Tuesday, March 20, 2018

Rural Nurse Diagnoses and Treats His Own Heart Attack

Here is a remarkable feel good story as reported in the letters section of The New England Journal of Medicine. 

A 44 year old male nurse was working alone in a rural part of Western Australia when he developed severe chest pain and dizziness.  He knew these were symptoms of a heart attack and he was over 90 miles from the nearest medical facility and 600 miles from Perth, where advanced care could be obtained.  He got an EKG on himself and sent it electronically through the Western Australian Department of Health which was started in 2012 for rural community practitioners.

Sure enough, the electronic read came back and showed he was in the middle of a massive myocardial infarction (MI).  Did he panic?  Hell no!
This remarkable nurse proceeded to chew an aspirin, take sublingual nitroglycerine and start an IV on himself.  He administered the right drugs; intravenous heparin, opiates and another blood thinner called clopidogrel. He got him self ready for thrombolysis and received this "clot buster" when the Royal Flying Doctor Service arrived and transported him to Perth.

The next day a stent was placed in the mid right coronary artery and he was discharged home within 48 hours.

I'm trying to imagine starting an IV on myself while in the middle of a heart attack and keeping this cool.  It's such a great story and EverythingHealth hopes this guy goes on to help lots of patients in rural Australia.

Saturday, March 17, 2018

Rectal Exam-Is it Needed?

Medical practice is constantly changing and this is a good thing.  As evidence comes forth, we change how we care for patients to ensure "evidence-based" quality. We no longer bleed patients or deliver caustic enemas.  We understand that ulcers are the result of H pylori bacteria and that autism is not caused by bad mothering.  It took 20 years for hand washing to be accepted for infection control after Ignaz Semmelweis made the connection of why 1/3 of hospitalized women died after childbirth in 1850.

Our newest evidence is that digital rectal exams (DRE) looking for prostate cancer in men is probably not effective for diagnosis.  In fact is might even be harmful if it leads to biopsies and further studies.

As an Internist, I was trained that a digital rectal exam (DRE) was needed and essential for every male physical exam after the age of 40.  And my male patients have come to expect it.  The March-April issue of Annals of Family Medicine reports that in 7 studies with 9241 male patients, the DRE is not sensitive or specific for evaluating prostate cancer.  This means there are more false-positives and more men sent for biopsy and further studies that prove to be not needed.  It is not an effective test for screening or diagnosing prostate cancer.

Digital Rectal Exam for screening of prostate cancer is no longer recommended.  In fact, in 2016 a large study in a little read journal, Current Medical Research and Opinion, also spoke against DRE as a recommended test.  I don't know if Medical Schools are still recommending DRE in physical exam.  Since 81% of doctors perform this test and patients expect it to be helpful, I suspect it will take time before this medical practice changes.  

Friday, March 16, 2018

Internal Medicine Needed for Future

It's almost Spring and that means the "Match" has occurred for medical school doctors-to-be.  As American med students go through their four years of post-graduate training, they try to decide what type of doctor they want to be for the rest of their career.  Many things factor into this decision.
How were they treated on specialty rotation? Did they have a mentor? What do they know about the life-style and future earnings of that specialty? How much debt do they carry? And finally, what is intriguing and interesting about that line of work.  Once that decision is made, they apply for residency positions around the country.

I am a comprehensive Internal Medicine doctor, (now known as PCP), so I've always been interested in the fact that we need more physicians to work in primary care to care for the aging baby boomers and complexity of population growth and changes in medicine. Unfortunately, we are far from keeping up with the need.

In the 2018 Match, only 374 primary care residency positions were available across the country.  The remainder (7,542) of the Internal Medicine positions were for doctors who would specialize in Internal Medicine subspecialties (Neurology, Cardiology, Gastroenterology, Rheumatology, Dermatology etc).  International Medical Graduates filled 66% of these positions.  How many of these doctor will remain in the US after training is a big question, especially with current immigration policies.  The US graduates choosing primary care training positions have been declining every year.

The benefits of patients having a personal primary care physician that can help a patient navigate the complexities of care has been proven repeatedly.  Episodic care with a specialist has been shown to be more expensive, poorer quality and fragmented. The high cost of health care in the US correlates with the decline of primary care physicians. 

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment and compassionate care of adults across the spectrum from prevention to complex illness. 

We are seeing increased training and hiring of allied health practitioners to fill the primary care gap. As much as I value the contributions of nurse practitioners and physician assistants, they do not have the training or expertise to substitute for an Internal Medicine doctor. They are not interchangeable.

How can we remedy this?  National health policies that include complete loan forgiveness and decreasing the burgeoning administrative burdens (paperwork that is now done on computer) would help.  Increasing reimbursement to account for the time spent with patients would help.  High ranking PCP mentors for medical school trainees would help.  National health policies that relieve the reporting and documentation requirements would help.

This problem has taken decades to get us to this critical point in time.  The solutions are complex but if we don't address it head-on, the US will continue to lag in health outcomes and cost.

Monday, March 12, 2018

Saturday, March 10, 2018

Want to Lose Weight? Understand Calories

The United States is facing an obesity "epidemic" and the interest in the perfect diet for weight loss has never been higher.  Low-carb, low-carb-high-fat, HCG, Mediterranean, Paleo, anti-inflammatory diets each have their own champions and doctors who swear this is the final answer to losing weight.  Each week there is a new medical analysis on mainstream news that touts the effectiveness of a certain weight loss diet. This week it is the low-carb-high-fat ketogenic diet.  Maybe it suppresses hunger.  Maybe it's the diuretic effect and rapid weight loss in the first week.  Maybe it reduces insulin secretion. But maybe it is really because people have reduced their caloric intake.

Here's a fact: all diets work when people reduce their caloric intake.  

The various well-known diets all result in similar weight loss if the individual sticks to the diet.  Each diet reduces calories.  And when the diet is over, if the calorie count goes back up...weight is regained.

An easy way to think about it is that if one reduces the daily calorie count by 500, a person will lose 1 lb. a week.  We are lucky now that calorie counts per serving can be easily found on all prepared foods by reading the nutritional label.  And it is easy to find the calorie count of just about every item or combination of foods on-line. Apps like Lose It can be used to set the desired weight loss and the app will tell a person how long it will take to reach that goal based on how many calories they eat in a day. The app will also give calories of certain foods and allow customization so a person can watch how many calories they are eating in a day.

Understanding nutrition labels is key to understanding how many calories one is eating daily.
"Low Fat" or "Low Carbohydrate" on foods is misleading because these foods can be very high in calories.

Reading labels helps a person see that 15 potato chips is 150 calories. 2 Tbs of Kraft 1000 island dressing is 110 calories.  One Duncan glazed donut is 260 calories.  An orange is 45 calories and a Big Mac with cheese is 540 calories. 

For weight loss to work, calories must be understood and limited.  As people's eyes are opened up to the calories in various foods, they can make trade-offs based on what they like.

Important things to note on the label are the # of servings in a container.  If a person ate the entire box, they would eat 1000 calories.  And they would be getting no fiber and loads of saturated fat.  This is a terrible choice for weight loss (or good health).

Once a person knows how many calories a day they want to eat to lose weight, it's pretty easy to make food choices that get there.  And once the high caloric foods are known and avoided for every day meals, healthy eating is preserved and the weight loss can be sustained.  That is the hard part of any diet.

Tuesday, August 22, 2017

Probiotics - What and When?

Probiotics contain microorganisms that are similar to the beneficial bacterial that occur naturally in our intestinal tract.  There is solid scientific evidence that these microbes can help certain conditions. We know that the gut microbiome is altered by disease, with antibiotics, infection and even constipation. Probiotics have an important role in keeping the gut equilibrium by directly interacting with immune cells.  But all probiotics are not alike and it can be confusing for doctors and patients to know what to take.

Consider this a little primer with conditions, probiotic names and prices. 

Probiotics come in two main forms: food and dietary supplements.  There are so many different brands and formulations and quality control is not well regulated. The effectiveness is specific to the disease and the dose taken.

1. Diarrhea after taking antibiotics (or to protect your GI tract when you take an antibiotic)-
    DanActive - $5
    Align -         $50
    Bio-K+ -      $17-27
    Culturelle-   $40
    Forastor-      $50

2. Ulcerative Colitis
     Activa -       $6
     Align-          $50
     Bacid-          $20
     Culturelle-   $40

3.  Irritable bowel
     Activa-        $6
     Align-          $50
     Bacid-          $20
     Culturelle-    $40

4.  Constipation
     Any of the above.  Activa yogurt is easy and effective.  The active bacteria is Bifidobacterium     animalis.

I always tell my patients to take probiotics along with antibiotics and after they are done to restore the normal gut bacteria that are wiped out by antibiotics.  They are generally considered safe, even in children.

Rural Nurse Diagnoses and Treats His Own Heart Attack

Here is a remarkable feel good story as reported in the letters section of The New England Journal of Medicine.  A 44 year old male n...