Friday, September 27, 2013

I was prompted to write this article when I heard a 2 pack per day smoker complain about genetically modified organisms (GMO's)

(I don't think his tobacco was organically grown) Frankly I don't understand the controversy. I welcome illumination on this matter. As a scientist and student of genetics for many years, I can tell you that we have received so many benefits from genetic modification. It is not a new concept. Gregor Mendel, a monk in the 1800's, demonstrated patterns of trait inheritance (Mendelian inheritance) by crossing genes from variety of peas, bees etc . . Since then we have exploited  Mendelian concepts and improved our efficiency in "trait management".

          Tremenous advances in Medicine have been made possible by genetic modification. Not too many people know that millions of diabetics are alive because of Humulin insulin, a hormone that is produced by a DNA modified E Coli bacteria that is made to "think" it is a pancreas cell. This E Coli produces human insulin that is bottled and injected by diabetics.  Genetically modified (GM) vaccines such as HPV will eradicate cervical cancer in our lifetime. One million people die from malaria every year. Mosquitos in the Carribean, genetically modified to resist the malaria parasite, have reduced carriage by 80%. Countless drugs, developed by genetic modification, have saved lives of patients suffering from HIV, cancer, and other chronic illnesses.  And so on .....there are just so many example of medical breakthroughs that resulted from genetic RNA / DNA manipulation.

          As far as GM food is concerned; in 2010, the European Commission Directorate-General for Research and Innovation reported that "The main conclusion to be drawn from the efforts of more than 130 research projects, covering a period of more than 25 years of research, and involving more than 500 independent research groups, is that biotechnology, and in particular GMOs, are not more risky than conventional plant breeding technologies." (http://ec.europa.eu/research/biosociety/pdf/a_decade_of_eu-funded_gmo_research.pdf) The original concern was based on the death of Monarch butterflies in England that were believed to die from eating pollen from genetically modified plants.  This was proven to be false and accepted by those environmental groups that raised the original objection.

         There has not been one allergic reaction attributed to a genetically modified food allergen. In fact, genetic modifications can remove allergens from foods that are know to cause severe allergic reactions. Imagine having the ability to remove the protein in peanuts that cause severe reaction.

          According to the World Health Organization 6 million children die from hunger every year. There are some who believe that genetic modification can start the "second green revolution" (the original green revolution is attributed to Norman Borluag and Gregor Mendel contributions) that would save countless people from starvation. Pest-resistant plants can be produced with greater nutrient content.  This would decrease the amount of pesticides in drinking water and improve quality of life in third world countries. 

          Now for my disclaimer.....My arguments presented in this post are based on my experience as a physician and as one who has participated in the scientific process for many years.  I am no expert in agricultural science and I make no extrapolations of the implication of GM in geo-politics, economics, ethics, or religion. I shun pseudo-scientific analysis but I accept the more philosophical arguments which may be just as valid.  Facebook type comments of the horrors of GMO's are akin to scams phishing for donations the likes of  " Stop the use of puppies as fishing bait" captioned over a photoshopped picture.

          The reality is that one way or another, all living things, good and bad, are the product of genetic modification...more or less.  The issues related to how fast genetic code is modified, who controls it,  and what it means to the human species are fodder for science fiction.... and other types of discussions such as one of my favorites.... "unintended consequences".

Friday, September 6, 2013

A Way To Think About High Blood Pressure


Just imagine you are going on a long road trip with the family.  You check the oil, gas etc.  Just before putting the kids in the car, you fill the tires with air until the pressure is 20 points above its rating.  The gas station attendant warns that you may have a blowout on the highway.  You answer the car rides fine at that pressure and you would know if there is something wrong. Well, that's the logic I am confronted with every day when it comes to blood pressure control.

 Your body is rated to work best at 115-120/80.  That means that at the normal blood pressure your heart and organs will function at maximum efficiency and last the longest.  Analysis of the data from Framingham Heart study demonstrates that just  a 2-mmHg reduction in blood pressure would result in 14% reduction in the risk of stroke and transient ischemic attacks, and a 6% reduction in risk of coronary heart disease. Look at the graph below.  For every 20/10 rise in bp, your risk for cardiovascular death doubles. 





Optimizing your blood pressure will significantly reduce the risk of stroke and cardiovascular death.  It is important you to monitor your own bp and keep a record of your readings. Show you doctor a variety of readings at different times of day. That would give a more "real world" indication of your blood pressure.  I recommend Omron monitors using a brachial (not wrist) cuff.  If you don't want to buy one (about $50 on amazon)  most local pharmacies have one for customer use. 




Saturday, August 25, 2012

Those Terrible Drug Compaines and What You Can Do to Save Money on Medications

It is easy to become enraged about cost of medicines in the US ; especially when you can get the same medication in other countries for a fraction of the amount.   Recently I prescribed a medication commonly advertised on TV.  Thirty pills cost over $700.  "This is outrageous", I agreed with the patient. Can they really expect people to pay this much!  Well before we light up the torches, grab our ropes, pitch forks, and gather all towns-people to hunt down this monster, lets think about this and extrapolate the consequences.  Here's another drug story.

There is a drug called cochicine for gout that has been around for a million years.  You could buy a fist full for less than a dollar. Then something strange happened.  Suddenly, this generic drug became unavailable. It turns out the company making this generic drug could not thrive because of the low profit margin.    In both cases, medication was essentially unavailable for opposite reasons.

Pharmaceutical companies will charge what the market will bear.  If the regional consumer, insurance company and employer will pay, then the drug company will charge. Undoubtedly, these companies have been gluttonous . Budgets and profit margins need to be trimmed so savings can be passed on to the consumer. But lets not throw the baby out with the bath water.  Profit motive has led to discovery of wonderful life saving drugs.  The quality of our lives are much better because of medicines like antibiotics, cardiac drugs, cancer drugs etc..  I do believe government has a role to assist in the development if "orphan" drugs, vaccines, and to ensure our safety. But to have government take over as some have suggested would be counter productive.  (You have to also ask what government and what companies since many are international )

There are things individuals can do to save money on medications:
  • Don't be afraid to ask for samples at the doctors office.  We are happy to give them away when available. 
  • The trend now is coupons.  Some will reduce the cost of the drug to generic level.  Go to the company website for more information. 
  • Pharmacies have special pricing so shop around.  Some pharmacies offer free antibiotics and diabetic medications. 
  • Call your insurance company to find out if there are equivalent medications that would provide savings and ask your doctor at the tome of your next visit if substitution is advisable. 
  • And finally if you cannot afford medication, most drug companies will give them to you for free.  You will have to provide them with some type of financial disclosure. 
  • One more thing.  Stay healthy.  Sounds obvious but I can't tell how many people on inhalers still smoke, hypertensives who overuse salt and diabetics who frequent all you can eat buffets. Most people can reduce the number of medications taken  by using a little common sense.

Sunday, July 29, 2012

"So What Do You Think About Obamacare?"

....Is the question I am asked all the time....usually as we are walking out of the exam room after the visit. The answer is so complicated, I wish I was asked "What is the meaning of life". I do have a clear vision of what health care will be like in the future but don't expect a sound bite answer. My vision is created by considering many aspects of care as well as unintended consequences. Over time I will elaborate and extrapolate in a Charles Dickens-like way. We will keep politics out of the equation because political thinking is short-lived and incapable of long term problem solving. Forces that will drive the direction of health care will include technology, economics, strategic planning, and last but not least, patient efforts to take responsibility for their own health. I will tell you this. Health care will not be anything like what we are used to. But of course that depends on your age and what you're use to.

In Response to Professional Courtesy Article

Professional courtesy is not obsolete in my practice.  It is a token of respect for a colleague or allied professional that has spent countless hours away from his or her family to ease the suffering of others. But I do agree with the author that it will be obsolete.

Extending professional courtesy usually means waiving copayments.  Medicare can fine physicians for fraud because they assume the the total fee is inflated to compensate for lack of copayment.  An analogy can be make with an auto body shop that waives a deductible. The auto insurance company will certainly investigate.  Years ago, I made house calls in a local convent.  I was treated with the respect usually given to priests as they were gratefull for my visit.  I had to demonstrate a reasonable effort to bill the convent even though I felt my visits were a courtesy.

Also, these days clinicians are increasingly removed from billing practices.  Most just want to document what was done and leave the billing to others. "Just take the ticket and bring it to the cash register" will be the prevailing sentiment.  No room to wiggle there. Maybe rightfully so. 

Saturday, January 29, 2011

Death Panels and "DNR"

Recently the term "death panel was used to described government's posture on end-of-life care.  Some authors have written government will withhold medical funding and restrict treatment our elder patients . They are strongly encouraging the use of the "DO NOT RESUSCITATE" (DNR) document to save health care dollars.  I have a different take on this than most.

The DNR is a legal document that states if your heart stops or you stop breathing you are not to be revived.   This seems reasonable to most who conjure the image an elderly brain dead person suffering on endless life support.  So why is this document a bad thing!

The flaw is the DNR document, in its current state, is often outdated and not specific to your condition at any given time.  Consider the case of the relatively healthy patient in a nursing home who chokes on a hot dog while playing Bingo.  That person may not be helped because of a DNR wrist band.  More often than not, decisions are made when it is impossible to determine the outcome.  The patient with Congestive Heart Failure may respond with  24 hours of respirator support and a shot of lasix ...........OR they may not.  Uncertainty is the rule; not the exception.

The DNR can become a legal and moral shield to provide a lower standard of care.  I cannot tell you how many times I have be confronted when I admitted a "DNR" patient into the intensive care unit.  The DNR is often a big "DO NOT ENTER" sign when it come to a higher level of care.  It is a guilt reliever for families and staff that have to make tough life and death decisions.  And it shields the conscience from the echoing self searching question, "Did I do the right thing". Unfortunately the DNR may put the patient further away from the nursing station (literally and metaphorically).
 
I am concerned with legislation that would label or categorize patients into an all or nothing level if care.  There is now government EMR requirements for hospitals to force a "DNR or No DNR" status at admission.  A bit too cut-and-dry for me. Time is needed for the patient and family to think about this in context of present state of health.  In the old days we had a poorly defined order called "comfort measures" . That meant withholding some aggressive interventions and giving patients treatment that would alleviate suffering even if it resulted in death.  This is not the same as Hospice care.  Hospice is palliative only. Patients receiving curative treatments would automatically dis-enroll patient from Hospice.  The physician must attest that the life expectancy of the Hospice patient is less that six months.  A better approach is combination or curative and palliative care depending on the current situation and tailored for the individual.

The most important advanced directive document is the health care proxy (HCP). In fact I would advocated that anyone that is 18 or older should have a health care proxy assigned.  I would love to see this become a requirement by DMV or medicare.  The health care proxy gives authority to someone you assign to make those decisions for you.  Why 18?  That is the legal age that a parent can no longer make legal decisions for a child who may be incapacitated.  This simple form can be downloaded from http://www.nylag.org/forms/Health_Care_Proxy_Form.pdf

In the older patient, a tool (such as polst) that assists in end of life decision making can be used to help communication between the patient, proxy and medical professional.  A copy should be part of their medical record. http://www.ohsu.edu/polst/programs/sample-forms.htm

Health care facilities should advocate the use of a health care proxy card and a more detailed end-of-life plan. Medicare has a "welcome to Medicare Visit" . Part of this visit is devoted to advanced care planning but there is not enough time for proper consultation.  I would propose that CMS covers a separate visit specifically dedicated to discuss and document end-of-life wishes. It should be a Quality Indicator encouraged by the HITECH stimulus and PQRI quality initiatives.

The Death Panel notion is far fetched and fodder for movies the likes of "Soylent Green".  But the concept of government promoting DNR orders for the purpose of cost containment, is a concern to some.

Thursday, December 2, 2010

Vitamin D!... Is more better? Not really.

Vitamin D! Is more better? Not really. A committee of experts, convened by the Institute of Health, announced their Vitamin D recommendations on November 30, 2010.  Below is a summary of their findings.


Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, however, does not support other benefits for vitamin D or calcium intake. More targeted research should continue. However, the committee emphasizes that, with few exceptions, all North Americans are receiving enough calcium and vitamin D. Higher levels have not been shown to confer greater benefits, and in fact, they have been linked to other health problems, challenging the concept that that “more is better.”
The new vitamin D recommendations are bound to kick up some controversy because many researchers, led by Dr. Michael F. Holick, have argued that Americans should be consuming a lot more vitamin D than they are now, with 800 to 1,000 IU a day being the bare minimum and over 2,000 IU a day as being closer to the optimum.
Vitamin D proponents have also said the goal for blood levels should be 30 ng/mL. The IOM panel says levels that high are not associated with any health benefit and adds that levels above 50 ng/mL “may be reason for concern.”
The committee’s calcium recommendations are not likely to be nearly as controversial as its advice on vitamin D.
The summary of the panels’ report says national surveys show that most people in the United States and Canada get enough calcium, the notable exception being girls ages 9 to 18. The panel warns that postmenopausal women who take calcium supplements may be increasing their risk for kidney stones by getting too much of the mineral.