Sunday, February 28, 2010

How to "Die Healthy"

     Let's face it! Numerous advances in health technology cannot change one fact. Sooner or later we will die. We read about Mr. Rich-And-Famous being admitted to Best Hospital and then succumbing to a life-ending illness - The Great Equalizer. All the resources at our disposal will not change that fact. At first blush this premise may sound too fatalistic; especially coming from a doctor. On the contrary, life and death situations we face allow us to be more pragmatic. Let me tell you about a lesion I learned as a young doc.

     Mr. Jones was in his 90's, living at home independently, driving and managing his own business affairs. Most of his contemporaries take more than ten medications. Mr. Jones took one multivitamin a day. His weight and blood pressure were normal. And except for occasional arthritis pain, he was rarely ill. "I know when it's gonna rain", he proudly proclaimed. I asked him about exercise. He answered, I work on my lawn every day. and when I finish mine, I start on my neighbor's." I marveled at every statement he made. One day he told me what he wants out of life. The words stuck with me. "I want to die healthy."

     This contradiction in terms made more sense as I grew older and wiser. One day I received a call from the police to tell me his housekeeper found him in his bed. He died in his sleep. His story exemplifies the concept of living a healthy lifestyle and being passionate about the things you care about. Mr. Jones lived his life to its greatest potential. He did not smoke. He ate his vegetables every day. And except for an occasional glass of wine, he did not drink in excess. Never afraid of physical labor, he was proud of his muscle strength. Best of all, his attitude was always positive. These are characteristics I see in many patients that live long healthy lives.

     In contrast, there's the story of Mrs. Smith. Initially, she was overweight and smoked 2 packs a day. She had hypertension and high cholesterol which did not stop her from her self-destructive lifestyle. At first she felt well except for occasional shortness of breath and a "smokers" cough. Within a few years she was sick all the time and was on multiple medications and inhalers. Over the years, she developed diabetes, eye problems, and arthritis which caused her to gain more weight. There was always an excuse for her behavior...problems at work and a husband who was not happy being home etc. Her children where having problems of their own and unfortunately, they were following in her footsteps. Eventually she became partially blind and had multiple procedures for her circulatory problems. She was admitted to the hospital frequently and the staff knew her as "Miss Personality". One day at age 70, she came into the emergency room and was placed on a respirator. A DNR (do not rescusitate) was never signed so she remained on life support for 3 weeks until she died. While in the hospital, she developed gangrene of her foot and pressure ulcers that reached the bone. This was not a "heathy death". Many would argue that Mrs. Smith received the best care science had to offer. Technology at its finest! After all, she had everything from MRI's to angioplasties and has a hospital bill to prove it. Among other things , this case illustrates the failure of our reactive health care system. Not only did she have an "unhealthy death"; most days in her life she struggled to live with each breath.

     The choices we make on a daily basis have the highest impact on our health. The industrial complex would have you believe that fast food equals happiness. "Don't worry be happy!" "Have it you way!" The next new drug will solve all your problems. And if that doesn't happen, there's a pill that will make you think it did. We are an ailing society misguided into making the wrong choices. Our decisions are shaped by someone trying to sell something and by a health care system that discourages prevention. When Mrs Smith was younger, she was convinced that "she's come a long way baby". Bad habits are learned by our children with their first Saturday morning TV session. The result: our next generation will have a shorter life expectancy than the previous one.

     So how do you die healthy? You must go against the tendency to rely on technology to solve all your problems. Make the right choices based on old fashion common sense. Value concepts of prevention, healthy lifestyle and ideals that strengthen the human bond. And every once in a while, do your neighbors lawn.

Wednesday, February 17, 2010

What's Wrong With Our Healthcare System. One Doctors Perspective

I recently read an article about soaring health care cost. Part of the new health plan initiative is to crack down on fraud and abuse by providers. Auditors and government agencies have testified at recent congressional hearings that they will hunt down the offenders and solve medicare's financial woes. They did agree reluctantly that some of these cases are due to clerical errors rather than actual fraud. Here is an example of such a case.

In order for a patient to receive medical supplies, a physician must fill out lengthy forms (that the physician cannot bill for) . A patient needed a walker after a sustaining a fractured pelvis. The medical necessity form was returned to me several times because a change that I made on a line item was initialed but not dated. The form was returned back to me because the date that I added not re-initialed and then again because it was not re-dated. There were four sets of dates and initials because I originally wrote the wrong age for this patient. Because of my original clerical error this case was deemed to be a fraudulent claim until I corrected my clerical error. Doctors in practice see these absurdities all the time.

In my opinion, our health care system is ailing because of misguided values. It is a system that rewards reactive rather than proactive behavior. It values procedures rather than outcomes. Insurance companies don't blink an eye when they have to pay thousands to remove a lung from a cancer patient. But they will not pay for smoking cessation. Physician's cognitive skills at history-taking, physical exam prevention are undervalued. Conversely a test such as an MRI is reimbursed many times the cost of an office visit. What is the value of counseling a patient about home safety and fall prevention versus the cost hip surgery and possible permanent nursing home placement. Ridiculous policies lack any remote connection to common sense. This is not more evident than in the frequently encountered situation of the patient who needs long term IV antibiotics. Medicare will pay $10,000 or more for temporary nursing home care rather than pay for home services at a fraction of the cost.

Medicare and insurance companies are not the only culprits. Consumers want the "latest and the greatest". They object when doctors don't order a branded drug when the generic drug will work just as well. And our lawyers will always always steer us toward ordering more test and consults. Our health care environment promotes chartsmanship over a substantive encounter. Fill in the correct boxes in the medical record and spend more time with the chart than you do with the patient and you will be ok. That why EMR's are so good at spitting out pages of verbal garbage that will satisfy the auditors and lawyers alike. And self-serving government watchdogs will hide behind bureaucracy and will never work themselves out of a job.

Now that I have enumerated the failings of our health care system I have all the solutions. But that's a topic for future discussions. However, I will give you a sneak preview.
(Encourage primary care at the med school level, year of social service, higher reimbursement for cognitive skills, bonus based on outcomes, eliminate bureaucracy (less government), tort reform, incentivize the consumer to take some responsibility for health care cost, encourage prevention etc)

Saturday, February 13, 2010

Should We Put Prozac in Our Drinking Water?

Prozac in our drinking water? Why not! After all, they did it with fluoride. You can make the same argument about many other medications and supplements. Newer antidepressants have relatively few side effects; it's hard to resist giving a happy pill to all woeful patients.

So what's the downside? Well aside from the potential for up-regulation, an increase number of re-uptake receptors that may decrease the effect of neurotransmitters, there is potential for "atrophy of the coping mechanism". Each of us cope with stresses in life differently. Some better than others. If all we do is take a pill when the slightest conflict presents itself, we will not learn healthy coping skills that will help us throughout life.

Then there is a philosophical/ moral issue we must consider. By prescribing medication that blunts emotion and passion are we "anesthetizing" the psyche. An illustration of this case would be a patient in an abusive relationship. Prescribing an "emotional anesthetic" may negatively influence the proper choices that need to be made by the patient. Then there's the yin/ yang argument. Overcoming hardship may be the key to a more joyful and fulfilling life.

So how does the practitioner reconcile issues around prescribing antidepressants. First and foremost, the goal is to a relieve suffering, maintain function and improve quality of life. I like to use the broken leg analogy. We will cast the leg and relieve pain. But we will work with the physical therapist to ensure proper function restored. When we use an antidepressant, we should use therapist to restore full psychological function and prevent "atrophy of the coping mechanism".

Wednesday, February 10, 2010

Telemedicine and The Virtual Doctor

Imagine this for a moment. You sit on the toilet at home and a urinalysis is performed automatically. Once you finish your “download”, information about renal function and glucose is uploaded to your doctor. You then look into the mirror which contains a retinal scanner, step on a scale, hold onto a special grab bar and tons of medical data streams to your ubiquitous electronic medical record. A galvanic skin sensor checks your anxiety level and automatically dispenses the right amount of Xanax. Or maybe it plays the right kind of music while you shower. Sounds far fetched? Not really. This technology exists today.

The military has always been a source of scientific innovation. Remember they are the ones that invented the internet. Surgeons sitting at a computer at Walter Reed Hospital are now able to assist battlefield surgeons operate in remote areas. In the same way pilots use joysticks to fly drones over enemy territory, doctors can perform remote robotic surgery by using the "DaVinci System”. This is a device which is now available in community hospitals. Critical care specialists can monitor their patients in the ICU virtually, by watching steaming video from bedside cameras. Tele-Radiologists in Australia are reading late night X-rays in taken in NY through the Night-Hawk system. Recently, a study showed that doctors can accurately diagnose appendicitis by viewing CT scans on their iPods. The Journal of Telemedicine and Telecare is full of articles about the advancement of medical care through technology.

There is no end to our fascination with technology. ….especially for those of us who remember huddling around a neighbors TV to watch a rudimentary graphic of a peacock fill with color. Yet, I sometimes wonder when enough is enough. Do we really need things to be more complex and so remote? Since the time I saw my first TV, obesity rates have skyrocketed and for the first time our life expectancy is decreasing. We are leaving more and more garbage around for subsequent generations to clean up. Don’t get me wrong. I love technology just as much as the next guy. But I can certainly imagine scenarios where it just can’t be right.

Will technology replace me with some virtual doctor! Juxtapose the scene where your doctor walks out of the OR with sweat on his brow with the scene a robot in a Woody Allen Sleeper-like movie. The LED message scrolls across its face, “It was touch and go but we were able to save him”. I don’t want someone that looks like my Wii fitness coach telling me I have cancer. What about compassion and caring. What will happen to the human touch and the reassuring smile that only a real doctor can give!

Saturday, February 6, 2010

Compression Only CPR

This week I gave a brief presentation to middle school students. The topic was the heart and CPR. Within the hour they learned more about the heart than most adults. They also learned a skill that could potentially save a life.

Compression Only CPR is used by non-trained bystanders who is a witness to someone who colapses from cardiac arrest. The first thing to do is call 911. Depending on your location it can take 8 to 10 minutes for help to arrive. You can dramatically improve that persons chance for survival by starting chest compressions. Simply place both hands on the breast plate and start pumping. Ideally you want to perform 100 chest compressions a minute. That's it! If you want to learn mouth-to-mouth, check with your local Red Cross for classes.

It's so easy a middle school student can do it.