The Annual Physical: Time Well-spent or a Waste of Time?

About 78% of U.S. adults, including 68% of adults under 45, reported seeing a doctor in the last year for a wellness check.

Is this a good use of your and your doctor’s time?

Academic studies of the value of the annual physical exam (APE) have focused on whether doing this saves lives. Here the evidence is mixed. An analysis of many large observational studies reported an impressive 45% reduction in mortality comparing those who had vs. those who did not have an APE.

As regular readers know, this type of study is often misleading. People who have an APE are likely to be more health-conscious and have better health habits than those who do not. Smaller randomized trials of APE/no APE found very little mortality benefit.

Why might an APE help you live longer? It is an opportunity for your doctor to review your overall health rather than focusing on a specific problem. It is the ideal time to discuss and perform (immunizations, pap smears) or schedule (colonoscopy, cholesterol blood tests) important preventive health measures.

In a young healthy person, the traditional head-to-toe physical is unlikely to find new conditions, but focused exams may. It is a great time for a skin check looking for cancer and to measure BMI and discuss weight if it is a problem. High blood pressure is generally a symptomless condition until far advanced and blood pressure should be checked annually.

An APE is also a good time to discuss sleep, diet and exercise and mental health. Smoking and alcohol use should also be discussed. Older adults may want to bring up hearing issues.

So, if you are a young adult who feels fine, and you are aware of the importance of good habits, you can probably skip the “routine physical.” If you do, be sure to get your blood pressure checked when you go in for a problem-focused visit and that you have had your cholesterol checked within memory.

If you are at risk for such chronic conditions as hypertension, diabetes or heart disease because of your weight or family history, schedule that visit.

If you are 50+ it is worth doing even if you feel fine; the biggest risk factor for many conditions is simply aging.

An APE is also a good time to be sure you and your doctor get along and review how their office works, including off-hour availability.

For many, a normal physical can also be reassuring.



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Fluoride - Friend or Foe?

Among the controversies around public health, fluoridation of the public water supply ranks second behind vaccination. The nominee for Secretary for Health and Human Services wants to remove it. Is that a good idea?

The major benefit of fluoride is that it dramatically reduces dental cavities in children and to a lesser extent in adults also. In 1945 Grand Rapids, MI, became the first city in the world to add fluoride to its water. Dental cavities in children living there have dropped by more than 60% since that was done. Calgary, Alberta, stopped fluoridation and the rate of cavities in children doubled.

Canadian, Australian and U.S. dental societies support fluoridation, though most European countries have stopped mandating fluoridation. Most dentists also recommend topical fluoride, including fluoride in toothpaste, which fights plaque but does not reduce cavities.

What are the hazards? Very high levels of fluoride can lead to bone disease and staining of teeth.

(I must note that very high levels of almost anything can be harmful. Marathon runners and others have died from drinking too much water.)

The biggest concern is that studies have suggested that when mothers drink fluoridated water, their children have lower IQs. These studies were done in regions of Asia and Mexico where naturally occurring levels of fluoride in water are very high. None were done in U.S. communities that had fluoridation programs.

Good studies show that there is no harm to animals or humans from levels up to 10 times the usual consumption of fluoride.

The FDA has recommended a very conservative level of 0.7 mg/liter in the public water supply, a level that maximizes benefit while minimizing risk. In the U.S., about 85% of communities fell in that range.

How can you know? In most of the U.S. and Canada, fluoridation is a local decision. Call your town’s Department of Public Works. If your town adds fluoride they should know, and indeed should publish that data annually. Not every state requires fluoride be added, and if it is not added testing will probably not be done.

If you use well water, you can arrange for private testing.

What about fluoride in toothpaste? If it is not swallowed, very little gets into the body. If you have children too young to follow the advice not to swallow, put a very small amount (less than 1/8 inch) on the toothbrush yourself.

If you are pregnant and worried, you can buy deionized water to drink during your pregnancy.

So, proven benefit for children’s teeth or very unlikely effect on their IQ? You decide.



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What shots does an adult need?

Much of the discussion around vaccines focuses on children, who get a large number in their early years, but adults also benefit from appropriate vaccination.

Which shots should you be discussing with your doctor?

People of any age should get an annual flu shot. Influenza is a serious illness, not just a bad cold, and older adults may be hospitalized or die from influenza. The efficacy of the shot varies year to year, as the CDC must make an educated guess as to which strains will circulate, but even partial immunity is better than none.

A bonus is that those who get their flu shot are less likely to suffer heart attacks.

COVID – yes, that old virus is still around. It has mutated enough that the vaccine you got a year or two ago is no longer that protective. The only vaccine available is the newer one, and you should get it.

Shingles is a very unpleasant illness that you do not catch from others; it is the virus that caused your chicken pox when you were a child and remained dormant in your body ever since. As we age and our immune system weakens, the virus can flare up. It causes a very painful rash which can go on to a persisting nerve pain for months or years after the rash clears. The 2-shot series is highly protective and is given once if you are 50 or over.

The shingles vaccine is associated with a decreased risk of dementia, an added inducement to get it.

The pneumococcus is a bacterium that causes pneumonia in many and meningitis in some. There have been many different vaccines and the subject of which vaccine(s) to get deserves its own column – discuss it with your doctor. Bring the record of any you have received.

RSV causes severe disease in infants. In adults it is usually just a cold, but if you have weak lungs or heart failure or are elderly, it can cause more severe illness. The new vaccine seems to be a one-time only shot that is worth considering.

Tetanus boosters are recommended every 10 years and are usually combined with either diphtheria or diphtheria and whooping cough. If you have new grandchildren, getting the DPT will protect them as well if you will be close to them.

A stitch in time saves nine, and the right shots can save you from serious illness.



If you enjoy these posts, you might want to also receive those done by my medical school classmate, Dr. Steven Kanner. Check out https://drkanner.com



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Killing Brian Thompson will not solve America's health care problems

The fatal shooting of UnitedHealthcare CEO Brian Thompson as he headed to a shareholder meeting should not have come as a surprise. The U.S. is a gun-obsessed culture and leads the world in gun fatalities. What was more shocking was the outpouring of “he had it coming” posts on social media.

Whether or not the killer was motivated by a personal experience with United, the numerous posts referenced people’s rage at the health insurance industry.

Should we be surprised?

Recent years have seen health insurance rates soar and out-of-pocket costs skyrocket. Even those with employer-provided health insurance are often unable to pay for needed care as deductibles and copays keep rising.

At the same time, the industry has had one black eye after another, with multiple insurers in the news.

Private health insurance companies offering Medicare Advantage plans routinely overstate the health problems of their enrollees to get unjustified extra payments from the government.

A former Aetna medical director admitted under oath that he never looked at patients’ records when deciding whether to approve or deny care but simply rubber-stamped the nurse reviewers’ decisions.

United was castigated by a Senate committee for using algorithms to deny care and it was noted that the denial rate for rehab care after hospitalization rose from 10.9% in 2020 to 22.7% in 2022.

Denying care is good for insurers’ profits, and these profits flow into executive salaries. The CEOs of America’s six largest health insurers took home a total of $122,970,614 in total compensation in 2023.

Taking money from employers and individuals and paying medical bills is not rocket science and does not warrant sky-high profits. Medicare operates with an overhead of about 3% while private insurers charge 15% or more.

As I document in my book, some 25% of U.S. “health care” expenditure does not go to health care but to administrative overhead.

We need to get the excess profits out of health insurance companies and put that money towards patient care.

Shooting one CEO will not change the culture. We must hold our legislators’ feet to the fire and get the excess profits out of health insurance, whether at the state or the federal level.



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When is it time to take away the car keys?

Our ability to safely drive varies enormously. Even though 75% of surveyed drivers felt that their skill behind the wheel was in the top 25%, statistics do apply, and 25% of us are in the bottom 25%.

Many factors determine whether someone should still be driving a car. Teens and young adults tend to take more risks than older drivers while older drivers have poorer vision, slower reaction time, are likely to be taking medication that may compromise driving safety and are at greater risk of cognitive decline.

The latest survey available showed that in 2020, 59% of people 85 and older in the U.S. still had their driving license.

Older drivers are not necessarily bad drivers; that distinction clearly goes to teenage drivers, who have by far the greatest number of accidents and fatalities. Accidents are relatively low for drivers 30 to 69 and then start going up.

What is of concern is that fatal accidents rise dramatically in drivers 80 and older.

So, what do you do if your parent or spouse should not be driving? Many states require older drivers to have their vision checked at license renewal, but none require a driving test.

You cannot rely on your doctor to be proactive; only six U.S. states require doctors to report people whose medical condition makes it unsafe to drive.

If you have witnessed unsafe practices such as running lights or stop signs, drifting across lanes or driving way below the speed limit on highways, you should bring the subject up. If this is met with denial, you could contact their doctor and ask the doctor to broach the subject.

If someone is clearly a risk to themselves and others, you may need to contact the registry of motor vehicles or local police department in a smaller community. In the extreme, you can make the car undriveable by disconnecting the battery.

The corollary is figuring out how to let them get places without a car – often a major issue for those who do not live in a densely populated area with shops and services within walking distance.

Sign them up for Uber or Lyft, contact the local Council on Aging about community resources and/or offer to drive them to medical appointments and shopping or arrange for others to do so. In much of the country, to be unable to drive dramatically shrinks a person’s world.

Just maybe, if you make good alternatives available, they will give up driving and save a life.



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Robert Kennedy Jr is a danger to our health

I will leave it to others to comment on the Caligula’s horse nature of other Trump nominations, but must try to convince you that Robert Kennedy, Jr is uniquely unfit to be the head of the Department of Health and Human Services (HHS).

Not all his ideas are bad. His campaign against ultra-processed foods and food additives could benefit the U.S. population if they withstood the onslaught of opposition from the food industry. It would also be better if the revolving door between industry and regulatory agencies could be shut, as he has proposed.

Unfortunately, his rabid anti-vaccination stand by itself should disqualify him from a position overseeing the nation’s health.

Vaccines, along with clean water supplies, have done more to save lives than almost any advance in history.

I am old enough to remember the scourge of polio. Almost every summer the City of Montreal would shut public swimming pools because of polio outbreaks. In the mid-20th century, over half a million people world-wide died or were left paralyzed by polio. The best care available was the iron-lung, which took over for paralyzed respiratory muscles.

The Salk inactivated polio vaccine was released in 1955, and in 2 years, U.S. cases of polio fell from 58,000/year to 5600. By 1961 that number was 161.

The Sabin oral polio vaccine soon followed, and the ease of giving an oral rather than an injected vaccine led to mass administration around the world. By 2021, only two cases of polio were reported world-wide.

Measles, too, sickened and killed millions before the 1963 introduction of an effective vaccine. Prior to vaccination, there were over 100 million cases and 6,000,000 deaths world-wide. In the U.S. there some 4,000,000 cases and 450 deaths annually, along with over 1000 left brain-damaged.

Andrew Wakefield, in Britain, published two studies in 1998 and 2002 claiming that the MMR vaccine caused autism. Both studies have been withdrawn by the publishers, citing fraud, and numerous studies since then have shown no association of vaccination and autism.

Celebrities with no scientific knowledge have continued to push this discredited idea, leaving some parents hesitant to vaccinate their children. The result has been a series of measles outbreaks across the U.S.

Even though most decisions about mandatory childhood vaccination are made at the state level, having a vaccine skeptic as head of the nation’s health agencies will only lead to more parents opting out and more children needlessly sick or dead.

Kennedy has also jumped to support therapies such as ivermectin for COVID despite very solid studies showing that no dose of the drug did any good and, in some cases, did harm.

If you live in a state with Republican senators, please write to them immediately and beg them to reject this flawed candidate as Secretary of HHS.



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Will a Sudoku a day keep dementia away?

As the population ages, dementia has become an increasing problem. World-wide, some 55 million people are living with dementia; in the U.S. about 7 million people suffer some form of dementia. The condition not only affects the sufferers but lowers the quality of life of their care-givers, who are usually family, and costs the health system an enormous sum.

To date, treatment has not proven to be the answer. Neither the older drugs nor the very expensive and dangerous new drugs do more than delay the decline by a few months.

For dementia, as for many health conditions, prevention is much better than treatment.

Good general health hibits: regular exercise, not smoking and treating high blood pressure are known to lower dementia risk. What about training the brain?

We strengthen our muscles by lifting weights and improve our heart and lung capacity by aerobic exercise, so it makes intuitive sense that exercising our brain should ward off dementia. There are many on-line sites and apps that promise to do just that. Do they work?

We have known for a long time that those with higher education levels have less dementia and get it later, but this may be an artifact: those with better brain capacity may gravitate to fields requiring more education. What about mentally challenging activities such as word games, crossword puzzles, Sudoku, chess and bridge?

A survey of many studies in different groups of people living in different parts of the world suggests that these activities do indeed lower the risk of dementia and delay its onset. Many activities were studied, both those listed above and reading and taking adult education classes.

The effect was not dramatic, but the risk of developing dementia was reduced by anywhere from 10 to 30% depending on the study, and those who did develop dementia did so about 2-3 years later. These numbers compare very favorably with existing treatments and have no side effects!

None of the commercial “brain boosters” as yet have any similar data available.

So, take out your pencils and get puzzling. Play mahjong or bridge. Read a challenging book. Not only will you get the social benefits, but you will stay sharp longer.

By the way, another intervention has pretty good data behind it: getting the shingles vaccine seems to also be associated with reduced risk of dementia. As if avoiding the nasty disease was not motivation enough!



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Lonely? You are not alone!

Last year, the U.S. Surgeon General declared loneliness a major public health problem. While it was made worse by the pandemic, both before and after the pandemic loneliness was common and troublesome to many.

A survey from Harvard’s School of Education found that 21% of U.S. adults described loneliness as a major problem; surprisingly, the age group that expressed the greatest problem (29%) were those 30-44, and adults over 65 had the lowest (10%) reported frequency.

If you have children or grandchildren, remember that they can also suffer profoundly from loneliness.

You do not have to be socially isolated to feel lonely; those with intact families and/or with many co-workers can feel lonely. Loneliness is a disconnection from others, even when they surround you. If you feel lonely in such a setting, you blame yourself but should not.

Our ubiquitous technology, which is supposed to help, often worsens the problem. Dealing with others through social media rather than in person does not create deep bonds.

Those who spend too much time at work may end up spending less time with family and friends with resulting feelings of loneliness.

Loneliness has been found to correlate strongly with both poor mental and physical health. We are social animals and do better in all spheres when we feel connected to others.

If you feel lonely, there are many ways to lessen this feeling.

Reach out to friends and family. Maintaining friendship requires work but need not be burdensome. A quick email with some news or a birthday or holiday card with some personal lines added takes little time and strengthens bonds. Pick up the phone.

Volunteer. Helping others gives you a sense of community connection and may lead to new friendships with those alongside whom you are working.

Join groups with whom you share interests. Alongside fellow photographers, quilters, singers or stamp collectors you will create new bonds.

There are many groups at churches, Councils on Aging and community centers where you can meet new friends.

Adopt a pet if you can deal with the time demands. The unconditional love of a dog is its own reward, and walking your dog is a great way to meet new people.

Limit your use of social media. Taking longer breaks from Facebook and the like and interacting in the flesh will usually make you feel better.

Have a single older friend or neighbor? Call them!

Finally, remember that feeling lonely is not something to feel ashamed of and that there are many people out there who would love to connect



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How to pay less for your medication

Most adults take prescription medications, either on a regular basis for a chronic condition or on occasion for acute problems. If you live in the U.S., you should be aware that you are going to pay 2-3 times what residents of most other countries pay for the same medication.

If you are wealthy and have great health insurance, you can stop reading and worry about something else. If you are like most of us, you may occasionally be faced with “sticker shock” at the pharmacy counter.

As health care costs and the cost of health insurance keep rising, one of the ways employers and insurers have reacted is by raising the co-pays that even those with health insurance are required to pay.

Many older adults and those with less-generous insurance plans have responded by skipping medication – simply not taking a prescribed remedy or trying to stretch it out by taking it less often than prescribed. This can result in seriously bad health outcomes.

How can you cut your prescription costs without risking your health? There are multiple ways.

First, be open with your doctor. Tell them if cost is a concern, as there are many things that the doctor can control. If you are prescribed a brand-name drug, ask if the same or a similar drug is available in a generic. There is usually a huge difference in price.

If the need for a medication is borderline, see if lifestyle changes can substitute for a prescription. For such conditions as mild high blood pressure or borderline diabetes, exercise and dietary changes may avoid the need for a drug. Obviously only do this with careful monitoring and discussion with your doctor.

If only an expensive brand-name drug is needed for your condition and you have commercial insurance, ask about drug-company provided co-payment cards, which your doctor will either have or can request. These are typically used as enticements to get doctors to prescribe new expensive drugs and are a last resort when the drug truly is best for you. (Note these are not allowed under Medicare, only commercial plans.)

Shop around! There will often be dramatic differences in price between different pharmacies. Local non-chain pharmacies (if you can find one!) and the big-box stores will usually have lower prices than CVS or Walgreens for identical products.

Use GoodRx for coupons. A large majority of prescription drugs are available this way.

Check out the Cost Plus Drugs on-line pharmacy, which sells many generic drugs at substantially lower prices than you will find at retail pharmacies.

Before reaching for your insurance card, ask the pharmacy what the cash price is. For many common generic medicines, this may be less than the co-pay you will be charged if you use your insurance.

If you are in Medicare with Part D coverage or in a Medicare Advantage plan, be careful to scrutinize the plan’s formulary every open enrollment period. Just because your medications are covered this year does NOT guarantee they will be next year.

Don’t be passive and accept sticker shock. A little work can pay big dividends.



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Read the fine print

My father had many aphorisms. One which I use frequently is “Figures don’t lie, but liars figure.” The drug companies are masters at using numbers to mislead; they will make big print statements that are accurate but convey a message not consistent with real value.

You might see “Our new cancer drug lets patients live 50% longer than current treatments.” Only in the small print do you find out that patients receiving their very expensive and very toxic drug live 3 months while those on a much cheaper drug with minimal side effects live 2 months. People might still opt to use the new drug, but they should do so with a real sense of what it does.

The food factory companies have come up with their own way of misleading with true statements. These have been termed “halo effects.” Adding some healthy-sounding ingredients has been found to sway most customers into believing the product is good for you.

Protein is currently in vogue, so many packaged foods are labelled High Protein. What you do not realize without looking more closely at the packet is that the “high protein energy bar” they are peddling is an expensive candy bar loaded with fat and sugar with some extra peanuts or soy added.

Another favorite is Vitamin Enriched. Adding even large doses of vitamins to highly processed foods still leave them as highly processed foods and not healthy.

“No Artificial Sweeteners” sounds good, right? But sugars of all sorts are “natural” while large doses are hardly healthy.

Organic or non-GMO may be inherently better than otherwise, but if the underlying food is not healthy, the fact that it is organic does not change that fact. Fatty meat is not healthy even if the animal was raised on an organic farm.

These tricks are used widely, but particularly for impulse purchases such as snacks.

Don’t let agribusiness manipulate your subconscious! Think and read before you buy.


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What to do when your insurance company won't pay

We are living in an era, in the U.S., when the insurance company often overrides your doctors’ decisions. Less often with traditional Medicare but more often with commercial health insurance and Medicare Advantage plans, you may find that a test or procedure your physician ordered is refused payment by your insurer and you are stuck with a huge bill.

A report found that in 2020, 18% of in-network claims were denied by commercial insurers. Don’t passively accept this decision! The denial letter is just the start of the process, not the end.

It has been shown that many of these denials are arbitrary and unjustified. A well-know example is the physician reviewer who admitted in court that he never even read the documentation but rubber-stamped nurse reviewers’ denials.

The denial may be based on a wrong diagnosis code being submitted or a failure of the insurer to consider changing medical standards.

While very few people challenge these denials, almost half the appeals succeed.

What can you do?

First, carefully read the denial letter to try to understand the reason coverage was denied. Yes, the prose is dense, but the insurer must explain its reason for denial.

You may find that before they pay for C, they want you to try A and B first and you have already tried A and B without getting any benefit. You may find that the test or procedure is not considered appropriate for condition X and you have condition Y.

If they have the facts correct and simply refuse payment, you will need to get the ordering doctor involved. They will have to write a letter explaining why they chose to do the test or procedure.

Your first point of contact should be the insurance company’s customer service line. Be sure to get the name of the person with whom you speak. For simple mistakes, they may be able to reverse the denial, but don’t count on it.

Your next step is to write a letter or an email requesting the denial be reversed and saying why. The process should be outlined in the denial letter. If not, it will be on the insurer’s website.

If the response is to still deny the claim, persist. Request an appeal. Indicate in your request that you plan to file a complaint with your state’s consumer protection bureau if the claim is still denied (and do so!).

Finally, outside help is available through the Patient Advocate Foundation and similar organizations.

Illegitimi non carborundum! Don’t let the bastards grind you down!


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Sleep problems and how to fix them

To sleep…perchance to dream

Insomnia, dissatisfaction with sleep quality or duration, is a common problem. Some 10% of Americans have chronic insomnia and another 15-20% have occasional insomnia.

While scientists do not fully understand why we (and virtually all living animals) need to sleep, lack of sleep contributes to many problems, including interpersonal, school and work functioning, depression and hypertension.

There are specific medical problems that may underlie insomnia. Restless legs and obstructive sleep apnea lead this list and will respond to specific therapies. Your bed partner is more likely to pick up on these than are you, and a session in the sleep lab will usually confirm the diagnosis.

Shift workers are particularly at risk for insomnia and the problem may not go away until you get a regular work schedule.

Most have insomnia as its own problem. Insomnia may have started at the time of a life stress or due to jet lag and then persists.

What can you do? There are many ‘common sense’ hints that may be all you need. Try to go to bed and get up at the same time every day, including weekends. Be sure your bedroom is dark and cool. Exercise early in the day, not in the evening. Do not work right up until bedtime; allow yourself time to decompress by relaxing reading or music. Do not eat within 2 hours of bedtime.

If these do not work, what next?

Sleeping pills, whether over-the-counter or prescription, are fine for short-term use but are not that effective when used chronically, and the more effective prescription drugs can have side effects.

Older individuals are at particular risk of falls, morning confusion and even dementia with chronic use of benzodiazepines (Valium, Ativan etc.). The so-called “Z drugs,” (Zolpidem, zaleplon and eszopiclone) have black-box warnings because of sleepwalking and other potentially risky sleep behaviors.

Sedating antihistamines like Benadryl have limited efficacy and cause dry mouth and daytime sedation. They are also potentially causes of dementia if used chronically.

Most experts strongly recommend cognitive behavioral therapy (CBTI) before medication. The success rate is high and there are no side effects. The problem is the lack of trained therapists and the cost.

An alternative is a web-based or phone app. These have been found to be almost as effective as in-person coaching. Two web-based programs that have good studies behind them are no longer available. I was able to download Shuteye, which promises a full year of coaching for $30 which appears good, but I have not fully tested it. Similar, and free, is Insomnia Coach, developed by the VA.

Also recommended, for technophobes, is the book Quiet Your Mind and Get to Sleep.

Should CBTI not work, young adults whose problem is falling asleep can try melatonin or a short-acting benzo. If sleep maintenance is the problem, low-dose doxepin or similar drugs are useful. Also approved for this use are three orexin receptor antagonists (ask your doctor!), which have fewer side-effects than benzos but are quite expensive. If you are going to use medication, be sure to also practice good “sleep hygiene” as noted above.

Sweet dreams.


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Medicare Advantage: Buyer beware

Medicare was established in 1965, freeing older adults from the trap of unaffordable health care in their senior years. It has been a highly successful program.

Medicare Part A, free for over 65’s and those of any age with permanent disability or chronic kidney failure, covers hospital care. Part B, for which you pay a monthly fee (usually taken out of your Social Security payment) covers doctors’ bills and other services. The more recently added Part D helps with prescription drugs. (Note that while Part D is optional, the cost goes up every year you do not take it.)

Because Parts A and B have deductibles, most people pay for a “medigap” policy to cover these.

In the spirit of “if it ain’t broke, fix it,” in 1982 Congress enacted laws establishing Medicare Part C, also known as Medicare Advantage, commonly abbreviated MA.

MA plans are run by private health insurance companies. They receive a fixed amount per enrollee from Medicare and are responsible for all health care costs. The amount per enrollee is adjusted upward if they can demonstrate that their members are sicker than average.

If you are 65 or older, you will soon be deluged with mailings and phone calls touting different MA plans and encouraging you to join their plan during the open enrollment period that runs Oct 15 to Dec 7 for the following year.

From a national viewpoint, MA has been a windfall for the insurance industry and a disaster for the federal budget. Insurers make double the amount per enrollee on MA than they do on commercial health plans for those under 65. The gross margins on MA enrollees in 2021 was $1730 per person vs $689 per person on commercial plans.

A recent report estimated that in 2022 MA plans cost Medicare at least $88 billion more than what it would have paid for the same people if they had stayed in traditional Medicare. How do insurers make MA so profitable? One way is through fraud. It has been widely documented that they use a variety of data mining techniques to make their enrollees appear sicker than they are, thereby getting excess funding that is not deserved.

Another way, of more concern to you if you are considering joining a MA plan, is by cutting expenses.

Under traditional Medicare, you can for the most part see any doctor you wish and be treated at any hospital. MA plans have a closed network: you must see a doctor in their plan and be hospitalized at a hospital in their network for your care to be covered.

If you are healthy and are sure you will be healthy all next year, you may not care. If you have a serious illness, you may be sorry to learn that the highly recommended specialist you want to see will not be covered, and the hospital with the most expertise in your condition likewise.

MA plans also require prior authorization for many surgeries and tests, unheard of under traditional Medicare. A government audit found that 13% of their denials were medically wrong.

If you need rehab after surgery, you should know that MA enrollees were much less likely to receive inpatient rehab at highly-rated facilities.

The pharmacy benefits under MA plans are often generous in covering cheap generic drugs but be aware that the common 20% co-pay may hit hard should you need one of the new highly effective but very expensive drugs for a serious condition.

Bottom line: MA plans often save you money by letting you avoid a Medigap plan (you still must pay Part B premiums) and add coverage for some things Medicare does not cover such as eyeglasses or limited dental or hearing aid coverage. The downside is that you will be restricted in your choice of doctors and hospitals and must accept that the plan will be able to over-ride some of your doctor’s decisions.

So… When the glossy ads hit your mailbox and telemarketers call, think carefully whether a contribution towards eyeglasses or a gym membership is worth it in the long run.


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Aging in Place: Part 2

Some more suggestions on how to start making your current home a place in which you can stay as you become frailer.

Stairs may become a problem as we transition from old to very old. I look upon stairs as a sort of built-in Physical Therapy, forcing us to strengthen our leg muscles with every climb, but arthritis, heart or lung issues or neurologic disease may eventually make that climb a challenge.

Ideally, if you are doing major home renovations, moving the master bedroom to the first floor will pay dividends in the long run. If this is beyond your budget, electric stair climbers may be the answer, with cost in the ballpark of $5000.

Over time, change most doorknobs to levers for easier turning.

Have proper storage, so that toys, shoes, boots, etc. are in a box or on low shelves and not sitting on the floor waiting to trip you.

Get a video doorbell tied to your phone so you do not have to rush to answer the door, and so that you can screen callers to be sure you want to answer it.

The last point brings up another: seniors are often targeted by scammers. Your local police department and/or Council on Aging probably offers lectures on how to avoid becoming the victim of a scam: attend one of these!

Finally, it is likely that at some point, one of a couple will become the primary caretaker for the other. Plan for this. Do not try to do it all. Accept help when it is offered, whether by family or friends. Use outside agencies for some meals and for respite care.

Join an on-line or in-person support group to share your experiences with others experiencing the same issues. Keep some “me time.” If you do not make time to relax and do something enjoyable, you will burn out sooner.

If you live alone, a personal alert system adds peace of mind for both you and your family.

Unless you have good long-term health care insurance, realize that costs of outside help are not covered by Medicare or other health insurance. Short-term help after a hospitalization is covered, but not the regular care needed to stay independent.

If you are very rich, no worries. If you are very poor, Medicaid will help. For most of us in between, be sure to budget and set aside money for these expenses.


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Aging in place - Part 1

A large majority of older people want to stay in their own homes rather than move to a retirement community or, heaven forbid, a nursing home. Closeness to friends and family is a key factor, as is the comfort of familiarity and the freedom to do what you want when you want.

At the same time, most of us develop at least some health issues as we age. Our strength, our balance, our vision and hearing inevitably decrease, no matter how healthy we are.

There are many things we can do now to make it easier to age in place. Some are very simple and inexpensive, others more costly.

A potentially serious problem for seniors is falls and resulting injury. To minimize the risk of falls:

Get rid of small rugs that slide. Have fewer rugs and be sure they are on a non-skid pad.

Have railings for all stairs, indoors and out.

Have adequate lighting, particularly by stairs and at entrances. Using higher wattage bulbs is the simplest way to do this, and if you need to, get an electrician to install new fixtures.

Use a night-light in your bedroom; falls getting up at night are common and can be serious.

Bathrooms need attention.

Install grab bars for every tub and shower – be sure your installer does this regularly.

Have a non-skid surface in the shower. A bench makes showering easier. This can be built-in (expensive) or a chair with good support (cheap).

If you much prefer a bath to a shower, invest in a walk-in tub.

Raise the height of your toilet seat with either a new unit or an add-on and consider a grab bar next to the toilet.

Kitchens also warrant attention.

Getting things down from high cabinets is difficult and can be hazardous if you use a chair or a ladder. Have your cabinets lowered, so that all the space you need to use can be reached easily. Slide-out shelves will make it easier to get what you want.

If you are facing the need for a wheelchair, be sure all surfaces are low enough that you can work in the kitchen from the chair. If you have an island in the kitchen, be sure there is at least four feet of space on all sides of the island.

All your chairs should have arms, to make getting in and out safer.

Part 2 next week!


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Should you be tested for Alzheimer's Disease?

Several recent studies have promised a reliable test to detect Alzheimer’s disease in people with mild memory loss. What are these and should you request one?

One test is a very expensive imaging test, a specialized PET scan, that will almost certainly not be covered by your insurance and is probably still best used in the research phase.

The other is a blood test – “phosphorylated tau” should you wish to Google it – that was reported to have over 90% accuracy in predicting Alzheimer’s in a group of elderly people (average age 74) who had either subjective memory loss, doctor-diagnosed mild cognitive impairment or dementia.

The blood test was better than both primary care physicians and dementia specialists in diagnosing Alzheimer’s disease and will probably soon be clinically available.

The real question, should the test be positive, is: what next?

The medicines available to treat Alzheimer’s are not miracles. Both the older oral medicines and the newer IV medicines slow down the progression of the disease but do not cure it.

Considerable media attention and soaring stock prices have greeted the newer IV agents, but their results are only mildly better clinically than the old ones, and their potential side-effects are worrisome, including bleeding in the brain.

The British agency responsible for approving new drugs in the National Health Service just turned down Biogen’s drug, Leqembi, and its U.S. FDA approval has been controversial.

There is hope, but it is yet unproven, that starting these drugs much earlier in the process might make them more effective. Hopefully clinical trials will be conducted to see if this is true.

My strong feeling is that for most people, the side-effects of the newer drugs outweigh their proven benefits.

Any medical test should only be done when knowing the results of the test is expected to have a beneficial effect on your health.

So, putting the horse in front of the cart, if you are worried about memory loss, have a full discussion with a doctor you trust. Ask what would happen after a positive test before you are tested. Then you can make an informed decision.


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Hello, Covid, my old "friend"

We’ve come to see you once again. (Cue Simon and Garfunkel)

The pandemic is behind us, and life has mostly returned to normal, but Covid has not disappeared. Instead, this summer has seen an increase in cases and in such measures as virus detection in wastewater samples.

Thanks to widespread vaccination and the immunity conferred by infection and recovery, we have not seen the huge numbers of hospitalizations and deaths that we did in 2020-21.

Covid is still a serious threat, particularly to the elderly and those with immune deficiency, and it has shown a remarkable ability to mutate into variants to which we are not fully immune. There has been a whole alphabet soup of new variants, and the original vaccinations you received will offer only limited protection to the current virus.

The FDA has recently approved a new vaccine and ordered the old ones taken off the market. The new vaccine is not perfect – the virus mutates too quickly – but should provide better protection and will be widely available in September.

While Covid is not “seasonal” the way influenza is, I expect an increase in infections as we get into colder weather and people congregate indoors.

What should you do?

If you have had a case in the last 3-4 months, the natural immunity this provides suggests you put off getting vaccinated until later in the fall.

If you have been lucky enough to avoid Covid over the summer, getting the new vaccine as soon as it is available is suggested, particularly if you are over 65.

Also, there is good evidence that wearing a mask in crowded indoor environments is helpful, as well as such commonsense advice as staying home when you are sick and using good hand-washing practice. This will reduce not only Covid, but other respiratory viruses.


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Getting the most out of a doctor visit

By now, most of us are all too aware that the doctor visit is becoming shorter and that the doctor seems to interact more with the computer than with you. It is frustrating to leave a visit that may have been made months in advance with your questions unanswered.

How can you get the most out of a medical appointment? The key is preparation.

Before you set out, you should have made sure that you have the correct date and time, that the doctor is on your insurance plan, and that if you need a referral, you have it.

Leave enough time to get there even if traffic backs up. Yes, you will probably have to wait, so bring a magazine.

If this is a new doctor, bring a list of all medicines you are taking, any medication allergies you have, major family history, recent test results and surgeries and hospitalizations you have had.

Key to a satisfactory visit is to know what you want from it. If you are scheduled for a follow-up of chronic health problems but you have a new symptom that worries you, get that out up front and not when the doctor has their hand on the door.

Bring notes and take notes. Have a written list of things you want to discuss in the order of priority you want to cover them.

It has been repeatedly found that most of what a doctor tells you is forgotten by the time you get to your car, so take notes of what you are being told. Doctors tend to slip into medical jargon, so do not hesitate to ask that they repeat something you do not fully understand.

It is very helpful to have a close friend or family member with you to act as a second set of eyes and ears, but be sure they understand what you want them to do and do not let them take over the visit. (Speaking of ears, if you need hearing aids, be sure to have them in for the visit!)

Be honest with your doctor. They have seen and heard it all, so any habits you have of which you are not proud, be upfront. Keeping secrets is not going to get you optimal care.

At the end of a visit, tell the doctor what you understood them to say and what is planned. It is rare that a problem is solved at one visit, so be clear in your mind if further testing is needed as well as what you should do if things do not go as expected. Be sure you know what to do before you leave.

If you are not comfortable with what you are told, do not hesitate to ask for a second opinion. This should not be threatening to a good doctor. In the case of a serious diagnosis, second opinions often change the diagnosis and/or the treatment.


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A new test for colon cancer

Late in July, the FDA approved a blood test to detect colon cancer. What does this mean for you?

Colon cancer is the second most common cause of cancer deaths in adults, behind only lung, and an estimated 53,000 people will die of colon cancer in the U.S. this year. At the same time, colon cancer should be almost completely curable if found very early and surgically removed.

Finding cancers in people without symptoms is called “screening,” and good screening tests are only available for a small number of cancers. Good screening tests should pick up cancers early, should be negative in people without the disease and should be proven to reduce death rates in screened populations.

For colon cancer, the gold standard screening test is the colonoscopy. It will detect both cancer and pre-cancerous polyps, most of which can be removed during the procedure. It is very sensitive – if the person has done a good clean-out “prep,” very few polyps or early cancers will be missed. It does not give false alarms – if your colon is normal, the endoscopist sees this and you can generally go 8-10 years before your next test.

The downsides are cost and the “ick” factor.

A recent report on the cost of cancer screening showed that fully 60% of the cost of all cancer screenings was spent on colonoscopies. The test requires a whole team, a special room like an operating room, anesthesia for most people having the test and costs thousands of dollars.

As Dave Barry so colorfully described, ((https://www.miamiherald.com/living/liv-columns-blogs/dave-barry/article1928847.html) the thought of a colonoscopy is repulsive to many of us, and the dietary and laxative preparation required is a turn-off for many.

The alternative has been to check the stool for hidden bleeding, the so-called FIT test. If done every year, this has a reasonably good pick-up if positive tests are followed by colonoscopy. More recently, a stool test looking at cancer DNA markers has been approved. It picks up about 85-90% of colon cancers but only about 40% of large polyps.

The newly approved blood test looks for circulating cancer DNA and was shown to detect about 83% of cancers found on colonoscopies. It had a “false positive” rate of 10%, meaning 10% of people with a positive blood test had no cancer. And it was poor at finding pre-cancerous polyps. Only some 13% of people with such polyps had a positive test.

The big advantage of the new test is ease – most of us are used to having blood drawn at a medical visit and do not mind having this done. No preparation is needed. The cost is dramatically lower than a colonoscopy. The biggest disadvantage is that it is not as good as a colonoscopy. It will miss most pre-cancerous polyps.

My take: if you have insurance that covers colonoscopy, gather up your courage and just have it done.

If the alternative is not getting screened, do the blood test.


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Shingles: more than just a rash

Some 95% of U.S. adults had chickenpox when they were children. Chickenpox, scientifically called varicella, is usually an annoying but not dangerous illness in children.

What makes the illness treacherous is that the causative varicella-zoster virus can go into a dormant phase, hiding out mostly in nerve roots near the spinal cord. When our immune system is weakened by stress, illness, medications or simply aging, the virus can spread out from the nerve root along the nerve.

This recurrence of virus along the course of a nerve is shingles.

The clinical course of shingles is usually very stereotyped. With a patient who is a good observer, I can usually diagnose it over the phone.

Stage one is an itching or burning pain localized to a band around one area of the body with nothing visible. To many, it feels as if they burned themselves when they did not.

The next phase sees them break out with blisters in the same area. It can be on any part of the body, head to toe, but is virtually always only on one side, right or left.

The blisters scab over and eventually dry up, but this may take weeks. Particularly in older people, the pain may linger for months or years after the rash has gone. This is called post-herpetic neuralgia and is very distressing.

If the involved nerve is one of the nerves of the face, the eye may be affected, and this can be a sight-threatening issue.

To fight back, we have treatment and prevention.

Two anti-viral drugs, acyclovir and famciclovir, are useful in shortening the course of the illness and in preventing post-herpetic neuralgia. To be effective, they should be given early, ideally within a day of the rash appearing. If you break out with what may be shingles on Friday, do not wait until Monday to seek help.

Vaccines are available that reduce the likelihood of getting shingles. The older one, Zostavax, is about 65% effective and the newer one, Shingrix, is over 90% effective. While Zostavax is easy to get: one shot, minimal side-effects, the more effective Shingrix requires two shots and is more likely to give you a day or two of flu-like symptoms.

There have been recent studies suggesting that vaccination reduces the risk of dementia, possibly by preventing the re-emergence of the varicella-zoster virus dormant in the brain.

Since most children are now vaccinated against chickenpox – the vaccine came out in 1995 – we can hope that shingles will follow polio and smallpox into “mostly of historical interest.”

In the meantime, most older adults should get the shingles vaccine. If getting Shingrix, don’t schedule your shot the day or two before an important event.


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Cannabis - good or bad for your health?

Cannabis (marijuana) products are widely used. Cannabis is now fully legal in 24 states, legal if medically prescribed in 15 and partially legal (depending on the composition) in 7. In only 4 states is it still completely illegal.

Among 176,000 primary care patients in a Los Angeles clinic, 17% reported regular use. Not surprisingly, use was commoner in younger people than older ones: 31% of those 18-29 used cannabis, while only 8.5% of those 60 and older reported use.

A large percentage of cannabis users say they do so to treat symptoms, largely stress, insomnia and pain.

Cannabis can be inhaled or eaten. Smoking gets the active ingredients into you faster, but the effects of edible (“gummies”) products is similar.

Do cannabis products help? Our evidence base is flimsy. The fact that cannabis is still classified at the federal level as “Class 1,” with no approved medical use, means funding for large well-done studies is limited.

Many of the studies of the benefits rely on self-reported use and are uncontrolled. An analysis of the use of cannabis for chronic pain found 7 large studies, including 13,000 patients, that were “observational” (uncontrolled) and 18 randomized placebo-controlled trials – but these were very small, averaging fewer than 100 subjects in each trial.

What we can gather from studies to date is that some cannabis products do help with insomnia, but this is countered by deterioration in sleep if use is stopped.

The evidence seems to show that cannabis has moderate effectiveness for chronic pain, but the benefit is countered by sedation and a marked increase in dizziness and falls.

What about the risks? Cannabis use by women during pregnancy results in increased likelihood of low birthweight, preterm birth and need for intensive care by the newborns.

Regular long-term use starting in adolescence and continued into middle age was accompanied by a fall in IQ and evidence of shrinkage of the part of the brain known as the hippocampus.

Participants in the United Kingdom Biobank (a large respected observational trial) who were regular heavy cannabis users, followed for an average of 12 years, had a higher mortality, both overall and from cancer and heart disease.

Older people should be particularly cautious, as side-effects such as dizziness and sedation are more likely. After cannabis was legalized in Ontario, Canada, the number of older adults treated in emergency departments for cannabis side-effects rose four-fold.

My take-aways? First, cannabis should be strongly discouraged in adolescents and young adults, whose brains are still developing, and in pregnant women.

It should be discouraged in older adults, where side-effects are more common and more likely to lead to falls and injury.

In the middle? Be cautious and minimize your use.

Finally, I do support the removal of cannabis from Class 1 to a lower class, so that proper studies can be done with federal funding. Only large, randomized, placebo-controlled trials can determine whether cannabis has a role in treating symptoms.


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Why do my feet tingle?

Peripheral neuropathy is a common condition, affecting some 6% of adults 45 or older.

What is it, what causes it and what can you do about it?

Our nervous system consists of the central nervous system (CNS) – the brain and spinal cord – and the nerves that carry sensation to and commands back from the CNS. These nerves are the peripheral nervous system.

The peripheral nerves can be thought of as the body’s wiring system. There are sensory nerves that bring sensations of touch, temperature and pain to the CNS, motor nerves that carry commands from the CNS to our muscles, and autonomic nerves, that regulate bodily functions not usually under conscious control such as heart rate, breathing and gastrointestinal function.

Many things can damage nerves, some of which happen no matter what we do while others are under our control.

If sensory nerves are damaged, we may be unable to feel hot or cold or where our feet are, or we may feel numbness or tingling, or we may feel pain for no reason.

If motor nerves are involved, you will notice muscle weakness.

Autonomic neuropathy can have many effects, including drop in blood pressure when you stand up.

Because the nerves to the feet are the longest peripheral nerves, they are most susceptible to damage and usually the first to suffer. Hence, we usually notice abnormal sensation in the feet rather than higher up. The fingers may be next.

What causes peripheral neuropathy? The commonest known cause is diabetes; the longer and more poorly controlled is the diabetes, the more likely to result in neuropathy. Another common cause is excess alcohol. Vitamin deficiency, particularly of B12 and other B vitamins, is a very treatable cause. (Oddly enough, excess B6 can also cause neuropathy!) Chemotherapy often results in neuropathy.

There are numerous diseases, too many to list, that have peripheral neuropathy as one of their symptoms.

Finally, there is that great wastebasket of “we do not know.” One of the commoner causes of peripheral neuropathy is simply aging, with no specific disease found after thorough testing.

What can you do? If you notice any of the symptoms listed above, bring it to your doctor’s attention. Verifying the presence of neuropathy is usually easily done by physical exam. If it appears likely, you should probably see a neurologist for a more thorough exam and testing.

To minimize the likelihood of developing neuropathy, eat a healthy diet with lots of fruits and veggies to get your B vitamins and minimize your alcohol intake. If you have diabetes, work with your doctors and nurses to keep it under good control.

Do not dismiss it (or let your doctor dismiss it) as simply aging. Only after treatable causes are excluded is this an acceptable conclusion.


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Are you taking a daily aspirin?

Should you be taking a daily aspirin?

First, a little bit of (easy) basic science: we cut ourselves all the time, and nature has given us protection against bleeding to death every time this happens.

The first line of defense is our platelets, small blood particles that go to the site of disrupted blood vessels and plug any small holes, like the little Dutch boy at the dike.

The second and more permanent way bleeding is stopped is that proteins in our blood form clots.

These protective forces can cause harm. Platelets attracted not to a hole in an artery but to an irregular surface such as a cholesterol plaque can block off the artery, causing a heart attack or stroke.

(Unneeded clots can also cause problems – we will discuss that another day.)

Aspirin works to prevent platelets from clumping together. This effect is rapid and effective: a single dose of 81 or 162 mg (“low dose”) aspirin paralyzes all the circulating platelets. Platelets turn over rapidly; you get an entirely new set every 7 days, so a single dose will be effective for a few days only.

Many decades ago, it was shown that daily low dose aspirin started within 24 hours of a heart attack dramatically reduced the risk of another heart attack and stroke. This effect is called “secondary prevention:” preventing a recurrence, and nothing has changed this benefit. If you have coronary disease, you should be on aspirin unless you are at very high bleeding risk.

The problem comes when the prescription of aspirin moves from this valid use to broader use. It seems logical that if aspirin taken after a heart attack prevents another one, taking aspirin before a heart attack should prevent a first one, so-called “primary prevention.”

Aspirin taken this way DOES decrease a first heart attack or stroke, but only by a very small amount. This benefit is typically outweighed by the increased risk of bleeding that comes with aspirin use.

The higher your risk of heart attack or stroke and the lower your risk of bleeding, the more the evidence says to take aspirin. If you have multiple risk factors such as hypertension, high cholesterol, smoke and have a positive family history, and particularly if you have a high coronary calcium score, the more likely you would benefit from daily low dose aspirin.

If your coronary risk is only moderate and if you have had a bleeding ulcer or other serious bleeding, you are better avoiding aspirin.

In between? The old fallback: talk to your doctor!

No known major coronary risk? The risks almost certainly outweigh the benefits.


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How much water do you need?

It depends!

Water truly is life – we can go without eating for weeks and survive but get very sick if we do not get adequate water for a few days.

You are doubtless familiar with “rules” such as the need to drink 8 glasses of water a day. The problem with relying on such simple rules is that the real answer truly is “it depends.”

A man who is 6’5” and weighs 205 lbs. needs more water than a woman who is 5’4” and weighs 110.

It is currently sunny and pushing 90 degrees F. Walking up to get the mail left me sweating. We clearly need more water under these conditions than we do when it is 65 and shady.

People doing physical work outdoors in the heat need more water than those sitting at desks in air-conditioned offices.

“Water” includes most other liquids such as herbal tea and fruit juice – but not caffeinated drinks or alcohol, which tend to pull water out of the body.

Finally, and perhaps less obvious, we do not get water only by drinking. Many foods, particularly fruits and vegetables, contain significant amounts of water. Our habitual diet will change the amount of water we need.

Then how do you know how much water to drink? A simple reliable way to assess this is to look at your urine. If your urine is dilute – clear to pale yellow in color – you are adequately hydrated. If your urine is closer to apple juice than lemonade in color, you are dehydrated and need to drink more.

If your urine is very dark, you ought to seek medical attention, as you may need intravenous fluids.

Do not depend on thirst as your sole indicator. If you are thirsty, you are probably somewhat dehydrated, but lack of thirst is not as reliable as the color of your urine.

So: drink up!


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A shot in the knee?

A lot of us develop osteoarthritis (“wear and tear arthritis” – though the process is not that simple) as we age.

If it is truly disabling, surgery may be the only way to reduce pain and increase mobility, but there are many less invasive options. Do any of them work?

Let’s get one myth out of the way first. Many people see an orthopedic surgeon and are told “your knee(s) are bone-on-bone, and nothing will work but surgery.” This is very often an exaggeration. There may be complete loss of cartilage in a portion of the knee, but rarely does this involve the whole knee. If it is on one edge, a brace may give great relief. The decision to have surgery should almost never be based on an X-ray.

The most time-tested non-surgical approach is an injection of a cortisone-type product into the knee, usually accompanied by a local anesthetic. This injection generally starts working in 2 days, and the effect may last 3-4 months. I had patients who got these shots 3-4 times a year for several years with good relief.

Like any treatment, cortisone shots do not work for everyone, and there is a worry that the drug may hasten deterioration of cartilage. The treatment is universally covered by Medicare and commercial insurance plans.

Hyaluronic acid is a lubricant that mimics the body’s natural joint fluid and injecting it into the knee is another “standard” procedure that is covered by insurance. Since most of the product leaks out of the joint within a few days, it is unclear how it works, and recent studies have suggested that it has largely a placebo effect.

Newer treatments are available that are considered experimental and typically NOT covered by insurance.

One is injection of platelet-rich plasma (PRP), drawn from your own blood, centrifuged to separate the PRP from the rest of the blood and injected into the knee. These seem to work by reducing inflammation and may provide relief for as long as a year. Be prepared to pay several thousand dollars out of pocket if you go this route.

Widely advertised is the use of stem cell injections, which can theoretically grow new cartilage. The jury is still out on this, but most studies show benefit lasting only 3-4 months. The cost, in the thousands, will almost certainly not be covered by insurance.

The newest kid on the block is radiofrequency ablation (RFA) of the pain nerves in the knee. This treatment has been shown to give pain relief for up to six months. It is minimally invasive and has few side effects, but is often not covered by insurance, at least not without prior approval from your insurance company.

Knee replacement surgery is generally, but far from always, successful. If you opt for this surgery, know that you must be committed to doing a lot of physical therapy for many months to get the best result.

Do not forget weight loss! Whether through use of the newer drugs or old-fashioned diet, significant weight loss will usually help your knees.


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Do you feel safe at home?

Domestic violence has been a plague throughout human history, but only in recent decades has it come to the forefront of medical and legal concerns.

Domestic violence or "intimate partner violence", is a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner. Abuse can be physical, sexual, emotional, or psychological.

While domestic violence most commonly involves a male against a female, the victim can be of any gender or age.

How common is domestic violence? Nearly 3 in 10 women (29%) and 1 in 10 men (10%) in the US have experienced rape, physical violence, and/or stalking by a partner and reported it having an impact on their functioning. In the United States, more than 10 million adults experience domestic violence annually.

Since the abuser is a spouse or companion, and often repeatedly apologizes and promises to stop, the victim is often reluctant to call the police, and the pattern continues.

If there are children, the victim may be even more reluctant to separate, and the children become emotionally (if not physically) traumatized.

Once thought of as a problem among lower socioeconomic classes, we now know that domestic violence is prevalent in every community, and can affect anyone regardless of age, socioeconomic status, sexual orientation, gender, race, religion, or nationality.

If you are the victim, or you know someone who is a victim, what can you do? First, know that it is NOT your fault. Disagreements among spouses or other domestic partners are normal and common, but never justify violence.

If you feel you are in immediate danger, call 911 and get help getting away from your abuser.

Find someone you can trust and seek their help. This may be your physician, pastor, or a close friend or relative. You almost certainly cannot solve the problem yourself.

For anonymous, confidential help, 24/7, call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY). Almost every state has 24/7 hotlines and most offer immediate help with shelter and legal resources.

If you suspect a friend or relative may be a victim, you can help. Be aware of clues such as bruising, cut lip or emotional withdrawal. Listen – let them know you want to help – but do not offer concrete advice until asked. Believe them – you may find it hard to believe but know how common the problem is.

Reassure them that you believe them, that it is NOT their fault and that they do NOT “deserve” what is happening. Help the victim create a safety plan that can be put into action if violence occurs again or if they decide to leave the situation.

This should include a safe place to go in an emergency, or if they decide to leave, a way to let family or friends know what is happening and an "escape bag" with cash, important documents (birth certificates, social security cards, etc.), keys, toiletries, and a change of clothes that can be easily accessed in a crisis.

Domestic violence will probably never disappear, but you do not have to accept it.


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We are having a heat wave...

The U.S. and most of the world experienced unprecedented heat waves last summer, and this summer promises more of the same. The Northeast is set to experience it’s first official heat wave as I write. Extreme heat can cause serious health issues, including death, so prepare – prevention is much better than treatment.

The body is generally quite good at maintaining a normal internal (or “core”) temperature. We get rid of excess heat by increasing blood flow to the skin, where it can be removed by air flowing over us, and by increasing sweating, which dissipates heat as it evaporates.

In extreme heat conditions, these mechanisms may be inadequate, and our core body temperature rises. The heart feels the stress – it works much harder trying push more blood through dilated blood vessels.

The first sign of heat beyond the body’s ability to cope are cramps and “heat exhaustion:” dizziness, weakness, nausea, headache, and an unsteady gait. If the sufferer is moved to a cool environment, these symptoms will usually pass.

If the core body temperature exceeds 104 (40C), you may go on to experience “heat stroke.” This life-threatening condition begins with confusion and can go on to seizures, delirium, coma, and death if untreated.

While everyone can experience these heat-related emergencies, certain people are at higher risk: children and the elderly, those doing physical work outdoors and those taking medications that impair the body’s response to heat (such as diuretics – fluid pills - many psychiatric drugs and anticholinergics, used for some urinary and bowel problems).

How can you prevent heat-related illness? The most obvious is the most important: stay cool! Keep blinds down to lessen indoor heat; use your air conditioner, and if only 1 or 2 rooms have AC, stay in those rooms. If you do not have AC, use public places that do, such as the library or official cooling sites.

Avoid doing physical work in the heat of the day; if you MUST run or cycle, do it in the early morning. Hydrate! You are going to lose water by increased sweating, so push the water and electrolyte drinks.

If you are experiencing any of the symptoms noted above, stop physical activities and get to somewhere cool. If you do not improve, call 911. An emergency home remedy is to get in a cold tub or to put ice bags under the armpits, behind the neck and in the groin.

Check on any neighbors who may be at risk. Since an early sign of heat-related illness is confusion, they may not react properly.


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Symptoms and cancer

Most cancers eventually cause symptoms, but usually only when the cancer has been there a long time, and often when the optimal time for treatment has passed. This has led to the recommendation behind many “screening tests,” tests done in people with no symptoms.

Colonoscopy, Pap smears (often combined with HPV virus testing), mammograms and low-dose chest CT are among the recommended tests done routinely in people with no relevant symptoms.

Do symptoms have any role in cancer detection? Yes, in both directions.

Let’s start with men. Many men worry they may have prostate cancer when they begin noting urinary urgency and frequency, and feel that if they have no urinary symptoms cancer is unlikely. In fact, urinary symptoms reflect growth of the central part of the prostate, which surrounds the urinary passage out of the bladder, while most cancers begin in the outer part of the gland. So, counting on symptoms to prompt a search for prostate cancer is unwise.

Whether screening for prostate cancer saves lives remains controversial, but if you want to find it early, get tested regardless of any symptoms.

For both men and women, both kidney and bladder cancers are usually heralded by blood in the urine, though this may be small enough to only be seen when the urine is checked by a lab. Since a small amount of blood in the urine is common, and most often due to something else (infection and stones lead the list), there is tendency to overlook it. Don’t.

If your patient portal shows you that you have any amount of blood in your urine, be sure your doctor stays on top of it. At a minimum, get this rechecked. If it is still there, the next test is usually an ultrasound – both safe and harmless, so not to be feared.

Uterine cancer is becoming more common, for reasons not entirely clear. This cancer almost always announces itself early, with abnormal bleeding. If caught early, uterine cancer should be nearly 100% curable, but diagnosis is too often delayed because the bleeding is attributed to something else. Don’t accept a diagnosis of fibroids or endometriosis or hormone imbalance without at least discussing having a sampling biopsy. If you have been through menopause and then bleed, demand a biopsy.

Finally, for women, is ovarian cancer. This, like pancreatic cancer, is often found only after it has spread. It has been taught that early ovarian cancers do not cause symptoms, but a recent study found that 72% of women with early-stage cancer had one or more symptoms. The leading symptoms were abdominal and/or pelvic pain, fullness or bloating and urinary frequency. Most often these symptoms are not due to ovarian cancer, but do not ignore them. You know your body, and if these symptoms are new, persist and do not have another explanation, push your doctor to check for ovarian cancer, typically with a pelvic ultrasound. Catching it early may save your life.


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Here comes the sun - cover up!

After a cool rainy spring, at least in the northeast, summer has finally arrived, bringing promise of beach time, sailing, cycling and other outdoor activities.

As good as the sun is for the soul, it is hard on the skin. The sun’s UV (ultraviolet) rays age the skin, contribute to skin cancer and can cause painful burns. A good protective sunscreen lotion should be a key part of your outdoor gear.

There are 3 types of UV rays:

• UVA. These rays go into the skin more deeply than UVB rays. They play a major part in skin aging and wrinkling. They also contribute to the growth of skin cancer.

• UVB. These rays are the main cause of sunburn. They tend to damage the skin's outer layers. These rays also play a key role in the growth of skin cancer.

• UVC. These rays do not reach our skin. The Earth’s atmosphere absorbs them before they reach the surface.

Sunscreens are labelled with their SPF – skin protective factor – a measure of how much of the UVB rays, the rays that cause sunburn, they block. An SPF of 30 blocks some 97% of these rays. Going above 30 adds very little additional protection.

Since it is the UVA rays that most contribute to skin cancer, you should look for a product labelled “Broad spectrum,” indicating protection against both UVA and UBV.

There are two main types of lotion – chemical-based and mineral-based. Chemical sunscreens absorb UV rays while mineral sunscreens reflect them as well as absorbing them.

It has been found that the chemicals in sunscreens are absorbed and can be measured in the blood. To date, there is no evidence of harm, but this has only been studied recently. The zinc oxide and titanium dioxide in mineral sunscreens are not absorbed but can leave white residue on the skin and this may discourage use. The best sunscreen is the one you will use!

The ingredients in sunscreen degrade when hot, so leaving the bottle in a hot car or beside you on the beach is not a good idea. Keeping the sunscreen bottle in your cooler is wise.

Despite claims to the contrary, very few sunscreens are “waterproof.” Water resistant sunscreens will only work on wet skin for an hour or two and should be reapplied every 2 hours if you are sweaty and after you get out of the water if you swim.

Don’t forget to protect your ears, lips (with a sun-protective lip balm), feet and ankles and along clothing/swimsuit edges.

So…

Buy a broad-spectrum sunscreen with an SPF of 30 or higher, apply it liberally every 2 hours (sooner if you go in the water) and be sure to protect all exposed skin. Keep the bottle cool if possible. Do not forget the option of protection with a hat and light-colored clothing.




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FSA, TSA, HSA - two of these can help a bit with medical bills

Except for some government employees, generous health insurance is rare. As the cost of insurance has skyrocketed, employers are shifting more of the cost to their employees, often through higher and higher copays and deductibles.

Either a Flexible Spending Account (FSA) or a Health Savings Account (HSA) can lessen the blow.

Note that in general you will be offered one or the other, but rarely will both be possible.

FSAs allow you (and also your spouse if they are employed) to put up to $3200 pre-tax income each year into an account that can be used to pay for eligible health and medical expenses. This saves you paying income taxes on the amount you put into the FSA. Your employer may, but is not required, to put money into your account as well, up to the amount you put in through payroll deduction.

Note that you can only contribute to an FSA if you have employer-sponsored health insurance.

It is very important to remember that these plans are “use it or lose it.” You may be able to roll over any balance at the end of the year, but if you do not spend these funds on eligible expenses, the money goes back to your employer. Also, if you change employers, your FSA does not travel with you.

Before deciding to contribute to an FSA, look carefully at your out-of-pocket medical expenses for the last year or two – and take into account any expected expenses such as dental work or elective surgery.

If it is offered, an HSA is an even better deal, particularly if you can afford to put in significant sums. An HSA can be set up by your employer or, depending on the type of health insurance you have, yourself. The contributions lower your taxable income, just as with an FSA, but there is no deadline for spending the money. You can let it accumulate, tax-free, and, as long as you use the money for health expenses, pay no tax on withdrawals. An HSA is yours – if you change jobs, it goes with you.

The maximum contribution limit of an HSA is higher than to an FSA. Individuals can contribute up to $4,150 to their HSA accounts for 2024, and families can contribute up to $8,300. People 55 and older are allowed an additional $1,000. As with FSAs, employers may but are not required to contribute.

On what can you spend the money in these accounts? Copays and deductibles are eligible, as are dental bills, medical equipment, eyeglasses and most over-the-counter medications. You can even use the money to pay for needed home renovations if they are medically-justified.

Neither of these types of accounts will remove all the sting of exorbitant medical costs, but if Uncle Sam is willing to help, you should let him do so.


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