Vol. 116 December 15, 2014 Obamacare Update

December 16, 2014

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“After a year in place, the Affordable Care Act has largely succeeded
in delivering on President Obama’s main promises.”
– NY Times

“Americans would rather see it improved than repealed.”
– Boston  Globe

Today, December 15, is the deadline for new enrollees to sign up for health care insurance under Obamacare ( December 23 in Massachusetts). It seems an appropriate time to take a look at how it is going. The deadline for renewals is February 15.

The recent Jonathan Gruber “revelation” about Obamacare’s “non-transparency” alleged that “ they did not tell the public that young, healthy people must subsidize sick people to make the numbers work.” Well, hello, what about insurance don’t you understand?! Those of us whose house has not burned down are subsidizing (aka “insuring the loss of”) those whose house has burned down!

Since the ACA was passed in 2010 the number of uninsured has fallen by 25%-33% depending on the study. At least 8 million and perhaps 11 million previously uninsured are now covered. Critics of the ACA charge that number is overstated by about 700,000 who merely got dental insurance coverage. More about that later in this blog. The law “is helping the health care industry by providing new paying patients and insurance customers.” It certainly is!  Health insurance companies are looking at a “nearly $2 trillion ( yes, TRILLION) of subsidized coverage through insurance exchanges and Medicaid over the next 10 years,.” Share prices of four of the major health insurance companies – Aetna, Cigna, Humana, and United Health – have more than doubled since March 2010. (1)

ACA subsidies are helping many who could not get health care coverage previously, but deductibles and variable out-of-pocket costs can remain a burden on low- and middle-income Americans. Please note the key word “Americans” here because the law does NOT extend coverage to un-documented immigrants. Undocumented immigrants and adults in 23 states that have not extended their Medicaid coverage as subsidized by the ACA comprise the major portion of uninsured persons. Texas, Florida, and California have the highest proportions of those people.

ACA health care insurance premiums were predicted to skyrocket, but in fact they will rise an average of 5% for 2015. “One reason may be that insurers who came in high in 2014 found themselves beaten out for enrollments. 77 new insurance plans will be competing for customers in 2015.” (2)  The online application for new customers is down to 16 screens from the original 76 screens that scuttled the first website application.

A physician from Kentucky in an essay in the NEJM pointed out that the two Kentucky senators remain vehemently opposed to Obamacare despite the fact that 413,000 Kentuckians have gained health insurance coverage under the ACA law. Senate Minority Leader Mitch McConnell (R-Ky) has suggested that Kentucky could keep its health care exchange established by the ACA, Kynect, “even if the ACA is repealed”. (Does “have your cake and eat it too” come to mind here?) “It is unfathomable that they can continue to oppose the law and that geography can determine the adequacy of American’s care.” (3)

Government reports reveal that 1.4 million new enrollees have made selections of plans through December 5 through federal exchanges in 37 states. Reaching the CMS announced target of 9.1 million enrollees by 2015 appears to be imminent. The law’s “penalty” for individuals remaining underinsured started out at $95 (or 1% of income) annually in 2014 will go to $325 (or 2% of income) in 2015.

It is too early in its implementation to evaluate the ACA’s promised improvement of quality. A recent study of Massachusetts mortality rates after ACA implementation suggested that its effect has been positive, but many criticized the study’s conclusions as speculative and premature. Obamacare did create the Medicare Hospital Readmission Reduction Program aimed at reducing readmission within 30 days of hospital discharge; an expensive event supposedly associated with inadequate treatment during the first hospitalization or inadequate follow-up as an outpatient. The national readmission rate for Medicare dropped from 19% in 2007-2011 to 17.5% in 2014, “in part as a result of the ACA”.

An early sign of the success of Obamacare might be the very recent demand to expand its dental insurance benefits for children to adults via a proposed Comprehensive Dental Reform Act of 2013. (4) Look to this concept and the coverage of non-documented immigrants to become issues in the 2016 election. For those of you with a really long-term outlook, expect Hilary’s Affordable Veterinary Office Care (HAVOC) to be a hot issue in 2020.

Even during this very polarized midterm election some perceived a subtle shift on the Republican side from “Obamacare opponents” to “Obamacare critics”. They may be getting the message that a large portion of the citizenry is liking the health insurance coverage that reduces their stress and concern about the potential impact of uninsured illness on their life and pocketbook. Maybe more member of both parties will switch from Obamacare “opponents” to Obamacare “critics”, since we all agree that Obamacare, or whatever Hilary chooses to call it during her first term, can be improved.

References:
1. Bos Globe Nov. 18, 2014; pg A8
2. Cape Cod Times Nov. 1, 2014
3. The Affordable Care Act, 1 Year Later, NEJM 371;21, pg. 1960, Nov. 20 2014
4. Integrating Oral and General Health Care, NEJM 371:24, pg. 2247, Dec. 11, 2014


VOL. 115 DECEMBER 1, 2014 MISTLETOE and POINSETTIA, REVEALED

December 1, 2014

hubDespite its strong association with romance during the Christmas season, mistletoe has a less than charming back story. Mistletoe is a parasitic plant that attaches itself to other trees to steal nourishment from them. Its berries are eaten by birds who then spread the seeds for new plants in their droppings. The seeds in the droppings stick to the bark of certain trees and burrow a root down through its bark. “Mistel” is an old English word for bird dung. “Toe” is derived from a word for “twig”. So, one could translate “mistletoe” as “poop on a stick”. (1)

Mistletoe was one of few plants still green during the winter for both Norseman and the Druids. The Norse considered it a symbol of love and friendship. The Druids noticed that it had berries, and they used them to encourage friendship while controlling kisses.  A berry was pulled off the sprig for each kiss. When there were no more berries, there were no more kisses.

“The physiological effect of the [ingested] plant is to lessen and temporarily benumb such nervous action as is reflected to distant organs of the body from some central organ which is the actual seat of trouble. In this way the spasms of epilepsy and of other convulsive distempers are allayed. Large doses of the plant, or of its berries, would, on the contrary, aggravate these convulsive disorders. Young children have been attacked with convulsions after eating freely of the berries.”

“In a French work on domestic remedies, 1682, Mistletoe (gui de chêne) was considered of great curative power in epilepsy. Sir John Colbatch published in 1720 a pamphlet on The Treatment of Epilepsy by Mistletoe, regarding it as a specific for this disease. He procured the parasite from the Lime trees at Hampton Court, and recommended the powdered leaves, as much as would lie on a sixpence, to be given in Black Cherry water every morning. He was followed in this treatment by others who have testified to its efficacy as a tonic in nervous disorders, considering it the specific herb for St. Vitus’s Dance. It has been employed in convulsions delirium, hysteria, neuralgia, nervous debility, urinary disorders, heart disease, and many other complaints arising from a weakened and disordered state of the nervous system.” (2)

“The tincture has been recommended as a heart tonic in typhoid fever in place of Foxglove [digitalis]. It lessens reflex irritability and strengthens the heart’s beat, whilst raising the frequency of a slow pulse. It is stated that in Sweden, persons afflicted with epilepsy carry about with them a knife having a handle of Oak Mistletoe to ward off attacks.”

Poinsettia derives its common English name from Joel Roberts Poinsett, the first United States Minister to Mexico, who introduced the plant into the United States in 1825. Despite its reputation, poinsettia are NOT poisonous for children and pets. According to the POISINDEX information source – the primary resource used by the majority of poison control centers nationwide – “a child who weighed 50 lbs. would have to eat over 500 poinsettia leaves to reach an even potentially toxic dose of compounds in the poinsettia plant.”  Doctors at the Children’s Hospital of Pittsburgh and the Pittsburgh Poison Center conducted a review of 22,793 reported cases of poinsettia exposures, the majority (93%) of which occurred in children, and found that 92% of those exposed did not develop any symptoms at all. Ninety-six per cent of those exposed were not even treated in a health care facility. Furthermore, no deaths resulting from poinsettia ingestion have ever been documented. (3)

Even though accidental ingestion of poinsettia leaves will not damage your body or kill you, it may lead to nausea and vomiting in some cases. Since the taste of poinsettia leaves is reportedly very unpleasant, it is unlikely that a child or animal who attempts to eat or chew the leaves will continue to do so after the first taste.

Boy, this blog about two beautiful warm, fuzzy Christmas plants reads like it was written by Debbie Downer. Maybe by the next blog I’ll be more in the Christmas spirit.

References:
1. http://www.whychristmas.com/customs/mistletoe.shtml
2. http://www.botanical.com/botanical/mgmh/m/mistle40.html
3. http://www.medicinenet.com/are_poinsettia_plants_poisonous_fact_or_fiction/views.htm


Vol. 114 November 15, 2014 Selected Issues for Modern Kids Listed by School Level

November 16, 2014

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“Everything I need to know… I learned in kindergarten.”
― Robert Fulghum, All I Really Need to Know I Learned in Kindergarten

 

Pre-school – Immunizations
When the first child under 2 yo. developed a severe seizure disorder after a measles vaccination it started the fire of resistance against immunizations which still burns today. Subsequent research proved that that child had a genetic abnormality as the CAUSE of her severe seizures, the Dravet syndrome. The immunization caused a fever that was a TRIGGER for the epilepsy.  One study of 14 children with onset of epileptic encephalopathy after vaccination revealed that 11 of them had a genetic abnormality, Dravet syndrome.  In a recent study of 45 children who had seizures within 24 hours of an inactivated virus immunization or within 12 days of a live virus vaccine, 65% of those children developing epilepsy after an immunization had an underlying genetic cause. The vaccines were NOT the cause. Fortunately only 16% of patients with that genetic defect will have a seizure from a fever following immunization. .(1)
Serious neurological illness is very rare after an immunization,… and the immunization does NOT cause it!

Kindergarten – IQ tests
Over 7000 pairs of twins in the UK were given the Goodenough (named for the developer) Draw-A-Person test and a standard intelligence test at age 4 and then at age 14.  The Draw-A-Person test is a common measure of “school-readiness” for 5 year olds. The drawing of a “man, a woman, and themselves” is then scored for 14 different aspects (body parts, scale, etc.) producing a score composed of 64 items.  At 14 years of age the same children were given another IQ test. “Figure drawing scores at age 4 correlated significantly with verbal and non-verbal intelligence at both age 4 and age 14.”  This contradicted a previous study of 100 children (not in UK) that showed NO correlation between Draw-A- Person scores and standardized IQ test at pre-school age.
…But, you may only be as smart as you are in kindergarten.

Middle School – Apple Allergy
A 11 year old boy with a past history of patches of eczema previously responsive to usual treatment with steroid creams developed a whole-body dermatitis that did not clear up with 6 months of treatment.  A variety of skin patch allergy tests revealed a 1+ reaction to nickel, a commonly seen cause of dermatitis in some people. Presumably he was being exposed to nickel by contact with his iPad surface that was positive for nickel. A plastic cover for the iPad resolved the rash. Cell phones, clothing fasteners, ear-piercing, video-game controllers, lap top computers , and some wind-up toys can also be sources of nickel allergic reactions by direct contact. (3)
iPads and other metal electronic products can cause a persistent allergic rash.

High School – School Start Time
Chronic sleep loss can impair academic achievement, physical health, and mental health. The American Academy of Pediatrics recently recommended that school should not start any sooner than 8:30 AM. Studies of high school seniors revealed that on average they sleep less than 7 hours a night and have difficulty falling asleep before 11 PM. The desired goal is 8.5 to 9.5 hours of sleep at night, and that “naps, sleeping later on weekends, and coffee do NOT restore optimal daytime alertness”. (4)
Later starting time for schools is good for kids.

College – Marijuana, Alcohol Use
Too much to say here about that right now. More later.

References:
1. Pediatrics 2014 Sept 15.
2. Psychol Sci 2014 Aug 20
3. Pediatrics 2014 Aug 1
4. Pediatrics 2014 Sept.


Vol. 113 November 1, 2014 Threat Levels for Children??

November 1, 2014

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Judging by the amount of media output (aka hype) about the perils of the world
our children live in, it does seem amazing that any of us adults survived our own childhood.

 

 

I just received a glossy, multi-color, four-page brochure from a leading children’s hospital’s “Injury Prevention Program” listing a whole host of “Fall and winter safety tips for kids”. It provoked some vivid memories of the “dangerous days” of my youth.

Here are some of the “tips” followed by an editorial comment based on my own childhood experiences.

1. “Children should NEVER push or roughhouse while on jungle gyms, slides, seesaws, swings, or other equipment.”
HELLO ?. If you can’t do that how can you determine who is “King of the Mountain”?

2. “Always slide feet first, don’t climb outside guard rails, and don’t stand on swings.”
Sliding head first was much faster, and after three sit-down slides, much less boring.
Billy Almy won the competition for the highest swing only because he was the tallest kid in the class when he stood up. It was certainly not because he was the best leg pumper! No way! Dick Perles was.
And how else could you practice for the rope climb in gym class except on the long, high leg of the tall slide?

3. “Remove all drawstrings from children’s clothing before they enter the playground. Other loose objects like necklaces should also be removed.”
I had no idea then that my hoodie was so dangerous. Without that hoodie drawstring what would I chew on while anxiously watching Billy Almy trying to beat my swing height?  Of course, today’s hoodies are considered a real danger in another way.

4. “There should be only one child on a playground device at a time. More than one child increases their risk of injury.”
See number 1 above, not to mention the seesaw where you could give the other kid a really good rump bump by quickly jumping off your side.

5. “Never let children trick-or-treat alone. Have them walk in groups with a trusted adult.”
We used to go out alone the night before Halloween, “mischief night”, to throw our toilet paper rolls, soap windows, and tip over garbage cans. As we parents grew older with our good neighbor friends, it became increasingly harder to find a “trusted adult”;  one that didn’t mooch a shot of scotch at every other house.

6. “Wear well fitted masks, costumes and shoes to avoid blocked vision or trips and falls.”
I guess that rules out any ET or clown costumes.

7. “During Christmas avoid sharp or fragile decorations for small children”
We always put the star on the top of the tree. Didn’t you?

8, “Avoid toys with pull strings longer than 12 inches and toys that have to be plugged into an electric outlet. Battery operated gifts are less likely to cause burns or electric shocks.”
Strangulation hazard x 2, I guess. BUT, they don’t mention those little lithium batteries that are so easy to swallow and can cause stomach lining burns. Good thing my parents didn’t have to worry about those when I was a kid.

9.“Use sleds you can steer. Always sit up with feet forward – lying flat increases the chance of head and abdominal injuries.”
Oh, now that they’re off the slide you want the kids to lie down! These rules that change with the season could be very confusing to an average kid. As I remember, our toboggans seemed to go willy-nilly where ever they wanted to go. That’s what made them so much fun.

10. “Melting or falling ice or snow can be dangerous for children. Avoid the sides of buildings or structures.”
Oh again, NOW it is safer to walk in the middle of the road!

11. “Children should only skate on public indoor or outdoor rinks.”
Where do we build the fire for the marshmallows?

12. “Cycling should be restricted to off-roads (sidewalks and paths) until age 10.”
Oh, now that the ice has cleared we can go back out into the street… if we are 10 or over.

True that “it’s a sad fact that injury is the number one cause of death and disability among children in the United States”, but the good news is that a whole lot of children are no longer dying from streptococcal infections, whooping cough, pneumonia, measles, congenital heart diseases, croup, etc.

When you look at the actual causes of death by injury to children you get a different impression. “Motor vehicle traffic” accidents is the number one injury killer of children up until the age of 15.  At 15 years “suicide” and “homicide by firearms” makes its appearance in competition for 2nd and 3rd billing. As one parent told me, “My seven year old kid is smart and careful enough to walk the four blocks to school, but I walk with him.  Not because I fear that he will be abducted, but because I fear that some driver talking on a cell phone or texting or adjusting his radio will inadvertently run him down.”

In the 0-4 year old age group “drowning” and “unintentional suffocation” trump “motor vehicle traffic”. That statistic is the basis of the quote that “under the age of 14 a child is four times as likely to drown than to die from a gun shot”, so pool safety (fences, direct visual adult supervision, and early swimming lessons) is key for protection of children.

One result of this well-intentioned brochure highlighting the dangers of schoolyard and playgrounds may be to just increase parental anxiety about local neighborhoods and fear of things that normal kids do.  I think that is unfortunate. Efforts to push safety around pools and other bodies of water, to reduce the number of guns in homes, and to increase the safe keeping of guns that are in homes are better directed ones.


Vol. 112 October 15, 2014 MORE Medical Mixed Messages?

October 15, 2014

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Science and medicine over time often seem to be giving us mixed messages. That is actually a good thing. It shows that medicine is always seeking and responding to new information, new data, and revising “the truth”. In our modern world, egged on by rapid technology upgrades and our insatiable demand for “no-risk” living, these “truth revisions” can be difficult to keep up with. Here is a brief update on some recent evidence-based revisions of the truth.

TREATMENT OF THE FLU
The World Health Organization for several years and still currently puts Tamiflu on its list of “essential drugs” and recommends its use in clinical practice as an anti-influenza drug.

A new Cochrane Collaborative meta-analyses of 20 controlled studies which included thousands of pages of previously unavailable data from drug manufacturers concluded that Tamiflu provided minimal benefit for treatment of flu symptoms. Flu symptoms in adults treated with Tamiflu were reduced from 7 days to 6.3 days, about 17 hours. In children, flu symptoms were reduced for a whole day (29 hours). Use of Tamiflu did not reduce hospitalizations and did not decrease complications like otitis media, pneumonia, or sinusitis. There were no flu-related deaths in any of the studies, so effect on mortality could not be determined. (1)

A 10 day course of 75 mg. per day of Tamiflu costs anywhere from $70 to $340 on the internet. At CVS and Kmart it costs about $125, or $12.50 a pill. The Cochrane study did show that if Tamiflu was taken as a drug to prevent flu symptoms after one was exposed to someone with flu, it could reduce the incidence of symptomatic flu by 55%.

So, like so many things in medicine, “ya (or your insurer) payz yur money and takes yur choice”.

VITAMIN SUPPLEMENTS AGAINST HEART DISEASE AND CANCER
In 2003 The United States Preventative Services Task Force (USPSTF) studied vitamin supplements as a means to reduce the incidence of heart disease and cancer. They concluded that there was insufficient evidence to recommend Vitamins A, C, E, folic acid, beta-carotene, or anti-oxidant combination supplements as beneficial in reducing the incidence of heart disease or cancer.

This year the USPSTF studied all evidence published since 2003, and came up with the same conclusion and recommendations. It reemphasized that Vitamin E “more certainly” does NOT reduce the risk of heart disease and cancer, and repeated its warning that the use of beta-carotene (vitamin A) pills actually increased the risk for lung cancer in smokers. The 2014 USPSTF report also added Vitamin D, calcium, and selenium (may actually increase risk of prostate cancer) to its “insufficient evidence of benefit” list. (2) In a separate study, swallowing omega-3 pills (fish oil) did not significantly reduce the risk of stroke or heart attacks. (3)

But remember, these vitamin supplement studies, perhaps spurred by the $28 Billion-plus vitamin supplement industry, are prompted by evidence showing that diets (real food, not supplements) rich in these trace vitamins and minerals are associated with decreased incidence of heart disease and cancer.
If the diet does it, why don’t the pills?
“The biology is complicated,” says Stephen Fortmann, MD, Kaiser Permanente Center for Health Research.

WHAT ABOUT HERBAL SUPPLEMENTS?
“Supplements are regulated (by the FDA) more like foods, which is to say, they’re generally considered safe unless proved not to be”.

A FDA 2013 study using DNA analysis of 44 readily available herbal products revealed that fewer than 50% could be verified as containing the advertised ingredient. Since 2008 the FDA has issued warnings about 330 supplement products that turned out to be adulterated with active drugs not listed on the label. (3)

Three herbal supplements NEVER to take because of serious adverse side effects:
Kava to relieve stress and anxiety can cause liver failure
Yohimba to treat erectile dysfunction can cause volatile blood pressures and rapid heart rate.
Aconite to relieve joint pain can cause nausea and vomiting, low blood pressure, breathing paralysis, heart rate dysfunction, and even death.

GLUCOSAMINE FOR KNEE PAIN
Many patients take and some physicians recommend glucosamine for knee and hip pain due to osteoarthritis because a few small studies have suggested a benefit.

A study of 201 adults with knee pain who were given 1500 mg of glucosamine daily for six months showed no benefits. Compared to the placebo there was NO protection against progression of MRI changes, reduction of biochemical markers of cartilage degradation, or reduction of pain. (4)

References:
1. Journal Watch, General Medicine, May 15, 2014, vol. 34, no. 10
2. Journal Watch, General Medicine, June 1, 2014, vol. 34, no. 11 3.
3. Consumer Reports on Health, June 2014, pg.4
4. Arthritis Rheumatol 2014 Apr; 66:930


Vol.111 October 1, 2014 ; How Does Your Doctor Rate?

October 1, 2014

hubI think this is actually a trick question. I know very few people who have only one doctor. They have several, spanning different specialities.

 “Doctor Rating” sems to be  a thriving business. Consumer Reports Magazine (October 2014) lists six websites that present some sort of doctor ratings that go beyond the basic info provided by the AMA, Medicare, and state Boards of Registration in Medicine and state medical societies.

I examined these websites to see what I could learn how each one rated some primary care doctors that I know in my own vicinity. What I found was not particularly helpful nor illuminating for a variety of reasons.

The websites usually used two sets of criteria for ratings, one for the office (“ease of making appointment, friendly reception, etc.”) and one for the physician (“bedside manner, waiting time, clarity of discussion”,etc.”). Most used a rating of 1-5 stars, but one used “A-F”. Physician groups were rated, but to learn about individual doctors within the groups I had to scroll through individual patient text comments.  All of the websites had errors such as listing physicians who were dead, retired, back in India, or now in New Zealand.

I searched under “internists” and often also got dentists, obstetricians, cardiologists, oncologists, and even “lice doctors”. There seemed to be no rhyme nor reason to the sequence in which doctors were listed, except for the one website that highlighted the “Top 10” (apparently “patient satisfaction” was the sole criteria). Some websites forced me to scroll through all the names alphabetically to find the one name I was looking for. Some allowed me to search by individual name. Despite entering my zip code as a clue I got lists of doctors from many miles away. Some websites listed nurse-practitioners (NP) in the list which is not bad, might even be helpful, but it was not always clear with which physician(s) the NP was affiliated.

In the instances that I was able to find physicians about whom I had my own rating opinion, I did find that the website ratings generally matched my own bias. In the few instances that I could find the same physicians on different websites, the website ratings agreed.

Here are comments on my experience with specific websites:

Angieslist.com    “A to F”    Access to doctors’ rating for a year costs you $20.($16 if you use PayPal)
Gives number of reviews used to decide the rating (usually single digits); Have to click and scroll individual patient comments to identify individual physician rating in a group; three“A” reviews plus one “F” review created a “B” rating (4 reviews).

Healthgrades.com      1-5 Stars   Free Listed
177 internists near me, but listed only alphabetically; the first dozen or so listed would fit my “marginal” category; gives number of reviews used to decide the rating, but no patient comments/reviews presented; also included cardiologists and ophthalmologists.

Vitals.com    “Where doctors are examined.” 1-4 Stars   Free
136 internists near me, but the highest number of dead, moved, or wrong specialty doctors; had search “filters” to help me narrow my list, and the “patients’ choice” was the most helpful; you can choose a video that presents the ratings in a pleasing, non-revealing, fourth-grade-educational-level cartoon.

RateMDs.com     1-5 Stars     Free
Can search by name or “find a doctor by locale”; lists a “top 10” presumably based on patient satisfaction, but my doctor was NOT listed even though he is “the BEST doctor in the world” because no patients had submitted reviews.

Yelp.com   1-5 Stars   Free
The worst mix of wrong specialities and very few physicians listed; I suspect that doctors have to enter their own offices to this website or even pay for a listing, but I am not certain.

CastleConnolly.com   “Lists America’s Top Doctors”  An annual List and Book
Doctors are nominated, reviewed, and screened by a professional staff for this list founded by two men (neither one a physician) on the Board of Trustees of NYU Medical School; list is heavily weighted to academics in the NY metropolitan area.

Whosmydoctor.com    A work in progress; “not yet ready for prime time”
Leana Wen, MD, Rhodes Scholar, Director of patient-centered research at George Washington University, and a recent TEDMED presenter surveyed patients about what they wanted to know about their doctors. Almost everyone wanted to know that their doctors were competent, certified, and free to make evidenced-based medical decisions uninfluenced by whom they were paid. No surprise there. BUT, she also found that patients wanted to know something about the doctor’s values; what the doctors held dear to their heart!

“One after another, our respondents told us that the doctor-patient relationship is a very intimate one, that to show their doctors their bodies and share their deepest secrets, they want to first understand their doctor’s values.”

Dr. Wen set up a website “Who is My Doctor?” in which doctors could voluntarily state their feelings about reproductive medicine, alternative medicine, and end-of-life-decisions. This information, obviously beyond competency and source of compensation information, would be accessible to all patients and potential patients in an effort toward “total transparency”. The website and Dr. Wen apparently ran into a hailstorm of resistance from some physicians who did not believe that “total transparency” was a good thing. The website is currently just collecting signatures of those who support the concept, 387 to date.

Bottom line:
Doctor rating lists are not very helpful if you are blindly doctor-shopping in your area. If you do the usual thing and get some names of “good docs” from your friends and neighbors, then the rating websites could help you check out the opinions of other patients. None of these websites are as illuminating nor as complete as Trip Advisor…yet.


Vol. 110 September 15, 2014 Recent Updates From Around the World

September 15, 2014

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“Some believe in eating anything, while the weak only eat vegetables.
Those who eat must not despise those who abstain,
and those who abstain must not pass judgement on those who eat.”
Romans 14:2-3

This biblical citation has nothing to do with this week’s contents, but I was so surprised to hear it read in a church service,  and I want to preserve it to use in my defense when my children try to push lima beans, brussels sprouts, and quinoa on to my plate. Plus, I don’t think that it should be only the fundamentalists who quote the bible out of context to support their biases.

My favorite grace, of course, is the Robert Burns grace reproduced here in English (absent the Scottish dialect which really makes it poetic):

Some have meat and cannot eat,
And some would eat, but want it:
But we have meat, and we can eat,
And so let the Lord be “thanket”.

High Dose Flu Vaccine, Hype or Truth?

A study of 32,000 people over 65 years of age during 2011-13 showed that the “high dose” flu vaccine in that age group provided more protection than the standard dose. 1.9% (301) of the standard dose vaccinees got the flu while “only” 1.4% (228) of the high dose vaccinees did. Both vaccines had the same percentage of adverse side effects (9%).

The study’s conclusion was that high dose vaccine is 24% more efficacious, but to me these small numbers hardly justify the high-energy, hyped-up TV ads telling me to “Ask your doctor for the high dose flu vaccine!” AND the authors also remind us that any flu vaccine works best if it matches this year’s flu viruses. That is not always the case. Each year’s flu vaccine is developed from last year’s virus.

Bottom line: get a flu shot, any flu shot.

Too Much Salt Does Kill People, But Not So Much in the U.S.

In a huge, multi-year study funded by the Bill and Melinda Gates Foundation daily salt consumption was determined for 74% of the world’s adult population! The data taken from previously published surveys, 24-hr urine collection reports, and dietary intake studies was fed into a computer (Bill Gates, of course, but the authors added a disclaimer that the “funder had no role in this study or report”). The computer kicked out an average daily salt consumption by age, sex, and year for 187 countries.

The average worldwide salt consumption was about 4 grams per day, twice the amount recommended by the World Health Organization (2 grams per day). 181 of the 187 nations exceeded the WHO recommendation. The computer model went on to estimate that 2 out of 5 premature deaths (under 70 yo.) were attributed to salt consumption above 2 grams a day. The Institute of Medicine has stated that there is little evidence that reducing salt consumption below 2.3 grams a day reduces cardiovascular events. There is even some evidence that a low salt intake (under 1.5 grams a day) can increase your cardiovascular risk!

The good news, for us, is that the  U.S. and Canada have one of the lowest salt consumption rates, but still over the 2 grams threshold. The highest salt consumption associated mortality rates were in Central Asia, Central, and Eastern Europe,  Only Australia and New Zealand had lower CV mortality rates attributed to salt consumption than the U.S. and Canada (again, they beat us!).

Bottom line: If you’re worried about your future cardiovascular events try a 2 gram a day salt diet for a few days. Then very slowly, add a little bit more  salt each day until the food tastes good again.

From the “Duh Department”

Norwegians who have large, complex, or multiple non-cancerous polyps removed from their intestine by colonoscopy have a slightly higher death rate from colon cancer within 10 years than those people with small, single “low-risk” non-cancerous polyps. (3)

People in low income countries have lower risk factors for cardiovascular deaths, but have much higher death rates from heart attacks than middle- and high-income countries (Also true for “deaths from any cause”).(4)

References:
1. NEJM August 14, 2014 vol. 137, no. 7, pg. 635
2. Ibid; pg. 624 and 677 Editorial
3. NEJM August 28, 2014 vol. 371, no. 9, pg.799 and 860 Editorial
4. Ibid; pg. 818


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