Wednesday, February 29, 2012

Drugs, Pharmacology, and Humans, Part I

     Many patients do not fully understand the purpose of medication, and fall into the false belief that the less medicine they take, the less sick they are. While it certainly is  true that the patient who takes no medicine is fundamentally healthier than the patient who takes medicine, in some cases the patient who takes medicine (e.g. statins to lower cholesterol) may end up being healthier (have less chance of a heart attack) than the patient who takes none. The purpose of most medications  is  to try to return the patient to the "normal" state, i.e. one in which a doctor's attention is not needed. I will discuss several classes of medicines in this blog.

     I first want to emphasize the fact that not all side-effects are dose-dependent. Therefore any medicine you take can cause side effects without benefits if the dose is too low. Thus unless you take the full dose of the medicine as prescribed by your doctor, you are exposing yourself to possible side effects without getting the full benefit of the medicine. I have seen patients try to self-taper asthma, diabetes and blood pressure medicines, always without any benefit to them.

     Generics usually work as well as brand-name medicines, with the notable exception of any medicine that acts on the CNS system---i.e. the brain (and the spinal cord). This is because there is a natural blood-brain barrier that prevents many drugs from diffusing from the blood stream across the capillary wall and into the brain cells. Most notably, I have found that generic Prozac, generic Wellbutrin, and especially generic Ativan do not always have the same effect as does the brand name drug.

     Many patients ask "How do I know that we will not find out 20 years down the road that the medicine you are prescribing will not be found to have dangerous side effects?" Of course they never ask this question about the sweetener in diet sodas, the chemicals in herb tea, the various vitamins and pills they buy in a health food store, etc. In fact virtually no food that we ingest has been examined for long-term effects with two notable exceptions: alcohol in any form can reduce your risk of a heart attack, and although reducing the amount of salt in your daily diet can lower your blood pressure, this dietary intervention has  NOT been shown to  reduce your risk of a heart attack or to  increase your life span.

     Blood pressure medicine: Like diabetes, high blood pressure can be a "silent killer". The most destructive result of untreated hypertension is a stroke, which often leads to either death or permanent paralysis of a limb or one side of the body, along with the loss of speech, etc. And we know from clinical trials that treating high blood pressure with drugs can greatly lower your risk of having a stroke. We have no way of predicting which  bodily organ the high blood pressure will affect. If untreated it can cause ministrokes, heart failure, kidney failure, and /or damage to your vision. Just as a low salt diet can lower pressure, a diuretic ("water pill") is and should generally be the first line of treatment for this disease. A diuretic increases the amount of salt excreted in your urine, and thereby lowers the total amount of salt in your body. If it is not the first medicine you are given, it should be the second, as an added treatment, because lowering the amount of salt in your body potentiates the anti-hypertensive effect of all other classes of blood pressure-lowering medicines. The other medicines used to treat hypertension are beta-blockers, calcium channel blockers, ACE inhibitors, ARB's, other vasodilators, and anti-renin drugs.

     The choice of a second anti-hypertensive drug if a diuretic alone does not achieve a low enough blood pressure depends on the type of individual as well as his/her underlying medical conditions and medications that are already being taken. Male, female, black, white, old, young, heart failure, asthma, COPD, GERD, smoker, chronic edema, are all some of the factors that will affect the choice of a second anti-hypertensive. I would also like to state that for reasons that we do not understand, black males are the most likely to suffer a stroke from untreated hypertension, and therefore blood pressure must be treated aggressively and closely monitored in this group.

Statins and the FDA

     In a blog I published in 2009 I discussed the pros and cons of statins. I have received many calls from people on statins wanting to know if they should stop taking them. Let me review with you exactly what the FDA has advised, what I have told people, and my own views on the subject.

     Again we begin with the fact that cholesterol is a constituent of EVERY ANIMAL CELL MEMBRANE. (One way in which vegetable cells differ from animal cells is that while both types of cell have a membrane bounding the cell, only vegetable cells have a cell wall around the cell membrane, which accounts for the resistance of vegetable cells to dessication, and also provides roughage for people who eat it.) Since the behavior of each and every cell in your body is partly governed by the flux of ions and other molecules across it, it immediately follows that a change in the %of cholesterol in a cell membrane must alter this trans-membrane flux.)

     One group of cells that is highly sensitive to trans-membrane fluxes are the muscle cells, which respond to a chemical secreted by the nerves that innervate the muscles. Any change in the cholesterol concentration will alter the ionic flow induced by these chemicals, and make the muscles more or less sensitive to stimulation by the nerve. The most common effect I have seen with my patients on statins has been vague muscle aches, with occasional awakening by severely painful muscle cramps. We therefore deduce that striated muscle cells are made more sensitive. Often I have been able to minimize  this problem by cutting the statin dose in half (e.g. 10 mg of Lipitor, not 20) or changing to a different statin (Crestor 5mg in place of Lipitor 10). It has been my impression that Crestor causes the fewest muscle aches and cramps. Sometimes these muscle symptoms are accompanied by an increase in a specific muscle enzyme in the bloodstream (the MM component of CPK) in which case it is mandatory to stop the statin, lest the patient suffer acute renal failure secondary to myoglobinuria.

     We also have smooth (involuntary) muscle, under control of the autonomic nervous system, and a syncytium of muscle making up the walls of the heart.I have not heard of either of these two muscle systems being affected by statins.

     Although the initial warnings of side effects by statins included elevation of liver enzymes, I have never seen this happen to any of my patients. Whether or not statins are safe in patients whose liver enzymes are already elevated is an unanswered question. The FDA has now stated that liver enzymes do not have to be monitored periodically.

     The elevations in sugar appear to be minor, and since I get a cholesterol and chemistry panel every three months in my patients on statins, I would find this problem and I never had.

     I have been aware since I started prescribing statins that some patients taking this medicine have difficulties doing the NY Times x-word puzzle with the same facility they had previously. Upon questioning, they also report difficulty having sustained concentration, or reading for long periods of time. Again, reducinmg the statin dosage or changing to an equipotent dose of a different statin would solve the problem.

     Since the biggest risk for having a heart attack lies in those who have already suffered one, no one who has had a heart attack (or  unstable angina, or other conditions which your cardiologist deems to pose a significant risk) none of these patients should ever stop their statins.


Sunday, February 26, 2012

Nutrition and other Thoughts on Medicine

     From time to time I have had certain thoughts about the practice of medicine as well as what patients have been told by their doctor, or by advertisements, or by TV "talking heads". Some of the thoughts are summarized below. Please remember that due to my training in and work in physics, I cannot accept any statement about medical treatment unless it has been substantiated by at least one clinical trial. Often medical treatments or suggestions are inferred and never tested. As a writer once remarked: "Just because roses smell sweeter than cabbages do, it does not follow that rose soup tastes better than cabbage soup, or that rose soup is healthier".

     Let me first re-iterate an important point about all studies of human diets and their conclusions: A laboratory white rat reproduces every 30 days, so in six months I can study six generations of rats, and develop a pretty good idea of foods that are beneficial for or harmful to them. Humans reproduce every 25 years, and the longest forward interventional study was a five year study of approximately 5,000 American women, or a study that just looked at 20% of the human reproductive time. We have absolutely no good interventional studies in humans, i.e. where  we have a study group and a control group and the diet of the first group is artificially controlled.

     What we do have is a lot of epidemiological, retrospective studies, comparing groups of humans on one diet with those on a different diet. Coincidence and correlation are not the same as CAUSATION, and the results suggested by a statistical analysis of human diets should be treated as hypothetical, to then be verified by a proper single or double blind study that goes forward in time. In an earlier blog I have mentioned some of the statistical problems that arise when we do such comparisons.

     I am constantly astounded at the number of different vitamins and "health" foods my patients ingest. They all assume that if a little is good, then a lot is better, and that no "health food" could possibly be dangerous. I will tell you here and now that almost no health food has been tested on humans with a view for looking for dangerous side effects, probably because it is not in the manufacturer's best interests to do so. For instance it is widely assumed that milk thistle is protective of the liver,  but I know of no study that looked to  see if milk thistle can damage the liver or elevate liver blood tests.

     Except for the fat-soluble vitamins A,D,E, and K, if you ingest more of a vitamin that the body needs, then it is excreted (usually unchanged) in your urine. The B-complex vitamins cause the urine to look deep yellow or gold, so now we know why the book was titled "The Golden Stream". (For those of you who lever learned this joke in elementary school, the author of the book is I. P. Daly.) A curious fact is that penicillin is excreted almost 100% unchanged  in the urine. When it was first introduced, supplies were scarce, so the urine of any patient given penicillin was collected, and the penicillin re-crystalliazed from the urine to give to the next patient. So the members of the richest country in the world have the richest urine in the world.

     I think that it is healthy to be at ideal body weight (whatever that is) and to take a vitamin a day to prevent any deficiencies  that may develop as well as 1 mg/day of Vitamin B12 and400 Units /day of Vitamin D.
One should also remember that it is easier to achieve a balanced (i.e. contains the eight amino acids and three fatty acids as well as all the vitamins  that the body cannot manufacture for itself) diet with a meat diet that a vegetarian diet.There is no evidence to show if it is healthier to eat one, two, three or many meals a day, and whether or not all meals should have an equal calorie content. Or if the Spaniards are healthier or not because they start their largest meal at 10PM. When we look at long-lived octogenarian (age 80 +) people around the world, they have widely varying diets, because your diet is largely a function of where you live: north Africans eat more orzo than we do, the Far Easterners eat more rice, and people more than 500 miles from a lake or ocean eat very little fish. BTW, there is no evidence that a daily children;'s aspirin (81mg) is beneficial for the average patient with no chronic diseases.

     Every study shows that moderate drinkers live longer and have fewer heart attacks than non-drinkers. I have seen studies with scotch, wine, beer, brandy, etc. Our government has accepted this fact half-heartedly: They say that if you are a moderate drinker, please continue, but if you do not drink, don't start. Huh? If doing something is beneficial for your health don't start doing it? Also I have seen at least two studies showing that the consumption of a glass of wine or its equivqalent on a daily basis for a pregnant woman does not cause any damage to the fetus.

     Your parents may have told you that swallowing watermelon seeds or chewing gum is dangerous to your health, or not to swim right after eating, or to drink eight glasses of fluid a day----all bushwah.

     Do you recall the food pyramid you learned about in school up to about the year 2000? The pyramid has now been inverted by nutritionists, and the foods at the top, of which you were supposed to eat only once a day, you now should eat frequently (!?) And there is no mention of two key food groups: caffeinated coffee, especially in the morning, and (dark?) chocolate. Who among us could eat just one Mallomar after opening the double box? I have been reliably informed that in Ohio a giant Mallomar is sold without the cookie crust on the bottom, and is called a "Chocolate Whip".

     If you leave the table before you are completely full, avoid white potatoes (including French fries) because they are the most glycemic food of all, and remember that ALL white bread is useless calories (exception made for dipping French bread into bouillabaise), you should be able to lose weight easily.

     "I can resist anything except temptation"----Oscar Wilde

     "I wish I had drunk more champagne----Jackie Kennedy on her deathbed.




Saturday, February 25, 2012

Cancer Part I

     This blog is not a general review of cancers, but rather simple facts about all cancers in general. I was motivated to write this blog as a result of my volunteer work with Gilda's Club of Northern New Jersey. It really is true that only a person who has cancer can really understand and relate to another person who has or had cancer. There still are a lot of untrue beliefs floating around, and this blog is an attempt to correct some of them.

     First, the only trustworthy site is WWW.NATIONAL CANCER INSTITUTE.GOV.  This is the only totally unbiased reference available on the internet. It lists all the cancers by organ, and then breaks the organ cancer down into subtypes (e.g. nodal non-Hodgkins lymphoma). It lists the standard treatment, secondary treatments, etc. and also refers to a site where you can find a list of clinical trials. Any website published by a hospital or any other institution is biased by institutional philosophy----e.g. the  chairman of the Urology Dept. at John Hopkins published a book about the virtues of using surgery to treat prostate cancer, so if they have a patients' website, you might see some bias. But the NCI has no such axe to grind.

     Second, all doctors want to heal their patients. There are really NO SECRETS in medicine. In these days of Oprah, etc., if a doctor had a new cure for cancer, he/she would scream it from the rooftops, get on Oprah and Jay Leno, be on talk shows, etc. We all want to cure all our patients, and we are constantly seeking new treatments via journal article, conferences, etc. (And The National Enquirer is not now and never will be a refereed medical journal.)

     Each major hospital has a weekly conference open to all its oncologists and other interested physicians. In a large city, there are monthly cancer conferences to which all hospitals send a doctor-delegate. Finally there are quarterly divisional meetings as well as annual conferences on cancer to which all doctors are invited. We also have publications by the Mayo Clinic, etc., which are distributed to all interested doctors. So again, there are no secrets about treating cancer. If a doctor had a new method, he/she would publicize it so as to become famous as well as rich.

     The only people who really can  judge a physician's brains and abilities are the residents who work with him/her especially if they have operated with the surgeon in question. No one else, including your next door neighbor, your best friend, and your aunt Sally know anything about the doctor in question. When I was a medical resident at Columbia , I asked all the surgical residents who the best general surgeons, breast surgeons, vascular surgeons, gynecologists, oncologists, chest surgeons, heart surgeons, orthopedic surgeons, neuro surgeons, urological surgeons, etc. were, and I referred my patients only to those surgeons. In fact, I convinced my older partner to switch away from the surgeon to whom he usually referred his patients.

     The most certain method of treating/eliminating cancer is to surgically remove the mass before it has metastacized. This means taking out the tumor en bloc, with a good margin (i.e. non-cancerous tissue)  around it. The surgeon will generally also remove or sample nearby lymph notes to look for local spread. This is why it is so difficult to treat brain, pancreatic, or ovarian cancer. Note: I said difficult, not impossible. As a rule, it is difficult to get a good margin around a brain tumor because the tumor has spread its tentacles (like a "crab"  aka "cancer" in stellar constellations) into vital tissues that control memory or the contraction of muscles.And unlike most organs, neither the ovary nor the pancreas is surrounded by a protective sheath, as is the colon, or the liver, so these two cancers spread locally very easily, although as a rule they are detected while they are still contained within the abdominal cavity.

     Surgery is often followed by radiation therapy and/or chemotherapy. The idea is to get any few cells that have escaped (micro-metastases) beyond the organ before the surgery. Of course with any cancer based in the bone marrow such as the leukemias, the lymphomas and the myelomas, surgery is usually of no use. All these treatments rest on the same principles: cancer cells have a higher metabolic rate and multiply faster than nearby normal cells in the same organ. We have known for almost 100 years that cancer cells have a higher metabolic rate; this was determined by showing that they utilize oxygen at a higher rate that normal cells. This is also the basis for the PET scan, which replaces oxygen-16 with radioactive oxygen-17 in a sugar molecule, and determining which cells absorb and use this sugar the fastest.

     All radiation and chemotherapy modes (with a few exceptions, such as we have with l-asparaginase in one type of leukemia, or the use of monoclomal antibodies to kill other cancers) can kill all cells, and our  hope is that the more rapidly dividing cancer cells will be killed faster than normal tissue. This is why treatment schedules are carefully monitored as to dosage (mg/kg), time, and frequency. You want the normal tissue to be able to recover between treatments.

     I have barely scratched the surface of this topic, and have deliberately omitted discussion of the role of your immune system in controlling or killing cancer and cancer cells, because then the blog would have been much too long.


Monday, February 20, 2012

Medical Sayings

     Over the years, many doctors have heard many aphorisms. The good ones stick with you. I have listed some of them below. And please remember that jokes about medicine are probably part of a doctor's defense mechanism which helps him/her to deal with death on a daily basis.

1) You can always spot a radiologist at a medical convention---they're the ones who glow in the dark.

2) (in answer to a question about a patient): TTT, which means Tough To Tell

3) To hide something from a surgeon, write it in the chart. To hide something from an internist, put a bandage over it.

4) There are only two acceptable reasons for not doing a rectal (a) no rectum, and (b) no finger.

5) Internists know everything but do nothing , surgeons know nothing but do everything , and pathologists know everything and do everything, but by then it's too late to benefit the patient.

6) All Indians walk in a single file---at least the one I saw did.

7) When you hear hoofbeats in Central Part (NYC) don't look for zebras. (We have mounted police.)

8) Neurotics build castles in the air, psychotics live in them, and psychiatrists collect the rent.

9) When two psychiatrists walk past one another, each says "You're fine. How am I?".

10) Most patients get better with time.

11) If you see your doctor for a head cold, he/she  will cure you in seven days. If you don't see your doctor, your cold will last a whole week.

12) Don't waste the patient's time by telling him/her your personal problems.

13) (especially for busy interns): Sleep when you can, go to the bathroom when you can, and eat only when you have the time.

14) NEVER diagnose cancer until the cancer cells are seen by the microscope.

15) When taking a patient's history, double the amount of alcohol and cigarette usage reported, and divide by half the reported frequency of sex and exercise.

16) Always do a pregnancy test on any patient admitted to the hospital, or who presents to the ER.

17) Trust in the Lord, but keep on swimming towards the shore.

18) Doctors prescribe, but God heals.

19) Always try Lithium on any psychotic patient, even if the patient seems schizophrenic.

20) The biggest sin in medicine is to make the same mistake twice.

21) In med school and in the hospital: See one, do one, teach one.

22) Never be the first patient to undergo a new procedure.

23) (from an anesthesiologist) It's easy to put a person to sleep. The challenge is to awaken him/her up  in the same condition.

24) Beware of the patient who comes to the ER with a small suit case that contains toiletries and a second set of underwear.

25) When one doctor tells another to "get a porcelain level" on a patient, he/she is conveying the message that the patient is a "crock".

Thursday, February 16, 2012

What Makes Doctors Angry

     All doctors get angry/frustrated/exasperated about the  things we have to do that take us away from the practice of medicine. I have read and heard many of their complaints in my various capacities, and I am listing a few of them. The complaints deal with the states, the federal government, and of course the patients.

1) The patient who asks you to renew a prescription, but doesn't know the pharmacy phone number.

2) The patient on vacation who forgot his/her medicine, and has the local pharmacy number, but doesn't know the dosage or frequency of the medicine (and sometimes not even the name, just the "blood pressure medicine").

3) The patient who calls up with an anxiety attack, but can't come in right now to be seen because he/she has an important appointment.

4) The spouse who asks you to convince the patient to do something you know full well the patient has refused to do.

5) The spouse who asks you to call him/her on the telephone and keep the line open so it acts as an intercom and the spouse at home can see if the spouse in the office is telling the "truth".

6) The patient who comes into your office with the printed cure for his/her disease cut out of  the National Enquirer.

7) The patient who skips his/her blood pressure medicine for 24 hours before your appointment and then triumphantly announces this fact after the blood pressure has been found to be normal: "You see, I really didn't need the medicine". Then you have to try to explain the concept of the half-life of a drug, and how if the drug is taken every 24 hours, there is still at least half-strength left in the bloodstream.

8) Doctors are not supposed to treat their family, because of possible emotional interactions, but the state gives the children the power of "pulling the plug" on a comatose parent---terribly cruel for the children.

9) Arguing with an HMO that you know that their preferred drug (i.e. cheapest for them) for suppressing stomach acid is Prevacid, but only Aciphex works on this particular patient.

10) Trying to explain to an HMO that in this particular patient generic Ativan does not work, and only the brand name does.

11) Trying to explain to an HMO that although the allowed (i.e.paid for by them)  dose of a medicine is 40 mg/day, your patient needs 80 mg/day to control symptoms.

12) Trying to understand why all HMO's will only pay for 8 Viagra/Levitra/Cialis a month. I guess they figure that no married couple should have intercourse more often that once every 3 to 4 days. I always ask the HMO rep  how often he/she has  sex, just for the heck of it.

13) How Medicare can review 10 office charts at random, decide that you overbilled (i.e. your notes did not justify a fee of $75.06, but only $53.45) on 2 of the charts, and therefore you have to refund (2/10) or 20% of ALL the Medicare fees you received in the past 12 months, or allow them to do a chart by chart audit of all the visits by Medicare patients in the past 12 months, with you there to answer their questions.

14) How Medicare part D suddenly decided they would pay only for generic drugs, and not brand name, unless the doctor can convince them to make an exception for this particular patient. (Lots of luck with this one!)

15) How you have to call a central number to get permission for certain Xray studies such as CT scans and MRI's on HMO patients, and sometimes they insist on speaking with me rather than my secretary.

16) The fact that in  a one-man office I should need only two staff: a receptionist and a lab tech/chaperone. But I have a third employee who does nothing but call HMOs all day long for various permissions.

17)  The fact that most HMOs only allow a 30-day supply of medicine to be dispensed, so if a patient is going on vacation someone has to call up for authorization for a 60-day supply.

18) The fact that Medicare annually threatens to balance its budget by cutting fees by 23% to primary care doctors. The government always relents at the last minute (does anyone out there remember the TWU president in NYC, Mike Quill, threaten a midnight New Year's Eve strike of subway motormen?) but this pattern is not a way to generate enthusiasm for a primary care practice in medical students.

19) The spouse who not only comes into the consultation room, but also into the examination room, so as to hear anything the patient says to me.

20) The spouse who calls up to ask: did you tell my spouse "........" and you have to reply that that answer is confidential.

Monday, February 13, 2012

Emergency Room: Use and Misuse and Cost

     Not enough people realize how expensive it is to society when a sick patient uses the Emergency Room rather than going to his/her private physician, or even a local UrgiCare Center (otherwise known as " Doc-in-a-Box"). There was an article a few months ago in "Archives of Internal Medicine" that demonstrated the cost of a visit to the ER by a patient complaining of dizziness: $20,000 for all the tests and consults. But if you called your family doctor and saw him/her with the same complaint, the cost would be much, much less.

     The problem is that to the ER doctor and staff, you are an unknown person with an unknown medical history both recent and remote. And they will not quite trust either your memory or the computer history (EMR). If the record indicates that an echocardiogram showed mitral regurgitation, then they will want to repeat it to inspect the results themselves.  They also have to ask themselves, in addition to diagnosing and treating you, what tests they can do to avoid being sued in case you turn out to be a "zebra".

     Let me explain the above terms and concepts. First of all, unlike your family doctor, they cannot tell you to call them tomorrow or go to the ER if you are not feeling better. Secondly, although common diseases occur commonly, they can present with weird symptoms. (For instance, a female in her 20's with malaise, a diffuse maculopapular rash and wrist arthralgias has Hepatitis B until proven otherwise.) We tell our medical students "If you hear hoofbeats in Central Park (in NYC) don't look for a zebra". But if you die from a zebra, and it is within the differential diagnosis of your complaint(s), then the ER, the doctors and the hospital will all be sued, even if Osler himself would have not made the diagnosis.

     Insofar as Xrays are concerned, I know which of my referral radiology groups overread or underread xrays and CT scans and MRI's because I always review the radiological studies with the radiologist before I go home or see the patient in the hospital. The ER doctors have no way of knowing if the report was written by an over-reader or an under-reader. Now that we have color-Doppler echocardiograms, EVERYone's echocardiogram shows at least trace mitral regurgitation, delimited by a backwards color jet, but this is a simple matter of fluid dynamics because everyone's mitral valve takes a finite time to close and some blood has to back-flow. So how much backflow do you need before the "trace' becomes "minimal and therefore clinically significant?5%, 10%? Pick a number? Or do you have to hear the flow as well? But then women with less chest muscle than men would have an increased "incidence" of mitral regurgitation because they would have less distance across the chest wall between their mitral valves and the stethoscope.

     The ER has to function (a) to ask themselves what disease or process you could have that could kill you if they do not make the diagnosis, (b) what tests and consults they need to order to avoid a possible malpractice suit, and (c) how can they best ensure your compliance with whatever follow-ups they suggest and prescriptions they order, also realizing that they can be sued (successfully) if you do not follow their suggestions and something happens to you. I should add that (a) is what I tell my medical housestaff when I am ward attending, viz: if the patient is alive when I arrive at 8AM to start my morning rounds, they have done their job.

     Part of the ER's problem in dealing with uninsured patients (for which the state is supposed to reimburse them but that is another story) is that it is very difficult to arrange for an outpatient follow-up if the patient has no insurance. No doctor  will agree to see such a patient, and very few clinics will. Teaching hospitals generally have a medical clinic where indigents and uninsured patients will get the proper follow-up and care, but teaching hospitals are re-imbursed at a higher rate by both the federal and state governments than are smaller regional hospitals.

     I guess I am led to the conclusion that some sort of nationwide health care system where everyone within our borders has a family physician  would DEcrease the annual cost of health care. I still remember when I was a JAR (junior resident) in the ER. Part of our duties was to help the medical intern manage and treat DKA, diabetic ketoacidosis, a serious condition that often affects insulin-dependent diabetics, and can be fatal. My fellow resident had gone to medical school and interned at McGill University, a fine institution. But she had NEVER seen a case of DKA in the ER. We later mutually realized that since Canada has nationwide medical insurance run by the provinces, and each Canadian has a family physician, no diabetic ever gets so far out of control that he/she "crashes" in the ER with DKA. The flip side, as I have mentioned in an earlier blog, is that the number of surgeries in a given hospital is rationed: e.g. a given hospital may be allotted 100 open heart surgeries, 300 gall bladder removals and 200 hip replacements per month. If your doctor admits to that hospital, you go on the waiting list. Last I heard, the wait for elective hip replacement in England was over two years (!) So Canada spends more than we do per capita on primary care and less on surgery.

     So all countries ration medical care by time, or by money or by availability. For instance if Columbia-Presbyterian Medical Center wants to install another echocardiogram machine, they need permission from NY State. The reason given is that some Medicaid patients may end up being examined by that machine, and the state pays a certain % of every bill to Medicaid, so the fewer echocardiogram machines that a hospital has, the less the state has to pay annually for echocardiograms.

     "Whatever they are talking about, they are always talking about money."


Sunday, February 5, 2012

Poor Medical Care in Hospitals

     I recently was hospitalized on a non-medical floor for a procedure at a hospital which is directly affiliated with a major teaching hospital. I can only say that the nurses are wonderful, the medical support staff poorly trained, and the medical consults on my ward no more than casual and somewhat rude and impersonal. What I observed also further deepened my belief that hospital computer systems waste a lot of the doctors' and nurses' time, especially the time of the nurse who dispenses medications. I will just list the examples of poor medical care that I received, with additional comments for those of you who are not doctors.

1)  You should NEVER listen to the patient's heart and lungs through his/her hospital gown. The gown is an additional sound filter and the amount of sound that reaches the doctor's stethoscope is reduced. It is somewhat akin to driving at night wearing sunglasses. A faint I/VI murmur would  never be heard through a gown.

2) The patient's heart should be listened to in three different positions: sitting erect, supine, and then with the patient rolled over into the left lateral position. The latter position is sometimes the only position  in which the examiner can hear a faint S3 gallop, which sound is almost always indicative of heart failure.

3) You should never take the blood pressure through the patient's shirt. You will invariably get a falsely high systolic and diastolic pressure.

4) The digital BP machine that is so ubiquitous (because  anyone can use it) is set to read falsely high: typically 10 mm systolic and 5mm diastolic. Also, the proper method to measure the systolic pressure is to palpate the ipsilateral radial pulse as you manually pump up the sphygmomanometer: the systolic pressure is the pressure at which the pulse vanishes. This is even more accurate than listening with  the stethoscope.

5) If a patient has borderline or true hypertension, you must measure the BP in BOTH arms, because the two arms always have different pressures, and you want your treatment to be guided by the higher of the
two pressures. This occurs because the heart is situated in the left chest, so that  the path of blood and therefore the path of transmitted blood pressure is longer to the right arm than to the left.

6) The consulting internist never asked me when my last complete physical was, or did a rectal exam (forget about prostate cancer---you don't want to miss rectal cancer, which is both treatable and potentially fatal). He only listened to my heart sitting up. He did not palpate for a thyroid nodule, or listen to the carotid and femoral arteries for bruits, or palpate for my tibialis and dorsalis pulses. He checked one ankle for edema, but not both. He didn't even have the common courtesy to leave me one of his business cards, so I could call him if I had any questions.

7) He made several changes in the medicines I was taking. He NEVER told me that he was making these changes, so of course he never explained the reasoning behind the changes. I never miss a chance to educate my patients, and it is rude and counterproductive not to discuss the medication  changes with the patient.

8) Because I take a water pill to reduce my blood pressure, I also take a daily supplement pill of potassium chloride, since diuretics (water pills) accelerate the loss of potassium in the urine. He canceled my potassium, telling me that my potassium was normal when I questioned him. Duh----of course it was normal because I was taking supplemental potassium. He told me not to worry because they would check the potassium blood level in three days. This is just very bad medicine, and at the very least he should have discussed the planned change with my family doctor.

9) He ordered a chest Xray. This is just plain bad medicine, and would have exposed me to the increased cancer risk that any Xray does. The guidelines are very clear that if  any heart disease or lung symptoms exist as determined by examination or history a CXR is indicated, but in the absence of any such symptoms or findings, all the medical societies and groups strongly recommend that a chest xray NOT be done routinely. Perhaps the hospital just wanted to make some extra money.

10) An admission EKG, or electrocardiogram, was taken. A new medicine was added when I developed a complication from the procedure. I happen to know this medicine has a FDA mandated warning that the medicine could cause cardiac conduction problems, but a follow-up EKG to look for the development of a cardiac problem was never done.

11) And of course a PPD (skin test for tuberculosis) was never given, nor did I receive the pneumonia vaccine booster that I told them I was due to get.