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

Tuesday, March 19, 2019

Will an Apple watch really save your life?

Last year, Apple’s Tim Cook shared widely the story of an 18-year-old Florida girl who claimed that her watch saved her life by alerting her that her pulse was 190, prompting her to go the hospital for evaluation. She was found to have kidney damage of which she was unaware and referred for treatment. My problem with that heart-warming story was that it was hard to believe she was not aware of that rapid a pulse on her own, and that it may have had nothing to do with her kidneys. This week we have been bombarded with news from a study reported at the Annual Meeting of the American College of Cardiology about the watch’s ability to detect previously unknown atrial fibrillation and thereby “save countless lives.”
First, a brief word about atrial fibrillation (AF). AF is a very common heart rhythm disorder that gets much more common with age. While rare in people under 50, it may affect as many as 10% of those over 75. Most people with AF are very aware of the condition because the heart beats very fast as well as erratically. A few have no symptoms, particularly if they are on a medicine for some other reason that slows the rate. AF can be associated with heart failure and, most ominously, it is associated with a greatly increased rate of stroke. The accepted wisdom is that most patients with AF should be on blood thinning drugs to prevent stroke except for the minority who have absolutely no other stroke risk factors beyond the AF.
The study looked at the ability of the watch to use an app to detect AF. Over 400,000 people self-enrolled on an invitation they got when they down-loaded the Heart Study app. A pulse notification was received by 2161 (0.5%) participants. Not surprisingly, notification was highest in those over 65 (3%) and lowest among those under 40 (0.2%). ECG patches were sent to 658 participants and returned by 450. AF was identified in 34% of those who were notified and wore the patch.
So, a few conclusions can be made. First, the watch can pick up some cases of AF. Second, it has many “false positives:” people who did not have AF despite what the watch said. A huge problem is that the study was not designed to detect “false negatives:” we have absolutely no idea how many of the participants did have AF that was not detected by the watch because no one got a patch who did not receive an AF alert. Since Apple watch wearers tend to be younger and healthier than non-wearers, many of the alarms are likely to be false positives, thereby causing anxiety and unwarranted health expenditures to evaluate the alarms.
Another problem with the study is that we really have no idea whether treating younger people who do truly have AF detected by the watch will help or harm them. The evidence that using blood thinners prevents strokes was all obtained back in the 1990s and came from people who had symptomatic AF. These drugs have enormous potential for harm from bleeding, and it is very possible that treating people found via apps may do more harm than good.
So, take the hype with a grain of salt. Enjoy your watch but do not depend on it to save your life.

Prescription for Bankruptcy. Buy the book on Amazon

Monday, March 11, 2019


Case 1: On March 1, ABC News reported the story of a Florida woman bitten by a stray cat she was trying to help. Having heard about rabies in stray animals, she went to the closest emergency room, where she got her first rabies vaccine and was also given an injection of rabies immune globulin, designed to protect the victim before the vaccine takes hold. She also later got a bill for $48,512, of which $46,422 was for the immune globulin. The product is not in particularly short supply and is available from three manufacturers and the average price paid by hospitals for the dose she got would been about $4334.
Case 2: A posting on Kaiser Health News back in November epitomized much of what is wrong with health care in today's America. An English professor in the California state university system went to Stanford University's outpatient clinic for help with a rash that she thought might be due to a cream she had been prescribed. She had 119 tiny plastic containers taped to her back and ultimately learned that she was allergic to a variety of things, including the ingredient in her cream. All well and good until she saw that Stanford had billed her insurance company for $48,329! This included $848 for the time she spent with the doctor and $399 for each of the 119 small samples taped to her skin. The "usual and customary" charge in the San Francisco Bay area for this is $35 per sample.
Case 3: There is also the story I recount in Prescription for Bankruptcy about a man who was mugged and taken to the emergency department for attention. He was aware (and concerned) enough to check before being transported that the hospital to which he was taken was “in network” for his insurance. He had suffered a broken jaw and was taken to the operating room for repair. Weeks later he got very large bills from the oral surgeon and anesthesiologist who cared for him who were not in his insurer’s network.
These three cases cover most of the causes for surprise medical bills. The Florida cat lover was at the mercy of price-gouging by the hospital she went to for help. The California professor and her insurance paid astronomical prices to the prestigious hospital system that knows it can overcharge because they are in the driver’s seat. It is hard to sell a health insurance package in northern California that does not include the perceived leading hospital in the area. The mugging victim was victimized a second time because even when a hospital has signed a contract with a health insurance company, many of its doctors may not. This practice is particularly common among specialties where the patient does not really have much choice in who sees them: emergency physicians, radiologists, pathologists and anesthesiologists.
Hospitals are now required to post their charges on-line, but to date they have (probably deliberately) done so in the most abstruse manner possible, using obscure terms that most non-medical people find hard to read or search. Hopefully some clever people will soon come up with an app to make the search more user-friendly.
What can you do about these nasty surprises? For diseases – like rabies – with obvious public health importance, you may be able to get treated at your local public health department for free. DO NOT POSTPONE TREATMENT to save money. If your problem occurs on a Saturday, go to the ED.
You must get in the habit of asking the doctors assigned to you if they take your insurance. Do not assume that they do because they are affiliated with a hospital that does. If you get an obviously-inflated charge compared to what others charge, you are entitled to, and should ask for, an itemized bill to see why the total is so high. First take your complaint to the hospital administration and offer to pay a more comparable charge. If that is rejected, and you have employer-paid insurance, take the bill to your HR department and ask them to intercede. If that does get an acceptable result, go to your local newspaper or television station. It gives them material for a human-interest story and just may get the hospital to offer a lower charge. Use social media to try to shame the over-charger.

Prescription for Bankruptcy. Buy the book on Amazon

Thursday, March 7, 2019

Do I really need all these pills?

A prior post discussed the importance of taking medication as prescribed, focusing on medications that were intended to prevent things like strokes, heart attacks and fractured hips. There is another side to the coin.

Doctors are increasingly aware of the problem of “polypharmacy:” taking a lot of pills. Almost 60% of all Americans take at least one prescription medicine and a third of Americans over 65 take five or more medications daily. Add to these various supplements and over-the-counter (OTC) pills and that can add up to quite a handful. At times this may be appropriate and beneficial. If you have diabetes, hypertension and congestive heart failure, most of your pills may be needed. However, in many cases pills have been added by one doctor unaware of what another doctor prescribed.

Your primary care doctor (if you are fortunate enough to have one) may not even be aware of everything you are taking. Many medications interact in ways that may be harmful. Some may have been intended only for short-term use but were never stopped. Some may have been appropriate when you were younger but have more side effects as you age.

Some specifics: many drugs to treat bladder problems cause dry mouth in everyone but also constipation, confusion and falls in the elderly. Young patients with diabetes with good home support benefit from having their blood sugar tightly controlled; it prevents later eye, kidney and vascular problems. Older patients benefit less and are much more at risk of low blood sugar (hypoglycemia) which can be a serious threat, even fatal, if they are over-medicated.

Some patients whose blood pressure has been well-controlled can lower or stop their medications and maintain good pressure for extended periods or indefinitely.

Anti-anxiety medications and many sleeping pills have been repeatedly linked to falls in older patients who take them. Digoxin has been used for a century to treat heart failure but more recently has been found to increase death rates in people who take just a bit too much.
What can you do? First, be sure to carry with you a list of every pill you are taking. This may be life-saving should you end up in an emergency department, but it should also be shown to any doctor you see. Periodically it is useful to ask your primary care doctor to review what each of the pills is for, and to ask whether there are any that might be safely stopped.

I would always ask my patients once a year to make a “brown bag visit,” bringing in every pill they had at home and we would often be able to cull many that were duplicating each other. It was amazing to find that people were often taking the same medication twice, because the pills in the different bottles looked different because of different manufacturers and may have even had different names – one branded, one generic. It may be appropriate to ask if lifestyle changes could take the place of some of your pills. If you are willing to put in the effort, this is often possible.

The same review may be able to identify expensive pills that have an equally good and cheaper alternative.

Prescription for Bankruptcy. Buy the book on Amazon

Monday, March 4, 2019

Yes, you DO need to take that pill

Over the past 60 years we have come a long way in treating many conditions in ways that prolong life and health. Perhaps this is best exemplified by the approach to high blood pressure (“hypertension” or HTN). History buffs may be aware that Franklin Delano Roosevelt died of complications of HTN. In 1937, when FDR was 54, he had a BP reading of 162/98, but the prevailing medical opinion at the time, espoused by such eminent men as Paul Dudley White, was that HTN should be considered necessary and not be treated. Even had his physicians wanted to lower FDR’s blood pressure, there were no effective ways to do so at the time. As was the rule in those days, his BP rose inexorably and he subsequently developed heart failure and had a series of small strokes, and finally died of a massive brain hemorrhage.
Life insurance companies were aware as early as the 1950s that people with HTN died prematurely and refused to insure them, and the medical profession belatedly began to connect untreated HTN with heart and kidney failure and stroke, and effective medicines to lower blood pressure became available. Since the 1950’s there has been a dramatic reduction in HTN-related illness and death.
Another area where preventive medicine has made enormous strides is in lowering cholesterol and preventing coronary artery disease. Added to this has been the drop in the number of people who smoke, another major factor in causing heart attacks. When I was an intern and coronary bypass surgery was in its infancy, the recipient of successful coronary grafts was often told “see you again in 10 years,” as little was done to modify the factors that had brought them to the catheterization lab and surgery. Nowadays, with aggressive risk factor control, the CABG patient may be good for 20 years or more.
Osteoporosis is another condition that now has multiple available treatments that have been shown to reduce fractures that add to disability and death.
The common thread among all these conditions is that the medicine must be taken to work! About 70% of Americans have been prescribed a medication for chronic use and more than half take two or more. Despite the overwhelming evidence that these medicines, when properly prescribed and regularly taken, extend life and prevent disability, nearly half of us do not take our medications as prescribed. Surveys show that half of us missed at least one dose, one in three could not remember if they had taken a medication and 25% did not refill a prescription when it ran out. Even participants in clinical trials, who are followed much more closely than are patients under routine care, often stop taking the study drug.
The reasons people do not take medications as prescribed fall into several categories. The most obvious potential cause, cost, is one of the less common reasons given. For any individual patient cost can be a huge factor, but cost is only cited as the reason for non-compliance by about 16%. A similar number stop because they are concerned about side effects or by something they have read (often on the internet!). Many people stop taking their medication because they do not feel any better and do not feel it is worth the bother. This is certainly true for HTN, osteoporosis or high cholesterol, which are symptom-less conditions until they are far advanced. The commonest reason of all is simple inattention, forgetfulness.
Non-compliance, according to estimates in a study published in the Annals of Internal Medicine in 2012, may add $100 billion to our national health bill due to preventable hospitalizations as well as many premature deaths. The most recent data shows that patients with coronary disease who were less than 50% adherent with their "statin" had a substantially (30%) higher death rate than those who were more than 90% adherent.
What can you do? First, if your doctor prescribes a new medication, be sure to ask why it has been prescribed, what you should expect to see, good or bad, and if there are alternatives should it not agree with you. Ask what to do if you forget a dose: should you double up or just get back on schedule? If you get sticker shock when you go to the pharmacy, refuse the medicine. Once you have walked out with it, they cannot take it back, but either you or the pharmacist can call your doctor and ask if a less expensive alternative would work. If you experience what may be side effects, do not simply stop but call your doctor and discuss these. Do NOT take frightening tales you read on social media as the truth and discuss these with your doctor or pharmacist before acting on them.
Finally, make it easy for yourself. Put the pill bottle out where you can see it – that may be on the bathroom shelf or the kitchen table, but it should not be in a cabinet or drawer. If you are taking several pills, particularly if they are taken at different times, use a pill organizer which you can fill once a week and then leave it out in an obvious place. (And ask your doctor if a simpler schedule would work as well!)

Prescription for Bankruptcy. Buy the book on Amazon