What is Needed for Supplements and Vitamins

With constant messages and studies that contradict each other, it is no wonder patients are confused about vitamins and what is needed to stay healthy.  While most supplements cause no harm, except to the wallet, people do sometimes forgo needed good health habits with the erroneous assumption that they are doing the right thing by popping lots of vitamin pills.  Based on current research, here are the supplements I recommend for good preventive health:

• Low dose aspirin (81mg).  Although a recent study did not recommend women take aspirin as a preventive medication, there are others that show its benefit for preventing heart attack and stroke in both men and women.   A recent study reported in The Lancet showed low-dose aspirin taken for 5 years or longer reduced mortality from esophageal, pancreatic, brain, stomach, colorectal, prostate and lung cancer.  If you are over age 40, I recommend one low dose aspirin a day.

• Omega-3 Fatty Acid (fish oil).  The benefits of Omega 3 have been reported for years for depression, hyperlipidemia, heart health, ADHD, clotting disorders and even arthritis.  The newest study published in The American Journal of Cardiology, showed that patients with heart failure improved their exercise duration and left ventricular ejection fraction by taking 12 months daily Omega 3 FFA.  Yes,  you can get this by eating fish and flax seed and certain vegies, but our modern diets are deficient in Omega 3 so an extra supplement is easy.

• Vitamin D.  This vitamin is essential for a number of body functions including bone health, autoimmune diseases, cancer,  heart disease and cognitive function.  I have no idea why there seems to be an epidemic of low Vitamin D levels in Americans, but there is. It might be dietary because we need the right mixture of amino acids to convert Vitamin D in the body.  I am still checking all patients 25 OH Vit D levels by a blood test.  If mid or high normal range, great.  If they are low, I recommend 1000 IU a day.  It is cheap and easy.

• Calcium.  Calcium is needed for good bone and heart health, especially as we age.  Women especially may be deficient in dietary calcium unless they drink milk, eat yogurt or cottage cheese.  Any women with a family history of osteoporosis should be making sure she gets at least 1500mg of calcium per day.  One cup of cottage cheese contains 1, 300 mg calcium. Unfortunately the blood test for Calcium is not an accurate way to see if you need supplements because the body will steal calcium from bones to keep the blood level steady.  If you smoke or are a thin woman past menopause, you probably need Calcium supplements.

So what about Magnesium, CoQ10, Vitamin B, Carnitine, Biotin, Folate, Iron?  Readers, vitamins are big business.  It is estimated to be a $61 billion dollar industry in the U.S. alone.  If you don't believe me, just google a vitamin and see how many ads pop up. There is no evidence that taking these extra vitamins as additional supplements improves your health or lifeline.  

We all want to live long and healthy.  Use the money you would spend on supplements for organic fruits and vegetables. 

Breast Milk Ice Cream - FAIL

Say it isn't true! A restaurant in London is planning on serving breast milk ice cream called "Baby Gaga".  The expensive treat will cost £14 pounds ($23 US dollars) a serving. Where does this breast milk come from?  Mothers answered an ad that was placed online and are selling their milk to the restaurant for £15 pounds for every 10 ounces of milk.

One of the donating mothers said she believes if adults realized how tasty breast milk actually is, then new mothers would be more willing to breast-feed their own newborns.  Do moms really decline breast feeding because they don't know how good it tastes?  That is a ludicrous concept.  She also said, "What's the harm in using my assets for a bit of extra cash?"  Now that is more like it!

Baby Gaga is said to "melt in the mouth".  The recipe blends breast milk with Madagascan vanilla pods and lemon zest.  Churn it a bit and you have ice cream.  They are planning more new flavors to serve up to the public.

Free-range, organic, natural,  milk.  What's not to like? 

Ex-Convict Sisters Can't Share Kidney Because of Obesity

I posted before about the bizarre case of two sisters who had spent 16 years in prison for stealing $11 from two men.  They were sentenced to two life terms in prison for the robbery until Tennessee Gov. Hailey Barbour granted Jamie Scott an early release because of kidney failure that cost the State $200,000 a year for dialysis.  He also released her sister, Gladys on the condition that she donate a kidney to her sister.

Now it seems the doctors will not consider them for transplant surgery until Jaimie loses over 100 lbs and her sister sheds 60 lbs.  Gladys also needs to quit smoking and at 4 feet, 9 inches and 184 lbs she certainly has some weight to lose.

This case is so strange on so many levels.  First of all, why should two young women (age 19 and 21 at time of sentencing) be given life for a simple robbery?  The inequities of our legal system are profound and this case proves it.  To read a bit from Jamie Scott about the conviction go here.

2nd, this shows how unhealthy prison can be.  Prisoners age much faster than the normal population due to overcrowding, poor medical care, carb heavy food and general stress.  Women prisoners are generally overweight, as these two have shown.  Smoking is rampant in prison and cigarettes are bartered and sold and used as rewards.  I am not saying prison is the cause of the poor health habits of these two women, but it is a rare person who can maintain good health in that environment.

Finally, how odd to choose this reason to parole the sisters.  Neither had been previously tested for compatibility and there is no real way to enforce compliance.  Barbour hasn't responded directly to numerous questions about whether he'll send the sisters back to prison if the transplant doesn't occur.

The final ending to this odd scenario has not been written.  I would suggest the producers of "The Biggest Loser" snatch these two up right away and get some good high ratings.  I am just glad they are out of prison, back with their children who have suffered so much,  and can try to regain their lives.

Animal Testing

Medicare Scammers Busted

I am always happy when I read about fraudulent doctors, nurses and businessmen getting busted.  Medicare is, unfortunately, a program that lends itself to crooks.  The more of these crooks that get prosecuted and sent to jail, the happier I am.  Each of these busts should be made public.  This time Federal authorities have charged over 100 doctors, nurses and physical therapists with massive Medicare fraud in Miami, Los Angeles, Dallas, Houston, Detroit, Chicago, Brooklyn, Tampa and Baton Rouge.

These crooks billed Medicare more than $225 million for services that were not performed.  One Brooklyn proctologist billed $6.5 million for phony hemorrhoid removals.  He claimed he performed 10 on one patient alone.  Impossible!   Are there even that many potential hemorrhoids in Brooklyn?  A podiatrist billed Medicare $700,000 for toenail removals.  The stupid guy said he removed 20 nails on 3 toes of one patient.

Three physical therapy clinics that were run by an organized network of Russian immigrants billed $57 million for elderly patients that had no PT.   This involved the usual recruitment and kickback to elderly patients just to get their Medicare number.

Medicare is one of the largest health care payers in the world with 1.3 million licensed suppliers nationwide.  Medicare not only pays doctors and hospitals, but also chiropractors, podiatrists, physical therapists, Christian Science practitioners,  home health agencies, medical supplies and  equipment manufacturers.

Now that Medicare is so large and cumbersome, we need to strengthen the enforcement and applications for providers.  How about criminal background checks for provider applicants?  Unfortunately, right now  a fraudulent clinic can shut down in one locale and open a new operation and begin billing all over again. 

As a taxpayer I support strict enforcement and prosecution.  As a primary care physician who saw her reimbursement cut this year to $84.00 for taking care of a complicated medicare patient, I am outraged at the waste.

White Coat Hypertension

"But doc, my blood pressure is always normal at home."  I wish I had a dollar for every time I have heard that line and I know it is true.  When some patients come to see me, their blood pressure is abnormally high (above 130/90) and this is known as "white coat hypertension."  Although it has been thought to be from anxiety about seeing the doctor, even long established patients who have no conscious anxiety can exhibit elevated blood pressure in the office.

Because blood pressure naturally fluctuates and the office visit is not a "normal" setting,  it is important for patients who have hypertension (high blood pressure) to have their own BP cuff at home.  Now that devices are automated and easy to use, everyone with hypertension should be monitoring their BP in the comfort of their own home.  I advise multiple readings over a week at different times of day.  Get a reading when resting and when rushing around.  Take the BP after you exercise and after a meal.  It is important to keep a log and write it down.  Only then can we see patterns and know if the blood pressure is controlled or not.

Blood pressure readings in the doctors office are not necessarily the most accurate.  Patients are often rushed trying to get parked and in on time.  Medical assistants can use the wrong size cuff or not position the arm correctly.  Auscultation (listening) is not very accurate due to errors.  It is the multiple readings over time that give a more accurate picture of blood pressure control.

High blood pressure in the office can be true hypertension or it can be "white coat hypertension" that is usually controlled at home.  If a patient is on blood pressure medication and has controlled BP at home, I will not add more medication just because they are elevated in the office.  If a patient has not been diagnosed with hypertension and the BP is elevated in the office...that patient is advised to get their own home cuff and return with readings for us to review.  This way we can minimize unnecessary and expensive medication and make sure we are protecting the patient as well.

Ganglion Cyst

At least once every quarter, for all of the years I have been in practice, I see a patient with a swelling on their wrist, ankle or foot.  This common problem is a ganglion cyst.  These cysts are located on tendons and occasionally are tender but more often just seem to develop painlessly for no reason.  The tendon sheath may rupture suddenly or slowly and allow the fluid to bulge out.  The swelling is filled with a thick gelatinous substance called synovial fluid and it can feel spongy or firm. 

Most ganglion cysts can be diagnosed just by vision and palpating it.  If they are on extensor tendons, they might bulge more when the joint is moved and disappear when it is flexed.

A majority of ganglion cysts disappear without treatment.  If it is painful, the doctor might aspirate it with a needle.  About 1/4 of patients will have a recurrence after removal and aspiration can be tried again.  Surgical removal is needed only if it is painful or causes numbness in the hand or fingers.

There is no way to prevent a ganglion cyst from occurring.  In the old days a patient would undergo "bible treatment".  Grandma would whack it with a heavy bible.  We don't recommend that any longer.

Health Care Costs Too Much

Almost every day I hear a story about health care that makes me cringe. (I also hear good stories about health care, but that is another post)  Today while buying a pair of shoes, the sales clerk told me how upset she was that a chest X-ray cost her $350.00.  That amount is her portion...she has insurance and the full charge was over $800.  She wishes she would have known the cost and said,  "I would have thought twice about getting it.  I had a cold that lasted several weeks and the doctor just wanted to make sure it wasn't pneumonia."

(Try as I do not to 2nd guess my physician colleagues, I do have to wonder if a chest X-ray is indicated in a healthy young non-smoker who is not sick and just has a lingering cold)

This woman went on to say, "I can't believe it.  I pay $380 a month for health insurance just for myself and I only get a pap smear once a year.  And I still got stuck for $350.00 for the chest X-ray.  My employer pays even more for my insurance so the insurance company gets about $1000 a month for me. It will take me 3 days of working on Saturday just to pay for that X-ray that I probably didn't need."

Had she asked her doctor what the chest X-ray would cost, I doubt the doctor would have known. Had she called the hospital and asked what it would cost, I doubt they would have been able to tell her.  Had she been able to read her insurance coverage handbook, I doubt she would have found that the X-ray would cost her $350.00 out of pocket.

It is hard to be an informed and savey consumer of health care when you cannot find out the price of a service.  The prices are so variable between one hospital and the next one down the street and the imaging center on the next block,  that a person could spend a day price shopping and comparing and still not make the best choice.  The range for a simple chest X-ray can be between $80 and (gulp) $850 as this one cost.

I didn't have the heart to tell her that she will probably get a 2nd bill from the radiologist who interpreted the study. 

This is a very broken system that isn't working for the average working woman.

Nursing Shortage Big Disconnect

With the aging of America, it is well known that there will be a shortage of registered nurses and nurse aids to take care of the population.   It is predicted that the shortage of nurses to take care of people will climb to 80,000 by 2015 in California.  California has just 653 registered nurses employed per 100,000 people.  One of the problems is a lack of qualified faculty to teach at Nursing schools.

California was forced to turn away 23,000 qualified applicants from nursing programs during 2008-2009.

And this week, Humboldt State University announced plans to discontinue the school's nursing program because of financial concerns and inability to retain nursing faculty.

Shortage of Nurses and Closing Nurse training programs...now there is a big disconnect.

Big Changes in Breast Cancer Care

I always say that medicine is a dynamic changing field and today's JAMA study on the standard practice of removing lymph nodes in women with cancer is flipping medicine on it's head.  For over 100 years, the standard practice has been to remove cancerous lymph nodes in early stage breast cancer.  It has been common practice to sample these nodes and remove them if there was any evidence of cancer, with the hopes of stopping further spread.  It made common sense and it was done by all surgeons.  Women who had their underarm lymph nodes removed often suffered complications and severe persistent lymphedema arm swelling and pain.  But it was considered the price to be paid to be cured of cancer.

The new study, which examined data from 900 women,  showed no difference in 5 year survival rates between women with lymph nodes removed and those who did not.  These results will change the way we practice medicine.

Cancer is found in lymph nodes in about 1/3 of the 200,000 women with breast cancer in the United States each year.  Even women who have lumpectomy rather than mastectomy, have undergone lymph node removal.   To spare women the complications, doctors sample one "sentinal" node and continue removing them if that shows cancer.  This study shows there is no advantage to removing additional nodes, even if cancer is found.

It should be noted that this study only applies to women with T1 or T2 tumors, meaning small and with no enlarged nodes that could be felt.  It also excluded women with other know metastasis.

But 60-70% of women with breast cancer found in lymph nodes may not need to have those nodes removed and they will be spared additional surgery and complications.

Vote for Everythinghealth

If you are reading this, I hope you will click here and cast your vote at MedGadget for EverythingHealth in the category of "2010 Best Ethics/Health Policy Weblog".  I am honored to be a finalist and am trailing in the votes (sob!) so your support is appreciated.  Vote now.
Thank you!

The management

A Marathon a Day for 365 Days

I would not have believed it was possible, but Stefaan Engels, a 49 year old Belgian man has run his 365th marathon in 365 days.  Mr. Engels has set a new record after running 9,569 miles across seven countries.  He finished his final race in Barcelona, Spain. He ran races in the UK, Spain, Portugal, Belgium, Canada, Mexico and the U.S.

Stefaan Engels also holds the world record for completing the most "Ironman" Triathlons in a year.  He did 20 in 2007/8.

This is his second attempt at the 365 day marathon running challenge.  The first time he injured his leg.  This year he attributes his success to running a slow pace over each 26.2 mile marathon.  He averaged 4 hours per marathon day.  Four hours!!

He stated "I wanted to inspire people by showing that if I could run a marathon a day for an entire year, that anyone could run or bike a little each day or do something about their weight problem."  I would certainly say he succeeded at being inspiring.

I'm going to just stop typing, take a rest and ponder this for awhile.

What Doctors Want Patients to Know

Consumer Reports surveyed 660 primary care physicians about what they wish their patients knew and what they faced as professional challenges.  Some of the highlights are:

• Doctors believed forming a long term relationship with the primary care physician is the most important thing a patient can do to obtain better medical care.  They believe continuity is really undervalued and patients who frequently switch doctors have more health problems and spend more on care than patients who have a relationship with one physician.

• Doctors want respect and 70% said that respect and appreciation from patients had gotten worse since they started practicing medicine.

• Doctors want patients to be compliant with advice or treatment and 37% said non-compliance affected optimal care "a lot".

• Doctors don't think they are very effective at minimizing pain, discomfort or disability caused by a chronic condition.  Only 37% thought they were very effective, yet 79% of patients said their doctor helped to minimize their pain or discomfort.

• Doctors want patients to know that each patient should keep track of their own medical history. Eighty nine percent said that keeping an informal log of treatments, drugs, changes in condition and tests and procedures would be helpful.  Eighty percent also thought taking a friend or relative to the office visit could be helpful.

• Doctors are not convinced that online research is very helpful.  Only 8% thought it was helpful.

• Doctors said the sheer volume of insurance paperwork was the number 1 thing that interfered with their ability to provide optimal care.  Financial pressures that forced them to see more and more patients and work more than 50 hour weeks to break even came in at number 2.

• Doctors talk to drug salespeople more than patients realize.  The majority of physicians surveyed said they were contacted by pharmaceutical sales reps more than 10 times a month.

• Doctors don't think patients knowing about malpractice claims or professional disciplinary action was of  value.  Only 17% of physicians surveyed said that information about disciplinary actions by medical licensing boards was "very valuable".

The survey was conducted online and that is certainly not a random sample of all primary care physicians.  The results are interesting but should not be interpreted as speaking for all doctors.

Norovirus Stomach Flu

After spending a weekend in bed with self diagnosed Norovirus,  I thought the information would make a great post. Norovirus is a contagious virus that causes sudden onset of nausea, vomiting, headache, body ache and feeling very very sick.  It strikes 12-48 hours after exposure, either by ingesting contaminated food or water or close contact with someone who has the virus.  When you hear of a cruise ship being struck by illness or nursing homes or child care facilities...the culprit is usually Norovirus.  I have no idea where I caught it. It wasn't a patient and I seldom catch anything from patients. No one else in my family was sick. I hadn't eaten out so the source will remain a mystery.

I can tell you from personal experience that like most viruses, this one starts with body aches, headache and malaise. That viral feeling is followed by vomiting and abdominal cramping. You just feel knocked out. No reading, no blogging, nothing but misery.

Like any gastroenteritis the biggest health danger is dehydration. If a patient can replace fluid by drinking water, he will be fine. Small children or debilitated people are at most risk. The average person like me just gets over it.

The good news about Norovirus is that it only lasts about 24-48 hours. Just long enough to ruin a beautiful weekend with lots of activities planned including playing a tennis tournament and a fancy gala fundraiser for Make a Wish Foundation.

What did I do?  Complained a lot.  Washed my hands scrupulously and used bleach on surfaces to clean.  Drank water followed by juice and finally ate wah wah ton soup (my sickness comfort food).  Now I'm ready for work on Monday.

Stroke Patients Stop Taking Medicine

A study published in the Archives of Neurology reported that a quarter of patients who have a stroke stopped taking their medication within 3 months of hospital discharge.  These medications were meant to be prevention for future strokes.  With 180,000 recurrent strokes occurring in the U.S. each year, that is an astonishing number of patients who stop their prevention meds.  Also,  the recurrence rate is the highest during this 3 month period so these patients are at risk of losing more brain function.  Twenty percent of the patients were taking half of the prescribed medication and 3.5% had stopped all of the meds.

We need to understand why patients who have suffered a stroke would put themselves at risk for a 2nd event.  The reasons for going off medication were multiple.  And some of them are no surprise.

• Not understanding the importance of the medication
• Not understanding how to take the medication or to refill prescriptions
• Increasing age and confusion
• Financial hardship
• Too many confusing medications
• Lack of health insurance

This study points to the flaws in our medical system.  We are so good at heroic life saving interventions and then sending patients out of the hospital with expensive medication but that is where our "goodness" stops.  If a patient is lucky enough to have an intact family, health insurance, and a good network of out-patient doctors,  they might do well.  If any of those factors are missing, the likelihood for another stroke and re-hospitalization is high...and we start all over.

To really impact health we have to stop the silos of treatment.  It is equally important that time be spent explaining the medication and what it is for, as it is to administer clot busting drugs.  An evaluation of the patient's living situation and ability to understand and take medication is as important as those weeks of expensive hospitalization that got them to a  point where they could go home.  And if the patient has few resources, spending up to $84.00 a month for Plavix and more for a Statin  is impossible.  Helping them get discount medication is essential if they are going to take it long-term.

Before the patient leaves the hospital, we need to understand all of these dynamics.

This study shows us how far we need to go to be a truly great health care country.

Women Doctors are Paid Less Than Men

A new study published in Health Affairs reports that female doctors fresh out of training are paid significantly less than their male counterparts.  The gender gap has been getting worse since 1999 and is now $16,819, up from $3,600 in 1999.   Readers, we are definitely going the wrong way here!  Women doctors are being paid less than men.

The widening pay gap cannot be attributed to the specialty they choose because the researchers controlled for that aspect.   Even when they account for specialty and hours and other factors, the gap remains.  The same gap exists for women in primary care as in other specialties.  Female heart surgeons were paid $27,103 less than males.  Female ENT doctors made $32,207 less than male doctors.  The women who specialized in pulmonary disease made a shocking $44,320 less than their male counterparts.

What about practice location?  It didn't matter...women were paid less than men.  Could it be that they work less hours?  Nope, even with the same hours, women were paid less than men.

We can only speculate why this is happening.  The most obvious answer is;  "Yes, there truly is gender pay discrimination."  No-one really wants to consider that or admit it but the facts seems to speak for themselves.   Other considerations are that women  fail to negotiate salaries as well as men.  That is a skill most women do not develop and most starting salaries are negotiated within a certain range.  Women may just accept the first (low-ball) offer made,  while their male counterparts would hold out for more.

Another thought is that women are trading pay for less call time or a better lifestyle.  I doubt that is the case because the authors controlled for hours worked.  Frankly this trend of gender difference in pay cannot readily be explained by any of these excuses.

I will be the first to admit that women have come a long way.  But this study is disheartening and shows we may be heading back in the wrong direction.

Blog Award Nominee for EverythingHealth

I am happy to announce that EverythingHealth has been nominated and is a finalist for the MedGadget blog award in the category of "Best Health Policies/Ethics Weblog" for 2010.  The other blogs in my category are outstanding and the competition is tough...but that is a good thing and I am honored to even be mentioned with these prestigious writers.

Check out some of the other categories too.  Many of my favorites are there like "other things amanzi" and my new favorite and bbb (blog best friend) "Reflections of a Grady Doctor".  I'm making my way through the others.  It is a great way to stay informed and these are the best of the best health blogs on the internet.

Please vote for EverythingHealth by clicking here.  Don't we all love an underdog?

Sex in Pregnancy is Safe

The Canadian Medical Association Journal has published a new primer designed to help physicians when they counsel pregnant women.  They note that sex during pregnancy is normal and is generally considered safe.  The authors point out that there are very few proven contraindications and risks regarding intercourse in normal pregnancy.

Pregnant women and their partners are often afraid to have sex.  Men may think they are "invading" the home of the fetus and could actually harm the baby.  In fact, the fetus is quite safe, ensconced in the uterus (womb) and the cervix (opening of the uterus) is closed in normal pregnancy.  The penis has no contact with the fetus or the uterus during normal intercourse, no matter what the position.

When is intercourse considered risky?  Only for women who are at high risk for preterm labor and for those with placenta previa because there is increased risk for hemorrhage.  Even women who have had preterm labor may safely have sex unless they have cervical incompetence or a lower genital tract infection.

Women who are under the care of an obstetrician should know if they have any of these risks. The vast majority of women should be reassured that sex during pregnancy is safe for mom and baby.