Sunday, May 19, 2019

Baby, its later than you think

A recent New York Times Op-Ed piece had the catchy title “Don’t see your doctor in the afternoon.” It was prompted by a study published in JAMA Network Open that had the much less catchy title “Association of Primary Care Clinic Appointment Time with Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening.” The study found that the frequency of appropriate ordering of mammograms was highest (64%) for patients with 8 AM appointments and lowest (48%) for those seen at 5 PM. Similar results were seen for colorectal cancer screening, (36.5% at 8 AM and 23.4% at 5 PM). [Why so much lower for colon cancer screening is a subject for another day.] Patients did not follow through with all the recommended testing, but the trend was the same, with more patients completing the recommended tests if they had early morning appointments.
Why is this? Part of it is simple fatigue as the day goes on. Similar results were found when the National Highway Safety Administration looked at when most fatal traffic accidents occur. The evening, but not the morning, rush hour saw the greatest number of fatal accidents. Decision fatigue is used at car dealerships, where the most expensive and unnecessary options tend to be given at the end of a series of choices. Doctors, believe it or not, are human. We get tired as the day goes on, and fatigue clearly has a negative effect on decision-making. There is also the factor that primary care doctors these days have impossible workloads, with more things to be crammed into a 10-15-minute visit than can possibly be done, and the ever-lurking electronic record and its insatiable demands for data making things worse. We know that talking someone into a screening test takes time, and it is much easier to do this before we are already half an hour behind schedule.
While not recommending a screening test can be made up at a later visit, I strongly suspect that other forms of decision-making also suffer as the day goes on. It is much easier to prescribe an antibiotic that we know is not needed than to explain why the patient would be much better without it. I don’t have the data, but I would be willing to wager that more diagnostic errors are made on the last patients of the day than the first.
What can be done? Ideally, doctors would have more time for a visit and not be so rushed. In the real world, when you are scheduling your next visit, try hard to make it early in the day, before your doctor is too tired to think optimally.

Prescription for Bankruptcy. Buy the book on Amazon

Monday, May 13, 2019

Doctor - could I have Alzheimer's disease?

As my patients aged along with me, I noticed both the expected increased numbers of people with some form of dementia and even more patients who were worried about this topic. Unless you have been away on a ten-year safari, you are very aware that dementia is a growing problem. Some 5.8 million Americans are living with Alzheimer’s Disease, and similar numbers occur in most western countries. The incidence goes up with age, and we are living longer. As I responded to a questioner recently, the only way I know of to avoid getting the disease is to die young (which I don’t recommend as a preventive strategy).
The subject gets complicated because normal aging is often accompanied by some mild memory loss. A not-unfamiliar dialog between a couple in their 70’s might be: “I was thinking we might watch a movie – the one with that actress we both like.” ”The one that starts with M?” “Yes, Meryl.” Which movie?” “Oh, the one we thought was out of her usual.” “You mean that comedy?” “Yes, about a wedding.” “OK – the Abba musical.” “That’s the one!” Mild changes in memory or less ability to quickly learn new facts are both common as we age and do not usually interfere with functioning.
There is also a condition called “mild cognitive impairment” (MCI) in which the changes in thinking and memory are more than one would expect with normal aging but not severe enough to be called dementia. The latter usually includes both memory loss and some other symptoms such as trouble with word-finding, getting lost in familiar places, inability to cope with unexpected events or handling complex tasks. Some, but by no means all, people with MCI will go on to dementia and doctors really cannot predict which will.
If a person appears to have dementia, the task of the primary care physician, often with the help of a neurologist, is to decide what is causing the dementia. While Alzheimer’s Disease is the most common, there are a variety of other brain diseases that can cause dementia. While there are some clues to be gotten from detailed brain imaging, particularly the PET scan, Alzheimer’s is in essence a clinical diagnosis, as there are no blood tests that can be used. It is important to not overlook the treatable causes of dementia. Depression can cause a “pseudo-dementia,” and a variety of medications can do this, including many that are used by the elderly. Both B12 deficiency and an underactive thyroid can cause dementia; while infrequent, testing for these is easy and reliable and should always be done once.
To complicate matters, a group of neurologists specializing in dementia have recently proposed that, particularly in the oldest group, over 80, a newly described condition they call LATE, for “limbic-predominant age-related TDP-43 encephalopathy,” may be even more common than Alzheimer’s and may co-exist with it. Their main reason for bringing this to doctors’ attention is that this condition does not respond to the medications used now to slow the progression of Alzheimer’s. The main reason in general to try to make a specific diagnosis is to guide treatment. There are no cures for Alzheimer’s or most of the other dementing illnesses. The medications we have are modestly useful in slowing the inevitable progression of the disease, but that is all they do.
Can you ward off Alzheimer’s without dying young? About all we know is that regular exercise does lower the incidence of dementia, and that a healthy plant-based diet also has modest protective effect. Keeping the brain busy by learning new things is also probably helpful.
So, if your only problem is occasionally forgetting where you left the keys but do find them, you can relax. You probably do not have Alzheimer’s. Get out there and exercise, eat healthy and learn a new language.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, May 4, 2019

Who is to do the rationing?

One of the arguments made against adopting single-payer health care in this country is that it would “lead to rationing.” This assumes that we lucky people in the US have unlimited access to whatever health care we need and are at risk of losing it. This argument came to mind when I saw a few recent news items. One was that a federal judge, US District Judge Robert Scola, recused himself from a case in which a cancer patient was suing United Healthcare for their refusal to cover the recommended proton beam therapy for his prostate cancer. Judge Scola said he could not rule on the case impartially because he himself had been treated for prostate cancer and had been offered proton beam therapy (though he ultimately chose surgery). In his order of recusal, he wrote “To deny a patient this treatment, if it is available, is immoral and barbaric.” Saturday’s Boston Globe featured an article about a young woman with advanced cancer of the cervix who was referred to Mass General Hospital for proton beam therapy whose insurer refused to pay for the treatment despite multiple appeals.
Moving from anecdotes to a larger sample (and I am well aware that the plural of anecdote is not data), I found a survey conducted among radiation oncologists this Spring. Nine out of ten said their patients faced delays in getting recommended therapy for their cancers. Almost a third (31%) said that such delays lasted more than five days, the equivalent of a standard week of therapy. The reason that this is important is that for every week therapy is delayed, there is about a 2% increase in mortality. Almost two thirds (62%) said that the denials were ultimately overturned on appeal, making one wonder why the therapy was denied in the first place. Having been harassed for years by insurance company clerks over getting approval for tests and treatments, I have my own theory, which is that the insurer hopes that blanket denials will weed out many expenses, as the doctor will be too busy or frustrated to spend the time to appeal, thus saving the insurer money. As I note in Prescription for Bankruptcy, an AMA survey in 2018 of 1,000 physicians found that 92 percent felt that prior authorization programs delay access to care, with 78 percent saying that prior authorization causes some patients to abandon recommended tests or treatments. Maddeningly, 30 percent said they had waited three or more days to get a decision from the insurance company. The radiation therapists noted that when their appeals reached the point of speaking to a “peer,” the physician with whom they spoke was almost never in that field and often demonstrated little knowledge of the problem being addressed. Put this together with Aetna’s recent settlement of a lawsuit alleging that their physician reviewers rarely even read the patients’ records before issuing denials, and one sees a pattern. While there is room for legitimate disagreement about the value of some therapies, it is inappropriate for the insurer, with a clear financial stake in the decision, to be the decision-maker about what tests and therapies are covered. In any rational health care system, the determination about paying for a procedure would be made by disinterested experts who could look at the scientific evidence and make a recommendation with no financial stake in the outcome.
Rationing? We have rationing now, but the rationing is done by those who save money from doing this. In my ideal system, patients, clinicians and statisticians would make evidence-informed guidelines. In the absence of such a rational process, I would rather this be done by “bureaucrats” than by the for-profit insurers as it is now.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, April 27, 2019

Is anyone healthy?

A wag once said: “There is no such thing as a healthy person, just one who has not had enough tests.” As we make every minor deviation from the average into a disease, that jest is becoming uncomfortably close to the way our current medical system behaves.
Part of the problem is that many “diseases” represent an arbitrary cut-off of a number. Thus “hypertension” is defined as a blood pressure above a specific threshold. We all have blood pressures, and these pressures vary from minute to minute. Clearly everyone with any medical background would accept that a BP of 220/150 was a very bad thing and should be treated. But how about 142/90? To demonstrate how arbitrary any number is, consider that the diagnosis of hypertension starts at 140/90 according to the European Guidelines, and 130/80 according to the US Guidelines. The US definition was recently changed to a lower cut-off, overnight classifying tens of millions of people as having a disease. Using this definition, almost half of all adults would now carry a diagnosis of hypertension.
Before the discovery of insulin, pregnant women with diabetes all died. Once insulin was introduced, diabetes became a treatable condition, and doctors went looking for it. Since blood sugars also range widely, and reflect when and what we last ate, arbitrary thresholds were set to define gestational diabetes, or diabetes developing during pregnancy. The numbers used were changed in 2008, not because of new knowledge but by consensus among experts. As is virtually always the case, the numbers were set to label many more women as having the disease – and therefore creating many more customers for the physicians treating them and the pharmaceutical industry.
Then there are “diseases” that are only laboratory numbers. Thus “chronic kidney disease” is defined by a serum creatinine above an arbitrary number. The number picked does not take into account that kidney function slowly deteriorates with normal aging. Almost half of older adults are thus labelled as having chronic kidney disease even though most of them will never have any symptoms from their kidneys in their lifetime nor benefit from any treatment.
Proponents of these expanded definitions may well have the best of intentions, but over-diagnosis is not harmless. In many cases, people newly labelled with a disease are put on medications that are of minimal benefit and may do harm. They may become uninsurable or may have to pay higher premiums for life and health insurance.
The “expert panels” that promulgate these definitions almost invariably make changes that expand the pool of patients. They rarely look at the downside of over-treatment, and they tend to be dominated by academics with multiple financial ties to the pharmaceutical industry.
Your best defense against being labelled with one of these “diseases by definition” is to suggest that your doctor give you 6 to 12 months of lifestyle changes before giving you either a label or medication. Perhaps the desire to escape being labelled as hypertensive or pre-diabetic may be just what you need to motivate you to lose that 10 pounds you have always said you would and to start walking at lunch time.

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Saturday, April 20, 2019

So, you are going to "rehab"

This is the scenario. You (or your mother) were admitted to the hospital with pneumonia. On the third day a cheery continuing care nurse comes in and says “you don’t have a fever any more and the doctors feel you can be discharged to finish your course of antibiotics but your nurse tells me you are still too weak to go home, so we are going to send you to rehab. Here are three facilities that have a bed for tomorrow. Why don’t you discuss this with your family and tell me which one you prefer.” This happens dozens of times a day in every community.
Several issues immediately arise. The first is that when you ask the continuing care nurse which is best, she tells you she is not allowed to make a recommendation. Another is whether this transfer is really necessary or whether another day or two in hospital would allow you to go home instead. If a rehab stay is necessary, how do you decide on a facility with very little time to research your options?
Remember that hospitals are paid by Medicare based on the admitting diagnosis, not on how long you are hospitalized. For pneumonia, the hospital will get the same payment if you are out in 2 days or spend two weeks. This means that the incentive is to get you discharged ASAP. If you feel you are almost ready to go home, dig in your heels and say you want to stay another day and then go home; they won’t like it, but will usually agree.
Also, critically: Medicare will pay for a rehab stay only if you are admitted to hospital and spend three nights. “Observation” days do not count. As the patient, you have no way to tell an official admission from an observation stay – same room, same bed, same nurses most of the time. ASK!
Most hospitals will not make recommendations about facilities. Hospitals say their reluctance is due to fear about violating a government decree that hospitals may not "specify or otherwise limit" a patient's choice of facilities. But that rule does not prohibit hospitals from sharing information about quality, and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality nursing homes while still giving patients all alternatives. Most hospitals simply dump the choice in the lap of the patient and family.
One easy way to get a “first pass” screen of nursing homes is to use the Medicare web site. Go to and enter your zip code. You will see a list of all Medicare-certified nursing homes and their ratings across the results of state health inspections, staffing ratios and “quality measures.” These are listed by distance from the zip code given. Staffing ratios are obvious: the more nurses, aides and therapists per resident the better. The quality measures include such things as how often residents were successfully discharged to community setting, how often they had unplanned ED visits or readmission to hospital, how often antipsychotic medications were started and others.
This information will let you immediately eliminate the poorly-rated nursing homes – and if all the ones on the list with openings are one or two-star (out of five), I would refuse all of them. If one or more are four or five-star, you are probably safe. The next step is to have a friend or family member visit and get a gut feeling. Do not be over-impressed with the newness of a facility or the paintings on the wall. You are, hopefully, not going to be there long, nor is this a hotel. What is crucial to a good recovery is the staff. Look around. Are most of the residents restrained in chairs? Visit the PT department. Ask residents about the food and about how quickly call bells are answered. If the staff seem defensive and uncomfortable answering such questions, this is probably not the facility to choose.
Once you are at a rehab facility, the more family involvement the better. It is human nature for the staff to pay more attention if they know concerned family and friends are around a lot. They are also the best ones to notice if things are not going well and seek remedies. Be sure to eat even if the food is not home cooking: you cannot recover without adequate nourishment. Even if you would rather rest, do your physical therapy. Remember, the more work you put in, the sooner you get out of there.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, April 13, 2019

When is a check-up not a check-up?

Kaiser Health News told the story of a 69 year old woman who went to a new doctor for her annual check-up, assuming it was covered by Medicare, and was happy with the visit until she got a $400 bill.
Most Americans believe in “annual check-ups,” at which your doctor reviews your medical history, gives you a thorough physical and orders lab tests. The actual value of such visits has been questioned, but they are ingrained in our psyche. Such “well visits” are helpful for children, where preventive care, including counselling and immunizations, adds value. It is not of nearly as much value in adults, and the vaunted “executive physical,” with its extensive battery of tests has been largely discarded. Yet, most of us still have gotten used to seeing our doctor once a year even if we are feeling fine.
When Medicare was first established, it was specifically geared to treating illness, and preventive care was excluded from coverage. Over the years a variety of preventive measures have been added as covered services, including screening tests and immunizations. A full list of these can be found at The newest addition to this list is the “Annual wellness visit,” which is fully covered under Part B. For those who are used to seeing their doctor for an annual check-up, this sure sounds like the same thing, and it does to many doctors as well. Unfortunately, if your doctor conducts this visit in the same way, with a review of your history, a physical and lab tests, you are likely to get an unexpected bill.
The Medicare Annual Wellness Visit is a very limited and specifically described set of services. At this visit your height, weight and blood pressure are to be measured, but no other physical exam is to be performed. The doctor is supposed to assess your risk of falling, your ability to bath and dress yourself and whether you are safe at home. You are to be screened for depression and dementia. Medications should be reviewed. A schedule of preventive services should be provided. If you have seen this doctor regularly, these may sound like a waste of time, and they may well be. I rarely did such visits. If at his last visit a patient had told me he had chopped too much wood and was willing to sell me a cord cheap, I would have felt like an idiot “assessing his fall risk.” What the doctor cannot do at such exams is check your blood pressure, tell you it is a bit higher than ideal and adjust your medication; if he or she does this, it is outside the parameters of the Wellness Visit and not covered. Because of the limited nature of the visit, over half of medical practices surveyed a few years ago did not offer these visits, and only 19% of Medicare beneficiaries received one.
What makes it even more confusing is that some (but not all!) Medicare Advantage plans WILL cover an old-style Annual Check-up.
So, bottom line: if you have standard Medicare, do not schedule an “annual physical” unless you are prepared to pay for it. Assuming you, like most of us over 65, have some chronic conditions being monitored, you should be able to get a longer visit at which all of these are addressed and the doctor has enough time to throw in a little more preventive care.

Prescription for Bankruptcy. Buy the book on Amazon

Monday, March 25, 2019

My last doctor said I had lupus!

During my time in practice, I had at least eight patients who came to me sure they had systemic lupus erythematosus, also commonly called SLE or lupus. This is an “autoimmune disease,” characterized by joint pain, that can affect almost any organ, including skin, kidneys, brain and heart, and can even be fatal. In every case, they had been given this diagnosis because of a blood test called an ANA, for anti-nuclear antibody. Not one of these women (they were all women) actually had lupus. Why then were they told they did?
All of us, doctors and patients, tend to have too much faith in tests. When something is written on paper with a decimal point, it must be true, right? What is hard to accept is that just as a patient’s story may change with retelling, or a doctor may not hear a murmur they did hear previously, lab tests are far from perfect. If your serum sodium was 137 last time and is 144 this time is that different? Quite possibly not. Plus/minus 3-4 % is normal variation; even if you took a tube of blood and split it in two and sent the samples labelled Smith and Jones, they would be unlikely to have identical results.
Many tests do not have numeric results but are “positive or negative” or “normal or abnormal,” and here is where it gets complicated. Essentially every such test used in medicine, whether it is a strep screen or a cardiac stress test, has false positives and false negatives. That is, you are fine but your test is not (false positive), or you are sick but your test is fine (false negative). A test for which 90% of sick people had an abnormal result and 90% of well people had normal results would be considered a very good test. Thus, any test must be interpreted in the context of the person on whom it is done. If you are a middle-aged smoker with high cholesterol and you have been having chest pain when you take out the trash, then a positive stress test helps to confirm that you have coronary disease. If you are a fit 30-year-old woman whose family all lived to 90 and have a stress test as part of an executive physical, a positive test is most likely to be erroneous, a “false positive.”
So, let’s get back to my patients who were told they had lupus. The most widely used screening test for lupus is the ANA. It is a very useful test, because 99% of people with lupus have a positive ANA, so a negative test makes it very unlikely the person has the disease. The problem is that about 30% of healthy people also have a positive test. There are ways of making the test better, but these are often not done by non-specialists. So, indulge me in some simple math. Lupus is not a common disease, but neither is it really rare. About 1 of every 200 people going to a doctor for joint pain have lupus. As noted, about 30% of all people, sick or well, have a positive ANA. So, if you do an ANA test on all 200, the one who has lupus will have a positive test, and so will 60 people who do not. This means that 60/61, or 98%, of the positive tests will be false positives. If the doctor does not take this into account, it is easy to tell someone that their test says they have lupus as the cause of their joint pain, when they actually have something else and a false positive test.
The bottom line: do not take medical tests as gospel. If you get a new diagnosis, question it. If you are not entirely satisfied with the explanation, consider a second opinion.

Prescription for Bankruptcy. Buy the book on Amazon