Conquering Fear

So much to blog about and so little time....
A patient of mine turned me onto the television series Doc Martin years ago, and I wondered why the good doctor never did a repetitive exposure protocol to reduce his blood phobia. 
If anyone out there is not getting medical care or blood draws for good preventive care because they are afraid of needles, there are great ways to help yourself. 
I highly recommend a workbook which a patient of mine introduced me to called 
Mastering Your Fears and Phobias.  
http://www.amazon.com/Mastering-Your-Fears-Phobias-Treatments/dp/0195189183
This book is meant to be used in conjunction with a therapist who is using this book:
Mastering Your Fears and Phobias: Therapist Guide
http://www.amazon.com/Mastering-Your-Fears-Phobias-Treatments-ebook/dp/B00192LYRG
This is the link to the Kindle edition but you can also find it in hard copy from Barnes and Noble and other places online. 
Unlike with most books, I found that the authors' blurb on the cover of the therapists' guide delivered exactly what it said and that the two books together are an extremely effective system. So I will reproduce the blurb on the therapists' guide here:

"Specific Phobia is the most commonly occurring anxiety disorder with approximately 12.5% of the general population reporting at least one specific phobia during their lives. People may fear heights, flying, spiders, blood, water, and any other number of circumscribed objects or situations. Research has shown the most effective treatment for these fears and phobias is an exposure-based, cognitive-behavioral program.  Written by renowned researchers, this Therapist Guide provides you with all the information you need to help your clients ease their anxiety and conquer their fears. Whether they are afraid of dentists, dogs, or driving, you can teach your clients the necessary skills to overcome their phobia in as little as a few weeks. The strategies outlined in this book include exposure exercises and cognitive restructuring techniques. The corresponding Workbook includes blank forms and records for tracking progress and allows the client to extend the therapeutic experience outside of the office. Together, both books form a comprehensive package that has proven to be the most effective and successful treatment available for specific phobia. TreatmentsThatWorkTM represents the gold standard of behavioral healthcare interventions! All programs have been rigorously tested in clinical trials and are backed by years of research A prestigious scientific advisory board, led by series Editor-In-Chief David H. Barlow, reviews and evaluates each intervention to ensure that it meets the highest standard of evidence so you can be confident that you are using the most effective treatment available to date.  Our books are reliable and effective and make it easy for you to provide your clients with the best care available Our corresponding workbooks contain psychoeducational information, forms and worksheets, and homework assignments to keep clients engaged and motivated."
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Unlike other phobias, it is hard for a regular psychotherapist to provide the exposure needed if you are afraid of needles or blood.  Your therapist will need to work with a doctor who can expose you to needles and blood.  Or, like my client did, you can buy your doctor the Therapists' Guide and convince them to help provide you with the needed exposures. Be prepared to spend some money on this as it would not be surprising, given the sorry state of our insurance system, if your insurance plan did not cover the doctor visits needed for this type of treatment. 

So, if you have nothing to fear but fear itself, take heart and buy these books and enlist your doctor in helping you get rid of this disabling phobia which is preventing you from taking care of yourself.

Ode to the Bedpan

   Having taken a few years off to begin and run a primary care practice, it's time to start blogging again. Erstwhile followers have clucked disapprovingly about the sparsity, nay absence, of posts since 2011, while flattering me that they used to enjoy them. Today, finally out of activities to distract me from my tax return or writing the website content for my new medical aesthetics practice (www.skinlifemedical.com), I feel compelled to write a blog post.
    On telephone coverage today for myself and several other physicians, I got an amusing call from a hospital nurse confronted with an order to remove a Foley catheter (a catheter used to collect urine from the bladder during and after surgery to collect the urine)  The nurse noted that the patient could not yet walk steadily after hip surgery, and asked "What should I do? Should I just leave the Foley catheter in another day or should I let her be incontinent?"  Puzzled, I asked whether because of the hip surgery the patient was unable to raise herself for a bedpan,  Or was she was unable to control her bladder perhaps until the bedpan came? Or were they understaffed on the floor and unable to come in time to bring a bedpan when people called? "Oh, a bedpan!" the nurse exclaimed, "that's a good idea! I'm so glad I talked to you!"
   Some of you may be laughing as much as I was, and some of you may be wondering what was amusing. Regrettably perhaps, my reluctance to dampen your fun has ceded to the desire to express the sadness which followed my initial amusement. Writing about it will improve my mood, because it is so much more pleasant, as anyone in the word of quality improvement can tell you, to point out others' failings than to do one's own work. Taxes, anyone?  I think not!  And, my inattention will ensure that myown  failings will remain to provide an endless source of pleasure to my teenage daughter. And, to you, Gentle Reader, should you wish to elevate your own mood after reading the sad things I write herein.  Yes, instead of doing my taxes, or writing my website content for my new medical spa (www.skinlifemedical.com) I will spend a most pleasant half hour writing this post and shaking my head once again about how far our hospital staff will go to avoid doing the simple task of answering a call bell and bringing a patient a bedpan when needed. My mussar teachers will (oh, so gently) point out how mistaken this course of action is, and I am delighted to allow them that great pleasure too.
   Is it right to keep in a foreign object with the potential to damage our urethra and bladder and muscles which control continence, and with a great potential to introduce infection, rather than to arrange for the patient to ring a call bell when she has to go and then bring her a bedpan? When someone is unconscious for surgery or can't move at all, there is no option. But once she is even slightly mobile after surgery, and can't walk, isn't it better to use a bedpan than to leave in a Foley catheter?  Yet the bedpan is so out of use that this nurse had completely forgotten the option existed!
   Bringing a bedpan rather than leaving in a Foley catheter creates many other opportunities that improve a hospitalized person's health care. Since the patient will need more frequent encounters with staff for bedpans than to change a Foley bag, it offers more opportunities to introduce ourselves with a smile. These personal encounters with staff make some people feel secure when they are hospitalized and vulnerable, whereas others feel their privacy has been invaded. Regardless of which type of person we are treating, and I believe the former are more prevalent in the great majority of hospitals, the encounters offer many other opportunities for improving health care. For example, after removing the bedpan and wiping, a nurse or aide can examine the backside for pressure ulcers (bedsores), reposition to avoid causing bedsores with prolonged immobility, evaluate if the mental status is OK (cognitive issues such as hallucinations or confusion may indicate overmedication or onset of infection postoperatively), ask if the person needs water, and check that the call bell and telephone are within reach.  In addition, removing the Foley catheter makes it easier for hospital staff to try to help someone begin to walk (have you tried walking with a large plastic tube sticking out your urethra and a bag of urine hanging from your leg?) How sad that the nurse didn't even think of this option before calling.
  Bedpans do have some downside. As mentioned above, we invade patient's privacy more frequently with bedpans than with Foleys where our postoperative care is limited to emptying the bag. And, nurses or nurses' aides can spread infection when bringing bedpans too if they don't wash their hands.  Because bedpans require more patient encounters with staff, they require more nurses' aides in hospitals.  As administrators try to reduce hospital costs, I am sure there are pluses and minuses to the equation of more Foley catheters and fewer people interactions. These are things which can be studied. My hunch is that the humble bedpan and the equally humble aides who bring and empty it probably are cost-effective given the complications they prevent. Or, maybe Americans should just spend more money on new versions of the iPhone.  Or let Comcast make another $1 billion dollars per year by charging each American household $10 more a month for what they said was included in the package to begin with when they sold it to us.  Or perhaps each doctor and hospital should pay for yet another electronic health record because the one we have isn't working and doesn't talk to anybody else's and we should spend a good portion of our societal and healthcare budget on health IT.  Our society seems to be fine with all that waste, but Heaven forbid there should be a nurse's aide to bring a bedpan.
  Alas, the taxes beckon.  Perhaps I can clean out my refrigerator...

US life expectancy drops

According to the U.S. Centers for Disease Control (CDC), for the first time in 25 years there was an actual drop in overall life expectancy in the US, calculated in the year 2008 (since the data take some time to calculate, the CDC usually puts things out a couple of years after the fact, and 2008 is the most recent year for which data were released). This is not very good news. The bright spots were infant mortality and death from stroke.

This stands as an indictment of our health care system as well as what we do as a society to prevent illness and promote wellness. We can only hope that more Americans will be adequately insured and receive more appropriate health care in the future, and that our health care system will turn more towards prevention, where its bang is likely to be much bigger for the buck.

Sublingual allergy tablets effective in preventing seasonal nasal allergy

A new meta-analysis (synthesis of all available clinical trials) in the Cochrane Library has found that under-the-tongue immune treatment (which can be done at home) is effective without the side effects of weekly allergy shots. This advance in allergy treatment is particularly good for kids, and of course whether for children or adults reduces the major hassle of driving to the allergist's office, not to mention the pain and not infrequent reactions experienced with allergy injections. Very good news for allergy sufferers.

Getting doctors to follow our wishes with advance directives

People of all faiths and atheists should be interested in doctors ignoring patients' wishes about life support. Whether or not you are predisposed to a particular religious point of view about life support, whether your wish is to be on life support, or not to be on life support, or something in between depending on the circumstances, we need a way to make sure doctors are paying attention to what our wishes are.

Three things are particularly important for everyone: 1) filling out an advance health care directive to indicate your wishes and your desired medical agent (durable power of attorney for health care), 2) having a knowledgeable health care advocate; in addition to designating the person who cares about you most as your agent, this person if they do not have a lot of experience from the medical care system may need help from someone more knowledgeable, and 3) the importance of registering your advance directive with an organization such as US Living Will Registry so that hospitals and health care facilities can check to see if one is present when you are admitted.

Great info about how to make sure your meds don't cause you harm

http://www.ahrq.gov/consumer/cc/cc120710.htm

Getting tested for BRCA genes

I have been asked many times whether to be tested for the gene mutations which increase risks of breast cancer, also known as BRCA genes. There are a few such gene forms identified, which together account for a large percentage of hereditary breast cancers, as discussed in this National Cancer Institute fact sheet. These genetic mutations code for faulty enzymes responsible for repairing damage to DNA that causes cancer.

The first question in deciding whether or not to get tested is whether you have had breast cancer!! If so, get tested!! If you are positive for one of the BRCA mutations, it should have a big impact on whether you decide to have a prophylactic, that is, preventive mastectomy of the other breast. Women without BRCA mutations do not survive longer if they have second mastectomies. It also affects how frequently you screen the other breast with a mammogram. I am always surprised by how many people (yes, men get it too) who have had breast cancer have not had these genetic tests! This is a situation in which the downsides are much fewer. Specifically, the documentation of increased risk which might make it hard to get health insurance, is besides the point, since the history of breast cancer already confers that risk.

If you haven't had breast cancer yourself, the next question is if you know the medical history of your first degree female relatives, your mother and your sisters, or your father's sisters and mother. If you do not, consider whether you are in one of the ethnic groups at higher risk of the genetic mutations which increase the risk of breast cancer (Ashkenazi Jews, Icelanders, Norwegians, and Dutch). If you are in one of these ethnic groups, and you don't know your personal family history, you are likely to benefit from being tested.

If you do know your mother's, your sisters', both of your grandmothers' and your father's sisters' medical histories, and know what they died of, and they lived into their older years (70s or 80s, say) without developing breast cancer, then there is little chance that you have an extra genetic risk of breast cancer. Your lifetime risk is then like the risk in the general population without a family history of breast cancer, or about 12%, and there is no special reason to be tested.

Now, if your mother or sister did get breast cancer, is there any additional advantage in getting tested for BRCA genes?

The first step is, if the person who had breast cancer is still alive, to ask that person if they were tested for these gene mutations. If they were not, you could ask if that person is willing to be tested. The reason is that if they are negative for one of the gene mutations, then you are unlikely to have an increased risk on that basis too, and testing is much less helpful and not recommended. The second reason is that if they are positive, and you then get tested and test negative, you can set aside worrying about increased risk due to your family history as you have probably not inherited that risk.

If the person in your family who has breast cancer has died or refuses to be tested, the pros of getting tested are that if you test negative, you can get screened less often than if you are positive. If you are positive, you can get screened more frequently, and using different forms of screening such as ultrasound. Also, if you are positive, you can get screened for ovarian cancer, which is not normally done otherwise, because women with BRCA genes have increased risk of ovarian cancer. You may also wish to have prophylactic bilateral mastectomies, or if you develop cancer, to get the other breast removed at the same time. The lifetime risk of developing breast cancer when one is identified as being at genetic risk is extremely high, and many women opt for this solution, even some without BRCA genes. Finally, as above, if you do develop breast cancer, evidence has shown that if you do not have a BRCA mutation, having a prophylactic second mastectomy does not improve your survival.

The biggest downside of testing for breast cancer risk genes is being identified by insurers as being at increased risk. While there is now a federal law against insurers discriminating against women on this basis, this is totally unenforceable. Women can be denied by insurers for a host of spurious reasons (one woman I know was denied because she had had a urinary tract infection treated with antibiotics in the last year!) which may be cover-ups for other risk factors. We also have no assurance that health care reforms banning exclusion of pre-existing conditions or refusal to insure people with those conditions, will remain after future changes in the political landscape. Many women will feel with some justification that it is simply better not to have this risk recorded.

The solution to this downside, of course, is to get tested anonymously outside the insurance system. Then, at least, you will not be classified as being at extra risk unless you divulge this information to a physician because you wish to do something about it (such as bilateral mastectomies). Most labs will send specimens anonymously as long as you are paying for it and not the insurance company. Now that the patent on the BRCA1 gene has been struck down, other companies besides Myriad Genetics will spring into the marketplace and testing is likely to become less expensive. This brings up a new downside: the cost of testing, which depending on how many genes are tested for, can be anywhere from a few hundred to a few thousand dollars. See this discussion in the National Cancer Institute's factsheet

Getting tested may cause other harm worth mentioning. The increased screening for breast cancer which you are likely to have if you test positive carries risk. If you get screened more, you are more likely to have a false positive mammogram, or ultrasound, or breast MRI, with unnecessary biopsies, etc. Radiation from mammography and MRIs may also cause some increased risk. There has been a lot of recent publicity around why one might want to avoid mammography and screening despite a family history of breast cancer such as this recent column in Health Affairs.

The organization Facing Our Risk of Cancer Empowered (FORCE) runs a hotline to help answer questions about breast cancer risk and screening for breast cancer genes. Local communities often have support networks as well. In Palo Alto, there is also an organization called Breast Cancer Connections which specializes in helping newly diagnosed women, but also provides a lot of information to women about risks for breast cancer.

For additional information, ask your doctor to refer you to a genetic counselor. You can check with your insurance about whether they cover a visit like this. They may only do so if you have a family history of breast cancer.

Who should be your medical care "proxy" with durable power of attorney?

When you visit a good estate attorney, he or she will usually instruct you to fill out an advance medical directive if you don't have one already. The link in the previous sentence is a sample document provided by the State of California, although the directive does not have to be in this specific format. This document allows you to leave some specific instructions, but most important, allows you to designate whom you want to represent you for medical decisions if you are unconscious or cannot make your own decisions.

Many people designate a trusted loved one, such as a child or a spouse for this role, if they have one. However, some people do not have such a person. Such people should hire a primary agent to whom to give durable power of medical attorney in case they are incapacitated. My new business, Your Health Care Advocate, provides this service. Although I don't have a website specifically for this arm of my business, you can find contact information at http://www.myadvicedr.com. Please note that if I am serving as your agent, I cannot provide any other medical services to you as this would be a conflict of interest. Conversely, if you have consulted me for medical advice, I can become your agent as long as you realize that once the agency takes effect (you become unconscious or unable to make your own decisions), I will not be able to provide other medical services or advice to you, but rather would follow your wishes or attempt to figure out what your wishes would be in making decisions or providing input for medical decisions.

One of the reasons for appointing an agent who works for you is that doctors are unlikely to follow patients' wishes about life sustaining care, as demonstrated by the SUPPORT study . In my own experience, this goes in both directions, where doctors keep patients on life support that they wouldn't have wanted, or discontinue life support earlier than patients might have liked. In a recent case, doctors were ready to discontinue a man from life support on the same day as a cardiac arrest, before they had even assessed that his brain function was gone, despite the wishes of his medical proxy, his wife, that he wished every intervention to be done to attempt to save his life. In another case of a man with congestive heart failure who had dementia from several strokes, who had expressed his wishes to his family that he did not want to be put on a ventilator except for acute pneumonia, young doctors on call came in to the intensive care unit prepared to to intubate him (put him on a ventilator) when he stopped breathing during another massive stroke, despite very poor brain and heart function before the event happened. Had an agent not been present, he would have been put on life support, as his wife was not confident enough to question the doctors. From many religious perspectives, withdrawing life support is more problematic than not using it in the first place when it is not indicated. And, of course, failing to provide it when indicated and desired is even more concerning.

Thus, while it may superficially seem to be the most prudent avenue to appoint a family member to this role, there are some significant drawbacks to this choice.

1. If it is a child, they may not live where you do. Critical medical decisions in an emergency require very quick answers or the doctors are left to their own choices instead of getting input from anyone you instructed or anyone you trust. Telephone conversations are not that great for helping people understand critical medical situations. In this case, you may wish to designate a local alternate agent as well as the child who serves as primary agent. Consider hiring a medical agent or advocate to play this role if you do not have any friends with extensive medical knowledge.

2. If it is a spouse, he or she may already be frail and have health problems or may be emotionally fragile, or may lack self-confidence interacting with doctors. These are likely to be exacerbated by your being critically ill. This will make it difficult for them to have any meaningful input into the process. They are likely to feel overwhelmed and simply trust the doctors to carry out your wishes. Therefore, you may wish to designate or hire an alternate agent with a medical background in case your spouse feels too overwhelmed to carry out this responsibility effectively and wishes to delegate it.

3. The trusted person you designate may have little or no medical knowledge. Therefore it may be hard for them to understand the implications of the choices doctors are asking them for input on. You may wish to hire someone with a good medical background.

4. Conflict among family members often revolves around these decisions. It creates significant conflict among family members when one has decision-making authority and the others do not, and input from the others is ignored or devalued. Children also have conflicts of interest. In the worst cases, issues of inheritance and property may drive a child who has not been close with you to argue in favor of discontinuing life support, or, if you have children who live in your house, are very emotionally attached to you, or will benefit more by your survival in some way, they may militate for interventions you do not wish to have. A spouse may be somewhat narcissistic, and feel angry with you for abandoning him/her, and ignore your wishes not to intervene in certain situations.

A great alternative is to hire a medical agent who works for you to carry out your wishes and has no vested interest one way or the other.

[Of course, you may have little or no medical knowledge too, which is why I recommend that for important medical decisions, you consult a skilled doctor as a health care advocate (like me! http://www.myadvicedr.com)]

US Worst of 11 Industrialized Nations in Cost-Related Health Care Access Problems

http://www.commonwealthfund.org/~/media/Files/Publications/In%20the%20Literature/2010/Nov/Int%20Survey/PDF_2010_IHP_Survey_Chartpack_FINAL_white_bkgd_111610_ds.pdf

Where does the US stand

Loved this compilation posted by a doctor on Medscape

Healthiest: the U.S . ranked 11.
http://www.forbes.com/2008/04/07/health-world-countries-forbeslife-cx_avd_0408health.html
top-ranking Iceland, Sweden and Finland
Obese: # 1 United States: 30.6%
Murder rate http://www.nationmaster.com/graph/cri_mur_percap-crime-murders-per-capita
# 24 United States:
Best Health System http://www.photius.com/rankings/healthranks.html
# 37 United States of America
Heart Disease Deaths: http://www.nationmaster.com/graph/hea_hea_dis_dea-health-heart-disease-deaths
# 13 United States: 106.5 per 100,000 people
Longevity: http://www.nationmaster.com/graph/hea_lif_exp_at_bir_mal-health-life-expectancy-birth-male
# 49 United States: 75.29 years 2008
Human Development Index: http://en.wikipedia.org/wiki/Human_Development_Index
#4 United States 0.902 ( 9)
Richest: http://www.worldsrichestcountries.com/
#Liechtenstein $118K USA # 10 47K
Best Place to Live: http://www.huffingtonpost.com/2009/10/05/norway-best-place-to-live_n_309698.html
Norway is # 1
The United States placed 13th.
Gender Equality: http://english.peopledaily.com.cn/90001/90777/90853/7167348.html
Iceland # 1 followed by Norway, Finland and Sweden.
The United States # 19th
Corruption: http://www.nationmaster.com/graph/gov_cor-government-corruption
US # 17
Fastest Internet: http://www.speedtest.net/global.php#0
South Korea; # 30 USA

More on red yeast rice and cholesterol

The Archives of Internal Medicine published a study which evaluated different red yeast rice supplements and found them highly variable in the amount of monacolin (sometimes spelled monocolin) they contained. This ingredient is the active ingredient lowering cholesterol, which is similar to that in lovastatin. They also found that some of the supplements contained a compound toxic to the kidneys.

The important distinction here is between red yeast rice and red yeast rice supplements. This study evaluated 12 supplements in capsule form. While the study raises a caution about purchasing extract supplements in capsule form, I stand by my previous post on the subject with respect to the whole grain. Buying the whole grain red yeast rice and preparing it just as one would prepare any other type of rice should not be subject to regulation as a drug.

Does chocolate lower risk of carotid atheroslerosis in women?

Another study shows some possible benefits of cchocolate: the study suggests that chocolate lowers risk of carotid atherosclerosis (the thing that causes strokes and transient ischemic attacks, or TIAs) in women.

This study has a weak study design (prospective cohort study), and there was no difference in outcomes between those consuming weekly and daily chocolate. This makes it more likely that the findings may be misleading, since there is no dose-response relationship demonstrated.

The authors (like others before, if you're a regular reader of my blog!) properly call for a randomized controlled trial of chocolate in preventing atherosclerotic vascular disease such as transient ischemic attack (TIA) and stroke.

Can't wait!

Pregnant mothers: watch those poppy seed and everything bagels!

This mother ate an "everything" bagel, tested positive for opiates in her prenatal drug test, and had her baby taken away for 5 days before she was able to fight it successfully. Much as I dearly love poppy seeds, it might be a good idea to tive them up when you're pregnant, well before you take your prenatal blood work!

http://criminaljustice.change.org/blog/view/losing_a_baby_over_a_poppy_seed?me=nl

More dark chocolate benefits - higher HDL in diabetics

OK, on the subject of dark chocolate my blog entries are getting to sound like a broken record (anyone out there know what a record is? NOT like breaking the record in the Guiness Book of World....)

So here's another study showing its benefits. Investigators randomized 12 patients with diabetes to eat 45 grams (a total of about an ounce and a half) of very dark chocolate (85% cocoa solids) daily or a similar amount of chocolate without the cocoa solids or polyphenols present. dyed to the same color. Patients who ate the real dark chocolate had better HDL levels and therefore better total/HDL cholesterol ratios.

People in the group that ate real chocolate did not gain weight and did not ingest more calories, because the chocolate generally resulted in their eating less snack food and eating less at the next meal than those who ate the "placebo" chocolate. They also had equivalent blood sugar and glycosylated hemoglobin levels.

This study had a small sample, but if it is repeated and borne out, it should mean that we don't have to advise our diabetic patients to stay away from anything sweet and yummy.

red yeast rice and cholesterol

I've been meaning to post about red yeast rice for some time. Red yeast rice, is produced by cultivating the yeast strain Monascus purpureus, either spores or a prior fermented rice, on rice. Each rice grain turns bright red in its core and reddish purple on the outside.

The fully cultured rice is then either sold as the dried grain, or cooked and pasteurized to be sold as a wet paste, or dried and pulverized to be sold as a fine powder. China is the world's largest producer of red yeast rice.

Many red yeast rice products contain monacolin K, a compound identical to the drug marketed in the U.S. as lovastatin. Red yeast rice products that contain monacolin K, are banned in the by the Food and Drug Administration in the United States, which has stated that such products are identical to a drug and thus subject to regulation as a drug. In 1998, the FDA initiated action to ban a product (Cholestin) containing red yeast rice extract. The U.S. district court in Utah allowed the product to be sold without restriction. This decision was reversed on appeal to the U.S. District Court. Shortly thereafter the FDA sent warning letters to companies selling red yeast rice,and the product disappeared from the market for a few years.

In 2003 red yeast rice products began to reappear in the U.S. market (see the Wikipedia discussion referenced above) and avoid FDA requirements by making no claims about cholesterol lowering. Some contain no monacolin K. Two reviews referenced on the Wikipedia site indicate that monacolin content of red yeast rice varies widely. The FDA also issued a warning press indicating that consumers should “…not buy or eat red yeast rice products…[which] may contain an unauthorized drug that could be harmful to health.” The rationale for “…harmful to health…” was that consumers might not understand that red yeast rice might have the same side effects as prescription statin drugs.

In my view, this is absurd and is like saying that because tomatoes have potassium we are now banning tomatoes since potassium is marketed by itself as a drug and can be harmful to people with kidney failure who might not realize that they contain potassium. All Americans should be up in arms at these FDA rules. There seems to be no other reason for this than the financial well-being of the pharmaceutical companies selling statins. No pre-existing foodstuff, extract, or supplement, should be banned simply because a drug company decides to isolate and sell a compound in it for profit. If it requires regulation, then regulate it, and if it is identical to a drug, then it should be lawful just like that drug. If it does not require regulation (which I believe), then perhaps its drug cousins should be made over the counter too. Many of our OTC drugs have dangers which consumers need to know about, but regulating them through prescription is ineffective and just makes them expensive.

I welcome my reader's views on this topic!

Stick with the best thing, not the next best thing

I keep seeing advertising touting the efficacy of fruit and vegetable extracts such as Juice Plus, promoted by some local practices which call themselves "Integrative Medicine" practices. Juice Plus and similar products purport to lower your cardiovascular and cancer risk and to have research to back them up. The Juice Plus website contains links saying "feel free to look at the research" I decided to do so for my readers to see if there is research supporting its efficacy.

The research I found was all based on what I would call "surrogate markers". That is, no studies demonstrate that anyone actually lives longer through using Juice Plus. All the studies focus on clinical endpoints like flow through certain vessels, or inflammatory medidators in the blood. Most of the trials, also, were not randomized controlled trials, that is, there was no control group in the study, which compared subjects to themselves at "baseline". The problem with this approach is that other changes occur when people are enrolled in studies which may have nothing to do with what is being studied.

So, while these results do not suggest that Juice Plus does any harm, they are certainly not conclusive about its benefits.

The studies do not compare Juice Plus to a diet containing lots of whole fruits and vegetables. This would be the most relevant comparison, and I remain an advocate of eating the whole fruits and vegetables instead in absence of evidence otherwise. Cheaper and more flavorful, too.

I would like to be cautious as I may have missed some literature, so if anyone including the makers of Juice Plus knows of evidence of which I am unaware, please comment on this post!

new brain death guidelines

The new guidelines for brain death in the journal Neurology this year state that they are attempting to make a very variable process for determining brain death more uniform. I am concerned about two things in the guidelines.

The first problem is accepting only one examination to determine brain death. All human evaluation is subject to error and a brain death exam is no exception. The reliability and consistency of all physical examination and diagnostic tests is not 100% and in some cases is extremely low. When declaring brain death, a judgment based on many, many tests and findings, the possibility of error increases, and requiring two examinations would make the probability of error a little lower, although not zero. Allowing brain death to be declared with only one exam greatly increases the false positive rate. I cannot agree with this strategy, inconvenient and costly as it may be for our medical system to keep someone alive who has only a slim chance of recovery.

Many of my readers may not agree, but I personally abhor the recent trend in Medicine towards allowing people to die, even when they and their families wish such efforts to be made. While I will defend to the death (now increasingly easily labelled!), that we should follow patients' wishes, those who wish to "rage, rage against the dying of the light", as Dylan Thomas urged, should be supported to do so. It is a very important moral and ethical use of our health care funds, as this care for life is an important piece of our humanity.


I have always valued the lesson taught me by one of my patients when I was a medical resident in training. She was a radiologist in her 30s who developed very severe systemic lupus erythematosis. She had hemolytic anemia (a process where her immune system destroyed her own blood cells), gangrene, and many infections of a catheter inserted for temporary dialysis. She needed constant transfusions, and her blood was infected. She had pneumonia and kidney failure. Her blood pressure was low. She kept us day and night for weeks treating her illness. We became tired and fatigued. I felt we were fighting a hopeless battle and that we should let her die. Her husband wanted us to do everything to try to save her. Her attending physician insisted that we keep at it. We did. She recovered completely. 25 years later, she is still alive. Recently on an East Coast trip, I took a detour and visited her at her home a few years ago and thanked her for what she taught me: A patient's life should not be threatened by doctors' fatigue and their feeling that dedicated family members are over the top. These family members may need to be over the top to save the lives of their dear ones. Young doctors do not appreciate the potential for recovery and the meaning of death. How can they when they so often have had so little experience of life?

Our protocols for brain death should err on the conservative side, because the doctors in charge, de facto, of these decisions in our acute care hospitals are so young and so often err the other way. What's your opinion?

Why hire a health care advocate

Here's a good article by Dr. Carolyn Clancy of Agency for Healthcare Research and Quality (AHRQ) about why you may want to have a health care advocate with you in the hospital or doctor's office.

I am proud to provide health advocacy services, among others, to my patients. If you are over 18 and live in California, and may be interested becoming part of my practice, please see www.myadvicedr.com for information about how to obtain a free consultation to see if I may be able to help you.

So how homey is a medical home?

The new health care legislation is looking to primary care doctors to create "medical homes", defined as primary care practices that provide 24/7 access to their doctors, electronic medical records with exchange of information with other providers, a patient-centered holistic approach, and coordination of care by other specialists.

A study published today funded by the Commonwealth Fund, carried out by the American Academy of Family Practice, shows that to achieve this, doctors need a lot of help, and that even with this help, they may actually not improve things, as evidenced by patients being less satisfied than before. The national demonstration project published today showed that 36 family practices made small improvements in clinical quality measures, summarized as "better preventive care and access". Access meant ability to get in for an appointment or reach someone to talk to...not related to patient's views of their access or whether they were able to go to the best specialist, surgeon, and the best hospital they could have for specific medical conditions requiring intervention). Patients with high blood pressure and diabetes had slightly better control of their blood pressure and hemoglobin A1C (a measure of blood sugar control for patients with diabetes) levels. However, patients actually rated their care worse after the practices made changes. Patients' ratings of access to care, care coordination, comprehensive care, and service relationship were worse after implementing more of the features of the "medical home". I guess the medical home can be not too homey.

In contrast, Group Health Cooperative of Puget Sound, a large health care system, mounted a successful demonstration project of the "medical home", showing it boosted quality and patient satisfaction and saved money by helping its practices become "medical homes".

The message is that big organizations will be much better able to achieve the "medical home" features in a way that does not impair service to patients. Large organizations may also already have had lower levels of patient satisfaction, so they did not fall by becoming "medical homes", which generally rely on ancillary practitioners for more things and may reduce access to doctors. For smaller practice, electronic medical records, registries and greater use of ancillary support do not necessarily mean that things will get any homier for the patient. On the contrary.

Unfortunately, big organizations may also provide perverse incentives to helping patients choose the best specialty and surgical care. We've seen this with the Medicare Advantage plans. When primary care doctors have incentives to choose doctors and specialists and hospitals in the same health care delivery system, or coverage requires them to, patients lose out, because it will limit the specialty and surgical providers and hospitals to whom primary care doctors refer their patients. Often there are financial incentives within the same system to choose providers there, and this will be even worse when payment moves to an "episode of care" approach, meaning that patients will have to go to the same system of care for an entire "episode", even if there were better providers around for specific pieces of that episode. So, for example, you will no longer be able to receive your follow up care from surgery in a different system than the surgery itself, since the payment is likely to be bundled.

Many patients would prefer to go to smaller practices for their primary care, with a more personal feel where they still feel like human beings, and prefer to be able to choose the best specialty surgical provider and hospital for their particular problem. Unfortunately, the direction in which our health care system is moving will make this model more difficult. If episode-of-care bundled payment happens, small primary care practices unaffiliated with surgeons, specialists and hospitals will be forced out of business.

The authors of the summary article reached that same conclusion and recommended that third-party payers turn to arrangements such as monthly capitation payments to make medical homes worthwhile for physicians. "Expecting practices to front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed," they write.

more coffee and tea associated with lower risk of brain tumors

You knew there was a reason you drank coffee or tea...Maybe this will make up for your heavy cell phone use!

http://www.nutraingredients-usa.com/Research/Tea-and-coffee-may-reduce-brain-tumor-risk-EPIC-Study