Thursday, December 31, 2009

New Year's Resolution - Don't Multitask. We Can't Do It. It Could Kill You.

I've been fighting pretty hard to avoid the temptation to multitask. I plan to do so again this year. People who claim to multitask are viewed with awe. Attaining the skill is a badge of honor. In a society that is increasingly 24 /7 where demands from work, family, and friends seems endless and the opportunities to be connected are more, how can a person survive if they simply do one task at a time?

Simple. Research suggests that the person who single tasks actually does better work, focuses better, and is productive.

Oh and it might save your life.

The term multitasking became part of our language a few years ago when single tasked computers running DOS (remember them?) could now run multiple programs or tasks at the same time in multiple windows. The computer could download a program off the internet, play music, and let you type up term paper simultaneously in Microsoft Word. Initally, however, that was just an illusion. Computers in the past only had one processor or one brain. It gave the perception of multitasking by switching from one of the three above tasks so fast that it gave the impression of doing everything at the same time. Today many if not most computers have multiple computer processors or more than one brain and each can be dedicated and focused to the task at hand.

While we all might want the ability to multitask, the truth is we can't really do two cognitive tasks at the same time. Ever notice when you try to talk to someone on the phone she either lifts a finger to say what a minute or cups the receiver, stops the phone conversation, and then addresses your presence? It's because we can only do one task at a time.

Don't believe me? Still think you can multitask?

Next time, when while you are in conversation with a friend do this simple math problem, take 311 and divide by 113. You can't either keep up with your friend without stopping, pausing, and thinking or you need to stop doing the math if you are engaged in talking. In other words you can't be fully conscious of doing two things simultaneously. You move from one task to the other much like single processor computers. The difference is we don't and can't switch as fast as the brains in our PCs.

So how might avoiding multitasking save your life?

Don't talk on the cellphone when driving or text message. Ever.

Many laws missed the point about hands free driving with cell phone usage. It isn't about the hands being off the steering wheel. The problem is that the brain is engrossed in conversation. Although the foot is on the accelerator and the eyes do see the road and cars ahead, the brain isn't fully cognizant of what is going on. It can't respond should something happen.

Sadly, examples from the news make this painfully clear.

A recent Los Angeles Times article found that a Metrolink commuter train ran a red light. This is particularly worrisome as on September 12th 2008, Metrolink had the worst accident in its history when a crash killed 25 people and injured 135. Investigators believe that in the latter case, the engineer had been text messaging and ran a red light. These trains can travel as fast as 90 miles per hour or 132 feet per second. Or 44 yards per second nearly half the length of a football field! Stopping at that speed requires over half a mile or a little more than two laps around a typical high school track.

In October, Northwest airline pilots missed landing at Minneapolis by 150 miles. They denied being asleep but using their laptops and trying to get their scheduling software to work. The merger between the airlines Northwest and Delta also caused some system flaws that prevented communications between air traffic control and the pilots. Radio contact was not established for over one hour. At the typical cruising speed of over 500 miles per hour for the Airbus A320 even a small five minute distraction can result in flying over 40 miles.

How might these stories apply to you and more importantly save your life?

As I note in my book, unintentional injuries are the leading cause of death among people age one to thirty-four and the third leading cause among forty-five to fifty-four-year olds. The most common cause of unintentional injuries is motor vehicle accidents. This was before the cell phones and text messaging was as mainstream as it is now.

Driving at 60 miles per hour or about 1 mile per minute you cover 5280 feet per minute or 1760 yards. 17 football field lengths.

10 second distraction? 293 yards. 3 football fields.

Any text message worth it? Phone call?

Unlikely. A Virgina Tech study found that those text messaging where 23 times more likely to get into a car accident.

Get the word out. Stay focused. That's why this year I'm still staying away from smartphones, using my trusty old cell phone, but leaving it on the off position.

Wednesday, December 9, 2009

Why Medical Students Should Choose Primary Care - Not for the Reasons You Think

The current generation of medical students are not choosing primary care and instead are flocking to specialty care medicine in droves. Unlike decades ago when the best and brightest often went into internal medicine, the vast majority of students opt for dermatology, radiology, anesthesiology, and ophthalmology. Reasons for doing so include better predictable schedules, work-life balance, and compensation.

While I understand that proponents for more primary care doctors use other reasons to increase the primary care workforce, namely decrease the healthcare cost curve and improve health outcomes, medical students today need more compelling and practical reasons to do primary care.

I'll give three. Information technology / primary care transformation, globalization, and payment reform.

Before delving into the reasons, we must address why primary care is so unattractive to medical students. It isn't because of the relatively low pay of primary care doctors receive compared to other specialties and the high medical student debt that studies often suggest. The real reason is as primary care currently exists there is no sustainable work-life balance. Among gen X and the millenials, their identities isn't defined by their career. Unlike their baby boomer parents who lived and breathed their jobs, the newest doctors have other things to do in life.

This is why becoming a family doctor or internist isn't appealing. During their third and fourth years, students do clerkships or clinical rotations in all fields of medicine, including primary care. They experience first hand the daily struggles current primary care doctors have in administrative hassles, difficulty in care coordination in a paper chart world, decreasing reimbursement, and challenges accessing accurate real-time medical, prescription, and laboratory information. These headaches coupled with the intellectual need to be knowledgeable about a variety of aliments and problems seems too difficult to be a lifelong career.

This is true, if they were practicing today. However, by the time they finish training the world will already being shifting. When they retire thirty years later, primary care will have once again become the desired specialty of choice. Today's medical students are thinking a lot like the executives at General Motors; they are looking to the past - gas powered bigger trucks and SUVs. They should be thinking more like Toyota - hybrid or electric smaller vehicles.
The question medical students today need to ask is, where do they wish to place their bets?

They are extrapolating the future world based on their past experiences rather than envisioning the future.

If all they experience in their junior and senior year is the hurried, stressed, primary care doctor buried under paperwork, missing charts and lab results, and hurdles in communications and handoffs to other doctors then it makes why they choose dermatology, radiology, anethesiology, and ophthalmology.

But the primary care of today already looks very different for some doctors in this country and will be fundamentally different in a decade. As a result, the work-life balance problem actually is a non-issue. Those who choose specialty care will, in the future, be looking for jobs or taking pay cuts to live in especially desirable places.

Here's how the future is already taking shape.

Information Technology / Primary Care Transformation
For those individuals who have an entrepreunial spirits, groups like the Ideal Medical Practice, headed by L Gordon Moore, and Hello Health, lead by Jay Parkinson, allow doctors to practice true primary care. Both concepts focus on the doctor-patient relationship by getting off the fee for service treadmill which values patient volume and medical procedures. Since primary care medicine is a cognitive specialty requiring thought which take time and does not have the procedures that a cardiologist or gastroenterologist has, these doctors can only make a reasonable living by seeing more patients per day.

The Ideal Medical Practice (IMP) gets off the fee for service treadmill by slashing overhead cost dramatically by reducing ancillary staff and other fixed costs like office space to a minimum. Therefore the amount needed to cover the costs is less. As a result, one does not need to see as many patients as before to maintain a practice.

Hello Health works by having patients pay a monthly membership fee as well as direct payment when seen in the office. They generally don't work with insurers but instead get their payments directly from you. The benefit, however, is with the membership fee you can communicate with your doctor online via email or webchat like Skype. If you need to be seen it is often same day. The monthly fees that patients pay for these conveniences pays for the doctor's salary, as a result like IMP, the primary care doctor can spend time with you to figure out how to keep you healthy or get you better sooner.

Medical students however who don't wish to start their own practice can find competitive salaried positions at Kaiser Permanente, Geisinger, and other integrated healthcare delivery systems, as well as other private medical groups in communities that are thriving. Primary care doctors work hard, but enjoy their job, are paid a reasonable amount, and aren't planning on quitting anytime soon.

The experience above already exist today, but only exist in the minority of primary care practices. What they all have in common is the elaborate use of information technology, specifically electronic medical records, a can-do spirit on doing things far differently that what is currently experienced and observed by medical students in their clerkships in primary care, a relentless approach to managing expenses and overhead, and the mindset to always change. As a result, doctors are less stuck on the adminstrative hassles, less frustation on inadequate and often dated medical information, and are able to spend more time on valuable elements they enjoy in primary care, namely fostering the doctor-patient relationship.

As all successful healthcare organizations and systems know, the best infrastructure to deliver high quality medical care at the least cost requires a robust backbone of primary care doctors. With the healthcare crisis in the United States, primary care workforce shortage will be a priority. As primary care doctors embrace, and need to embrace, the technological innovations as well as the business practices, in the cases of those entrepreuners, primary care doctors ability to have reasonable compensation and work-life balance will be secured.

So why are all of these medical students going en masse into specialty care doomed? It's not to say that the United States doesn't need specialists, but do we need as many? The reasons are globalization and new medical advances.

In terms of globalization, other doctors in other countries can do the same level of care for less. Currently elective surgeries like joint replacements and heart bypass can be done at 1/6 the cost in America if performed overseas in foreign hospitals by US trained doctors. Patients report experiences better than what they receive here. The outcomes are comparable. Some employers and insurers in the US send patients overseas, cover travel for themselves and a family member, as well as a small fee to do it. While the numbers are small, patients are willing to go.

With the digitization of radiology imaging and the creation of the internet, MRI and CT images can be sent quickly not only to hospitals but overseas. Radiology costs is about 1/3 the cost and images are being read by doctors in India, Austrialia. While US radiologists relish the fact that they no longer need to take night call for late night emergency room CT scans, they should also worry as should medical students contemplating a career in radiology.

It is only a matter of time, unless US doctors wish to take dramatic paycuts to match the pay of doctors in places like Thailand and India, that many elective surgeries and routine imaging reports are outsourced. Don't believe me? Ask the United Auto Workers or other cities and towns built on manufacturing and factories. They couldn't compete with Mexico or China.

In terms of medical technology disrupting specialty care, one only need to look at cardiothoracic surgery. The number of bypass surgeries for heart disease have fallen since the advent of cardiac stents. The number of cardiac stents done can be lowered with the improved focus on cholesterol management with statin drugs and blood pressure control. In other words, patients can avoid having any surgery done much more than even a decade ago as better medications and understanding of illness has occurred.

Who will manage these new medications and keep people healthy? Primary care doctors.

When laser eye surgery for vision correction started years ago, it required the expertise of a highly skilled ophthamologist. Cost for the procedure was thousands of dollars. Today computer assisted laser machines do the bulk of the work. Cost of the procedure now? Few hundred dollars.

As an overwhelming number of students go into specialty care, simple supply and demand coupled with the expensive elective procedures (and most lucrative procedures) being done overseas, and as medical technology continues to get better, specialists will have no choice but to take paycuts or move to areas perhaps less desirable to make a living.

Payment Reform
While primary care doctors current suffer under the fee for service reimbursement system, it is clear that the United States cannot continue to do so indefinitely. One need to look no farther than Massachusetts, which a few years ago was the first state to have universal coverage for all of its inhabitants. The state failed to address payment reform. As a result, and not surprisingly, costs continue to escalate with no demonstrable improvement in quality.

To address the budget gap, a state commission proposed changing the payment system to one that favors keeping the patient healthy, preventive interventions, and primary care by paying a monthly or annual fee. Insurer Blue Cross and Blue Shield has done just that in an experiment.
As a result, the incentive to increase volume or procedures is diminished and doctors are focused on delivering the most cost effective care.

So students going into primary care should take heart. You are choosing the right specialty for the future. To avoid the traps that your mentors have fallen into, be very picky about where you practice. Want to be your own boss? Want to be an employee? Either is fine. Make sure however that you work at a place dedicated to using electronic medical records not only for charting, but ordering and reviewing medications, lab results, and imaging. Check to see that your compensation isn't significantly died in to the fee for service service treadmill.

Then be thankful you made the right choice. There is no more rewarding experience than having a long relationship with another person which typically only comes by being either an internist or family doctor.

Friday, December 4, 2009

Near Misses by Air Traffic Control Still Better than Healthcare System

ABC News reported that two regional jets nearly collided before Thanksgiving near Denver when an air traffic controller accidentally told an approaching aircraft to make a u-turn into the other.

The error was both unbeknownst both pilot crews of the airplanes as well as the air traffic controller. Only 200 feet apart in altitude and less than 2 miles away, these planes flying at hundreds of miles per hour were within seconds of catastrophe.

What prevented this disaster so that it was simply a near miss? Two critical factors.

Computers in both cockpits alarmed imminent collision and advised immediate course of action. Pilots trained to trust the safety systems built to identify threats and problems and not question them.

Although human error is to blame for the near miss, it is clear that technology can assist to improve safety. Also, more importantly is that those using the systems need to have a mindset of trust and act accordingly even if it isn't immediately obvious why the action must be taken. As a result, the aviation industry is the leader when it comes to safety.

When it comes to patient safety, the healthcare system could do much better. Approximately 100,000 Americans die annually due to these preventable medical errors or errors of omission and missed opportunities. However, since these typically only occur one death at a time throughout the country no one seems to notice.

100,000 Americans is about 250 Boeing 747 jumbo jets filled to capacity. Imagine if that many crashed in a year. Would that get your attention?

These errors and omissions occur because doctors and hospitals lack the basic information technology for making patients safer. The vast majority of healthcare providers still use paper charts and handwritten prescription pads. Without a comprehensive electronic medical record which would help identify drug-drug interactions, avoid dispensing the wrong medication or dosage due to illegible handwriting, suggest the lab tests due for specific medical conditions, or prompting both doctors and patients when to get important screening tests done, all of us instead depend on our doctors and pharmacists never to make a mistake.

This is of course impossible.

So why doesn't the healthcare system do better?

Two simple reasons. First, the implementation of technology like electronic medical records is costly and no one wants to pay for it. For a doctor to implement an electronic medical record can easily cost $30,000. If it prevents a drug drug interaction or stops from having the wrong prescription dispensed, the patient benefits. Does the doctor or pharmacist benefit?

Second and perhaps the biggest challenge is in changing the mindset of doctors. Pilots and flight crews are trained to communicate and speak up regardless of their rank. Doctors, however, operate in a world with a set hierarchy and perspective that impedes safety. The pecking order still is medical student, intern, resident, fellow, and attending physician. Medical assistants, physician assistants, nurses, and doctors. Attending doctors tell residents what to do. Residents tell medical students what to do. Doctors tell support staff what to do.

As a result, the mindset becomes one of self reliance and a top down approach rather than one that values collaboration and team orientation. Rules, regulations, and computerized systems aren't going to tell a doctor what to do. This perspective explains why wrong side surgeries still occur and surgical instruments are left in patients even though surgical timeouts and checklists have been implemented in hospitals. Despite built-in safety systems and reminders in electronic medical systems which could help doctors provide better and safer care, doctors balk at the hassle factor of being slowed down or being prompted by a computer even though using paper charts they have more potential for serious harm.

The aviation industry takes safety seriously. When two Northwest airline pilots were using personal laptops in the cockpit which resulted it distracting them from their duties, being out of contact with air traffic control for 90 minutes, and resulted in them missing their destination airport, the airline suspended the pilots immediately while the FAA revoked their license.

The healthcare system says that it takes patient safety seriously, but do we? If doctors don't wash their hands routinely before every patient and every time, should physicians be suspended? Watch your doctor next time you see him. If he doesn't wash his hands, a simple yet important ritual to avoid spreading germs, then what other important steps might he be skipping?

The healthcare industry still has a long way to go in regards to patient safety. Until the mindset changes where doctors embrace systems and teamwork to prevent adverse outcomes which will invariably occur due to human errors and flaws, you'll be far safer flying than staying overnight in a hospital.

Monday, November 30, 2009

H1N1 Update and ABC News 10 Sacramento

Streaming live on ABC 10 today with Sharon Ito about questions regarding H1N1 vaccine.

Sharon's summary of today's discussion.

SACRAMENTO, CA - On Monday's Live_Online at 11 a.m., we talked with frequent contributor Dr. Davis Liu, a family physician with Kaiser.

Liu said Kaiser, along with other health providers, are still awaiting additional shipments of the H1N1 vaccine. He said Kaiser closed its flu shot clinics a couple of weeks ago after running out of the vaccine, but he expects the vaccinations to resume shortly. Liu said the vaccine's manufacturers were overly optimistic when initially projecting the distribution of the vaccine.

Liu told viewers he can't understand why some doctors and nurses around the country have refused to get the H1N1 vaccine, especially when they're seeing sick patients and their potential exposure to the virus can infect other people.

Liu told viewers the manufacture of the H1N1 vaccine is similar to the production of other flu vaccines, and he said those methods have proven safe.

You can reach Live_Online at:

Copyright 2009 / All Rights Reserved

Watch the entire interview here.

Saturday, November 28, 2009

Secrets to Weight Loss -- Part Two -- The Body Doesn't Lie

Now a couple days after Thankgiving, an important concept to remember is the following:

The body doesn't lie.

We've all eaten a little too much. If we've done any exercise, then it is likely standing in line during Black Friday (or clicking the mouse on Cyber Monday). We should not be shocked about some weight gain. Although my patients find it hard to believe, the body doesn't lie and are stunned that they continue to gain weight in subsequent office visits. It can't be due to anything they are doing.

It must be due to a medical problem. Aside from hypothyroidism, low thyroid levels which can be determined by a simple blood test, or other even less common illnesses like Cushing's disease, the reality is that the vast majority of individuals I see who are overweight or obese simply due to their dietary and caloric intake. Simply put, they eat more than they burn.

It isn't necessarily due to a lack of willpower. The majority of patients who are obese (body mass index or BMI of 30 or greater) report to me that they were normal weight at the end of high school. Decrease activity, disability, and pregnancy are some reasons patients are heavier than years past. Many not only are surprised about their weight gain, but also on how difficult it is to lose.

Why is it more difficult to lose? Caloric intake or eaten exceeds that which is expended or burned off. It doesn't take much.

A typical American is supposed to take in only 2000 calories per day. Sounds like a lot, but it isn't. An In and Out cheeseburger with cheese, fries, and a soda is 1100 calories. A Subway 6" cold cut combo, mayonnaise, soda, and chocolate cookie will add another 950 calories. Eat one for lunch and the other for breakfast and one has already exceeded the 2000 calorie daily limit. Not a lot of food.

Many of my patients who work construction don't realize how many calories they eat when going out to lunch. A typical Burger King double whopper with cheese, large fries, and large regular soda equals 1890 calories! Yet, they don't feel like they overeat. Nevertheless, the body doesn't lie and neither does the scale (although many of my patients swear that our office scale isn't accurate).

Portion sizes have increased over the past couple of decades. Despite well meaning public initiatives like having nutritional and calorie information available on menus, it is doubtful that alone will help change behavior. What is needed isn't the calories, but how much physical activity one needs to do to burn off the extra calories.

Image if a slice of pizza came with the disclaimer, each slice requires a 30 minute walk. With activity listed rather than calories, individuals would begin asking themselves whether second helpings, supersizing meals, or even finishing the entire meal (rather than taking it home) would be a good idea.

Since it only takes 3500 calories to equal a pound. Any calories left unused the body dutifully begins storing for a rainy day (which doesn't occur as much industrialized countries as it does other places around the world). Since the rainy day never comes, your increased fat stores result in a heavier weight.

Unless the food and restaurant industry voluntarily decreases portion sizes, then expect more Americans to be heavier and less healthy. Cases of obesity and type 2 diabetes are occurring at an alarming rate. It is expected that children born since 2000, will be the first generation of Americans not to live as long as their parents. While type 2 diabetes affects about 1 in 4 adults over age 65, for children born at the beginning of this century the rate will be 1 in 3.

Is it the food and restaurant industries fault for the obesity epidemic? Regardless of what you believe, it is unlikely that significant changes in health will be the result of those organizations making substantial changes. Americans demand cheap food that is quick and convenient.

So the world is against you in maintaining a healthy weight (or losing weight if you are overweight or obese).

What can you do? Some simple ideas:

  • Purchase some frozen lunches / dinners with the Weight Watchers, Healthy Choice, South Beach labeling. Save the containers and use those as your new plates. Don't pack in the food. Don't go for seconds.
  • Switch to diet sodas or zero calorie drinks like water or tea.
  • If drinking fruit juices, consider diluting the amount with water.
  • Never ever supersize anything. Consider having children sized meals or smaller versions.
  • Avoid packaged foods like chips, cookies, candies etc., and opt for fruits.
  • Hold off on second helpings (and don't simply double the size of the first helping).

Learn more about calories and more importantly how much activity you must do to burn off the calories to maintain or lose weight by reviewing the Portion Distortion quiz by the National Heart, Lung, and Blood Institute and other information by the U.S. Department of Human and Health Services.

Remember, the body doesn't lie.

Check with your doctor if you have special dietary needs or diabetes whether the above dietary adjustments are safe to do. Make the changes permanent. It's a lifestyle change. Don't expect friends or family necessarily to follow suit. It really is building a system that you can do consistently daily in response to a society which encourages more food and calories.

Any other helpful tips or ideas?

Wednesday, November 25, 2009

e-Patients, Dr. Google, Your Doctor, and You

A recent article by NPR confirmed what many patients and doctors already know. The internet is leveling the playing field and allows individuals to access information easier and more quickly. Research by Pew Internet and American Life Project found:

  • 61 percent of adults say they look online for health information - known as e-patients
  • 20 percent of e-patients go to Internet and social-networking sites where they can talk to medical experts and other patients
  • 39 percent of e-patients already use a social-networking site like Facebook

Yet as individuals embrace new technology, the New England Journal of Medicine found earlier this year that only 17 percent of doctors use electronic medical records. To say doctors are conservative and slow in adapting to new ways of communicating and accessing information would be an understatement. An article in TIME magazine proclaimed "Email Your Doctor" which graced newsstands in 1998! Email communications with doctors is still the exception rather than the rule.

Many doctors actually are very concerned about patients using the internet to research information. Stories of physicians being inundated with printouts or patients insistent that they have a certain diagnosis based on a description abound. Doctors don't always appreciate patients googling their medical information.


Because although information gathering is far easier than a decade ago, the problem is data overload. How does one filter out all of the different diagnoses with similar symptoms? How does one use judgment when theirs is based on little experience? Medical students commonly come down with medical illnesses after studying a subject. It's the power of suggestion. Fever and a little neck stiffness? Meningitis. Intermittent numbness in the arm? Multiple sclerosis. Circular rash? Lyme disease.

Only through experience and actually caring for patients diagnosed by more seasoned colleagues do medical students see the textbook descriptions come to life. Patients diagnosed with meningitis, multiple sclerosis, and Lyme disease and their associated symptoms and signs are seared into students' memories. Words in the textbook now have far different meanings. Reading and book learning while important only provides the foundation to build upon. It's seeing and doing that matter.

Doctors can't know everything. So it can be helpful if you research information and bring in some ideas or questions that you have about a particular diagnosis. I know patients are more empowered with more information, but realize there is still value in clinical expertise. Have a frank discussion with your doctor whether the information obtained by Dr. Google is accurate or relevant to your concerns. Keep an open mind. Don't be anchored by what you read. I certainly learn from my patients. My patients learn from me. It's a win-win.

While the internet can make anyone more knowledgeable, it doesn't make someone an expert. The good news is that the survey found in the end that the source people still trust the most is their doctor. So go ahead research, but find reputable sources like the Mayo Clinic or Medline Plus. Talk to your doctor and perhaps email him. Gain from both knowledge tempered with expertise.

As we all gather around for Thanksgiving, savor the time with family and friends. While I would never be mistaken for a chef, let alone a good cook, I will be making a delicious butternut squash soup which is a new Thanksgiving tradition. The recipe? Courtesy of the internet and Wolfgang Puck. How hard could it be? I finished organic chemistry.

Wednesday, November 18, 2009

Breast Cancer Screening with Mammograms at age 40? 50? Who is the USPSTF?

When the U.S. Preventive Services Task Force (USPSTF) updated their recommendations and were against routine mammography for women aged 40 to 49, it certainly got a lot of attention. These guidelines are far different than those advocated by the American Cancer Society (ACS) which recommends screening starting at age 40 with annual mammograms.

  • Who is the USPSTF?
  • What does their recommendations mean for women?
  • Why is there conflicting recommendations?
Who is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF) is an independent committee of primary care and preventive physicians that periodically reviews the latest medical research and recommends tests and screening methods that have scientifically been shown to make a difference. As a result, its recommendations are the most conservative of any national organization.

The USPSTF’s recommendations are considered the “gold standard” for determining which clinical services are preventive. They review and look at various screening tests and preventive medications to determine whether there’s proof these interventions work and that the benefits they provide outweigh the potential harm. USPSTF indicates how strongly it recommends a particular method with a letter grade designation (A, B, C, D, and I). An A recommendation means that USPSTF strongly recommends that doctors provide a particular service to eligible patients. A B rating is simply a recommendation. A C means the task force recommends against routinely providing the service, but leaves the decision to the discretion of the individual doctor and patient. A D rating means the group recommends against providing for a particular intervention. An I recommendation indicates that there is not enough evidence to determine whether to recommend for or against a particular procedure.

The USPSTF recommendations tend to be the most conservative of any national organization, because they look for interventions that have proven benefits backed by research. Therefore, promising new technologies and tests that are yet unproven (and at times remain unproven or shown to be no better than existing tests) will not be recommended. As a result, the USPSTF’s guidelines may lag behind those of other organizations. But because they set such a high standard before recommending a particular treatment, insurers should cover the tests and procedures rated A and B.

From the November 2009 update on breast cancer screening update, the USPSTF recommended:

  • Against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  • Recommended biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  • Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  • Against teaching breast self-examination (BSE). Grade: D recommendation.
  • Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  • Insufficient evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

What does this mean for women?

First, that there is some evidence that screening between ages 40 to 49 for breast cancer among women with average risk may not be as beneficial as we previously thought. There has been evidence from other countries, like Canada, which have suggested that. However, it is highly unlikely that the American Cancer Society (ACS), being an advocacy group for cancer awareness will change their stance. They said as much with the following:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

The American Cancer Society neglects to mention the potential number of extra women harmed with the extra screening between age 40 to 49. An additional 565 women need to be screened above and beyond the 1,339 women to save one life. Within this additional group, many women will have abnormal mammograms and require breast biopsies only to discover that the results were normal. The mammogram was a false-positive.

The USPSTF found in a study in the Annals of Internal Medicine, funded by the National Cancer Institute, that screening every other year achieved over 80 percent of the benefit of screening annually while cutting the false-positive result by nearly half. While every other year screening from age 50 to 69 years resulted in about a median 16.5% (range, 15% to 23%) decrease in breast cancer deaths compared to no screening, starting mammogram at age 40 decrease the death rate further by 3 percent, but increased the costs as more false-positive cases occurred. This article helped influence their recent decision.

Realistically for women, since ACS will not change their recommendation, is that mammograms will still be a covered benefit for any woman who desires to have a mammogram as early as age 40 and can be repeated annually.

What does this mean for you? If you are worried about breast cancer, consider getting screened starting at age 40, however, the benefit of screening may not be as good as we first thought. Certainly if there is a family history of breast cancer, you should discuss with your doctor whether mammography is enough or whether a breast MRI is needed.

Why are there conflicting information?

This won't be the first time USPSTF will have different recommendations than groups like ACS or other professional medical associations. Reasonable doctors and researchers can look at the same data and have different results. It speaks to the problem of screening for cancers and the tools that we currently have. The amount of precision that we would like as patients and doctors in identifying which group of individuals truly need a screening intervention and who does not have yet to be discovered. USPSTF and ACS disagree a bit on colon cancer screening as well. For example, when it comes to colon cancer screening USPSTF gives a grade A recommendation and suggests that:

Using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.

Yet, ACS also recommends virtual colonoscopy or stool DNA testing as reasonable alternatives even though there is no proof they save lives.

Stay tuned. Medical science continues to evolve and recommendations continue to change. The the mean time, exercise regularly, don't smoke, eat five servings of fruits and vegetables daily, and you might extend your life by an additional 14 years!

Your most crucial and trusted relationship is between you and your doctor. Questions? Speak up and ask. Don't be scared. Be informed.

Thursday, November 12, 2009

Secrets To Weight Loss - Part One

It's disturbing that in the United States, two-thirds of Americans are either overweight or obese. As a doctor, it is one of the most common problems I address, even if a patient doesn't ask me to. Got a cold? Feeling stressed? Want a physical? Rolled your ankle?

Has anyone ever discussed your weight? Are you concerned about your weight? What have you tried for weight loss? What did you find successful?

In this series, I'll reviewed my discussions with patients so you understand what it will take to lose weight and keep it off.

Losing weight is hard work and frankly can be a difficult and lonely experience since the majority of Americans are overweight or obese. The problem of heaviness in this country is only becoming worse.

First some basic concepts. Overweight is defined as a body mass index or BMI greater than 25 and less then 30. Obesity is a BMI greater than 30. Morbid obesity is a BMI greater than 40. Calculate your BMI. Although BMI isn't perfect, unless you are a high performing athlete (not a weekend warrior) and have significant muscle mass, BMI is a reasonable way of determining which category you fit into.

Second, the body does not lie. Unless you have some sort of medical problem like a low functioning thyroid (hypothyroidism) or other less common hormone problem, your body does not lie. If you eat exactly the same amount as you burn, then you will not lose or gain weight. Eating less and burning more consistently will cause weight loss. Eating more and burning less will result in weight gain. Simple concept. What goes in must equal what goes out to maintain weight. Any alteration in this simple equation causes weight loss or weight gain. The body does not lie.

Third, I don't think you overeat to the degree you think I do. Patients invariably tell me that they eat very little and certainly a lot less than their friends or family. While I know individuals aren't eating a Thanksgiving dinner or eating an entire large pizza for lunch daily, weight loss requires a caloric intake less than the output. Note the previous point the body does not lie. If a person did eat a lot, he would continue to gain weight, not maintain.

Fourth, you need to understand basic math. Know this number. 3500. An addition of 3500 calories equals one pound. If your body has 3500 calories left over, then you gain a pound. Burning 3500 calories, then you lose a pound. Sounds like a lot of calories, doesn't it? But it's not. If you drank a can of regular soda daily (and yes, diet doesn't count as it has zero calories), then that is an extra 130 calories per day. In 27 days less than one month you would gain a pound (3500 / 130 = 27). In one year you would be 12 pounds heavier.

Fifth, think of calories as money and your weight as a savings account. Your savings account goes up or down depending on how much you save. Put more into the bank and withdraw less? More in your savings account. Taking out more than you put in, the amount in the savings account falls. Your bank doesn't care if you deposit $100 in pennies or in a crisp C-note. Skipping the discussion of nutritional value, your body doesn't care if the 2000 calories you are supposed to ingest comes all via salad greens or the equivalent of a box of chocolates. Money is money. Calories are calories regardless of how you get them.

Sixth, your body is built for survival and isn't stupid. Go back to the previous point. Your weight is a savings account and to keep it level what goes in equals what goes out. If all of a sudden, your income gets cut then to make ends meet you must take withdrawals from your bank account. If the income doesn't return to previous levels, then the savings account continues to get smaller.

Faced with this situation of being unable to restore deposits to previous levels, would you continue to spend as much? Of course not. To avoid bankruptcy you would make hard choices like downsizing your expenses and making adjustments. As a result you slow down the outflow of money so that eventually the amount that you spend is equal to the new decreased amount coming in.

Your body is built for survival and isn't stupid either. Faced with a budget crisis, that is a diet where calories coming in is less than what is burned, initially the body hasn't had adequate time to make adjustments. It depletes its savings resulting in weight loss. But since it is built for survival, it will make adjustments necessary to that its expenditures exactly made your diet. You no longer lose weight. Your body doesn't know whether it is on a desert island or living in the United States where food is plentiful, but all it knows is that its caloric budget was cut. It needs to keep you alive until it can find its next meal. Adjustments are made. Weight loss stops. Naturally, it will deplete fat first, then muscle. So don't worry about that being a reason not to being weight loss.

Seventh, the vast majority of patients I see weren't overweight or obese to being with. Weight gain typically occurred after high school or college, job change which was less physically demanding, after pregnancy, and as they got older. Sadly this isn't the case today where children are increasingly obese and will be the first generation of Americans not to live as long as their patients because of weight related medical problems.

Finally, the success to long term weight loss is permanent reduction in calories and increase in physical activity. It's not a diet but a lifestyle change. You can lose weight in the short-term with fewer calories, which is the reason why gastric bypass works. However, long-term weight loss requires physical activity.

Saturday, November 7, 2009

Union Behavior Might Be Obstacles in Transforming American Healthcare

Some interesting articles in USA Today regarding union positions about the H1N1 vaccine which suggest that transforming American medicine so that it is higher quality, improved access, and even more affordable will be extremely difficult if not impossible.

Some hospitals, healthcare organizations, and the state of New York attempted to have staff required to get the seasonal and H1N1 vaccines. Even though, Infectious Diseases Society of America recommended all healthcare workers get flu shots, the Service Employees International Union (SEIU) opposed this and won.

Although patients are lining up demanding flu shots, doctors and the Centers for Disease Control want those at risk, SEIU indicates that the issue is education, rather than attaining compliance by fiat. To be completely fair, too many doctors don't get vaccinated either which is equally as disturbing. In healthcare, we make too many exceptions rather than require that the right thing gets done at all times.

While I was troubled by the behavior of SEIU, I can understand while disagree with their opposition to mandatory vaccination. It seems more of a political decision rather than scientific.

Yet, later that week SEIU was again in the news. This time upset about the distribution of flu vaccine to companies that have employed in-house doctors and clinics. Specifically, the union had a problem with companies like Goldman Sachs which received vaccinations from the City of New York in a equitable system where only those at highest risk (chronic illnesses or pregnancy) were to be immunized and the original distribution was reserved for pediatricians and obstetricians who requested vaccine. Sadly only about half of the pediatricians in New York City wanted it. As a result, the city moved on to give vaccines to those doctors caring for adults, which included the physicians working at Goldman Sachs as well as the Federal Reserve Bank, Columbia hospital, and Time. From the article:

"Wall Street banks have already taken so much from us. They've taken trillions of our tax dollars. They've taken away people's homes who are struggling to pay the bills," union official John VanDeventer wrote on the Service Employees International Union website. "But they should not be allowed to take away our health and well-being."

The union has about 2 million members, including health care workers.

Um, so wait. Healthcare workers are considered a high-risk group as defined by CDC. Naturally healthcare workers should be among the first in line to get the vaccine. If you had agreed to a mandatory vaccination program for those in the union who are healthcare workers, wouldn't that mean those in your union therefore are vaccinated and kept healthy? Getting the vaccine, which is in short supply wouldn't be a take away, but a benefit!

Having mandatory vaccinations in really only a small issue in a much larger problem. How can employers and unions get together and transform American healthcare?

To be clear, I'm not opposed to unions. One of the most successful organizations ever is Southwest Airlines, which to the surprise of many who don't know, is among the most unionized airline in the country.

I'm troubled because companies like General Motors failed because unions and employers were unable to see eye to eye. As a result, it failed because it was unable to compete with foreign competitors. Unlike the auto business, there foreign national healthcare organizations wishing to take over the US marketplace.

What it does mean, however, that making healthcare better and cheaper won't happen. Result? Government takeover or increasingly more Americans uninsured, worsening healthcare quality, and increased costs.

Wednesday, November 4, 2009

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All

A fascinating article and equally disturbing is a fantastic article from Wired magazine. An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All is an objective look at the two different camps regarding vaccinations and the concern whether they are the cause of autism.

Both camps want to keep children safe. Both have very different ideas on what that means. For doctors and the medical profession, the science has been drowned out by a very effective media savvy campaign which has resulted in significant decreases in immunization rates resulting in the return of previously contained childhood illnesses like measles and pertussis.

As the internet connects more of us and removes obstacles for acquiring knowledge, it has instead reinforced and caused polarization not only in politics, but even more so in medicine.

Find out the truth on how to stay healthy and well by asking questions, listening to opposing points of view, and then making your own decision. I learn from patients. Patients learn from me.

As the article rightly notes, choosing not to have a child vaccinated isn't risk free, but rather a different set of risks occur. While I may disagree with patient's decisions, I do respect them as long as I feel they are informed about the pros and cons. I only hope that they choose based on rational thinking rather than emotional fear.

Monday, November 2, 2009

Can Doctors Provide Rational Care or Cave In? H1N1 Experience with Public Health Indicates Latter

As the country discusses providing everyone with health insurance, an even more important conversation is how to slow the rise of healthcare costs. Many studies and research point to the ability of doctors to remove waste by not performing unnecessary tests or procedures and not prescribing the latest medications which are proven to be no better than generic versions. There is a belief that much of this additional cost is due to the fee for service reimbursement system where doctors get paid more to do more.

For example, spending 30 minutes on nutritional counseling, weight loss, and exercise for one patient with hypertension doesn't pay as much as prescribing blood pressure medication for three patients in 10 minutes. In the fee for service environment, volume is key, not necessarily providing the right care or the most rational care. A recent Newsweek opinion piece by an emergency doctor showed how he evaluated a patient appropriately for a recent head injury, discussed the plan with the family, and arranged follow-up with the pediatrician all without getting a CT scan of the head. Result? Patient did fine. No radiation exposure to the brain. No additional cost to the healthcare system, insurer, or family. Everyone benefited.

While the example isn't rare, it also isn't common. Some 30 percent of tests or procedures performed in this country have been suggested to be unnecessary and added no value to improving patients' quality of life or outcomes.

In other words, if we removed the fee for service reimbursement system, then doctors would prescribe only the right care. Not too much or too little, but just right.

Or would they?

Recent articles should make us think twice. The H1N1 virus which has been demonstrated to affect those under age 25 years old and pregnant women disproportionately than the general population now has a vaccine available, albeit in short supply. This limited supply has been given to individuals not deemed at high-risk for adverse outcomes by CDC.

While the issue might be that some public county clinics received more vaccine than others (a systems or distribution problem), the bigger question is whether public county officials and doctors are willing to have honest and frank discussions about a person's need for the vaccine. Unlike doctors in the fee for service environment, these providers don't get paid more to do more. Since compensation isn't an issue, then can they talk through the fear that people have and provide the appropriate care?

Answer? Unfortunately no. Public health officials don't want to be the police and determine who should justifiably get the vaccine and who should be turned away.

In other words, if people want it, then they will get it. If public health officials can't say no appropriately, then can we expect much better for doctors in the future? Even if the fee for service reimbursement structure is removed, unclear if that will ever happen, will doctors provide rational care and advice or cave in when patients demand prescriptions based on television ads or care recommended by celebrities?

As I received my vaccine at a flu clinic, there were nurses asking each individual in line what vaccine did they want. The nurses appropriately advised those not in the high-risk groups that they would only receive the seasonal flu vaccine and not the H1N1 vaccine. There were no fights, outbursts, or fear. Patients understood that they were getting the right care. Not too much and not too little, but just right.

If America is going to solve the affordability issue of healthcare, then doctors will need to lead the way.

Based on the public clinic officials' performance, I'm even less optimistic about the medical profession's ability as a whole. While I have great confidence in my fellow medical school alumni from the University of Connecticut School of Medicine, the colleagues I work with at the Permanente Medical Group as well as the many medical bloggers I've encountered (many who follow me via Facebook or Twitter - thanks everyone!) , I have real concern about many doctors nationwide and specifically on their ability to provide rational care and not to cave in and take the easy way out when making decisions about medical care.

What does this ultimately mean? Without doctors leading the way, the only choice left is government run healthcare. If doctors can't say no based on scientific and medical evidence, then Uncle Sam will say no. Don't say I didn't warn you.

Tuesday, October 27, 2009

Why I Chose to Get the H1N1 Vaccine

As a practicing primary care doctor and as the only doctor in my family, I take my job very seriously. Particularly now with so much information available literally at anyone's fingertips via the internet that separating the truth from hype can be impossible for patients. The public often gravitates towards those with media publicity and exposure rather than expertise. This was reinforced by a recent Newsweek article which found Suzanne Somers recent book about nutritional cures for cancer treatment as questionable.

So certainly the amount of exposure regarding the H1N1 vaccine and who should get it and why has been getting plenty of airtime, bandwidth, and newsprint.

So, why did I chose to get the H1N1 vaccine?

Because it is the right thing to do for myself, my wife, and my children.

Here's the scenario. A new novel flu virus that targets those 25 years and younger and who are twenty six more times likely to come down with it than those 65 years and older appears out of the blue in April 2009. Healthy children, young adults, and pregnant women are disproportionately affected. Many die. The world's best scientists and researchers, using the latest in medical research, identify and sequence the virus in record time. The blueprint is handed off to pharmaceutical companies in a herculean effort to produce enough vaccine for a world fearful that another 1918 pandemic is among us where millions of young and healthy individuals died before their time.

The 2009 summer continued to see significant cases of H1N1 flu. In late October, 46 states report widespread H1N1 virus activity. Doctor visits related to influenza like illnesses stand at 7 percent with no end in sight.

Based on the latest monitoring, the overwhelming virus type is H1N1. From CDC of the nearly 5,000 specimens that tested positive for influenza, 99.8% where influenza A and nearly 70% were confirmed to be 2009 H1N1. Of the remaining 30% that weren't initially subtyped, those that were submitted to CDC for further analysis ultimately were H1N1. From CDC:

No. of specimens tested 12,943
No. of positive specimens (%) 4,855 (37.5%)
Positive specimens by type/subtype
Influenza A 4,844 (99.8%)
A (2009 H1N1) 3,378 (69.7%)
A (subtyping not performed) 1,436 (29.6%)
A (unable to subtype) 30 (0.6%)
A (H3) 0 (0.0%)
A (H1) 0 (0.0%)
Influenza B 11 (0.2%)

During week 41, influenza B viruses co-circulated at low levels with 2009 influenza A (H1N1) viruses. All subtyped influenza A viruses reported to CDC this week were 2009 influenza A (H1N1) viruses.
Finally, American medicine develops a designer vaccine that is specific for exactly the virus that is the predominate strain this flu season. The vaccine only has one virus type and not the typical cocktail of multiple viruses used in the seasonal flu vaccine. The flu season is caused by one type of virus, which the vaccine provides protection. In addition, this designer vaccine is produced using proven production techniques and given via a delivery system (injection form) used for years. Side effects are very mild and have been documented with previous vaccines.

That's the story. Here's the irony. Public response? 38 percent of parents when offered refused the H1N1 vaccine for their children.

Perhaps it is how we get our information and news. Our society is focused on 30 second soundbites. The general public lends weight to individuals with celebrity status and often equates their media exposure to scientific and medical expertise. Viruses don't care if you are Republican, Democratic, or Independent. When public figures like Bill Maher and Glenn Beck talk about their opinion, they need to state that their opinion is for entertainment only and in no way is a substitute for medical expertise (you would think that would be obvious to listeners).

As a practicing primary care doctor, I continue to worry about how the public gets its important health care information and its ability to separate hype from the truth.

Get educated. Get informed. If you refuse, then that is ok as long as it is informed refusal. If you refuse because of ignorance, then I hope you or your loved one never gets ill and dies from this preventable illness. A lifelong feeling of regret when something could have been done, but wasn't isn't a burden I wish on anyone.

Quick summary.
Novel potentially deadly virus preying on the young and healthy as well as pregnant women? Identified and sequenced.
Possible vaccination? Developed using proven techniques.
Side effects? Well known and mild.
Public response? Fear, apathy, and inaction.

My worry? That the flu season isn't as bad as what the President's Council of Advisors on Science and Technology forecast as one scenario of a 30% prevalence of H1N1 resulting in 90 million ill, nearly 2 million hospitalized, and at least 30,000 dead.

The best part so far with the H1N1 vaccine? The side effects of the shot are actually much better than the seasonal vaccine, which we all received last month. Children didn't have any fever. My arm wasn't sore at all.

I'm ready for this flu season as one of the front line primary care doctors.

Are you?

Still confused? Find out of the vaccination or the nasal spray is best for your children. Why people fear the H1N1 vaccine. Fast facts about H1N1 - although for the latest information go to or CDC.

How Effective Are Generic Drugs?

A brief ABC News video titled How Effective Are Generic Drugs? provides the truth about generic drugs. For the vast majority of individuals they are equally effective and less expensive. If you truly need a brand name drug, then obviously you'll pay more.

For many however, generic is perfectly fine.

Sunday, October 18, 2009

How to make your health insurance count as if your life depended on it

Five years ago, I penned an opinion piece which appeared in the San Francisco Chronicle titled, "How to make your health insurance count as if your life depended on it".

The most disturbing and troubling aspect of the piece is that if it was published today it would still be completely accurate. Healthcare quality still varies dramatically over the past decade despite the Institute of Medicine's 1999 landmark report "To Err is Human".

Even as many expect President Obama to have healthcare insurance reform bill requiring universal coverage signed by the end of this year, the reality is that it will still be a full decade before meaningful improvements in the healthcare system will be seen. That's optimistic to say the least.

What should you do? Make sure you make the right choices today so you will be around for years to come because it isn't clear even five years later after my opinion piece that the healthcare system is in any hurry to fix itself soon.

Who pays for this inertia? You do. But with some education (and even the critical insider tips from my book), you can get the best healthcare American medicine has to offer without overspending).

The op-ed piece follows.

How to make your health insurance count as if your life depended on it

It's that time again, and every year I dread this activity almost as much as April 15, or trying to find my wife the "perfect" Christmas gift. Typically, autumn is open-enrollment time for choosing a health-insurance plan. Though we gripe about increasing out-of-pocket costs, for most of us, health insurance is a hassle, a formality and not worthy of much attention. But we could be dead wrong. Unlike other products and services we purchase, health insurance makes it difficult for consumers to adequately determine whether it is worth their hard-earned dollars. As a result, many of us chose the plans based on cost or whether our doctors participate in the plan. This ignorance could cost you your life.

The National Committee of Quality Assurance estimates that this year, 79, 000 Americans (nearly twice the number who died of breast-cancer) died prematurely -- not because of hospital errors, misdiagnoses or negligence, but because they chose the wrong insurance plan. Had they selected a high- quality program, the simple things like controlling high blood pressure, lowering cholesterol and managing diabetes to levels recommended by the American Heart Association or the American Diabetes Association would have been reached and their lives prolonged.

When NCQA compared the performance of the top 10 percent of health plans with the national average on certain measures like breast-cancer screening, advising patients to quit smoking, immunization rates for flu shots, it discovered variability among plans exceeding 20 percent. If one used similar criteria to compare the safety performance of the top 10 percent of airline carriers with the national average, the quality gap was far less than 1 percent. The same applied for banking and manufacturing. How safe would you feel about flying if among the various airlines there was a quality variance of more than 20 percent? Yet, when it comes to health care, consumers don't appear to be concerned.

An additional frightening fact is that only 25 percent of all insured Americans have health plans that voluntarily provided their performance data for review by the NCQA . This means you have an increased chance of not knowing whether you're choosing a poor-quality health plan this year.
As if that weren't enough, during this enrollment period, the term "consumer-driven health plans" is the new catchphrase for cost containment. In an effort to save money, employers are less likely to provide comprehensive coverage, but rather directly give you the dollars to manage and spend on health care. Now you, not the health-insurance plan, will decide what tests, treatments and procedures you can afford. For your nagging sciatica, should you pay for an MRI of the spine or a CT scan to rule out a herniated lumbar disc? For your sake, with the burden of financial responsibility and the lack of consistency among health plans, you'd better hope you never ever get ill.

So what can you do? Although there is no national urgency to fix the problem, you aren't completely powerless. First, check out the NCQA Web site ( and see if your health-plan options are accredited and approved by NCQA for providing high-quality health care. If not, consider talking to your human resources department and getting NCQA accredited programs on your roster next year. It's your money. Don't you deserve the best value and quality?

Next, take charge of your health now, get the overdue preventive screening tests done, and work with your doctor on getting the right treatment, not necessarily the newest.

Finally, do the boring but simple stuff: Get control of your blood pressure, lose weight, lower your cholesterol and stay active. These interventions really do save lives. How do I know? I am employed by one of the health plans highly rated by NCQA. My hope is that with hard work and some luck, you might just be around long enough to see an American health-care system that is known not as the most expensive, but the best at promoting a healthy and productive quality of life for us all.

Sunday, October 11, 2009

The Truth About H1N1 Vaccinations - Shot, Nasal Spray, or Neither? Parents Uncertain.

A recent Associated Press-GfK Poll found that one-third of parents will not have their children vaccinated with the H1N1 flu vaccine. While 59 percent of parents were willing to give permission to schools to administer the H1N1 vaccine to their children when available, 38 percent refused.

Sounds like a lot, doesn't it?

But it's not. News reports failed to highlight another fact in the same survey. Two-thirds of parents (66 percent) planned on having their children vaccinated against the traditional seasonal flu and one-third (32 percent) did not.

In other words, the number of parents opposing the H1N1 vaccine is about the same as the seasonal flu vaccine. As a whole, a significant number of parents oppose flu vaccinations whether for the seasonal or H1N1 virus, which was commonly referred as the swine flu in the spring.

Yet, reports from CDC show that the flu outbreak is widespread in 37 states with the vast majority being H1N1. The number of pediatric deaths for the 2008 to 2009 flu season (starting September 28, 2008) stands at 147 with 76 deaths due to the 2009 H1N1 virus. Twenty-nine of the H1N1 deaths occurred since August 30, 2009. What is concerning is that the number of pediatric deaths is higher than in years past. Since the H1N1 virus started in the spring, it is very possible the number of pediatric deaths will only increase for the 2009 to 2010 flu season.

The H1N1 virus is particularly harmful in children and young adults aged 25 years and younger. CDC reported in the spring that the number of H1N1 cases was 23 to 26 times higher in individuals 24 years and younger than people 65 years and older. The older cohort had some natural immunity while the younger group had none.

Given all of this information, why aren't parents acting?

Psychology may explain this. People tend to have more regret when they actively make a decision that results in a bad outcome than if they passively had it happen.

For example, some research suggests that changing answers on a test on average benefit the test taker. Yet, most of us are quite reluctant to do so even if it is in our best interest. Why? Feelings of regret are far more powerful if did something to result in a bad outcome than if the bad outcome occurred due to no action on our part. In the case of test takers, they felt better if they left a wrong answer (inaction) than if they actively changed an answer and then got it wrong (action). Even though having a wrong answer, the bad outcome, was the same in both cases the latter group felt far worse.

Actively scheduling and then taking a child to get the flu shot and potentially needing to deal with side effects are not very likely, but still a real possibility. Should the child suffer an adverse reaction, then naturally the parent would feel terribly responsible. If the child instead developed H1N1 and had not gotten vaccinated earlier, the parent would feel not feel as guilty.

Yet as for the threat of H1N1, I suspect many parents see what they want to see. If their child isn't ill and they don't know others who are ill, inaction is preferred.

This inaction is just a sign of a disturbing trend. Increasingly more parents are concerned about vaccinations in general than the illnesses they protect against because people don't have personal experience with individuals suffering from illnesses like polio, mumps, or measles. They don't recall the scare sixty years ago when polio outbreaks closed public pools, paralyzed otherwise healthy individuals, and prominently impacted the life of a sitting American president, FDR. Despite all of the medical advances in the 21st century, new cases of polio still occur throughout the world despite the availability of effective polio vaccines. Children still suffer from devastating life altering complications from polio because their parents refused get them immunized. Vaccinations work.

Given a choice between the inactivated flu shot, which uses a killed virus, versus a nasal spray vaccine, which uses a live but weakened flu virus, I would suggest parents who are concerned about safety to opt for the former. I feel better about receiving a dead virus to train the immune system rather than subjecting the body to a weakened one. I would note, however, that both vaccines are approved for usage.

Although the inactivated H1N1 flu shot must be given on two separate occasions for children 9 years old and younger (up to 6 months old), this is not different than when children get the seasonal flu vaccine for the first time. Read more about the inactivated H1N1 flu shot via the vaccination information statement. Research has shown that children 10 years old and up only need one H1N1 flu shot.

The nasal spray uses a live, but weakened virus which can only be administered to children ages 2 years and older. Therefore, children age 6 months to 2 years desiring a H1N1 immunization will need to get the shot. More about this nasal spray H1N1 vaccination via its vaccination information statement. It only needs to be given once.

In the end, I hope these parents that choose not to vaccinate their children against H1N1 are right. I hope their assessment of risk to their children is correct. I hope that they aren't wrong, because if they are wrong, they could be deadly wrong.

A vaccine exists and has the real potential to save lives. It's safe. Instead many parents are walking away partly due to psychology, some fear, and often due to lack of experience with formerly common debilitating illnesses. Often what troubles me as a doctor is knowing something could have been done to save lives, decrease suffering, and improve health, only to discover that the opportunity is missed and it never happens. I hope that the concerns parents have about H1N1 or the seasonal flu and their subsequent inaction do not become one of these tragic missed opportunities.

Monday, October 5, 2009

Voluntarily uninsured isn't a calculated risk but a gamble. Can you really afford to lose?

This recent NPR piece on Voluntarily Uninsured: A 'Calculated Risk' got my attention. There are some people who don't buy health insurance. They are healthy. They can afford health insurance. They don't feel the need.

They are wrong.

As a practicing doctor, it is worrisome to hear people are voluntarily uninsured because of a false belief. Having good health is highly unpredictable. Children develop cancer without having a family history or adequate time to assault their bodies with cigarettes or alcohol. Women with healthy pregnancies may need a crash C-section, which is far more expensive than a vaginal delivery. Too many people are injured from motor vehicle accidents requiring significant medical care. Non-smokers do develop lung cancer and the astronomical costs of chemotherapy.

Good health is somewhat unpredictable the same way the chances of you getting into a car accident is a crap shoot.

Assume you are an excellent driver. Never speed. Never had a traffic violation. In fact, you abide by the rules and recommendations to stay safe that other drivers honk you incessantly when you drive 25 miles an hour in a residential area and that even the police department flags you down when going 55 miles an hour on the highway because it is such an anomaly. Your passengers groan when you buckle up simply to move your car from the street into the driveway.

A drunk driver seriously injures you on your way home from work.

You did everything right and yet there you are. An accident occurred and no fault of your own.

At least you have auto insurance and can get some of the costs back.

Serious car accident or serious illness. While we have some control, in many cases it is out of our hands. In other words, while we can decrease risk by staying healthy, as a doctor I see too many times people getting seriously ill with no definable cause. Voluntarily uninsured is not calculated risk but rather a gamble. It's a gamble none of us can afford to lose because of a misconception.

As the subject in this NPR article finally admitted in the end, serious illness could bankrupt her and cause her to lose her business. She is seeking some catastrophic insurance. In the end, some insurance is better than none.

Thursday, October 1, 2009

Breast Cancer Awareness Month - Truths and Myths You Must Know

Besides being known for Halloween, the first full month of fall, and also a day to recognize Christopher Columbus, October is also known as breast cancer awareness month.

It not only is a good time to remind women to get screened for breast cancer, but also an excellent opportunity to clarify many myths that continue to persist among many women I meet in the office as well as community outreach programs I lead.

The lifetime risk of a woman developing breast cancer is one in seven. One common misconception is that breast cancer occurs primarily in women with a family history. In fact, the vast majority of breast cancers occur in women with no family history. The other misconception is that many women feel as they get older that their risk of developing breast cancer decreases. Their risk of breast cancer actually increases.

With increased awareness, thanks in part to the pink ribbons, the annual Susan G. Komen Race for the Cure, the breast cancer research stamp, and breast cancer awareness month, you would expect that women would be well informed about breast cancer. You’d think women would get regular mammograms, perform breast self-exams, and have regular clinical exams performed by physicians. An October 2005 article in the New England Journal of Medicine found that in fact mammography was largely responsible for the improvement in breast cancer survival over the past twenty-five years.

Despite this, women are not getting mammograms as suggested. In 2002, only 62 percent of women forty and older reported having a mammogram within the previous year. The number decreased to less than 40 percent in women without insurance. Another study showed that only two-thirds of women forty and older in New Hampshire received mammograms annually or biannually even though 97 percent had health insurance and over half (61 percent) were college educated.

Screening for breast cancer begins by doing a self breast examination monthly. Learn how to perform a breast self exam (BSE) correctly at To be completely thorough, also get a mammogram if it is indicated for your age group. Often, mammograms detect breast cancer at a much earlier stage and well before a lump is large enough to be felt by yourself or a doctor. Mammograms can also detect growths too deep in the breast to be felt by anyone. However, performing a breast self-exam regularly is equally as important, since some breast cancers cannot be identified by mammography.

Women are recommended to get mammograms annually starting at age forty. Make sure that your mammogram is performed by an accredited facility and the results are interpreted by qualified radiologists. Refer to the FDA Center for Devices and Radiological Health at and look for the mammogram program.

If you feel a lump, or your breast just doesn’t feel right to you, see your doctor right away even if you had a normal mammogram recently. Sometimes growths can occur and you may need another mammogram or other additional tests like an ultrasound.

Newer digital mammograms are on the horizon. Preliminary results have shown that these mammograms may be more effective in detecting tumors in women with dense breasts, who are not menopausal, or are under fifty years of age. And for women who do not fit into these categories, digital mammography was found to be equally as effective as traditional film-based mammograms.

In 2007, the American Cancer Society recommended breast MRIs as another way of screening for breast cancer in women who were considered high risk for developing the disease. (A lifetime risk of 20 percent or higher is considered high risk.) Your doctor has a variety of tools that can predict this risk. One is available from the National Cancer Institute at

If you are considered high risk, ask your doctor whether a breast MRI is right for you and whether your hospital can perform the test. It may be a while before your local MRI facility will have the appropriate setup and radiologists trained to interpret the breast MRI correctly. The breast MRI is to be used with a mammogram and should not replace mammograms. Women at high risk for breast cancer should consider getting both a mammogram and a breast MRI at age thirty. Women with a risk of 15 to 20 percent should ask their doctor whether a breast MRI is a good idea.

Regardless of whether you use traditional film-based or digital mammograms, if a mammogram is indicated for your age group get it done.

For more additional helpful insider tips you must know to keep well, get the easy to read book – Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.

Tuesday, September 29, 2009

NutureShock - New Thinking About Children

I could not put down this fascinating book on the latest research regarding child development. What we've been told has been wrong. Chapters include - The Inverse Power of Praise - Sure, he's special. But new research suggests if you tell him that, you'll ruin him. It's a neurological fact. Another chapter - Why Kids Lie - We may treasure honesty, but the research is clear. Most classic strategies to promote truthfulness just encourage kids to be better liars.

A very shocking chapter - The Search for Intelligent Life in Kindergarten - Millions of kids are competing for seats in gifted programs and private schools. Admission officers say it's an art: new science says they're wrong, 73% of the time.

An easy read full of stunning and thought provoking research it will make you think hard about how you raise and interact with your children. A must addition for any parent's bookshelf.

Friday, September 25, 2009

Evidence That Doctors Will Not Support Healthcare Reform

While doctors are interested in covering all Americans with health insurance, universal coverage alone will not resolve the healthcare crisis. One of the major cost drivers in healthcare is due to more imaging tests, use of expensive medications, as well as more medical interventions which actually don't result in better outcomes.

This has been well described in various articles and books.

Despite our perception as physicians, it isn't necessarily defensive medicine and ordering more tests, procedures, and imaging that is driving overall healthcare costs, but is the reimbursement system. It rewards volume over quality and is particularly true for specialties that can increase volume. This is why primary care doctors have not seen increases in compensation and medical students are flocking to other specialties like dermatology, radiology, ophthalmology, among others. Primary care doctors can only increase volume by seeing more patients. Other specialties can improve compensation and volume by doing more surgeries and procedures, which in many instances are questionable if they are truly needed, effective, or even better than non-invasive treatment or watchful observation.

So it comes as no surprise that the New England Journal of Medicine's article - Physician's Beliefs and U.S. Health Care Reform - A National Survey finds doctors agree in abstract with universal coverage, but when asked to make that happen by asking themselves which expensive treatments really work and which are unnecessary that they walk away from the responsibility. Excerpts from the article:

Although physicians tend to agree in the abstract that health care resources should be distributed fairly, they may be unwilling to endorse concrete policies that expand coverage for basic health care by limiting reimbursement for costly interventions. And despite widespread discussions about using cost-effectiveness data or comparative-effectiveness research to guide clinical decisions, physicians may remain skeptical about such practices.3,4 Thus, physicians may not be willing to take on the role that the President and health policy advocates want them to play.

...surgeons, procedural specialists, and those in nonclinical specialties were all significantly less likely than primary care providers to favor reform that expands access to basic health care by reducing reimbursement for expensive drugs and procedures...

First, the President, lawmakers, and reform advocates can vigorously engage physicians in deliberations on health care reform, cognizant that most physicians see it as part of their professional responsibility. However, more controversial elements of reform, such as limiting reimbursement under Medicare (i.e., expanding the ranks of the underinsured), using cost-effectiveness data in treatment decisions, and limiting reimbursements for expensive drugs and procedures — all of which are elements of current reform proposals — may face serious opposition from segments of the medical profession.
In other words, you can't have your cake and eat it too. If we as a nation wish to expand coverage so that it is universal and everyone has health insurance, then we can't have every test, procedure, medication, and intervention that we want. However, that really isn't the right way to look at solving the problem.

The right question to ask is do we as a nation need every expensive test, procedure, medication, and intervention when others that are less costly but just as good work (comparative-effectiveness research - think Penicillin is still used for strep throat and has been around for over 60 years)? If we agree on the latter, then the problem becomes those medical specialties that benefit from more volume will see a pay cut.

When the abstract of universal coverage meets the reality of taking money away from someone's pocketbook, in this case more specialty doctors than primary care doctors, expect the discussion to become vocal and talk to elevate about rationing care rather than providing rational care. Healthcare reform does NOT require rationing.

Monday, September 21, 2009

Zoster / Shingles Vaccine - Is it Necessary?

I often get questions about the zoster or shingles vaccine known as ZOSTAVAX. Shingles or zoster is the painful skin condition that typically occurs in older patients and is caused by the chickenpox virus. If you've ever had chickenpox, then you are at risk for developing shingles later in life.

Typical symptoms initially include painful area for a few days which may be related to viral like symptoms of muscle aches, low grade fever, and malaise. The painful area usually is on one side of the body (unilateral) and along a dermatome, a nerve distribution root. The pain can be excruciating and often described as burning and intense. Patients often do not like any clothing to touch the area.

After the pain appears, a few days later a small rash of clear small blisters, known as vesicles, erupted and are typically grouped together on a base of redness. The rash appears on the exact same area of the pain.

The vesicles eventually scab over and over a period of a few weeks and resolve. The pain typically goes away as well but can take longer.

However, in some patients, the pain continues and can be irritating enough that it interferes with people's lives. This condition is known as post-herpetic neuralgia (PHN) and is more common in individuals aged 60 and older and who have other chronic illnesses like diabetes.

This is why many patients are worried about shingles / zoster. A friend has suffered from PHN and has made sure everyone they know get the vaccine to decrease the risk of developing shingles and then potentially PHN.

So how good in the vaccine? Should you get it? How common is shingles?

It depends.

From the vaccine insert of ZOSTAVAX

The rate of getting zoster is WITHOUT the vaccine:
10.8 per 1000 people per year - aged 60 -69
11.4 per 1000 people per year - age 70-79
12.2 per 1000 people per year - age 80 and older.

This means about 1 percent of the population aged 60 and up will develop shingles annually.

The rate of getting zoster is with the vaccine
3.9 per 1000 people per year - aged 60 -69
6.7 per 1000 people per year - age 70-79
9.9 per 1000 people per year - age 80 and older.

Note the decrease of those developing shingles age 60 to 69, but that the vaccine's ability to prevent shingles diminishes. This isn't due to the vaccine per se, but the immune system's ability to mount a response. As we get older, the immune system is less effective.

As a result the vaccine effectiveness is as follows:

Effectiveness of Zoster vaccine is
64% for pt aged 60-69
41% pt age 70-79, and
18% for those 80 and older.

Also from the package insert although the vaccine did decrease the rate of PHN due to decreasing cases of shingles, other complications of shingles like zoster around the eye, pain, and scarring from the rash were unchanged.

ZOSTAVAX is only indicated for people 60 years and older. Some patients cannot get the vaccine so check with your doctor.

It is covered under Medicare Part D.

More at the CDC website.


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