can be worse in the long run because you can gain weight which will increase the load on joints, and lose muscle strength that supports your joints.

Exercise that is non-weight bearing is best: swimming, water aerobics, aqua running. If this is not practical, exercise that does not involve impact against the ground is good. This is referred to as closed-kinetic chain exercise and includes bicycling, stationary bike, elliptical trainer, Stair Master, etc.

Applying ice or a warm water bottle several times a day is also helpful.

Tylenol would be the best medication to use first. It relieves pain as well as any other over-the-counter or prescription medicine and has fewer side-effects. Kidney injury is rare, it cannot cause bleeding or stomach problems and it cannot hurt your liver (if you have hepatitis or drink over 2 drinks a day, cut the following doses by half or bring it up with your doctor).

The correct dose of Tylenol (or generic acetaminophen) is 1,000 mg at a time, 3-4 times a day. Yes, that's 8 extra-strength Tylenols a day.

If you take an aspirin a day for your heart or are on "blood thinners", it is okay to take Tylenol. It does not interfere with the aspirin's ability to prevent heart attacks and strokes, and cannot cause bleeding, and does not interfere with Coumadin/warfarin.

If that isn't enough, try adding topical capseicin (such as Zostrix). This is a topical ointment containing an oil-based extract of cayenne pepper. You apply it to your arthritic joints 3-4 times every day. It burns a bit for the first week or two, but after this it relieves arthritis pain by depleting a chemical that your nerves use to send pain signals to your brain. Native Americans in the Southwest have eaten cayenne for centuries as a treatment for pain. Applying it as an ointment works very well to relieve pain, though you should wash your hands thoroughly after rubbing it on!

If Tylenol and Zostrix are not adequate, then you may want to try anti-inflammatory pain relievers (NSAID's) such as Advil or Aleve instead. Tylenol is usually worth trying first since wear-and-tear arthritis doesn't cause joint inflammation.

Prescription level doses on these are double those on the label: 4 Advils 3 times a day, OR 2 Aleves 2 times a day.

• Do not take NSAID's along with Tylenol. You should only use them if Tylenol isn't working well enough, therefore you should then stop the Tylenol.
• Do not play mix-and-match. Use on or the other, not both.
• It's okay to take them with food or on an empty stomach.
  
• You cannot use NSAID's with Coumadin/warfarin or Plavix/clopidogrel which are prescription "blood thinners". Taking NSAID's along with these can cause fatal bleeding problems.
• If you have had a heart attack or have congestive heart failure, you should consider use of NSAID's with caution. They can keep aspirin from protecting your heart, and can cause fluid retention which could worsen your heart disease.
  
• If you take an aspirin a day to prevent heart attacks or strokes, you may as well stop taking it since the NSAID keeps the aspirin from doing its job. Yes, that does mean you are losing your heart attack and stroke protection!
• You can prevent these medicines from causing an ulcer, which is definitely worth doing, especially since 85% of these ulcers are totally painless.
• Take one 20-mg Prilosec OTC a day, and this will reduce the chance of an ulcer to nearly zero.
• Ignore the labeling on the package about not taking it for over 14 days. Or rather, do not suppose that this means it's not safe to use. The label is intended to keep folks from using it for stomach pain for over two weeks without seeing a doctor about it.

Narcotic pain pills may be appropriate for treating arthritis since the disease can really impact your quality of life. However, they have numerous side-effects and can be addictive so should be used with caution.

Mail Order Pharmacy

Mail order prescription services are known to your medical insurance companies as Pharmacy Benefit Managers (PBM's).

PBM's are middlemen that obtain contracts with pharmaceutical manufacturers ("drug companies") for discount prices on large sales volumes for the insurance companies. In theory, this is supposed to be a win-win situation for everyone. The insurance companies save money on cost of medications, they incentivize you to participate by lowering the out-of-pocket cost of your pills, and otherwise pass on the savings to you.

Of course, you could reasonable ask why your premiums keep going up, but that's a topic for another time. You might also ask what that's doing to your friendly and trustworthy local pharmacist, but I guess the idea is that it's a tough old world out there.

If you want to use your PBM, and would like our help in making it work for you as smoothly as possible,

• They will usually send you a renewal form for each of your medicines when your yearly prescription is up.
• Please let us use these for renewals. Using hand written prescriptions for renewing already existing prescriptions is very confusing to them.

• PLEASE, PLEASE USE YOUR LOCAL PHARMACY FIRST FOR NEW MEDICINES OR FOR CHANGES IN DOSES ON MEDICINES!
• It's not unusual to start or change a medicine, only to find that you have to switch to something else because of side-effects, or that you have to make another change in dose at the follow-up visit.
• Because of this, it's a good idea to make sure that the medicine and it's dosage is right for you before getting 3 months worth for a year!
• Yes, we know it's cheaper to do mail order.
• Yes, we know a few dollars is a lot of money these days, especially if you are on a fixed income.
• The problem is that serial mail-in prescriptions reflecting changes in medications and/or dose changes can lead to confusion as to your medications.
  

Do I Need Antibiotics Before I Get My Teeth Cleaned?

Short answer: For most patients, probably not.

Long answer:

The American Heart Association has been refining recommendations on who should take antibiotics before certain kinds of surgeries or procedures for about 50 years.

Revisions to prior recommendations were made last year. Factors that weighed into these new recommendations included existing evidence, recognition that bacteria entering the bloodstream occurs with normal daily activity, and the awareness that antibiotic use itself is not without risk.

Who may need antibiotics for dental visits? Those with conditions of highest risk for heart infections as a result. These would be folks who (1) have had heart infections before (Infectious Endocarditis), (2) those who have artificial heart valves or heart valve repairs using artificial materials, (3) those who had a heart transplant and then developed heart valve problems, and (4) those who were born with structural heart problems (Congenital Heart Disease) which were not repaired, or were repaired with artificial materials.

What kind of dental visit needs antibiotics? This would really depend on what your dentist plans to do.

What antibiotics should be used? Amoxicillin is the best choice, though there are several alternatives if you allergic to it. The antibiotics should be taken 30-60 minutes before hand, though could be taken for up to 2 hours after the work.


PLEASE NOTE:

We will work in conjunction with your dentist to identify whether you fit into one of the four high-risk groups described above.

However, only your dentist knows whether what they plan to do will make antibiotic treatment beforehand advisable or not. That decision needs to be made by them.

Peter Lockhart, DDS, Chair of Oral Medicine at Carolinas Medical Center is a member of the committee that wrote these new recommendations, and comments that:

"the primary care physician’s responsibility is to determine whether the patient has one of the four qualifying cardiac conditions. If the patient has one of those conditions, it’s the dentist’s responsibility — not the physician’s — to determine whether the upcoming dental procedure warrants prophylaxis."

Back Pain

Back pain is the most common problem people see a doctor for, and runs to about $6,000 per person per year in terms of U.S. medical care expenses. So, it's not just you...

Sudden back pain certainly gets your attention, and should also raise some concern especially if a cause is not evident.

Alarm bells should go off if back pain comes with fever, chest pain, shortness of breath, vomiting, loss of normal bowel or bladder function or tingling or weakness in your legs. These may be signs of infection, heart attack, aneurysm rupture, or spinal cord injury and should prompt urgent medical care.

However, most back pain that comes on for no memorable reason or after a hard day brush clearing or gardening is the result of muscle strain.

When this happens, muscle and other connective tissues are torn and your body responds through inflammation which tries to limit the damage by causing swelling and pain. This limits further use of the inflamed strained muscle until it can heal.

Unfortunately, this inflammatory response can be counter-productive as anyone who has "pulled a back muscle" can agree!

So, best treatment at the outset is a cold pack for 15-20 minutes 3-4 times a day for the first day or two to decrease inflammation to the area. Do not put ice right to the skin as this can cause frostbite injury. Use a chilled rice bag or other cold pack.

After the first day or two, use warm packs if this feels better. Do not overuse heat as this can cause burns or worsened muscle spasm.

Anti-inflammatory pain relievers are helpful for both relieving pain and also reducing the inflammatory response. Examples include aspirin, ibuprofen (Motrin, Advil) and naproxen (Aleve). These should be safe to use for brief periods of time assuming that you do not have any pre-existing stomach, liver or kidney problems.

If you smoke or drink or have ever had an ulcer (or if you are simply interested in keeping these medicines from being able to cause an ulcer while you take them), take one 20-mg Prilosec/OTC a day while you are using these medications. This medication is not dangerous to take for over 14 days. The warning on the box is to prevent people who take it and overlook dangerous symptoms from suing the manufacturer.

Please note that normal adult prescription level doses of Aleve would equal two pills twice a day, and Motrin at four pills three times a day.

Normal daily activities can be continued. Just pay attention to your body, and avoid activity that starts to worsen pain.

Back pain can actually take a surprisingly long time to go away. Half of people with simple back muscle strain have pain that lasts over one month; one quarter for over three months and ten percent of folks take over six months to heal up!

If your back is taking longer than seems right, physical therapy can be very helpful in alleviating some of the pain and in strengthening underused muscles that can add support to your back and help you heal more quickly and also prevent re-injury.

Cheap Drugs (Inexpensive Prescription Medications)

Times are, as they say, tight.

While I'm no particular fan of Wal-Mart, they are offering $4/30 days on over 360 commonly prescribed medications. That's mighty tough to beat. Yes, that's $4.00 for up to 30 days on normal dosages which is 13 cents a day.

Cash paying patients should compare this to other large operations such as Rite-Aid and Long's where the average mark-up on medications is 5-6 times the Manufacturer Suggested Retail Price (MSRP).

If you have prescription drug coverage including "mail-in" pharmacies (Phamacy Benefit Managers, or PBM's) this still might beat the co-pays.

Furthermore, these are real every day widely used medicines and not oddball rarely used ones.

Check it out.