Just a simple vanilla blog site from a physician

Archive for the ‘Health and wellness’ Category

Can a picture promote good behavior?

Have been getting on the treadmill due to the ice and snow preventing me from running outside (run exclusively in 5 Finger barefoot shoes) and playing golf (hey, it’s a 4-6.5 mile walk with 30 lbs of clubs).  In order to make the work constructive I’ve been launching online Continuing Medical Education programs from Medscape and AAFP’s Learning Link and getting about an hour’s worth of CME with each session.

Effect of eating extra 50 calories and watching TV

Small decisions matter

Have gone through Pain Management, Diabetes, Obesity and several other series.  What’s astonishing about all of these series is that in every case exercise has been shown to be as effective, if not more, than medications.  A few slides stand out but one of them today illustrated the impact of small decisions.

The good news about these slides is that the corollary should be true: It takes only small, daily decisions to lose weight and improve lifestyle, not major changes.

So what’s the best way to do this?  A number of people have suggested using any of the myriad of web or smart phone applications that track calories and energy expenditures.  I’ve found them to be quite good but it’s usually a pain to look up and add everything.  There are some, like Fooducate, that only require one to  take a picture of a food label to do to provide the information.  But the irony of these programs is they usually work best on the most unhealthy food products and the worst on natural, unprocessed foods that have no labels.  As much as I’d like to see an application that recognizes foods (slice of apple let’s say) without any further input I don’t think we’re going to see that soon in a mobile application.

But maybe we don’t need to wait.  There may be other solutions.

What if you could just take a picture of what you’re about to eat, zip it to your nutritionist, nurse practitioner or physician and have them either do the work for you or simply provide feedback? Would you do it? Would it provide value?   Most likely but there aren’t enough nutritionists or professionals that would tolerate getting bombarded all day long by food photos.

Nevertheless, I’ve been photographing everything I eat to see if it’s realistic to photograph everything eaten and now on the 3rd day of doing so.  For example, here’s what I had yesterday:

Here’s what I observed in my own behavior

  • It does become second nature … almost like reaching for the napkin or giving thanks.
  • A picture is a lot more objective than memory.
  • It is hard to see everything that is in the photograph so a extrapolating calories from a photograph is going to be problematic, especially for home cooked healthy meals.
  • Behavior modification, however, does occur.
    For example: just the thought of taking a picture has actually stopped me from reaching out and eating that extra handful of nuts, opening the candy jar or even having that extra drink. And I’m doing this just for myself and am not trying at all to lose weight!

This has prompted me into wondering if beneficial lifestyle changes could be as simple as taking pictures of what we eat?  Whip out your smart phones and take a picture of what you’re about to put in your mouth and let me know if you experience the same behavior changes.

We are the problem … and the solution

An article, Cost of Doing Nothing by Reed Ablelson in this morning’s New York Times, illustrates clearly why no matter what happens in Congress over the next few weeks our Health Care will never be the same. Our current system is simply unsustainable and incremental changes have done nothing to curb the escalation in health care costs. It is apparent that large changes are coming. The question is not if but when and by whom? 

I was struck by how much blame each of us carries in this dilemma. Most physicians in this country are payed by what they do, not what they produce. As a result we are all under pressure to bring in enough income to pay our nurses and staff. Estimates vary but most primary care physicians (of which I am one) need to post at least $400,000 – $600,000 a year in order to make ends meet (staff, malpractice, lease, equipment, supplies, etc.) and even then profit margins are very slim.
In large multispecialty groups where salaries are often calculated by Relative Value Units (RVUs), physicians need to crank out 5-6,000 units just to break even. What’s insidious is that a physician will tally up more RVU’s for procedures than brain work. So it’s much simpler to do something to a patient than work with the patient … a lot simpler and a lot more profitable.

This has led to serious shortages of primary care physicians and an abundance of specialty physicians partially due to the high cost of medical school, the need for repayment of student loans and prestige that comes with disciplines with high revenue potential.
We physicians have lobbied heavily to keep our costs from dropping, forcing Congress to delay each year the implementation of the Sustainable Growth Rate formula that was voted into law in 1992. These small, yearly decreases in payment have gradually accumulated to where a massive 21% cut in Medicare payments is scheduled to go into effect this coming Monday, March 1, 2010 (was to have taken effect January 1 but Congressional action forestalled it until February 28 and will be in effect barring further action by Congress). The AMA is confident that emergent legislation will prevent these cuts from taking effect and forestall them yet another year and CMS is holding payments for 10 days to allow action to take place. Physicians have seen real reimbursement declines in the face of increasing costs everywhere else so the net effect of inaction might be to further reduce the access of patients to physicians.

Eventually, the system will collapse and the results will be catastrophic not only for physicians, their offices and staff but for Medicare patients who may not be able to get in to see a physician at any costs because doors will be shut to them as it is to many Medicaid patients around the country.
Physicians can still afford to do this because there are enough privately insured patients to generate the revenue needed to keep their doors open for now. At some point this house of cards crumbles.

We patients are also to blame. In the last 20 years we’ve seen an ever increasing cost of health care diverted towards chronic diseases that are in large measure preventable. Obesity, diabetes, high blood pressure, coronary artery disease and many forms of cancer can be directly linked to lifestyle choices.
In addition we choose ignore “natural” ways of preventing diseases through immunizations and dietary changes.
When we hurt our backs we refuse to go to physical therapy and instead insist on medications, MRI’s and even surgery when the evidence points to better results with simple physical therapy.
We patients insist on antibiotics when we feel bad even though repeated studies have shown for many of these conditions we will get better faster without them.
It is infinitely cheaper to stop smoking and avoid lung and heart disease than to pay for cigarettes, medicine and procedures. Yet we complain about the cost and effort involved in smoking cessation programs (even though they are less expensive than the monthly cost of a pack-a-day cigarette habit).

And it’s worse when we’re healthy! We often choose not to purchase health insurance, which only drives up the cost of health insurance for everyone. If only sick people purchased health insurance it would be more costly than medical care (providers of health insurance have the cost of medical care, their own business and profits to shareholders to address). Insurance only works when a critical mass of enrollees never utilize their insurance.
And then there’s politics. The cost of being a politician by its vary nature will prevent the politician from making the hard choices. It’s simply much easier and less costly for supporters to pull funds from anyone making a hard decision since most hard decisions adversely affect a critical mass of supporters in the short term.

So what are we to do? Well, for one we need to act because no one else is going to.

For my own part I have resolved to be a role model for my patients. I am trying very hard to make the decisions I ask my patients to do. My diet has changed as have my exercise habits. In addition I have started listening more to my patients (it does adversely affect my income potential for the organization for whom I work). I make sure that each hour an appointment slot is left open for same-day appointments. I have encouraged patients to log into our web portal for routine things that can be treated without a face-to-face visit. I’m using this web portal to communicate directly with patients instead of having protecting myself from them using the phone triage, nurses and other barriers. This lowers the number of staff needed to meet their needs and, yes, has the potential to increase my own work. We’ve stopped taking samples in our offices and are working with patients to chose generic medications wherever possible.

There are many other things that we’re going to try over the next year to continue to provide more value for a unit of cost and all of you are encouraged to suggest ideas.

As patients it is usually less expensive to do the right things. First, change our lifestyles to maximize our genetic potential. We do need to stop smoking. We do need to move rather than sit. There’s no reason we shouldn’t all be at our ideal body weight and should constantly strive to maintain that weight.

We do need to be proactive and strengthen ourselves to grow old rather than sit back and let it happen. We do need to leverage our own immune systems and get vaccinated (which is really the best natural approach to preventing diseases) not only for ourselves but for those around us. It is much less costly to get vaccinated than to get sick, no matter how minor that illness is. The complications from vaccinations are infinitely smaller than the complications from any of the diseases.

When we do get sick it is our responsibility to learn about our illness and help the physicians make decisions. It’s my experience that most bad decisions are made from lack of information than from malpractice. It is our responsibility to know what over-the-counter medications, vitamins, herbal supplements and our past medical histories. Make sure the physicians making decisions are aware of this. If the recommendation is something other than medicine we need to follow that advice (physical therapy and counseling are effective and even if they are not “covered” by most plans are the things that will cost you less in the long term). If medicine is prescribed we need to know the medicine and take them as directed along with redoubling our efforts to make the changes necessary in our lives to decrease the need for those medications.

We all need to purchase insurance. Purchase only catastrophic if nothing else so that we don’t wreck our lives, the lives of our loved ones or undermine public budgets when major illness or injury strike.

We all need to wear seat belts, stop driving under the influence of mind-altering drugs, alcohol or texting. We need to wear helmets on bicycles, motorcycles and other vehicles without roll-over protection.

We need to care for others and not be responsible for hurting others.

Finally, we need to begin rewarding those politicians who make hard decisions. We need to counter the fringes and participate in elections. Neither the left or the right are going to be able to solve our problems. The center will and we need to begin rewarding those who work with others and not those who are obstructionists.

The bad news? It’s always easier to do nothing and be a victim than it is to do something positive and avoid being a victim. But that’s what we need to do if we went to lower the cost of health care and become part of the solution, not the problem.

Short term measures to increase Primary Care Medicine and lower medical costs

Primary Care Physician

The health care debate has demonstrated several cogent facts principal among them is that there is a shortage of primary care physicians. Some estimates put this as high as 40,000 fewer primary care physicians than are needed.  The experience in Massachusetts has shown that as more people are covered more primary care physicians are needed. As uninsured in Massachusetss fell from 13 to 7% wait times for primary care visits have jumped from a few days to weeks if not months according to a recent New York Times article.

In my opinion politics will prevent any major health care reform that will significantly impact this problem over the next 18-24 months, if ever. There simply are too many special interests and other orgnizations that benefit too much from the current model of care.

So what short term measures can be taken that don’t require special legislation but could improve the availability of Primary Care services in this country?

Primary Care and all phyhsicians be salaried

Most physicians are current compensated based on some form of volume sensitive measures.  These include fee-for-services rendered in which case physicians will increase their reimbursements by doing more for a patient whether or not it is medically warrented. Even in large groups the physician’s reimbursement is based on productivity that is measured by either Work Relative Value Units (WRVUs) which are directly tied to the volume of services they order whether or not their annual day-to-day pay is directly affected by the patient loads and services rendered.  
Keeping track and monitoring these services involves particularly elaborate relationships between what a physician documents, codes for Evaluation and Management (E&M) services, orders tests and services, documents CPT (Current Procedural Terminology) codes or other sources of volume-based measurements.  This leads to large overhead costs for physicians and 3rd Party Payers that doesn’t contribute at all to patient care.  An average Primary Care Physician must bill out over $400,000 a year in order to break even in most organizations.
Eliminating or reducing this practice has the potential to free up countless minutes, if not hours a day that could be devoted to seeing new patients.  Organizations like Cleveland Clinic and Mayo Clinic have experimented with salarying physicians and have documented reduced the total cost of medicine significantly compared to other institutions that continue the current paradigm.
 

PCP physicians need to give up inpatient services

Primary Care Physicians need to give up their hospital priviledges. All too often clinic care is delayed because the physician is caught up rounding in the hospital and encounters delays.  Every minute they spend in the hospital is a minute they cannot provide Primary Care services in their clinics.  Hospital care is not primary care by definition and current pressures on hospitals to process patients and discharge them as rapidly as possible require hourly interventions which a physician in the clinic cannot provide without detracting from their clinic services.  Simply eliminating their hospital care would add perhaps as much as a day a week for new or other types of clinic visits per primary care physician and cut into the shortage of clinic spots available.
 

PCP physicians should treat their entire practice instead of individual patients

Focusing their attention on their entire pool of patients to increase the percentage that are immunized, adhering to medications, and assuring all are getting preventive care has the potential to reduce the number of unnecessary clinic visits and may even improve the health of the community whereas continuing to serve only those that come to the clinic for acute care needs has little or no impact on the health of the community.

Routine follow-up and low level care should b provided by physician extenders

Once a patient is seen by a primary care physician and a plan of care is created, routine follow up care should be provided by physician extenders. Yes, the physician should touch the patient on these visits and assure that they are adhering to the plan but not be dragged into extended documentation or billing procedures for that visit. They should concentrate their attention on complicated patients, new patients and those requiring special services.

Too often we see physicians in large groups that are reimbursed by WRVU criterial "packing" their schedules with easy-to-see follow up patients for 1, 2 and 3 month follow ups in which no major medical decisions are made. Yet, these patients can be billed out as mid to complicated care for reimbursement reasons and could be seen by lower level providers.

Doint so would open up significant blocks of time for the Primary Care physicians to see new and complicated patients thereby reducing some of the shortage of primary care physician visit times.

Not doing so will continue to allow retail clinics who are staffed by nurse practitioners to provide this care which is not integrated into the primary care physician’s patient pool.
 

Immediately forgive medical school debt for those entering and practicing primary care

While this option may not be availabel for many solo or small group practitioners, larger entities ought to immediately pay off the medical school debt of those who have chosen primary care.  Servicing the large (average $140,000) school debt is given as one of the primary reasons medical students and residents avoid primary care.  Eliminating this would immediately benefit those that are currently in the field as well as dramatically increase the number of students choosing primary care in the next 18-24 months.  There are many mechanisms for doing this and it is true that many rural areas are already providing this as an enticement for primary care physicians to choose to locate in rural areas.  However, this should be a standard national policy.

These are just a few of the things that can be done relatively quickly that would increase the effective availability of primary care physician services in this country.  There are others but it all boils down to the money so the attention should be focused on reducing the negative impact to individuals who choose this if it is a national prioriy to increase the volume of primary care services in this country.

 

The Power of Patients

This week a patient of mine came in armed with research she had done about a perplexing set of symptoms she’d been having.  We’d discussed this virtually and tried several approaches to no avail.  We pulled open the Mayo Clinic and NIH web pages that she’d discovered through a variety of search engines and come up with a syndrome (http://www.nidcr.nih.gov/OralHealth/Topics/Burning/BurningMouthSyndrome.htm) that I’d never been exposed to that fit almost all of her symptoms.
 
As we read through the syndrome and also the recommended workup to rule out the other treatable causes that might be producing her symptoms it dawned on me that medicine would be a lot easier if we physicians would encourage our patients to help us with their diagnoses.
 
A little over 70% of my patients have electronic access to significant portions of their records. This access has enabled others, like this patient, to take second and third looks at their labs, medications and pathology results. I’ve tried to encourage them to ask the question I didn’t ask during the visit. Some are doing this and are taking charge of their own health in ways they didn’t think possible.
 
Another of my patients was astonished at all of the medications she’d been prescribed over the years by many physicians including me. When doing the research she discovered that the majority of her symptoms were side effects of one or more of the medications. She asked for my help in weaning her from those medications (if possible).  Over the last two months we’ve been able to eliminate all but two medications and she’s feeling better than she has in years.  She herself said that she always felt disappointed if she didn’t come away from the doctor’s office without a new prescription but now has a totally different approach?  When asked why she thinks it’s because she has access to the same information that her physicians do and now is working with physicians who don’t disparage her from managing her health.
 
Am really looking forward to the day when the entire electronic medical record that I use is the same one the patient uses. Where the patient and I can work together to improve a person’s health rather than treat a symptom.

Should all medicines, including narcotics, be Over-The-Counter?

Follow me on this carefully and add your thoughts. Treat this as an out-of-the box thought game than something being advocated. 
 
What would medicine be like if all medications, including narcotics, be sold directly to consumers over-the-counter?
 
  • For one, we probably wouldn’t have drug lords and the need for a big chunk of the DEA.  I doubt drug dealers could survive against the pharmas.  Their product isn’t pure enough nor has the quality control consumers would be demanding. They probably couldn’t meet the price competitiveness of global pharmas. 
  • Tax revenues from OTC meds might go a long way towards underwriting the cost of health care.
  • Emergency rooms wouldn’t have to guess what the overdosed patients would be taking and treatment might be easier.
  • Drug abusers would be better able to manage their own addictions since they wouldn’t have to look over their shoulders for law enforcement nor contend with lying to get their medications from doctors, nor deal with product cut with who knows what.
  • Doctors offices would have many appointments freed up that are now clogged with patients who don’t need to go to them to get the prescriptions they want. They could go directly to pharmacies.  More time for more patients with acute illnesses. Total costs would drop.
  • Opium would become an honest crop with outlets that would bypass drug lords and organizations like the Taliban.  The troops could come home from Afghanistan.
  • Personal health records and other types of self-management services would explode since people wouldn’t have to go to the physicians to get their medications.
  • Greater emphasis would be placed on sharing pharmacy information so that patients and clinicians would know what they purchased, when and how they purchased medications.
  • There would be much less government or regulatory intervention required allowing more resources to be spent on intervention and services.

See what else you can add. Of course there are many cons but my guess is that when the list is completed the pros would significantly outweigh the cons.

The problem I see now is that there is a trend towards the other way (taking more medications off the counter).  That will only clog up an overwhelmed healthcare system even more.

 

The thing about sodas

Drink Pop? You’re Probably Round.

 

“Have you noticed how people who drink pop are round?” an associate remarked to me as we sat around a conference table at the beginning of one more standing meeting. I looked around the room and saw that 6 of 7 people with their big gulp soda tankards had that unmistakable American look that foreigners joke about. You know, that “large” look: 30-50% north of ideal body weight and waist measurements that look down on the measly hip numbers. In short, round. I had to nod in agreement.

 

Her comment sparked a number of questions that seemed much more stimulating than anything on the meeting agenda so I casually pretended to take notes and, thanking the Wi-Fi gods, began Googling for answers. Learning is so much more fun these days, isn’t it?

 

First, I found out that the safe acceptable daily intake (ADI) of the various artificial sweeteners wasn’t as large as I thought. It amounted to only 5 mg/kg of sucralose (Splenda) and saccharin (Sweet’N Low, SugarTwin) which is about 5 cans of diet pop or 8.5 packets we all use; 15 mg/kg of Acesulfame (Sunett, Sweet One), about 25 cans of soda; and 50 mg/kg of aspartame (NutraSweet, Equal) the equivalent of 15 cans of soda.

 

Second, they do seem to work as designed in controlled studies when compared to sucrose (sugar) in short periods where the diet drinkers were noted to have lower total caloric intake, body mass and blood pressures than those drinking sugared drinks.

 

Third, each of these sweeteners is very sweet, some 200-300 times sweeter than sugar. And because of that they may actually increase our taste for sweet things.

 

Fourth, studies including the Harvard Nurse’s Health Study show that drinking pop, especially sugary pop, is linked to obesity and diabetes. Diet pop was also implicated. An 8 year-long study by Sharon Fowler, MPH, and colleagues at the University of Texas Health Science Center in San Antonio found that “overweight risk soars 41% with each daily can of diet soft drink.”  A table of her findings is startling:

 

 

Increased Risk of Obesity

Cans of Pop Per Day

Regular Pop

Diet Pop

0 – ½ can

26%

36.5%

½ – 1 can

30.4%

37.5%

1- 2 cans

32.8%

54.5%

> 2 cans

47.2%

57.1%

Adapted from: Fowler, S.P. 65th Annual Scientific Sessions, American Diabetes Association, San Diego, June 10-14, 2005.

 

Fifth, the average American consumes a huge amount of very sweet tasting carbonated drinks (whether sugared or diet) when compared to the rest of the world (from the equivalent of 12 bottles in 1900 to almost 600 12-ounce cans of soft drinks per person each year in 2005 with young males consumer almost 2 quarts a day!

 

Sixth, the average weight of Americans has mirrored the increase in soft drink consumption to where we weigh almost 25 lbs more now than we did in 1960 (166.3 lbs in 1960 to 191 lbs in 2002 in males and from 140.2 lbs to 164.3 lbs in women over the same period). In the same period we’ve only grown about an inch taller. Uh, you see roundness in those numbers?

 

It just seems that even though a direct causal relationship can’t be found, drinking pop (no matter what type) is linked very closely with obesity and diabetes. Why?

 

Sweet drinks (whether sugared or diet) don’t satisfy hunger nor curb a person’s appetite.  Consuming 150 calories from a can of regular pop doesn’t lead to people decreasing their usual dietary intact by 150 calories. Our bodies still need nutrients that they can’t get from sodas whether sugared or not. Sweet drinks don’t just sweeten out tastes but may even be appetite stimulants according to a number of studies. Those who drink more tend to eat more … and get round.

 

Most people understand how sugared drinks would cause weight gain. Each one contains the equivalent of 9-12 teaspoons of sugar and can conceivably overwhelm the body’s ability to metabolize that amount in the time most of us down a can of pop. But what about diet pops? Functional MRI studies have demonstrated that there’s no evidence that artificial sweeteners (at least for aspartame) increase the level of insulin like sugar. Yet they produce similar results over the long hall even though they don’t appear to have a direct link to disorders of carbohydrate metabolism.

 

What did I learn during the meeting? First, sugar, in the quantities present in pop is nothing but bad.  Second, just like how we’ve learned how damaging trans-fats are after years of thinking they prevented heart disease, I suspect we will uncover direct causal relationships between these artificial sweeteners and obesity or diabetes in the upcoming years.

 

In the meantime we all have choices. Don’t like being round? Start by taking an easy step and drop the pop.

Disease watershed

Most providers of care share patients within a disease watershed. This is a geographical area where people have a high probability of contact, share similar environs and where a critical mass of people spend the bulk of their lives.

Within any of these watersheds there usually are a variety of individuals who provide some type of medical care (physicians, specialists, podiatrists, chriopractics, alternative care, cosmeticians and a host of other people who in some way or another meet the populations’ health care needs). No one person provides all of the care for any one person. Many of these people share information, often at the bequest of the person seeking care. This sharing of information is time consuming, expensive and often trails the need at the time.

It is my contention that within these disease watersheds any person who’s licensed to provide any form of care should share a clinical repository in order to maximize their ability to provide the care they need.

Electronic medical record systems will eventually evolve into larger regional systems that will correlate with the local disease watershed. When they do the population living within those areas will see their diseases managed optimally. Then, and perhaps only then, will we begin to be able to tackle the health care needs that exist and improve the population’s health.