Wednesday, September 22, 2010

Does the Flu Vaccine for 2010 - 2011 Contain the Swine Flu Vaccine? Should you get a flu shot?

It's that time of year again.  Children back at school.  Football season is underway and baseball playoffs to start soon.  The television networks are rolling out their new shows.

And it is also time to think about getting flu shots.  Just got mine today as I have done annually since going to medical school.

Compared to last year, there isn't as much news about the flu or the flu vaccine. 

This year the Centers for Disease Control (CDC) gives clear guidelines that everyone aged 6 months and older should get the influenza vaccine. 

This month the American Academy of Pediatric recommends that all healthcare providers should be required to get the influenza vaccine.

And one fact that hasn't gotten much attention is whether the 2009 H1N1 virus is included in the 2010 - 2011 vaccine?

Yes it is.  This year's vaccine will be as safe as vaccines in past years as the production process is unchanged.  Inclusion of the 2009 H1N1 virus will not be a problem.

These facts are far calmer than the news in the spring of 2009 when the appearance of a novel influenza virus had the world extremely anxious.  Unlike other flu viruses, the swine flu or H1N1 virus was more easily contracted by young and healthy adults as well as infants, children, and pregnant women.  Older adults seemed to be spared.  A flu virus attacking young and healthy resulting in deaths raised concerns that perhaps this was the beginning of a pandemic much like the 1918 influenza pandemic which killed millions worldwide.  Influenza or flu is not simply a bad cold.  It's a viral illness that nationally causes tens of thousands of deaths.

When first signs of this new virus appeared in April 2009, scientists worked feverishly not only to identify it but also figure out how to create a vaccine to protect the public.  The potential for millions of deaths worldwide was a significant possibility.  By the fall, a new vaccine was available.  Because of the time it took to determine the viral DNA sequence, it was not included in the 2009 - 2010 flu vaccine combination batch.  Patients would need to get a separate flu shot in addition to the traditional one.  

That is when the firestorm of controversy occurred.  Instead of being grateful that scientists that a new vaccine was produced in record time, concerns of about safety appeared.  In addition on the initial rollout, there was inadequate or uneven supply of vaccine which resulted in lines of people waiting for a limited supply of vaccine.  People were being turned away.  To add to the uncertainty, the optimum dosage of vaccine to be given to children wasn't initially clear.  All of this didn't help allay fears.  "Deadly virus about to kill millions.  Untested vaccine rushed to production."

None of these stories panned out.  Fortunately the H1N1 pandemic wasn't as deadly as initially feared.

Nevertheless many of these unconfirmed concerns spread quickly and were repeated resulting in many unnecessarily scared patients.  People are increasingly skeptical of large institutions and organizations, even if they are working in the public's best interest.  As people become more irrational about making important decisions of significant consequence, it is vital that people can trust a group of individuals who put the well-being of others first.  It is vital that doctors step up and lead by example.

Doing the right thing means that if controversy appears, whether regarding vaccinations or healthcare reform and policy changes, doctors must step up and be heard.  Too much misinformation exists.  The public is increasingly confused.  Speaking up means sometime you have to disagree with fellow doctors.

Doing the right thing sometimes is the hardest thing to do.  Getting a flu vaccine certainly isn't one of them.  Do the right thing, roll-up your sleeves, and get the flu vaccine.  It's what I'll be doing for my family.  Demonstrate to your staff and your patients it is the right thing to do.

Doctor, get vaccinated.  Remind them to get the flu vaccine.

Thursday, September 16, 2010

Empowered Patient - Is This What Americans Really Want? Probably Not.

Empowered patient.  Consumer driven healthcare.  Transparency.  Access to their full medical records online.  Review the latest news and you'll discover more books and articles recommending patients be advocates for themselves.  The pitch?  The only way to get the best care is to be thorough, informed, and always asking questions. This perspective is understandable because advocates have observed a healthcare system that provides inconsistent quality, too many preventable medical errors, and overtreatment resulting in unnecessary injuries and deaths.  Even I've written a book saying the same thing and I hate to write. 

The public is urged to take charge of their health and their healthcare.  When they have a problem, ask the doctor questions.  Do research.  If they need a procedure, shop around to get the best deal.  Adopt good habits.  Eat more fruits and vegetables.  Stop smoking.  Maintain a healthy weight.  Exercise regularly.  These will improve health and be less costly in the long run.  

But is this what Americans really want?  Do they want to be empowered patients?  Can they be empowered patients? 

Frankly, no.

Americans don't want to be empowered patients anymore than they wish to be experts in retirement planning or IT gurus.  Life is already too busy.  Both parents are working, sometimes two jobs to make ends meet.  Children's schedules are packed with so many activities that simply having playtime to be a child is almost seen as being lazy (even though it might be the right thing to do).  People know they should exercise, lose weight, and eat fruits and vegetables.

But the problem is in adopting both healthy habits and having patients shift their behavior to be more engaged in healthcare is that it is more than the result of poor individual choices or lack of knowledge.  People are not particularly rational even when it is in their best interest and even when it makes economic sense.  In fact, it is incredibly hard to make those right choices unless the system is tweaked to promote the right behavior.  Shifting the system requiring patients to have more financial responsibility in medical care through higher deductibles and copays won't do it.  History has already shown how this failed in retirement planning.

In the 1970s when employers started shifting from pension plans (defined benefit) to 401(k) plans (defined contribution) for cost reasons, the theory was employees would do better in retirement planning.  No one would have more incentive than the individual employee to thoughtfully research and invest their money for retirement than the person directly benefiting from it.  Employees would deduct money from their paychecks, determine an appropriate asset allocation and rebalance their funds to maintain a risk level they were comfortable with.  It was thought to be a win-win.

Decades later, however, it became clear what people should have done and what they were actually doing was vastly different.  Observed behaviors were not consistent with academic theory.  Too many people didn't participate in their retirement plan.  Those who did often had funds in a money market plan which never kept up with inflation and cost of living increases.  Others didn't diversify at all putting their dollars at high risk for failure.  These discoveries led to the rise of behavioral economics which began asking the right question - why don't people do what is in their best interest?

It's because we aren't as rational as we think we are.

As a result, over the past few years employers and the financial services companies having been changing retirement planning to nudge employees to make the right decision.  Employees are now automatically enrolled into a 401(k) plan and no longer need to sign up.  A small portion is deducted from their salaries automatically.  The dollars are invested in target date funds.  Target date funds invest money among a variety of assets to promote diversification to mitigate risk.  More importantly, the funds are shifted automatically over time to more conservative assets as the employee gets closer to retirement, the financially prudent thing to do.  The rate of return typically is higher than the money market accounts and ahead of inflation.

As a result of these changes the number of people not participating in 401(k)s fell from 25 percent down to 5 to 10 percent.  More importantly, they are invested correctly for their retirement.  It is what they would have chosen to do anyway.  If they had time or the desire to do so.

For the minority of individuals who were far more motivated, these programs did not hamper them to invest as they saw fit.

This is a true win-win.

Yet in healthcare, the same troubling trends are occurring again.  The risk of making the wrong choice is much higher as are the consequences.

Much like pension plans decades ago, healthcare costs for companies are increasingly a larger financial burden.  As a result, more insurance premiums are being shifted to employees with increasing copays and now deductibles.  The theory goes if patients have more responsibility for their care that they will make the right choices to stay healthy and well.  Because they have more financial responsibility, they will be more thoughtful when they need to see a doctor and if testing is required they will ask questions, shop around, and do research.  After all, it's their life and their money.  Who else would be most vested in making the right decision than the patient?  It would be a win-win.

Sound familiar?

Familiar and flawed.  It's about improving the system and not relying on individuals to be heroic to do the right thing.

A recent USA Today article about the decline death rate from motor vehicle accidents reminded me of how powerful improving the system is in nudging the right behavior.  It also reminded me how experts continue to wrongly attribute either success or failure to the individual.

The number of people killed from traffic accidents in 2009 was the lowest in 60 years despite the fact that
in 1950 there were about 45 million cars for 150 million people while today's numbers are 256 million cars for a population of 310 million.

NHTSA Administrator David Strickland contributes the drop in fatalities to increased seat belt usage and a strong anti-drunken driving campaign nationwide.
Both of which are individual behaviors.  Now Mr. Strickland may be talking about the year to year decrease in fatalities.  He doesn't address or acknowledge the system improvements that have allowed six times as many vehicles on the road with a population that has doubled in size.  There is no mention of better highway design and signage, rumble strips, crash zones in front of highway off-ramps, guardrails, red traffic light cameras, safer cars with airbags, anti-lock brakes, and better engineering with crumple zones and stronger passenger cages to protect occupants as reasons for a death rate that is the best in sixty years.

Perhaps understanding the importance of system to help the individual, this blurb from the article shouldn't be surprising:
More people die from car crashes in rural areas, with urban areas a distant second, according to NHTSA's data. Driving off the road is the largest type of fatal accident. That's followed by accidents at intersections.

It's not just about individuals making right choices but about the system enabling them to get there.  Rural areas probably don't have sophisticated road design or some of the above system improvements.  Driving off road causing a large number of fatalities makes sense.  In that situation, it really is simply the individual and the car against the wilderness.

So it isn't I'm against the empowered patient movement.  I wrote a book giving them the same tools many others have.

It's a fundamentally different view of the world.  Does enabling good health and providing the right care at the right time boil down to either asking the individual to make the right choices or making the system to enable her to easily get to the right choice?

The former won't work.  With my colleagues, I'm working very hard on the latter.

Friday, September 10, 2010

Tom Brady Car Accident - Driving Safe Car Saves Lives and Careers.

New England Patriots NFL quarterback Tom Brady was on his way to practice when he crashed into a minivan which allegedly ran a red light.  His Audi S8 car T-boned the other vehicle a few blocks from his home.  A relieved New England Patriots owner Bob Kraft noted after the accident:

"[Tom] arched and prepared himself and we're just lucky with the glass and angles. We have a lot to be thankful for. It was really a miracle....We're very, very lucky. Patriot Nation is lucky he had his seatbelt on."

Was it simply luck or good car design and mechanical engineering?  Crumple zones and the passenger cage of a car when built for maximum safety decrease injury.  Yet, unfortunately, there is significant variability among safety in cars.  Brady walked  away from the accident for a variety of reasons.  As a future hall of fame quarterback, Brady has lightning fast reflexes when analyzing defensive blitzes and options when throwing the football.  Quickly bracing himself for impact may have helped.  Wearing a seatbelt definitely helped.

What also helped the most was the type of car he drove.  Audi cars were recently recognized by the Insurance Institute of Highway Safety as Top Safety Picks with the manufacturer recognized with more models than any other luxury German car brand. Earning a Top Safety Pick requires that the vehicle receive a good rating in each of these categories - high-speed front and side crash tests, a rollover test, and protection against neck injuries after rear impact with evaluations of seat/head restraints.  Perhaps had celebrity Dr. Frank Ryan driven a top safety pick car despite his vehicle's rollover, he might be alive today.  There is tremendous variability in a vehicle's ability to protect its occupants which vary among manufacturers as well as models and model year.

Driving a safe vehicle should be as important as exercising regularly, eating healthy, and maintaining a good weight.  Much like quitting smoking or losing weight, the goal is to prevent premature death or disability.  Unintentional injuries are the leading cause of death for those under the age of 34 and the third leading cause of death for people between ages 45 to 54.  Motor vehicle accidents account for the majority of unintentional injuries.  In that moment, all of those healthy habits become meaningless, even for a superstar athlete.  You can do everything right, like Dr. Oz, and discover that you still can have a precancerous colon polyp.

Life happens.  Simply bad luck?  Perhaps.  What can you do to mitigate the risk or bad luck further?

Plan for it the best you can.  In this case, having a car brand that is among the safest in the world, helps.  His car saved his life and saved his career.  It protected him from needing an emergency room visit and evaluation.  As a result, Brady simply walked away from the accident.  He made his practice a little while later and finished his drills with teammates.  He displayed no sign of injury or diability.

Was all of that worth the time and effort to find a car that is fun to drive and yet incredibly safe?

You bet.  Don't believe me?

Ask his wife, Gisele Bundchen, and his sons Benjamin and John.  I'm sure they are glad to have him home safe and sound even as he takes his hits on Sunday as the premier quarterback in the NFL.

Tuesday, September 7, 2010

Dr. Oz, Colon Cancer Screening, Colon Polyp, and Colonoscopy - What Can We Learn

I'm a big fan of Dr. Oz. What is there not to like about the guy?  He's incredibly smart, a graduate of my alma mater, the Wharton School, energetic, pretty good looking, and charismatic.  Though as a doctor I don't always agree with him, as I practicing primary care doctor I have great respect for his mission of getting all Americans healthier. (I wished he could have given me a testimonial for my book, though he sent a nice email wishing me luck. Perhaps my next book?). Though I have a busy day job, the season premier for his second season was one I could not miss. He turned fifty in June and had a colonoscopy in August to screen for colon cancer.  As a result he saved his own life.

Dr. Oz had a colon polyp.  The polyp which was removed was found at the distal sigmoid and identified as an adenomatous polyp.  These types of polyps have the potential to become cancerous over time.  Had it been left in the colon undetected, it could have become cancerous over a period of years.  Had he had delayed his colonoscopy until age 60 it could have developed into a full blown cancer.  Like most of us, Dr. Oz admitted that life is busy and we often delay important screening tests because we don't have time.  Fortunately, the polyp was removed and the likelihood of developing cancer from that growth is essentially zero.  Nevertheless to make sure, he will be repeating a colonoscopy again in a few months.

Understandably, Dr. Oz was shocked and humbled by the experience and the colonoscopy finding.  No one likes to be a patient, particularly cardiothoracic surgeons, who are often in complete control.  Like many patients and particularly even more doctors, he had a bit of arrogance going into the procedure because he works hard on staying healthy.  The colon cancer screening test was simply a thing to check off on his to do list.  A formality, but nothing that was taken seriously.

Instead, the procedure saved his life.  As a result, instead of leading in the second season with a ratings favorite of weight loss, the doctor in Dr. Oz did the right thing.  He aborted the original premier of weight loss originally scheduled because of the surprising colonoscopy findings and refocused the premier on the nitty gritty about hunting down the second leading cause of cancer deaths and filmed his most personal show ever.

He argues, rightly, that we must make time to do the right things.  Had he not been the host of his show, he would have been inclined to do procrastinate as he is a "sloppy patient"".  "Lifestyle is not the cure all by itself."  Part of being healthy and staying healthy is getting screened for cancer, high blood pressure, high cholesterol, and diabetes.

Dr. Oz had no symptoms, no family history of colon polyps or colon cancer.  What is particularly heart wrenching is that thirty-two thousand Americans died of colon cancer because they were never screened.  When caught early, colon cancer is highly curable.

According to Dr. Oz's expert, the majority of patients with colon polyps have no symptoms.  In other words, a deadly time bomb could develop and you wouldn't even know it unless you looked.  Even more disturbing is that seventy percent of patients with colon cancer have no family history.

Although Dr. Oz recommended that all Americans age 50 years and older be screened for colon cancer with a colonoscopy, his polyp was discovered at the distal sigmoid which would have been easily reached with a sigmoidoscopy.  Other options for colon cancer screening also include a virtual colonoscopy, stool testing, stool DNA testing, or barium enema, which are all recommended by the American Cancer Society.

My personal belief is out of all the options to screen for colon cancer, starting at age 50 all Americans who are otherwise healthy and have no family history of colon cancer or polyps should opt either for annual stool testing with a sigmoidscopy every five years or colonoscopy every 10 years. There is nothing magical or superior about a colonoscopy per se as it can also miss colon cancers or polyps as well. Research finds them equally as effective.

The biggest obstacle to preventing colon cancer deaths is that Americans simply don't want to be screened. Colon cancer screening is something I've been passionate about since residency training, when I learned one of my colleague's father died at a young age because of it. Getting my patients to want to have an invasive procedure like a sigmoidoscopy or colonoscopy is incredibly hard.  Yet, I have my 30 second elevator speech nailed.  With Dr. Oz's public campaign, I can refine it even further to this:

If Dr. Oz, arguably a very healthy individual, had a colon polyp, why can't you?

As doctors we need to lead by example. Thanks Dr. Oz for doing the right thing!


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