There are many ways to gauge the health of a population, whether a nation or some specific portion of it, but the commonest and broadest measure is the average life expectancy: the number of years a child born will live on average. Life expectancy in developed countries has increased for most of the past century, as antibiotics decreased deaths from infectious diseases and better sanitation became universal. US life expectancy began to lag that of most other developed countries in the late 1980s and by 1998 had fallen to a level below the average among OECD (the Organization for Economic Cooperation and Development) countries. Average life expectancy in those countries has continued to increase every year but stopped increasing in the US in 2010 and since 2014 has fallen, even though we pay almost twice as much per capita as do those countries on health care. Why is this?
Death rates among those 65-84, while obviously high (the biggest risk factor for most diseases is old age!), have fallen substantially between 1999 and 2017, while the death rates for those 25-64 reached a low in 2009 and have risen since. The death rates have risen significantly among those 25-44, as deaths from suicide (usually by gun), opioid overdose and alcohol-related liver disease – diseases of despair - have all jumped. Infant mortality rates have fallen slightly in the US over the past 20 years but remain well above those in other developed countries and are improving at a slower rate than theirs.
Differences in life expectancy are clearly related to factors other than health care expenditure. Researchers have shown dramatic differences in life expectancy among people living in zip codes less than 10 miles apart, sharing access to the same hospitals but having very different household incomes. Increased stress, including economic, has been linked to higher heart attack rates. Rising unemployment or under-employment probably explains the much higher suicide and opioid-related death rates in the industrial heartland, Appalachia and northern New England. Maternal death rates are 5-fold higher among African-American women than whites.
The solution to our discouraging health statistics is not more health care spending. Rather it lies in reining in our excessive and wasteful spending and re-directing this money to such areas as vocational education, improving social support, providing better access to healthy foods and increasing minimum wages. A living wage is the best medicine available for most conditions.
Prescription for Bankruptcy. Buy the book on Amazon
Sunday, December 1, 2019
Sunday, November 24, 2019
The problem of rural health care
There are many disparities in health care. Black mothers have a much higher rate of maternal death than do white women. All women are less likely to get guideline-advised cardiac care than do men. Among the many such examples, perhaps the hardest disparity to solve is that of the poorer access to health care faced by rural communities. People living in rural counties have higher death rates from cancer and heart disease than their urban counterparts, and there are more deaths from opioid overdose. Rural hospitals are closing every week, leaving their communities with less local access to needed services. Physicians practicing in rural communities are older and are not being replaced as they retire.
To keep small hospitals open, the federal government created the Critical Access Hospital program in 1997 that pays more to small (25 or fewer beds) and isolated (at least 35 miles from another hospital) hospitals. A friend who is an experienced nurse once told me she thought this was akin to the Chrysler bail-out, and these hospitals provided poor care and should be allowed to close. Many studies have documented poorer processes of care at small hospitals compared to larger one. It is certainly true that small rural hospitals do not provide the same level of service as do larger hospitals. They have few specialists and rarely have anything close to a critical care unit for truly sick patients.
I remember well an experience from many years ago. I was “moon-lighting” in the emergency department of a small isolated hospital when a patient came in with an obvious acute appendicitis that looked about to rupture. Unfortunately, the only surgeon on staff was quite inebriated after a night of partying and clearly in no shape to even drive to the hospital, never mind operate. The weather was foul and getting the patient to another hospital was going to be dangerous, so the nursing staff convinced me, a cardiology fellow, to operate. Luckily the OR nurses knew more about the procedure than I did, and I had assisted on a few appendectomies in medical school, so the patient survived, but at a larger hospital this dilemma would never have arisen.
What can be done? Better transportation would help. In truly isolated areas, air ambulances may be needed. Under our current system these are often exorbitantly expensive and a common source of “surprise medical bills” that run into the $10’s of thousands for non-Medicare patients. State governments and/or referral hospitals should establish fairly-priced air ambulance services if they cannot get commercial providers to bring down their prices. More use of tele-medicine would help, both in providing specialty consultation to the small hospitals and in allowing patients to avoid long drives. It has been found that pre-hospital personnel, EMTs and paramedics, can often avoid taking a patient to the hospital if they have telephone back-up at the scene. Consolidation of rural hospitals to provide more of a critical mass of physicians might require longer drive times but would provide better care in return. Medical schools should recruit more students from small communities, as graduates are much more likely to serve their own or similar communities than are students from an urban background, and rural students are now very under-represented among medical students.
In the meantime, if you are contemplating a move to the bucolic countryside after retirement, look carefully at the medical resources that would be available when you need them!
Prescription for Bankruptcy. Buy the book on Amazon
To keep small hospitals open, the federal government created the Critical Access Hospital program in 1997 that pays more to small (25 or fewer beds) and isolated (at least 35 miles from another hospital) hospitals. A friend who is an experienced nurse once told me she thought this was akin to the Chrysler bail-out, and these hospitals provided poor care and should be allowed to close. Many studies have documented poorer processes of care at small hospitals compared to larger one. It is certainly true that small rural hospitals do not provide the same level of service as do larger hospitals. They have few specialists and rarely have anything close to a critical care unit for truly sick patients.
I remember well an experience from many years ago. I was “moon-lighting” in the emergency department of a small isolated hospital when a patient came in with an obvious acute appendicitis that looked about to rupture. Unfortunately, the only surgeon on staff was quite inebriated after a night of partying and clearly in no shape to even drive to the hospital, never mind operate. The weather was foul and getting the patient to another hospital was going to be dangerous, so the nursing staff convinced me, a cardiology fellow, to operate. Luckily the OR nurses knew more about the procedure than I did, and I had assisted on a few appendectomies in medical school, so the patient survived, but at a larger hospital this dilemma would never have arisen.
What can be done? Better transportation would help. In truly isolated areas, air ambulances may be needed. Under our current system these are often exorbitantly expensive and a common source of “surprise medical bills” that run into the $10’s of thousands for non-Medicare patients. State governments and/or referral hospitals should establish fairly-priced air ambulance services if they cannot get commercial providers to bring down their prices. More use of tele-medicine would help, both in providing specialty consultation to the small hospitals and in allowing patients to avoid long drives. It has been found that pre-hospital personnel, EMTs and paramedics, can often avoid taking a patient to the hospital if they have telephone back-up at the scene. Consolidation of rural hospitals to provide more of a critical mass of physicians might require longer drive times but would provide better care in return. Medical schools should recruit more students from small communities, as graduates are much more likely to serve their own or similar communities than are students from an urban background, and rural students are now very under-represented among medical students.
In the meantime, if you are contemplating a move to the bucolic countryside after retirement, look carefully at the medical resources that would be available when you need them!
Prescription for Bankruptcy. Buy the book on Amazon
Tuesday, November 5, 2019
Vaping - what we know and what we don't
Some 70 years after Doll and Hill published their landmark paper in the British Medical Journal linking smoking to lung cancer, we know a lot more about both the dangers of cigarettes and the predatory practices of the tobacco industry. A major public health campaign that included both education and regulation has led to decreased smoking and a corresponding drop in coronary disease. We still need on-going efforts, as the effects can be overcome by tobacco advertising. Banning flavored cigarettes or restricting their sale was shown to work in a study comparing youth smoking in Lowell, which had such a restriction beginning in 2016 and Malden, which did not. The consequences of smoking are still a huge problem in China and in many developing countries where tobacco ads dwarf public health measures, so we must stay vigilant.
The new epidemic which requires action is the use of e-cigarettes, or “vaping.” Vaping is the act of inhaling the aerosol produced by a battery-powered device. E-cigarettes contain pre-filled pods of liquids that the user adds to the device, and now are most commonly small devices that resemble a USB stick, and so are easy to carry and use. The liquids generally consist of glycerin, water, propylene glycol, nicotine and flavorings. Juul, by far the leading seller of e-cigarettes, has claimed that they are selling their product as a smoking cessation aid, and prominently feature adult smokers extolling the value of the product for this purpose. However, they clearly market to youth on social media, and by far the biggest selling products are those that are flavored. Flavor was the reason that about a third of users first tried e-cigs and most (63%) current users used flavors other than tobacco. Fruit flavors were most likely to motivate young adults to try vaping. In 2018, two thirds of U.S. middle and high school students had tried e-cigarettes or been exposed to second-hand aerosol in the previous 30 days. E-cigarette use is also a strong gateway to use of tobacco cigarettes among youth, with over 4-fold greater smoking among e-cig users.
Are e-cigarettes safer than combustibles? Clearly smoking causes cancer. Mint- and menthol-flavored e-cigarettes have very high levels of pulegone, a known carcinogen. E-cigarette smoke has also been shown to induce cancerous changes in the lung and bladder of mice. Smoking is a major contributor to coronary disease. What about e-cigarettes? They are associated with an increased risk of myocardial infarction that is similar to that of smoking conventional cigarettes, and dual use is riskier than using either product alone. Many women use e-cigarettes while they are pregnant, perhaps believing that they are safer than combustibles, but e-cig use has been shown to delay implantation and cause reduced weight gain of the fetus. While some short-term studies have shown minor improvements in measures of lung function among COPD patients who switched from combustible to e-cigarettes, vaping has been clearly shown to cause airway inflammation and lung disease. Finally, our dental colleagues have reported that e-cigarette aerosols increase the risk of cavities similarly to gelatinous candies.
Last, but far from least, is the mysterious and frightening epidemic of vaping-related lung disease. This was first reported from the upper Midwest in the spring of this year but has rapidly spread. Vaping-related lung disease has now been reported in 49 states (all but Alaska), DC and the US Virgin Islands. The number of cases is a moving target, but as of Oct 29, 2019, there were 1888 confirmed and probable cases and 37 deaths. The illness consists of early symptoms of nausea, vomiting and abdominal pain, followed by progressive shortness of breath, often leading to respiratory failure and the need for being placed on a ventilator. The chest X-ray shows diffuse infiltrates. The exact cause is still controversial. Among patients with full data, 86% reported use of THC-containing products, 64% nicotine-containing products and 52% both. No single compound has been shown to be the cause. The majority of those affected have been teens and young adults, though the death rate has been higher in middle-aged and older victims. Because the cause remains unknown, the CDC recommends against the use of any vaping products.
The bottom line: vaping is NOT safe, and best avoided.
Prescription for Bankruptcy. Buy the book on Amazon
The new epidemic which requires action is the use of e-cigarettes, or “vaping.” Vaping is the act of inhaling the aerosol produced by a battery-powered device. E-cigarettes contain pre-filled pods of liquids that the user adds to the device, and now are most commonly small devices that resemble a USB stick, and so are easy to carry and use. The liquids generally consist of glycerin, water, propylene glycol, nicotine and flavorings. Juul, by far the leading seller of e-cigarettes, has claimed that they are selling their product as a smoking cessation aid, and prominently feature adult smokers extolling the value of the product for this purpose. However, they clearly market to youth on social media, and by far the biggest selling products are those that are flavored. Flavor was the reason that about a third of users first tried e-cigs and most (63%) current users used flavors other than tobacco. Fruit flavors were most likely to motivate young adults to try vaping. In 2018, two thirds of U.S. middle and high school students had tried e-cigarettes or been exposed to second-hand aerosol in the previous 30 days. E-cigarette use is also a strong gateway to use of tobacco cigarettes among youth, with over 4-fold greater smoking among e-cig users.
Are e-cigarettes safer than combustibles? Clearly smoking causes cancer. Mint- and menthol-flavored e-cigarettes have very high levels of pulegone, a known carcinogen. E-cigarette smoke has also been shown to induce cancerous changes in the lung and bladder of mice. Smoking is a major contributor to coronary disease. What about e-cigarettes? They are associated with an increased risk of myocardial infarction that is similar to that of smoking conventional cigarettes, and dual use is riskier than using either product alone. Many women use e-cigarettes while they are pregnant, perhaps believing that they are safer than combustibles, but e-cig use has been shown to delay implantation and cause reduced weight gain of the fetus. While some short-term studies have shown minor improvements in measures of lung function among COPD patients who switched from combustible to e-cigarettes, vaping has been clearly shown to cause airway inflammation and lung disease. Finally, our dental colleagues have reported that e-cigarette aerosols increase the risk of cavities similarly to gelatinous candies.
Last, but far from least, is the mysterious and frightening epidemic of vaping-related lung disease. This was first reported from the upper Midwest in the spring of this year but has rapidly spread. Vaping-related lung disease has now been reported in 49 states (all but Alaska), DC and the US Virgin Islands. The number of cases is a moving target, but as of Oct 29, 2019, there were 1888 confirmed and probable cases and 37 deaths. The illness consists of early symptoms of nausea, vomiting and abdominal pain, followed by progressive shortness of breath, often leading to respiratory failure and the need for being placed on a ventilator. The chest X-ray shows diffuse infiltrates. The exact cause is still controversial. Among patients with full data, 86% reported use of THC-containing products, 64% nicotine-containing products and 52% both. No single compound has been shown to be the cause. The majority of those affected have been teens and young adults, though the death rate has been higher in middle-aged and older victims. Because the cause remains unknown, the CDC recommends against the use of any vaping products.
The bottom line: vaping is NOT safe, and best avoided.
Prescription for Bankruptcy. Buy the book on Amazon
Monday, October 28, 2019
What is "pre-illness" and what can you do about it?
OK, so you have been told you have “pre-diabetes” or “pre-hypertension.” What does that really mean? What should you do about it?
“Pre-disease” is a relatively new concept, unheard of when I started practice, but being applied more and more. It simply means that you have some measurement that is abnormal but does not meet the established criteria for a diagnosis. A friend of mine once observed that “there are no healthy people, simply those who have not had enough tests,” and this concept of our fragility seems to be applied more and more. Commonly used labels I have come across, in addition to pre-diabetes and pre-hypertension (now more commonly described as “Stage 1 hypertension”), include dyslipidemia, osteopenia and pre-cancer. The rationale for applying these labels is that catching a disease early, in its “pre-“ stage, and treating it, will somehow help avoid serious problems down the road. The evidence that this is true is very limited.
The CDC recently claimed that 84 million Americans had pre-diabetes – an enormous number, and an enormous potential group of customers for the pharmaceutical industry. An article in the journal Diabetes Care in 2016, however, found that only about 2% of pre-diabetics went on annually to have overt diabetes. At least a third in whom no intervention was carried out reverted to completely normal blood sugars, and the rest remained with mildly elevated sugar values. A more recent study in the same journal looked at 3313 black adults and defined pre-diabetes as a fasting sugar between 100 and 125 (below 100 being normal). They found no increased risk of cardiovascular disease in those with mildly elevated sugars.
Hypertension was previously defined as a BP persistently over 140/90, but values of 130-139/80-89 are now called “Stage 1 hypertension,” and it is estimated that one third of American adults have this “condition.” There are many problems with this labelling. One is that there is increasing evidence that office or clinic BP measurements are not truly representative of our usual BP and are frequently not even measured accurately. Another is that there is to date no evidence that treating this with medication does more good than harm.
Another common “pre-condition” is osteopenia, a bone density below normal but not severe enough to be osteoporosis. Some estimates claim osteopenia affects about 43 million U.S. adults, mostly women. How important is this? A study of 5000 older women with osteopenia found that after 10 years, only 5% had gone on to develop osteoporosis. If you want to estimate your risk of fracture, and you know your actual bone density numbers, you can go to https://www.sheffield.ac.uk/FRAX/ and run the numbers. (If you are a U.S. Caucasian, go to https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9)
What should you do if you have been told you have one of these “pre-diseases.” What I would NOT do is begin medication. You may want to take this as a kick in the rear to motivate you to make some healthy lifestyle changes. Losing a few pounds or beginning a regular exercise program will usually reduce your sugar. Exercise, a more vegetarian diet and cutting down on alcohol will drop your blood pressure. Weight-bearing exercise and a diet rich in Vitamin D and calcium (but not supplements) and stopping smoking will strengthen your bones. Note the common thread in all of these?
Equivocal cancers are a whole other subject, which I will get to in another post.
Happy exercising!
Prescription for Bankruptcy. Buy the book on Amazon
“Pre-disease” is a relatively new concept, unheard of when I started practice, but being applied more and more. It simply means that you have some measurement that is abnormal but does not meet the established criteria for a diagnosis. A friend of mine once observed that “there are no healthy people, simply those who have not had enough tests,” and this concept of our fragility seems to be applied more and more. Commonly used labels I have come across, in addition to pre-diabetes and pre-hypertension (now more commonly described as “Stage 1 hypertension”), include dyslipidemia, osteopenia and pre-cancer. The rationale for applying these labels is that catching a disease early, in its “pre-“ stage, and treating it, will somehow help avoid serious problems down the road. The evidence that this is true is very limited.
The CDC recently claimed that 84 million Americans had pre-diabetes – an enormous number, and an enormous potential group of customers for the pharmaceutical industry. An article in the journal Diabetes Care in 2016, however, found that only about 2% of pre-diabetics went on annually to have overt diabetes. At least a third in whom no intervention was carried out reverted to completely normal blood sugars, and the rest remained with mildly elevated sugar values. A more recent study in the same journal looked at 3313 black adults and defined pre-diabetes as a fasting sugar between 100 and 125 (below 100 being normal). They found no increased risk of cardiovascular disease in those with mildly elevated sugars.
Hypertension was previously defined as a BP persistently over 140/90, but values of 130-139/80-89 are now called “Stage 1 hypertension,” and it is estimated that one third of American adults have this “condition.” There are many problems with this labelling. One is that there is increasing evidence that office or clinic BP measurements are not truly representative of our usual BP and are frequently not even measured accurately. Another is that there is to date no evidence that treating this with medication does more good than harm.
Another common “pre-condition” is osteopenia, a bone density below normal but not severe enough to be osteoporosis. Some estimates claim osteopenia affects about 43 million U.S. adults, mostly women. How important is this? A study of 5000 older women with osteopenia found that after 10 years, only 5% had gone on to develop osteoporosis. If you want to estimate your risk of fracture, and you know your actual bone density numbers, you can go to https://www.sheffield.ac.uk/FRAX/ and run the numbers. (If you are a U.S. Caucasian, go to https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9)
What should you do if you have been told you have one of these “pre-diseases.” What I would NOT do is begin medication. You may want to take this as a kick in the rear to motivate you to make some healthy lifestyle changes. Losing a few pounds or beginning a regular exercise program will usually reduce your sugar. Exercise, a more vegetarian diet and cutting down on alcohol will drop your blood pressure. Weight-bearing exercise and a diet rich in Vitamin D and calcium (but not supplements) and stopping smoking will strengthen your bones. Note the common thread in all of these?
Equivocal cancers are a whole other subject, which I will get to in another post.
Happy exercising!
Prescription for Bankruptcy. Buy the book on Amazon
Thursday, October 17, 2019
Should you get a flu shot?
Let’s get one thing out there up front: flu shots are not guaranteed to prevent you getting influenza. Neither are seat belts a guarantee you won’t die in a car crash or bicycle helmets that you will survive getting thrown off your bike, but we still strongly recommend that you wear your seat belt when in a car and a helmet when on your bike. Why? Because they both greatly increase your odds of surviving an accident. It is the same with a flu shot: getting the shot cuts your odds of being hospitalized or dying of influenza by about a half.
A few facts: during the 2018-19 flu season, about 50,000 Americans and 3500 Canadians died of influenza. When the CDC looked patients hospitalized with influenza, those who had received the vaccine had a 36% lower risk of dying and 34% less risk of needing to be on a ventilator than those who had not.
Even if you do catch influenza despite getting the shot, you are going to be less sick and have a much lower risk of passing the disease on to others, which is one reason health care facilities make such a push to get all of their staff immunized.
Let’s clear up some common myths. First, influenza is not just a bad cold. If someone says they missed a couple of days of work because of the flu, they did not have influenza. With influenza you are sick for a good week or more with high fever, terrible cough and ache all over.
Second, you cannot catch anything from the shot. I used to hear “I had a flu shot once and got sick, so now I don’t get one.” The influenza vaccine is a “killed vaccine.” There is no live virus in the shot, just ground up particles from killed viruses. What may happen is that after getting a flu shot you get the same cold you were going to get anyway, and blame it on the shot. While you may get minor soreness at the site of the injection, serious side effects are very rare.
“I’m not around people that much, so I don’t need it.” True if you are a hermit, but not if you are a normal person, even an at-home worker. It is clearly true that school teachers, bus drivers and others who are around lots of people are at higher risk, but in an epidemic year we are all at risk.
Finally, “they never get it right.” We are all aware that some years the vaccine seems more protective than others, because the public health authorities who tell the manufacturers what strains of influenza to include in each year’s vaccine are making “educated guesses,” based on which strains were common in the southern hemisphere during their season. Some years they get it spot on and others they do not, but even a less-than-perfect vaccine is better than none.
So… role up your sleeve and do it before the flu season is in full swing.
Prescription for Bankruptcy. Buy the book on Amazon
A few facts: during the 2018-19 flu season, about 50,000 Americans and 3500 Canadians died of influenza. When the CDC looked patients hospitalized with influenza, those who had received the vaccine had a 36% lower risk of dying and 34% less risk of needing to be on a ventilator than those who had not.
Even if you do catch influenza despite getting the shot, you are going to be less sick and have a much lower risk of passing the disease on to others, which is one reason health care facilities make such a push to get all of their staff immunized.
Let’s clear up some common myths. First, influenza is not just a bad cold. If someone says they missed a couple of days of work because of the flu, they did not have influenza. With influenza you are sick for a good week or more with high fever, terrible cough and ache all over.
Second, you cannot catch anything from the shot. I used to hear “I had a flu shot once and got sick, so now I don’t get one.” The influenza vaccine is a “killed vaccine.” There is no live virus in the shot, just ground up particles from killed viruses. What may happen is that after getting a flu shot you get the same cold you were going to get anyway, and blame it on the shot. While you may get minor soreness at the site of the injection, serious side effects are very rare.
“I’m not around people that much, so I don’t need it.” True if you are a hermit, but not if you are a normal person, even an at-home worker. It is clearly true that school teachers, bus drivers and others who are around lots of people are at higher risk, but in an epidemic year we are all at risk.
Finally, “they never get it right.” We are all aware that some years the vaccine seems more protective than others, because the public health authorities who tell the manufacturers what strains of influenza to include in each year’s vaccine are making “educated guesses,” based on which strains were common in the southern hemisphere during their season. Some years they get it spot on and others they do not, but even a less-than-perfect vaccine is better than none.
So… role up your sleeve and do it before the flu season is in full swing.
Prescription for Bankruptcy. Buy the book on Amazon
Monday, October 7, 2019
Getting the most from a doctor visit
For most of us, going to the doctor is not at the top of our favorite things to do list, but it may be one of the most important. Whether the visit is for a scheduled check-up or to deal with a new problem, there are ways you can make the visit less stressful and more useful.
You must remember that things have changed. In the “good old days,” when I started in practice, the visit involved just the patient and the doctor. Nowadays, there are many other players, who may not be physically present but are influencing the visit, including insurers, lawyers and the ubiquitous electronic medical record (EMR). I recently saw an article headlined “Don’t let patient care interfere with documentation,” not-so-subtly making the point that doctors are overwhelmed with demands for data to satisfy the demands of multiple third parties; it has been estimated that for every hour directly interacting with patients, doctors spend two hours on administrative tasks. Despite this, most doctors really do want to do what is best for their patients, and you can help them achieve this.
Arrive on time for your visit, but be prepared to wait. Doctors run late for many reasons. It may be the fault of the office, scheduling patients to maximize the doctor’s time at the expense of patient convenience, and if you ALWAYS wait a long time, you may want to change doctors. More common reasons are that earlier patients arrived late but were seen anyway or that patients had more complicated problems than anticipated, turning a 15-minute visit into 30 minutes or more.
Silence or turn off your cell phone! It is hard enough to have a good conversation about an illness without the distraction of a phone going off. If you actually answer the phone, my reaction would be that since you are clearly not very worried about your health problem, I will not be either.
Do your homework and arrive prepared. While the doctor may be the expert on medicine, you are the expert on your own body, and you are the one to note that while a symptom may not be dramatic, it is new. Before the visit, put things down in chronologic order – what happened first, what happened next, and over roughly what time frame. It is OK to check your symptoms “on-line,” but please use a legitimate web site such as NLM.gov, CDC.gov, webmd.com or mayoclinic.org and do not “google” your symptoms. Whatever you do, do not say “I read on Facebook…” or your doctor will mentally tune out everything else you say.
Bring notes and take notes. It is easy to get side-tracked and forget things you thought were important. Have a summary of prior surgery, current medications, medication allergies and major medical problems printed and on your phone. Since it has been shown that 80%+ of what a doctor says is forgotten by the time you leave the building, either bring a friend or family member to act as a scribe and second pair of ears or make some written notes. Ask the doctor if it is OK to record the visit so you can listen to the conversation and advice given when you are less stressed.
It is OK to question the doctor. While doctors know a lot more about medicine than you do, we are not infallible. If the doctor dismisses a complaint when you “know” something is wrong, it is reasonable to ask for a second opinion. Misdiagnosis is increasingly recognized as a serious problem. You should be prepared to ask the doctor why they have made a diagnosis and what else it could be. You should also have a timetable for when you should feel better and what the plan is if you do not respond to the suggested treatment.
Remember: it is not your job to please the doctor; it is the doctor’s job to help you feel better. If you have a doctor with whom you cannot communicate, look for another.
Prescription for Bankruptcy. Buy the book on Amazon
You must remember that things have changed. In the “good old days,” when I started in practice, the visit involved just the patient and the doctor. Nowadays, there are many other players, who may not be physically present but are influencing the visit, including insurers, lawyers and the ubiquitous electronic medical record (EMR). I recently saw an article headlined “Don’t let patient care interfere with documentation,” not-so-subtly making the point that doctors are overwhelmed with demands for data to satisfy the demands of multiple third parties; it has been estimated that for every hour directly interacting with patients, doctors spend two hours on administrative tasks. Despite this, most doctors really do want to do what is best for their patients, and you can help them achieve this.
Arrive on time for your visit, but be prepared to wait. Doctors run late for many reasons. It may be the fault of the office, scheduling patients to maximize the doctor’s time at the expense of patient convenience, and if you ALWAYS wait a long time, you may want to change doctors. More common reasons are that earlier patients arrived late but were seen anyway or that patients had more complicated problems than anticipated, turning a 15-minute visit into 30 minutes or more.
Silence or turn off your cell phone! It is hard enough to have a good conversation about an illness without the distraction of a phone going off. If you actually answer the phone, my reaction would be that since you are clearly not very worried about your health problem, I will not be either.
Do your homework and arrive prepared. While the doctor may be the expert on medicine, you are the expert on your own body, and you are the one to note that while a symptom may not be dramatic, it is new. Before the visit, put things down in chronologic order – what happened first, what happened next, and over roughly what time frame. It is OK to check your symptoms “on-line,” but please use a legitimate web site such as NLM.gov, CDC.gov, webmd.com or mayoclinic.org and do not “google” your symptoms. Whatever you do, do not say “I read on Facebook…” or your doctor will mentally tune out everything else you say.
Bring notes and take notes. It is easy to get side-tracked and forget things you thought were important. Have a summary of prior surgery, current medications, medication allergies and major medical problems printed and on your phone. Since it has been shown that 80%+ of what a doctor says is forgotten by the time you leave the building, either bring a friend or family member to act as a scribe and second pair of ears or make some written notes. Ask the doctor if it is OK to record the visit so you can listen to the conversation and advice given when you are less stressed.
It is OK to question the doctor. While doctors know a lot more about medicine than you do, we are not infallible. If the doctor dismisses a complaint when you “know” something is wrong, it is reasonable to ask for a second opinion. Misdiagnosis is increasingly recognized as a serious problem. You should be prepared to ask the doctor why they have made a diagnosis and what else it could be. You should also have a timetable for when you should feel better and what the plan is if you do not respond to the suggested treatment.
Remember: it is not your job to please the doctor; it is the doctor’s job to help you feel better. If you have a doctor with whom you cannot communicate, look for another.
Prescription for Bankruptcy. Buy the book on Amazon
Thursday, October 3, 2019
Where's the beef?
A study published by the Annals of Internal Medicine on October 1 titled “Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations from the NutriRECS Consortium” has unleashed a firestorm of controversy. This publication and the reaction to it reveal so much about medical studies and recommendations that I was tempted to write a book about it, but will try to be briefer.
The conclusion of the paper was that adults continue their current consumption of both red meat and processed meat, noting that the recommendation was a weak one based on low-quality evidence. The reaction from such groups as the Harvard School of Public Health, the American Cancer Society and the American College of Cardiology was vehement opposition to this statement, implying that the authors were irresponsible and would contribute to more heart attacks and cancer.
Why the controversy? First, we must note that the ideal way medical recommendations are reached is through randomized controlled clinical trials: a group of people are given treatment A or Treatment B, selected randomly, and neither the subjects nor the researchers know which they get. The groups are followed for an appropriate time and at the end, the researchers look for a difference in the outcome between those given A and those given B. If there is a substantial difference between the groups, and if the people given A and those given B are shown to be pretty much the same except for the treatment, it is assumed that the difference in outcome was due to the treatment. I must note that small differences in outcome may be “statistically significant” if the groups are large enough even though the magnitude of the effect may be so small that it is not “clinically significant.”
While randomized trials work well when comparing two medicines, they are impossible to do when studying diet. Most of us can tell the difference between a steak and a roasted cauliflower. Dietary studies are thus mostly done by looking at what people do, generally based on self-reporting, and comparing the outcomes between those who claim to eat one way or another. These observational studies are fraught with difficulty. We learned long ago that when you compare people who do one thing differently, it is highly likely they do other things differently. Studies comparing vegetarians with omnivores cannot assume that their diets are the only thing different between them. Vegetarians may smoke less, may drink less (or more), may exercise more, may be leaner – all factors that impact health.
The NutriRECS group took this into account when they looked at all the published studies on diet and health. They concluded that the evidence base for recommending people cut down on their consumption of red and processed meat was weak. They also noted that the absolute benefit, in terms of number of heart attacks or cancers prevented, was relatively small. One example was an estimated 7 fewer cancers per 1000 people over their lifetime, a risk that omnivores might be willing to take when weighed against quality of life.
So, who is right? Both sides! If you are a vegetarian, you can be satisfied that you are slightly reducing your risk of cancer and heart attack (though slightly increasing your risk of stroke per another recent study in the British Medical Journal!) If you like to eat meat, you can be content that the absolute risk of your preference is relatively small and you do not need to make yourself miserable – and you can always balance your love of steak by walking more and dropping a few pounds.
Prescription for Bankruptcy. Buy the book on Amazon
The conclusion of the paper was that adults continue their current consumption of both red meat and processed meat, noting that the recommendation was a weak one based on low-quality evidence. The reaction from such groups as the Harvard School of Public Health, the American Cancer Society and the American College of Cardiology was vehement opposition to this statement, implying that the authors were irresponsible and would contribute to more heart attacks and cancer.
Why the controversy? First, we must note that the ideal way medical recommendations are reached is through randomized controlled clinical trials: a group of people are given treatment A or Treatment B, selected randomly, and neither the subjects nor the researchers know which they get. The groups are followed for an appropriate time and at the end, the researchers look for a difference in the outcome between those given A and those given B. If there is a substantial difference between the groups, and if the people given A and those given B are shown to be pretty much the same except for the treatment, it is assumed that the difference in outcome was due to the treatment. I must note that small differences in outcome may be “statistically significant” if the groups are large enough even though the magnitude of the effect may be so small that it is not “clinically significant.”
While randomized trials work well when comparing two medicines, they are impossible to do when studying diet. Most of us can tell the difference between a steak and a roasted cauliflower. Dietary studies are thus mostly done by looking at what people do, generally based on self-reporting, and comparing the outcomes between those who claim to eat one way or another. These observational studies are fraught with difficulty. We learned long ago that when you compare people who do one thing differently, it is highly likely they do other things differently. Studies comparing vegetarians with omnivores cannot assume that their diets are the only thing different between them. Vegetarians may smoke less, may drink less (or more), may exercise more, may be leaner – all factors that impact health.
The NutriRECS group took this into account when they looked at all the published studies on diet and health. They concluded that the evidence base for recommending people cut down on their consumption of red and processed meat was weak. They also noted that the absolute benefit, in terms of number of heart attacks or cancers prevented, was relatively small. One example was an estimated 7 fewer cancers per 1000 people over their lifetime, a risk that omnivores might be willing to take when weighed against quality of life.
So, who is right? Both sides! If you are a vegetarian, you can be satisfied that you are slightly reducing your risk of cancer and heart attack (though slightly increasing your risk of stroke per another recent study in the British Medical Journal!) If you like to eat meat, you can be content that the absolute risk of your preference is relatively small and you do not need to make yourself miserable – and you can always balance your love of steak by walking more and dropping a few pounds.
Prescription for Bankruptcy. Buy the book on Amazon
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