A blog is not a doctor...

Nothing on this page is meant to substitute for getting the advice of a doctor who knows you and is familiar with your medical history. If you reside in California and wish to be a patient in my advice practice, please go to http://www.myadvicedr.com and click for your free initial consultation.

Search This Blog

Monday, April 26, 2010

Genital herpes

The Centers for Disease Control reported in its MMWR publication based on the 2005-2008 N-HANES (National Health and Nutrition Examination Survey) that 16% of 14-49 year olds have genital herpes. The prevalence among teenagers 14-19 was 1.4% (95% confidence interval 1-2%), 2.1% among females and 0.8% among males. The prevalence rises with each decade. Among 20-29 year olds, the prevalence is 10.5%, among 30-39 year olds 19.6%, and among 40-49 year olds 26.1%. The rising prevalence among those in their 30s and 40s indicates a similar proportion of people who begin negative who continue to be sexually active. Presumably, these rising prevalences reflect continuing acquisition of new sexual partners in these age groups in our society, whether through serial monogamy, divorce, or multiple partners(the breakdown by these interesting categories of single, married and divorced are not reported in the MMWR).

Take home messages: Both lower numbers of sexual partners and condom use limit the spread of genital herpes and your risk of acquiring it. Keep it zipped, say no or use a condom.

Sunday, April 18, 2010

Tuesday, April 13, 2010

Costs A Lot and Not Worth the Price

My last post was called "It don't cost nothing and it's worth the price." The EMR (electronic medical record) industry is quite another matter, an example of where most things cost a lot and are worth much less. I must exempt Amazing Charts, the $999 little guy, which is an incredible value. I tried it and considering the cost, it was good despite some limitations. But the other EMRs, some of which I've worked with in previous settings, have limitations too, and they cost much, much more.

As pointed out by the owner of Amazing Charts, Dr. Jon Bertman, on his own blog and on the Amazing Charts website, the availability of federal ARRA (American Recovery and Reinvestment Act) stimulus money has corrupted the EMR marketplace such that EMR vendors are trying to get their product to cost exactly as much as the maximum amount that physicians can get from the federal government to support the installation of an EMR. As he pointed out astutely in his blog, some conflicts of interest are at work related to connections between the Obama administration's advisors and EMR vendors. All this frantic activity with hundreds of vendors and investors in the vendors trying to sell over-priced record systems to physicians makes me glad that I don't take Medicare. I'd rather just practice medicine. Medicare and insurers generally don't pay for what I provide, that is, in depth, extensive, thoughtful internal medicine consultations and research about your medical condition.

As readers of this blog already know, I believe in the patient-centered model of medical record keeping, with patients having their own personal health records, (PHRs) to which providers such as doctor's offices and hospitals have portals and upload data about the patient. This achieves true "interoperability" (fancy word for doctors' records talking to each other and to other health care facilities), with the patient as the hub. Therefore, my main concern with an EMR is that it easily upload electronic data to a patient's personal health record. I'm waiting for Peoplechart (the PHR I recommend to many of my patients because of the availability of staff to help with the inputting of and indexing of the data), or Google Health, or Microsoft Vault, to create a physician EMR, that speaks easily to their PHRs as well as to other EMRs. I've been trying to get an EMR vendor to collaborate with a PHR vendor to do this, but so far there hasn't been any incentive for them to do so.

Monday, April 12, 2010


As a visiting doctor, watching the decline of people sent to nursing homes is painful. So often their behavior becomes an issue, resulting in the prescription of sedatives, which starts a spiral of decline. While such behavior problems are often attributed by nursing home staff to dementia, I have also seen behavioral problems among people who were not demented in the hospital prior to coming into a care facility, even when much sicker in the hospital.

While agitated behavior is often attributed to dementia, worsened by an unfamiliar environment, there are other causes in rehabilitation facilities and nursing homes. Often patients are relatively neglected compared to their prior home environment as well as the prior hospital environment. They cannot go to the bathroom alone, and need help with many things they want to do. Sometimes they do not have a means to call for help. However, when they do, staff cannot be everywhere at the same time, so even in the best of care facilities, people may feel neglected. No one likes neglect, so agitation or screaming can result. The feeling of completely social powerlessness leads to intense frustration which has little other outlet. Family members often notice that when they are present and responding to the person, the screaming or agitation stops. Intermittent positive reinforcement occurs, which results in the behavior becoming habitual.

Unfortunately, sedating people to manage their behavior has further terrible effects. Through being insufficiently helped to get up and exercise, and not being helped to the bathroom in a timely way, they lose continence, develop bedsores, and become weak through muscle atrophy. Excessive sedation also means they lose interest in their rehabilitation activities and are less aware of when they need to go to the bathroom etc, thus deteriorating even further. Delirium and confusion can be other consequences of too many drugs acting on the brain, especially in the frail elderly. This leads to more agitation and screaming, which leads to more drugs. Watching this can turn depressing quickly.

Staff requests for medications are understandable because screaming and agitated behavior can create a horrible environment for both staff and other residents.

The real solution lies in increased staffing and responsiveness by nursing home staff. Unfortunately, our society has not figured out how to care well for our elders. All of us should hope for the sake of our own lives to come, that the future will see a greater investment in making our elders comfortable instead of weakening them with under-staffing and over-sedation.

Home care is not feasible because most people are simply unable to care for a family member 24 hours in their homes, and cannot afford full time home care. This leaves working family members, those who find nursing very difficult, such as those too frail to lift a person, little choice but to put their loved one in a nursing home in such a situation. Family members find this decision extremely painful, and it signals an important turning point of decline.

Our society has a great need for better solutions for elder care. Your comments are welcome.

Thursday, April 8, 2010

It don't cost nothing and it's worth the price

The title of this post comes from an immortal Alan Sherman song, referring to good advice. I couldn't agree more. Some people think that they will save money on doctor bills if they ask medical questions in the course of casual social encounters. In this area, unfortunately, I believe that you get what you pay for. Be prepared to pay for the level of advice you want. If you are interested in a careful and informed opinion about what you should do for your best health, including taking supplements and vitamins, over the counter medications, prescription medications, surgery, or any other type of medical intervention, a good answer will come from careful review of your records, taking a complete history from you, reviewing your medications carefully, and in some cases, a physical exam.

A possible exception to this is if your question is purely informational, such as "what is a Roux-en-Y procedure?", or "what is peritoneal dialysis?" Even then, you are unlikely to understand and remember the answer by hearing it quickly in a place where visuals cannot be shared and you cannot write down the answer.

So, why not let your doctor friends and relatives enjoy themselves at that cocktail party? Instead, if you live in California, come get advice from me! (see www.MyAdviceDr.com) Your primary care practitioner can also do this, if you have one you trust and who is not always rushing to see the next patient. This will allow the appropriate record review, interview, and physical examination to occur if needed based on your question.

Friday, April 2, 2010

Dark chocolate benefits

A study by Dr. Brian Buijsee of the German Institute of Human Nutrition in Nuthetal, Germany, has been published in the European Heart Journal, March 31, 2010. It claims to demonstrate that chocolate consumption lowers cardiovascular risk. The study examined data apparently collected for the purpose of understanding cancer risk, and the investigators analyzed the relationship of chocolate consumption and cardiovascular risk. (Such "secondary analysis" studies analyze things the study was not originally designed to address, and interpreting them is often problematic.) The study shows that those in the highest quartile of chocolate consumption had lower blood pressures and lower stroke and heart attack risk. I loved the headlines this study generated, almost to the extent that I don't want to read it because I don't want anything destroy my hope that chocolate is really, really good for you, and observational studies always have flaws. OK, I said "almost".

Sadly, even from the news reports, I have realized already that this study cannot be used to justify what I would consider a satisfying amount of chocolate consumption, per day, such as 4 oz of the dark chocolate bar sitting in my drawer right now. According to Heartwire, "those who ate the most chocolate--around 7.5 g per day--had a 39% lower risk of MI and stroke than individuals who ate almost no chocolate (1.7 g per day)" Now 7.5 g per day is about 1/4 oz. of chocolate. This means the above-mentioned 8 oz. bar, 250 grams or so, would have to last me a month or more if I were to fit into the HIGHEST consumption category examined. Trust me, this is NOT happening!! (Maybe the investigators couldn't get institutional review board to approve studies of earthlings so they went to other planet to recruit?)

Message for the study participants: Do you know what you're missing? You're pretty close to Belgium, so try out their best export!!) The folks eating the least chocolate in the study had only an ounce or two of chocolate per month. This strikes me as very sad.....

So that you, Kind Reader, can properly evaluate conflicts of interest, let me hasten to add that my sister is a sales executive in a chocolate company that uses a Belgian chocolate product. May I also add, however, that my own proclivity to consume the stuff well predated this relationship!

The author of the study is quoted by news reports as saying that "...chocolate contains so many calories and sugar, and obesity is already an epidemic. We have to be careful," but that if people wanted to treat themselves they should eat a small amount of dark chocolate.

According to Medscape (quoting Heartwire), another expert has called for a randomized trial to see if "flavanol-rich chocolate" lowers blood pressure. One study I believe they will have no trouble recruiting for...count me in!

Useful tips from an insurer

Highmark, a care coordination subsidiary of Blue Cross, has disseminated these tips for a good hospital stay. I think they're pretty good, although understandably since they come from an insurer, they don't help much with the bewildering array of copays, uncovered services, and explanations of benefits, copays common hassles with insurance payment that plague most patients who have been hospitalized.