INTERNET MEDICINE


October 29, 2011

Many
of my recent articles have revolved around the influence the internet has had on patients, their health, and on the practice of medicine.  As patients become more engaged/activated (http://livewellthy.org/2011/10/24/patient-engagementactivation.aspx), they often become more concerned and worried about their health (http://livewellthy.org/2011/10/25/phobias.aspx).  Tonight, I read an article by Jill of All Trades, MD, a medical blogger, entitled “5 tips to evaluate medical websites” (http://www.kevinmd.com/blog/2011/10/5-tips-evaluate-medical-websites.html).  I thought the article was well worth sharing.


Jill of All Trades, MD states:


“And when they are reading, I ask them to keep these few tips in mind:



  1. In general, please be wary of any website with the ending “.com”, and opt for those websites with “.gov” or “.org”.
  2. If you are reading info online that is starting to become frightening to you, that is your signal to turn the computer OFF and make an appointment to see your doctor instead.  Please do not continue to terrorize yourself, because most of the time, what you are reading is not what is really going on.  Nothing good can come from that.
  3. Always ask yourself, “Who is writing this article?”  Is it written by a physician?  Most of the time, it’s not.  Many online health articles are written by journalists with “special focus” on medical information – and what does that mean, ask yourself.  Whatever that means, it’s NOT typically sufficient enough to be giving patients medical advice.  They are primarily writers, designed to catch headlines and grab your attention, not medically trained professionals who have enough knowledge to give accurate advice.  The scarier and more controversial their writings, the more money they make.
  4. Find out who sponsors the article, and if the writer is affiliated with any entity that wants to sell you a product.  Does the author work for a drug company?  What are they trying to sell you? Be wary…very wary.  Where is this article written?  I mean, is Vogue magazine a reliable source of medical information?
  5. Anything you read is one dimensional.  The computer cannot solve complex medical problems that require a background of experience and human reasoning.  The computer cannot perform a physical exam, or feel your level of pain, anxiety, or whatever it may be with one look.  Medicine is complex, that’s why it takes a minimum of eleven years of school to become a doctor.  Otherwise, doctors would be out of a career. Trust your doctor.”

One of Jill’s readers correctly stated that .org and .com are essentially the same and easily purchased.  Sites ending in .gov and .edu are better protected. 


It is hard to discern what sites are factual and which are not.  Merchandisers and marketers are very good at packaging their wares, using eye catching and reassuring tag lines and selling their products.  The articles on www.livewellthy.org represent my knowledge, biases, and interpretations.  The resource page on www.lzftc.com is designed to guide my patients to the trusted medical sites I use to research various subjects.


In “I Am a Responsible Patient” (http://livewellthy.org/2011/08/31/i-am-a-responsible-patient.aspx) item number 19 is “Studying.”  I still think studying about self is essential to good health.  Just be careful to remember that not every word you read on the internet is true and not every description of every symptom that applies to you means that you have a specific disease.

CHILDHOOD IMMUNIZATIONS


October 28, 2011


While reminiscing about the good old days of medicine usually brings back good memories, they are not all good.  In the good old days, my lobby was full of sick kids.  Throat infections, ear infections, and pneumonia were common place.  Several times a week, one of the kids I cared for had “tubes” placed in his eardrums.  Twice a year, I climbed into the ambulance with a kid who had epiglottis (life threatening infection of throat) for the trip to the hospital. 


Today, I do well kid exams.  I do not remember the last patient I sent for “tubes” and have not had to take an ambulance ride in over ten years.  Immunizations have changed the pediatric disease landscape in a major way.  Despite all of the benefits of today’s modern immunizations, I still have patients who are afraid of them.


Fear is the number one reason patients do not want to immunize their children and themselves.  Everyone seems to know someone who had some problem from an immunization.  Everyone has read something about immunizations causing some injury to the immune system or some such problem.  Old wive’s tales are hard to defeat.  Personal knowledge of some vague problem experienced by a friend or family member trumps my 28 years in medicine, as well as the American Academy of Family Medicine and the American Academy of Pediatrics.


As a doc, my job is to give my patients the knowledge they need to make healthy decisions.  While I’m not supposed to be a salesman, when it comes to immunizations, I can’t help myself.  I’ve seen too much good come from vaccines and far too much bad come from the lack of proper immunizations.


As flu and pneumonia season approaches, I get nervous.  My patients just don’t understand how bad influenza really is.  “Doc, I’ve never had the flu” and “Doc, I never get sick” means you’ve been lucky; but it doesn’t mean you won’t get the sick! 


“Doc, I’ve never been hospitalized” means this year could be your first year to sleep in a hospital bed.  As an adult, it’s your choice.  As a parent, it’s your choice, as well; but it’s your kids who will suffer if your choice turns out to be the wrong one.  No, I’m not playing the guilt card.  I’m doing my job, which is to make sure that you have asked yourself the questions you need to ask when it comes to immunizations.  If you’re still not sure, ask me.  If I’ve immunized my own kids and grandchildren, you probably should immunize your children and yourself. 


Remember, the life you save may be your own.

MEDICATION INTERACTIONS


October 27, 2011


Interactions between various medications can be serious, even life threatening.  When your doc prescribes a new medication, one of the things he does is, either mentally or using computer software, run through the possible benefits, risks, and interactions your new medication exposes you to.  When youR doc believes his choice is appropriate and safe, he writes your prescription and sends you to the local pharmacy to retrieve it.


Your pharmacist then repeats the same steps your doc went through.  The pharmacist’s computers run high tech pharmaceutical software which instantly looks for drug to drug interactions.  When he/she feels your medication mixture is safe, he/she fills your prescription and sends you on your way.


Unfortunately, there are multiple ways this seemingly perfect system can fail.  Medication errors are a fact of life in the medical world.  In “Uh Huh”, http://livewellthy.org/2010/11/28/uh-huh.aspx, I discussed those two dangerous words.


Nurse – “My record shows you are taking 325 mg of XYZ once daily.”


Patient – “Uh Huh.”


Nurse – “You’re taking 500 mg of ABC twice daily.”


Patient – “Uh Huh.”


In reality, the patient is no longer on either medication.  His cardiologist saw him five days ago and changed his medications.  “Uh Huh” means he wasn’t truly listening to the nurse as he thumbed a response on his blackberry.


Nurse – “Are you taking anything else?”


Patient – “Nope, just two meds.”


In reality, the patient is correct; he is on “just two meds,” just not the two the nurse recorded.  When I come in the room, I read what the nurse wrote and the patient again replies, “Uh Huh.”


Not having an accurate list of medications is just one way the system breaks down.  In this horrible economy, many of my patients are shopping around for the best price they can find.  Today I heard an excellent commercial on T.V.  United Healthcare addressed this very issue proclaiming that they now check their customer’s medication for interactions. 


When a patient buys two of his medications at CVS, two at Wal-Mart, and 1 at Osco, they sabotage the pharmacist’s ability to check for interactions.  I have often thought about having my patients run their own interaction software over the internet.  Interaction software, while excellent, can be very confusing.  There are multiple levels of drug-drug interactions, many of which have no clinical importance.


In “The Gambler” Kenny Rogers sings, “You’ve got to know when to hold them and know when to fold them.”  Your doc needs to see all the medications in your hand in order to know when to hold them and when to fold.  The pharmacist needs to know the same thing.


You can help!  Keep an accurate record of every medication, both prescription and non-prescription, that you take in your wallet or purse.  Make sure every doc you see knows what the other docs are giving you.  If you have a smart phone, keep your list electronically and share it with your entire healthcare team.  If you do your own interaction checks, be prepared to be confused.  If you have concerns, see your doc.  Discussions about medications should be face to face. 


When you are at the pharmacy, check the medication you are purchasing against your list before paying for it.  Once you pay for it, you own it!  If you are a shopper, make sure each pharmacy you buy at has your complete medication list.  Remember, the life you save may be your own.

WORSE THAN A FOUR LETTER WORD


October 26, 2011


We all know those dreaded four letter words that, as children, we dared not say on penalty of having our mouths washed out with soap.  Today, I diagnosed a friend with a viral upper respiratory tract infection.  Upon hearing the word “viral,” my wife remarked, “viral has one letter more than a four letter word yet it’s just as nasty.”


My family always hated it when I pronounced that the cause of their illness was viral.  It was not uncommon to hear my wife say, “I don’t care if it’s viral, I want an antibiotic!”  My family is no different than the rest of the world.  When they are sick, they want pills.


I hate viral infections.  It takes me three minutes to prescribe an antibiotic; and, in the eyes of my patient, I am a hero.  It takes me ten minutes to explain why I’m not giving my patients an antibiotic, and they walk out angry!  Antibiotics do not kill viruses.


“Dr. Segal didn’t even listen to me.  He spent 30 seconds in the room, told me I had a virus, and sent me home to die from this horrible sore throat!”  The patient did not hear anything I said after “antibiotics won’t help.”  I wish I had a prescription placebo!


I have written multiple articles explaining how docs make diagnoses and treat illness.  Unfortunately, most people are too busy making a living to take the time to read about healthcare.


When you are infected (sick), you need to know two things:



  1.  Where is the infection?
  2.  What organism is causing the infection?

In the real estate business, it’s location, location, location!  It’s the same in illness.  When your doc uses words like pharyngitis (infection in throat), bronchitis (bronchi), gastritis (stomach), and pneumonia (lungs), he is defining the location where the illness resides.  Think of infection as a crime.  Location tells you how potentially serious the crime may be.  (Generally, infections in the throat are less threatening than infections in the lungs.)


My brother has been in law enforcement for many years.  His job often entailed identifying which criminal(s) perpetrated the crime.  He had thousands of potential suspects.  I have it relatively easy.  My criminals fall into three classes:  viral, bacterial, and fungal.  Fungal infections are relatively rare so my job boils down to differentiating between bacterial and viral perpetrators.  Bacteria respond to antibiotics; viruses do not!  Your body has to kill viruses. (Your body can kill bacteria, as well; but antibiotics can help.)


After 30 years as a doc, I can tell you that deciding between viral and bacterial causes of infection is often difficult.  I would like nothing more than to prescribe a harmless antibiotic to every patient who comes to see me with an infection.  The problem is that I don’t have a harmless antibiotic.


Antibiotics come with risks.  Antibiotics can cause allergic reactions, nausea, diarrhea (sometimes potentially life threatening), yeast infections, and something docs worry about called bacterial resistance.  Treating patients always involve a risk-benefit ratio.   Treating a virus with an antibiotic has no benefit, leaving only risks.   


So, to my patients and family I’d like to say, “I’m sorry you have a virus!  The good news is you should be better in a week or two.  The bad news is that antibiotics can’t help you.”  Eat well, rest when you can, and drink plenty of fluids.  See your doc if you get worse as he/she could be wrong about the diagnosis or you might develop a secondary infection.


Yes, “virus” is worse than a four letter word.  Unfortunately, it’s a word I can’t avoid!

PHOBIAS


October 25, 2011


According to About.com/Psychology (http://psychology.about.com/od/phobias/a/phobialist.htm)), “Phobias are the most common mental disorder in the U.S.”  The web site defines phobias by stating, “According to the American Psychiatric Association, a phobia is an irrational and excessive fear of an object or situation. In most cases, the phobia involves a sense of endangerment or a fear of harm. For example, those suffering from agoraphobia fear being trapped in an inescapable place or situation.”


In a section entitled, “Phobias, A to Z,” I counted 97 named phobias.  Can you imagine 97 “irrational and excessive fears” that occur often enough to merit formal names?  I can’t!  Interestingly, the one phobia I see most often does not appear in this list.  Fear of cancer is a horrible phobia, causing pain and suffering often as bad as cancer itself would cause.


Phobias can be painful, crippling disorders.  In April of this year, I published “Cyberchondria” (http://livewellthy.org/2011/04/10/cyberchondia.aspx).  Recently, my articles have focused on empowering/activating patients by providing them with knowledge and medical resources.  Empowering patients with knowledge opens the door to wellness, as well as “Cyberchondria.”  I have to wonder if the internet and its volumes of medical information are also giving rise to the increase in phobias I have seen in the last few years.  If so, how much knowledge is too much knowledge?


How much knowledge is too much is a pivotal question.  I obviously don’t have the answer.  What I know is that you can Google any medical symptom and the search engine will take you to a site that lists cancer as a cause!  Read enough sites that list cancer as a reason for your fatigue, stomach upset, weight loss, or whatever, and you become fertile ground on which to grow an excessive or irrational fear of cancer.


As the intensity of a phobia grows, anxiety and panic kick in.  The physiologic effects of anxiety and panic then feed into the phobia.  Think about it!  Someone points a loaded gun at your head, then cocks the trigger.  What happens?  You begin to sweat.  You get sick to your stomach.  Maybe you vomit or have diarrhea.  You feel faint, weak, like passing out.  In time your stomach acids erupt.  You get a splitting headache.  All of these symptoms occur in the first minutes following the threat to your life.  If the threat persists, the symptoms worsen.


Now imagine you search the web, listing symptoms you are experiencing.  The website tells you that maybe you have cancer.  It figuratively points a loaded gun to your head.  The symptom cascade begins.  You look up the new symptoms, now you know you must have cancer.  You see your doc.


“Doc, I’m afraid I have cancer.”  The doc exams you and informs you that you don’t have cancer.  You are sure he must be wrong.  You want him to run test.  In “You’re Damned If You Do, and Damned If You Don’t” (http://livewellthy.org/2011/06/22/youre-damned-if-you-do-and-damned-if-you-dont.aspx), I explore the problem of doing too much or too little.  When dealing with phobias, doing too much often feeds the phobia.  Each test has a consequence.  Often the consequence is simply shifting the focus from the gut, to the lungs; from the lungs to the brain; form the brain to lymphoma, etc.  Tests sometimes cause side effects.  The side effects feed the phobia.  Tests sometimes have false positives.  They feed the phobia.


It’s the proverbial snowball, running downhill.  How do you stop it?  As a patient, what can you do?  As a doc, what can you do?  The keywords in the definition of phobia are “excessive and irrational.”  As a doc, the answer lies in working to make rational connections and avoid excessive testing.  As a patient, the answer lies in assembling a support team whose members may include the doc, your family, significant others, and a psychologist/psychiatrist skilled in dealing with phobias.  Perhaps cancelling your internet connection may be helpful as well! 


The take home message is there are risks involved in everything we do.  As medicine moves further into the realm of empowered patients and doctor-patient partnerships, we have to be careful to avoid information overload or get really good at treating “Cyberchondria!”

PATIENT ENGAGEMENT/ACTIVATION


October 24, 2011


Sometimes I amaze myself.  Apparently, there is now a name for what I have been doing for the past year:  “Patient Engagement/Activation.”  KevinMd recently published “Physicians should embrace patient engagement” by Dr Ken Bottles (http://www.kevinmd.com/blog/2011/10/physicians-embrace-patient-engagement.html). 


This blog has been my way of engaging/activating patients.  Knowledge is power and providing my patients with the knowledge they need to become active participants in their healthcare has been my goal. 


In Dr. Bottles’ article Jessie Gruman, a cancer survivor is quoted as saying,  “As a savvy and confident patient who is flummoxed by so much of what takes place in health care, I am regularly surprised by how little you know about how little we patients know. You are immersed in the health culture. But we don’t live in your world. So we have no idea what you are talking about much of the time. One way to help us feel competent in such unfamiliar environments is to give us some guidance about what this place is and how it works. What are the rules?”


In August, I published, “I Am A Responsible Patient.” (http://livewellthy.org/2011/08/31/i-am-a-responsible-patient.aspx)  The article outlined “the rules” for my patients, as well as for any of my readers who were interested in taking an active role in their health.  I have published multiple articles over the last year designed to help patients “feel competent in such unfamiliar environments is to give us some guidance about what this place is and how it works.” (Bottles)


According to Dr. Bottles’ article, “The ten categories of the Engagement Behavior Framework are:



  1. Find safe, decent care
  2. Communicate with health care professionals
  3. Organize health care
  4. Pay for health care
  5. Make good treatment decisions
  6. Participate in treatment
  7. Promote health
  8. Get preventive health care
  9. Plan for the end of life
  10. Seek healthcare knowledge.

I agree with each of these 10 principles.  It is critical that, as physicians, we engage and activate our patients.  The article goes on to report, “Recently Klick Pharma invited 19 health care activists from a wide variety of disease states to participate in a conversation about an ePatient Bill of Rights that would support patient engagement and activation. After four hours of conversation, this group reached consensus on the following key messages of such a bill of rights:



  1. Shared access to my data
  2. Attitude of collaboration and overall respect
  3. The patient is the largest stakeholder
  4. Transparency and authenticity across all areas
  5. Voice of the patient is a legitimate (clinical) source
  6. The right to efficient communication with providers who utilize the technology we need”

I think the key remark in this entire conversation is number three, “The patient is the largest stakeholder.”  The patient is the largest stakeholder, the one with the most to win or lose.  In this ever changing world, it is incumbent on the patient to take an ever growing and active role in his/her health. 


Investing the time and effort in “self” is critical.  “Seeking healthcare knowledge” (Bottoms) is time consuming and difficult but well worth the investment. Getting “preventative health care” (Bottoms) is important, but practicing “preventative health care” (Bottom) is more important (Segal). 


What is missing from Dr. Bottles’ article is the importance and key role of the concept of “continuity of care.”  Communicating with your healthcare provider and forming a longstanding, health care team is essentail in optimizing your health.  Long term patient-physician relationships promote trust and trust is the critical factor that allows for “safe, decent care.” (Bottoms)


Dr. Bottles’ article goes on to state, “Experts in patient activation/engagement suggest that hospitals and medical practices provide each patient with a short guide that explains how best to be a patient in that unique setting.”


A “short guide” on “how best to be a patient in that unique setting” does not exist.  There are now 326 articles on this blog and more to come.  Each article hopefully will enable you to be the best patient you can be.

If only there was a “short guide” to being the best doc you can be!

ALCOHOL ABUSE


October 21, 2011


According to an article in MedPageToday, Medicare has decided to pay physicians for performing alcohol and depression screening on Medicare recipients.  This is a good idea and an excellent place for the government to invest its funds.


Depression and alcoholism are major healthcare issues, particularly in the elderly.  Often, both illnesses lead to misery and grave physical, emotional, and financial costs.  Do you have a problem with alcohol?  I have always defined alcoholism not by the number of drinks ingested but, instead, by the consequences of drinking. 


My definition follows this logic:  If drinking alcohol has ever hurt you or a loved one and you continue to drink, you have a problem with alcohol.  If you have had more than one problem caused by drinking alcohol, you are an alcoholic.  Repeating an activity that injures yourself or others is not healthy!  Are you an alcoholic by my criteria?


According to government, “Risky or hazardous drinking, according to the United States Preventive Services Task Force (USPF) is defined as more than seven drinks per week or three drinks per occasion for women and more than 14 drinks per week, or more than four drinks per occasion for men.”  Are you an alcoholic by Medicare’s criteria? 


The article goes on to state:



“CMS will cover annual alcohol screening and for those that screen positive, up to four brief, face-to-face, behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:



According to the article, the “5A’s approach that has been adopted by the USPSTF to describe such services are:



  1. Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise:  Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree:  Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist:  Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange:  Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.”

Medicare’s new approach, paying family docs for what many of us already do, is refreshing!  While this is an excellent start, five sessions is woefully inadequate.  Treating alcohol abuse is a lifetime affair and starts with you asking yourself, “Could I be an alcoholic?”  That question might save your life!  If the answer is maybe, stop drinking.  If you can’t do it on your own, get help:  See your doc!  Join Alcoholics Anonymous.  They have helped many of my patients.

YOU ARE NEVER TOO OLD TO LEARN


October 22, 2011




Renee and I moved to Illinois in 1979 and I began the journey that led me to practicing in Lake Zurich, writing this blog, and publishing my first book.  During the last 32 years, I have been blessed to have several mentors.  Dr Edward Lack taught me the value of mentorship and has been a friend and mentor ever since. 



Today, Dr Lack proved that you are never too old to learn new tricks.  I have always tried to inspire my patients with cancer and fill them with the energy they need to “fight” cancer.  I have always looked at treating a cancer as a war between the good and the bad.  Yes, I knew “acceptance” was a necessary component of living with cancer but I never really understood its importance until I read Dr Lack’s article today. 



In “You didn’t choose to get cancer. You can choose to fight cancer… NOT” (http://blog.metropolitanmds.com/), Dr Lack begins by quoting a sign he recently saw.  “You didn’t choose to get cancer. You can choose to fight cancer”.  He then proceeds to dismantle and rearrange the sign as only he can.  His take home message is a powerful one. 


 


In reference to having cancer, Dr Lack writes, “This is a wake-up call. The needed emotion is acceptance.  Acceptance and not fighting.  Acceptance that this is a part of life. Some of us celebrate remission. Some of us celebrate life and sharing and companions and love for some precious and measured time.”  He goes on to say, “Cancer is not a death sentence. Cancer is a life sentence. It is a time of awareness and an ability to plan how we shall spend the balance of our lives and with whom.”



My dear friend and mentor has a unique perspective, being a cancer survivor himself.  He has made me reassess my approach to a very difficult disease.  Dr. Lack is right:  acceptance is what is necessary to live with cancer. 



I look forward to many more years with Dr Lack at my side, sharing his wisdom, his friendship, and his life.