NY Times - Finding a Quality Doctor - Why the Author and Doctors Are Wrong.

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes.  From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following - 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal.  She correctly notes that these measurements alone aren't what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor's bedside manner, should count as well. 

Her article was simply to illustrate that "most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care" yet when she offered this perspective, a contrary point of view, many viewed it as "evidence of arrogance."

She comforted herself by noting that those who criticized her were "mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care."

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card -

I don't even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It's too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them. 

As a practicing primary care doctor, I'm afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can't do both.  She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death.  They aren't in the office and yet are suffering.

Until we as doctors begin to take responsibility for our performance in hard clinical and objective outcomes like glycated hemoglobin levels, cholesterol, and blood pressure, our patients will pay a price.  We should not pretend that bedside manner should trump clinical outcomes nor that clinical outcomes should override the humanistic part of medicine.

It is possible to do both today.  It isn't theoretical.  I only serve as one example.


I'm a front-line primary care doctor who also takes care of patients. I like Dr. Ofri also get a report card on my performance in caring for patients with diabetes.

Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.

I suspect critics will immediately begin to make a lot of assumptions of how these scores were achieved, when Dr. Ofri, another primary care doctor had very different outcomes.  Is it that I am not a quality doctor? Perhaps I’m too driven by data and have no - “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.  Perhaps I "fire" those patients who are not able to achieve good outcomes.

I can tell you many patients wish to join my practice and rarely do people choose to leave it.  The organization I work for also takes the softer side of medicine, a doctor’s bedside manner, seriously.  My employer randomly surveys patients on their experience. Does your doctor listen and explain? Do they know your medical history? Do they partner with you in your health? Do you have confidence in the care they provided you?

For 2010, 92.8 percent rated me very good or excellent on these elements.

So what does this all mean?

We should not automatically assume that doctors with great bedside manner cannot also provide great clinical care.

I can achieve the goals, which patients would want, and still be a doctor with great bedside manner because I work in a functional system like Kaiser Permanente. Primary care doctors are blessed with a comprehensive electronic medical record, are partnered with staff who help patients get the care they need, and are surrounded by specialty colleagues equally as focused to keep patients healthy and well.

So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes.  Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn't necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves.  Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.

Until we as doctors lead, we cannot or should not expect improvement in patient outcomes.  We can no longer hide behind the reasons of our Herculean effort or bedside manner as what should really matter and account for something.  Patients expect these attributes intuitively.

With already so many examples of success in the country marrying the art, science, and humanistic part of medicine, the only thing stopping us to re-invent American medicine in the 21st century is simply ourselves.

Why Doctors Need To Be Less Like Chuck Yeager and More Like Captain Sullenberger

A recent medical error of a wrong site surgery that occurred in one of the country's best hospitals, Massachusetts General, reminded me why doctors need to be less like Chuck Yeager and more like Captain Sullenberger.  Growing up I always wanted to be a fighter pilot, years before the movie Top Gun became a part of the American lexicon.  My hero was World War II pilot Chuck Yeager, who later became one of the country's premier test pilots flying experimental jet and rocket propelled planes in a time when they were dangerous, unpredictable, and unreliable.  Much like the astronauts in the movie, the Right Stuff, Yeager and his colleagues literally flew by the seat of their pants, made it up as they went along, and never really knew if their maiden flight in a new aircraft might be their last.  They were cowboys in the sky wrangling and taming the heavens.

Fast forward to January 2009, when shortly after takeoff a one in a million chance, a double bird strike completely disabled a US Airways jetliner.  Captain Chesley Sullenberger with the help of his co-pilot Jeff Skiles ditch the aircraft in the Hudson River in under four minutes even as the nation surely expected a tragedy.  But not on that day.  Not with that pilot.  Though Sullenberger, an already accomplished pilot from being the top cadet at the US Air Force Academy, an aviation safety expert with his experience as a crash site investigator for both the military and civilian sector as well as an instructor for US Airways pilots, he credited much of the success to his training and his experience.  Sullenberger had studied why pilots and crews often failed in critical emergency situations.  He also mastered and understood the physics and performance aspects of the aircraft he flies (his wife calls him a pilot's pilot).  He also believes strongly and instinctively the need to follow checklists and protocols to ensure the right thing is done every time.  This was drilled in him in the military where the difference between life and death in a fighter plane could be simply a matter of feet and seconds.

Though the media dubbed the landing as the "Miracle of the Hudson" and named him America's hero, Sullenberger modestly noted he was simply doing his job, which only endeared him even more to a country looking for positive stories in a time of a new president, an unprecedented financial crisis, two wars, and an uncertain future.  Ask Captain Sullenberger, review the cockpit recordings, and you'll discover that he wasn't really flying by the seat of his pants but was very methodical, rational, and logical as he quickly evaluated his three options: return the plane back to LaGuardia, go to Teterboro, New Jersey, or ditch in the Hudson River.  While planning for a landing after the unthinkable, his co-pilot automatically did his job attempting an engine restart by cycling through the checklist seven times.  They landed the plane successfully with a little luck, a lot of skill, and a full understanding of how humans make mistakes in particularly stressful times and what mechanisms when put into place, checklists, protocols, and training, can decrease these to a minimum.  Frankly, no one else could have landed that plane except Sullenberger.

Which brings me back to the medical error noted in the New England Journal of Medicine.  Dr. David Ring, after a day of many carpal tunnel surgery releases erroneously performed the surgery on a woman who was supposed to get a trigger finger release.  Though he has been praised by many to be courageous to publicly acknowledge the error, what was quite disturbing was his one comment:

"I no longer see these protocols as a burden. That is the lesson."

His insightful comment should not be seen as an anomaly.  Dr. Ring should also not be ostracized.  He speaks the truth.  Doctors today still see themselves as cowboys, the heroic individual who despite whatever obstacle or hardship can just get the job done.  Somehow, we are too smart to rely on surgical timeouts, checklists and protocols.  Instead, we refer to the entire process "cookbook" medicine and go through the motions just to appease regulators and administrators.

It is this arrogance and hubris that pervades our profession that is quite disturbing and equally disappointing.  A March 2010 report found that medical schools are not doing enough to prepare future doctors on how to develop the mindset for patient safety.  Yet for much of medicine, we understand the precisely the science of how to do things better.  No central line infections occur when all doctors abide by a simple 5 point checklist developed by John Hopkins intensivist Peter Pronovost.  Merely having every surgical team member introduce himself before surgery as noted by New Yorker writer and general surgeon Atul Gawande improves communications so that the team is more likely to function better in times of crisis.  Even a singular phone call by Dr. Gawande to the blood bank to hold blood on standby for a "routine" surgical procedure, which he had done many times before and never needed the blood, ended up being critically important.  On that day with that routine surgery, his patient had a tear which required 30 units of blood.  If Dr. Gawande hasn't called for blood on standby before the operation started, his patient would have died.

We know much more about medicine since the development of antibiotics, antiseptics, and best practices, yet we act no differently than 150 years ago.

"In 1852, the Massachusetts General Hospital was featured in a New York Times article detailing a series of events that led to the death of a young patient. Under the care of the surgeon, Dr. John Collins Warren, the patient had received chloroform instead of the usual chloric ether anesthesia. The event that we describe here, more than 150 years later, is a sad reminder that despite expert and well-intentioned providers, our patients continue to face risks caused by human fallibility and systems that do not fully support our efforts to provide safe care."

It's time doctors stopped acting like the cowboy test pilots of Chuck Yeager's era and adopted the mindset of Captain Chesley Sullenberger and doctors Pronovost and Gawande.  Protocols and checklist exist for the safety of our patients and to ensure highly reliable outcomes everytime.  Until doctors all adopt this mindset, medical errors will continue to happen despite policies and regulations because somehow our profession still believes we are infallable.

Too Much Radiation From Medical Scans? Antidote is a Superb Primary Care Doctor.

The Associated Press has been running a fantastic series of must reads with the latest article highlighting the consequence of too many imaging studies, like xrays and CT scans, which are the biggest contributor to an individual's total radiation exposure in a lifetime. Americans get more imaging radiation exposure and testing than people from other industrialized countries.

Reasons for doing too many tests include malpractice fear, patient demands for imaging, the difficulty in obtaining imaging results from other doctors or hospitals, as well as advanced technologies, like coronary angioplasty, which have increased radiation but avoid a far more invasive surgery like heart bypass.

Although these are all legitimate concerns, one of the reasons listed was , include:

"Accuracy and ease of use. Scans have become a crutch for doctors afraid of using exams and judgment to make a diagnosis. Some think a picture tells more than it does. Imaging that shows arthritis in a knee or back problems doesn't reveal how to make it better, said Dr. Richard Baron, a primary care doctor in Philadelphia."

Dr. Baron was recently widely cited for his article in the New England Journal of Medicine on the true workload of primary care doctors which gives valid reasons why medical students as well as those in practice are avoiding the specialty or retiring respectively.

It really isn't accuracy and ease of use as Dr. Baron suggests, but rather a matter of survival for doctors on the front-line. The vast majority doctors are paid fee for service. That is the more you do the more you get paid. In the case of primary care doctors, the more patients you see the more you get paid.

It has been argued that if primary care doctors were paid a salary instead of by number of patient visits that more time could be spent on asking the right questions and doing thorough examinations to get to the root of a patients problem. When I train first-year medical students, I tell them exactly the same thing: If there is only one thing you learn from me, then it is how to take an accurate history and a relevant physical exam. Ninety percent of getting the right diagnosis is refining these two skills.

Students often ask how long it takes to be good at this.

A lifetime. Professional athletes, artists, and musicians never stop getting better and as doctors neither should we.

Why is this important?

Because the latest thought in healthcare is to slow costs by pushing more financial responsibility to patients. A report by the consulting firm PricewaterhouseCoopers found that majority employees will face a deductible of $400 or more, which is in addition to the annual premiums. Will patients really be able to ask or even challenge their doctors on the appropriateness of an imaging study? Do you ever tell your auto mechanic to not service your car when the airbag indicator or the brake light come on? (If you have, please let me know because I certainly didn't have the courage to do so).

The other thought is to make prices for procedures more transparent as start-up Castlight tries to do. Shop around for the cheapest imaging study. Although this also is a laudable approach to slow healthcare costs, it is also not addressing the root cause. Doctors are ordering too many tests. Though price transparency will make the unit cost of the test cheaper, Americans will still be overdosed with radiation.

Doctors need to step up and lead the way. They cannot until the reimbursement system changes that values primary care for time spent thoughtfully evaluating patients by talking and examining them. As Dr. Abraham Verghese of Stanford Medical School and an outstanding clinician notes, it is the patient's story that matter not the imaging tests. As he correctly argues in an editorial in the British Medical Journal

...clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test.

To avoid overtreatment and save money, find a superb primary care doctor will to talk to you about the pros and cons of medications, imaging tests, and procedures. Be thankful she did. As the Associated Press series of Overtreated articles illustrate, sometimes it is best not to keep up with the Joneses and walk away from too many tests while still staying healthy.

Can't find a stellar primary care doctor? No worries. The truth on how to avoid the traps of overtreatment are found in my book which is available on Kindle, iPad, and iPhone, as well as hardcover. This easy to read book offers the skills I use to keep my patients healthy while thoughtfully ordering treatments they really need to stay well.

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.

Why?

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.

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 www.komen.org/bse. 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 www.fda.gov/cdrh 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 www.cancer.gov/bcrisktool.

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.

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.

FAQs - Fast Facts - What You Need to Know About H1N1 influenza

I've been getting a lot of questions from my patients about the H1N1 influenza virus, which was commonly described as the swine flu earlier this year.

Naturally everyone is fearful, particularly about the unknown.

Do I need the vaccine?
Research has shown that the H1N1 virus, which is similar to that of the 1918 Spanish flu pandemic, was around until about 1958. Since then, other influenza types have pushed out this variety. In other words, individuals born before 1958 seem to have some immunity. Those born since then have less protection.

(Note the New England Journal of Medicine article - Historical Perspective — Emergence of Influenza A (H1N1) Viruses - July 16th, 2009, notes that the H1N1 human virus disappeared in 1957 and reappeared again in 1977. The 2009 pandemic H1N1 virus is created by multiple other influenza virus components which is beautifully diagrammed here in the Perspective piece The Persistent Legacy of the 1918 Influenza Virus related to the NEJM article).

CDC also observed that those most impacted by the novel H1N1 virus were those 25 years and younger. Specifically:

The information analyzed by CDC supports the conclusion that novel H1N1 flu has caused greater disease burden on people younger than 25 years of age than older people...

The number of reported cases per 100,000 population was highest among people in the 5 years to 24 years of age group (26.7 per 100,000). This was followed by those in the 0 to 4 years of age group, whose case rate was 22.9 per 100,000 people. The rate declined further to 6.97 people per 100,000 in the 25 years to 49 years of age group. The rate was 3.9 per 100,000 people in the 50 years to 64 years of age group. At 1.3 people per 100,000, the novel H1N1 flu infection rate was lowest in people 65 years and older.

This epidemiological data supports laboratory serology studies that indicate that older people may have pre-existing immunity to the novel H1N1 flu virus. This age distribution is very different from what is normally seen for seasonal flu, where older people are more heavily impacted.

As a result, unlike seasonal influenza the recommended group is young adults, age 24 years old and younger down to 6 months old, caregivers watching children 6 months and younger, as well as those ages 25 to 65 years old who have chronic illnesses and pregnant women. Naturally healthcare workers should all be vaccinated.

Typically seasonal influenza vaccine is given to people 65 years or older unlike the H1N1 vaccine. Also groups at risk very much similar to the list above should be vaccinated. In the past children 6 months to 59 months were recommended to have the vaccination as well. That has expanded to children and teenagers up to 18 years old.

So indications for the seasonal influenza vaccine are very similar to the H1N1 except that people over 65 years old won't need the latter.

Will I get a vaccine?
The information so far is that the H1N1 vaccine will be available in limited numbers because it has been difficult to produce. All influenza vaccines are grown in eggs, this is why before getting vaccinated patients are often asked if they are allergic to eggs. Unlike other influenza strains, this particular one has been very difficult to culture which has been frustrating.

As currently planned, the H1N1 vaccine will be given in two shots. Clinical trials are currently ongoing in Austrialia.

It will not protect against the seasonal influenza virus. So if you need that vaccine, you will need to get it as well.

Either vaccine takes at least 2 to 3 weeks before becoming effective and providing immunity.

For healthcare providers and doctors like myself, this means we will need three shots this year!

How dangerous is the H1N1 virus?
It doesn't appear to be any more dangerous that the typical seasonal influenza virus. However, the typical flu virus does kill about 36,000 Americans annually, so even the "normal" flu virus can be dangerous.

Nevertheless, because it is believed those born after 1958 may not have any natural immunity that the numbers of deaths could be much higher. Organizations are bracing for a busy flu season.

What are the symptoms?
Flu symptoms are classically, high fever, diffuse muscle / body aches, and dry cough. People often remember what time and where they are when symptoms first develop. It can last about 1 week.

It is not a bad cold and symptoms don't usually come on gradually over a period of days.

Complications of the flu can include pneumonia and death.

Can the H1N1 virus be treated?
If you contact your doctor within 24 to 48 hours of having onset of symptoms, then an anti-viral medication known as TAMIFLU can be very helpful. If you think you have the flu, then call your doctor as soon as you are suspicious.

How can I prevent getting the flu?
The typical preventive measures like handwashing and keeping your hands away from the eyes, nose, and mouth are helpful. Handwashing technique using regular soap is fine. The key is washing hands for an adequate period of time like 20 seconds.

Also avoid sick people as well.

If I contract H1N1 earlier in the year, am I immune for the remainder of the year?
Yes. However, it would be far better and presumably less misery if you used the vaccine to have your immune system learn what to watch out for in the future rather than contract the virus.

Note that much like seasonal influenza if you've been exposed that this immunity doesn't carry over to the following year as the strains of influenza virus changes annually. This is the reason that flu vaccines are given annually as the contents of the vaccine need to be changed to match the new viruses, while others like pneumococcal vaccine are given years apart simply as a booster.

Where can I find more information?
Learn more and get updated information at the Centers for Disease Control.

Weight Loss? It's About the Calories.

A recent article in the New England Journal of Medicine discovered that the secret for weight loss is simply calorie restriction. From the Associated Press news report:

Some previous studies have found that low carbohydrate diets like Atkins work better than a traditional low-fat diet. But the new research found that the key to losing weight boiled down to a basic rule - calories in, calories out.

"The hidden secret is it doesn't matter if you focus on low-fat or low-carb," said Dr. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute, which funded the research.

Limiting the calories you consume and burning off more calories with exercise is key, she said.

This makes sense. It's about the calories whether you eat less or move more. If you taking in fewer calories than your body needs, your body will find the needed calories from your fat stores. The good news is it doesn't appear that how you restrict calories, i.e. which diet plan is chosen, it is the amount taken in.

The other secret to long-term weight loss is to add exercise.