Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen. 

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.


Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.

The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

*********

It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

*********
The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

How to Pick Good Health Insurance - Your Life Depends on It.

Unless your doctor is a policy expert, in healthcare administration, a researcher, an author or blogger, I seriously doubt he will be reviewing an important report card that helps you pick the best health insurance plan that keeps you healthy.  Published annually by the National Committee for Quality Assurance (NCQA), this year's report card ranks 227 health plans across the country on their ability to keep you healthy and well, treat you quickly, and how patients feel about their insurance coverage.

Because unlike banking or airlines where there is not much difference in ATM machines or planes, there is a big difference in whether a health insurance plan helps in keeping its enrollees healthy.  Do children get their vaccinations?  Do healthy mothers get screened for breast cancer or cervical cancer with mammograms and pap smears respectively?  Do kids only get antibiotics appropriately for strep throat and not overtreated and unnecessarily when they have a viral illness or cold?  Are adults over 50 screened for colon cancer (something Dr. Oz can relate to).

You are incredibly busy living life.  Your health plan should proactively works with you and remind you to do the right thing?  It also helps doctors do the right thing.   

The NCQA report has been part of the US News and World Report best health plans over the past few years and will now be incorporated as part of Consumer Reports.

Be smart.  Be wise this year.  Trying to pick a health insurance plan seems easy.  They are all the same, right?  Simply look at the price.

No.

This is different.

This isn't auto insurance.  This is your health.  You want the best.  Choose wisely because your life and those of your family depend on it.

Pertussis (Whooping Cough) Kills in California. Key Prevention Tip - Vaccinate Adults, Teens, Pre-Teens, Children.

This month California recently declared an epidemic of pertussis, whooping cough, which resulted in the death of five infants under the age of 3 months. The pertussis vaccine, which is already given routinely to infants, is first given at 2 months of age, then 4, and 6 months of age, with an additional booster at 15 to 18 months of age, and then again at 4 to 6 years old.

The vaccines for Bortella pertussis bacteria, which causes whooping cough, does not confer lifelong immunity. In other words, fully vaccinated children who then become teenagers and then adults lose immunity, can acquire the infection and then spread it. Should babies acquire pertussis, as the public has discovered, it can be deadly. The persistent cough tires the baby, causes difficulty breathing, and can make them turn blue or cyanotic resulting in pneumonia or convulsions. According to CDC, about half of children aged 1 year and younger need to be hospitalized if infected with the illness. Although older children and adults can handle the cough, the infection can cause them to cough for weeks or months.

In 2005, a new vaccine known as dTap not only provides protection for both tetanus and diphtheria but also pertussis. The dTap vaccine replaces the dT vaccine and it is recommended that pre-teens starting at age 11, adolescents, and adults up to age 65 get the dTap vaccine as the booster every 10 years rather than the dT. Since the change, I've been a big proponent of getting my patients vaccinated. Many roll their eyes, particularly when I give it to them for visits outside a physical exam, like during allergy seasons, an evaluation for a cold or sports injury.

CDC advice says it best -

Most pregnant women who were not previously vaccinated with Tdap should get one dose of Tdap postpartum before leaving the hospital or birthing center. Getting vaccinated with Tdap is especially important for families with and caregivers of new infants.

The easiest thing for adults to do is to get Tdap instead of their next regular tetanus booster—that Td shot that they were supposed to get every 10 years. The dose of Tdap can be given earlier than the 10-year mark, so it's a good idea for adults to talk to a healthcare provider about what's best for their specific situation.

Newborns and infants aren't fully immunized at a young age and are at highest risk. To protect them from this deadly and preventable disease, those around them, caregivers, siblings, relatives, and visitors must do the right thing. Roll-up your sleeves. Take a little pain. Know that you are building a wall of protection around your little one.

Be sure to ask your doctor for the dTap rather than the dT. Although the new formulation of the vaccine has been around for years, research shows doctors usually lag national guidelines and changes for years as well. Sad, but true. Good bedside manner alone doesn't mean up to date care.

This reminds me to email my doctor to get scheduled for my dTap vaccine. It's been 10 years since my last one.

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.

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.

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.

Fear of H1N1 Flu Vaccine. Theories Why.

I'm hearing plenty of concerns from patients, particularly older patients, about the H1N1 flu vaccine. Some staff also seemed concerned.

Why? I have some theories.

The speed of developing the vaccine seems by many to have been rushed. Instead of being impressed that a novel influenza virus could be identified, sequenced, and subsequently developed into a vaccine seemed to escaped many. Does anyone remember the SARS / avian flu virus that caused problems in Asia a few years ago? No vaccine was developed as far as I know. When we watch and read about stories online and have no personal experience with the flu, then we become detached from the reality. It can't happen to me mentality.

I suspect that when faced with a choice of possibly getting a pandemic virus verus the reality of getting a real novel vaccine now and whatever problems it may or may not have (and really the vaccine should be as safe as previous flu vaccines), people not surprisingly are uneasy about rolling up their sleeves for the latter.

I would also suggest that the same type of denial occurs with other preventive measures like screening for cancer and is why many people don't get mammograms for breast cancer screening or flexible sigmoidoscopies / colonoscopies for colon cancer screening. People would rather wait until they have symptoms and then deal with the consequence, even if they are life threatening and when medical science often has no answers.

As for the H1N1 vaccine, clinical trials are already occurring in Australia which is in the middle of flu season. Safety data will come out eventually but probably not in time to allow people to truly have informed consent. It is expected that the H1N1 vaccine will be available in October.


Almost no one worried about the H1N1 uses the paralyzing condition - Guillian Barre as a reason for skipping the vaccine. Gullian Barre is a legitamate concern as a few hundred cases occurred in 1976 when a flu epidemic occurred at the Fort Dix military base. CDC found since then that the risk of Guillian Barre is small (about 1 in 1 million are potentially at risk), but there has been no strong link between flu vaccine and the condition.

Recommendations by CDC suggest that those who need H1N1 vaccination are individuals 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. Many of my older patients don't wish to have the vaccine do so on altruistic grounds, which I find rather amazing in a society where the current generation seems more focused on "me" rather than "we".


While it is true that people 65 years and older who are otherwise healthy don't the H1N1 vaccine, patients don't necessarily appear relieved when I tell them this. They seem more skeptical that the science shows they are at least risk.

I don't blame them. For years we tell those who are vulnerable, typically those who are younger and those who are older, to get vaccinated. (Recall that when there was a flu vaccine shortage a few years ago due to a manufacturing problem that President George W. Bush was on television urging Americans who were otherwise healthy to skip the shot as he was). Now, we are saying "over 65 and healthy? Don't need the H1N1 vaccine". Though my patients don't appeared to be swayed about allegations of "death panels" and rationing of medical care based on age which have appeared with the healthcare reform debate, one could understandably be suspicious about the H1N1 recommendations and the absence of including the elderly.

What to do?

At least get the typical seasonal flu vaccine which is available now (local grocery stores have it). The flu kills 36,000 Americans annually.

Think about getting the H1N1 vaccine if you are supposed to. The process of producing the vaccine is similar to that of prior vaccines. It has been more difficult to produce and as a result it requires two shots rather than one.

Still on the fence? Talk to your doctor. Check out the CDC's website for the latest information.

Book Review - Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life

As a practicing family doctor and author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System, I am a strong believer in empowering and educating patients so that they can make the right decisions to get the most out of life. As the only doctor in my family I don't think it is fair that only the people I know or care for are privy to the truth about staying healthy, so I looked forward to reading Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life, by Dr. Nancy Snyderman, chief medical correspondent for NBC News, which has a similar same perspective.

Overall, the book was a mixed blessing. It has interesting factoids, ideas we should all take to heart, but at times is misleading. As a consumer and a patient, I thought the truths and news you can use pieces were interesting. As a primary care doctor and patient advocate, however, I felt that many parts of the book were misleading. Perhaps one of the faults is it tries to be too ambitious and attempts to cover too many topics, which often are not in depth enough to be of much value.

Dr. Snyderman points out correctly multiple times that the path to good health is through prevention by adopting healthy habits, staying physically active, and maintaining a sensible weight. The structure of the book reflects this preventive focus and chooses to debunk many myths with these clever chapter titles - Annual Checkups Are Obsolete, Vaccinations Are Just For Kids, Doctor's Don't Play Favorites, Only Old People Get Heart Disease and Stroke, We're Losing the War on Cancer, Natural Means "Safe", and You Can Just Snap Out of Mental Illness. She tackles the truth about herbal and dietary supplements, the unproven value of full body scans, as well as the importance of vaccinations and preventive screening tests for cancer, heart disease, and diabetes.

Throughout the book there are plenty of truth tidbits including, "you cannot catch sexually transmitted diseases from toilet seats; you do not need to drink eight glasses of water every day", among many others and news you can use segments that will make some readers hopefully more aware of what is myth and what is fact. These small sidebars were very interesting. I think patients and consumers will find these factoids topics of conversation.

As a practicing doctor, however, there are many areas which are misleading and others that provide information too superficial to be of value. Dr. Snyderman is correct in one of her chapters that heart disease and stroke are the leading causes of death in this country. However, she uses two individuals, a twenty-six year old former beauty pageant winner, who suffered from a stroke, and a forty year old woman, who died suddenly from swimming, as reasons why we should be concerned. The problem is that these type of occurrences are extremely unlikely and rare for these age groups and gender. The typical cause of these problems, atherosclerosis, or hardening of the arteries didn't cause these cases. The former was most likely due to a heart wall septal defect or a blood clotting disorder, known as a hypercoagulable state. The latter was probably due to sudden cardiac death from a fatal arrhythmia, like ventricular fibrillation.

In the area of stroke, she talks about atrial fibrillation, a heart arrhythmia, as the leading cause of stroke. It is a cause, but this heart condition is typically found in patients over age 60 and far more common in people over 80 years old. She doesn't say that and one would naturally and wrongly assume based on the prior patient stories that it can happen at younger ages, which again is extremely unlikely.

Other areas that are covered superficially include when Dr. Snyderman discusses cancer and mental illness. She pushes for prevention as well as clarifies myths that still exist among the public. Unfortunately in the chapter on cancer, she also talks about various cancer treatments which isn't thorough enough and doesn't seem to fit in a book with this preventive theme. For the mental illness, one of the best written sections because of her personal experience, again the book is rather too ambitious and tries to cover anxiety, depression, and bipolar disorder and the various treatment options even as she admits that "it is impossible to go into as much detail as I would like to". Though she gives a website reference, perhaps it may have been better only to cover depression as she and her husband both had experienced it, and acknowledge the other conditions.

Overall, I wanted to like this book as I believe the intent of giving the public the facts about what they can do to stay healthy and well is vital. I think as a practicing doctor and insider, however, the book at times it is misleading, in some areas is too light in content and in others the information deviates from the book's intent of wellness and health promotion.

Wishing For Natural Therapies Can Kill or Injure

A couple of news reports reminds us about how as a society we have very short memories - one involves measles and the other involves raw cow milk.

The CDC reported a large increase in the number of measles cases. An outbreak in Illinois occurred in home-schooled children and none were vaccinated. Already in 2008, 131 cases were reported, which is three times that of 2007.

• "Before the measles vaccine in this country, there were 400 deaths of U.S. children each year caused by measles," says Dr. William Schaffner, department of preventive medicine chairman at the Vanderbilt University School of Medicine. "Measles carries serious complications, including pneumonia and encephalitis, which is a life-threatening inflammation of the brain tissue that can be caused by viral infections such as measles. Measles is a serious illness. To be cavalier and not vaccinate shocks someone like me, who has seen the devastating effects of this disease."

• So far this year, 15 patients have been hospitalized as a result of measles. They suffered symptoms such as high fever, dehydration and pneumonia. Four of those who were hospitalized for measles were infants.

Although there has been concern, but yet to be proven scientifically, a link between vaccinations and autism, it appears many parents refuse to have their kids immunized. Unlike Dr. Schaffner, who has evidently witnessed the complications of measles, since the vast majority of us have never seen it, we wrongly assume that it can't happen. One option parents can consider is delaying the measles vaccine until their child is older as the shot is given at 12 months of age. Since autism is picked up at about 18 to 24 months, one could ask the pediatrician if it would be ok to delay for a few months. For older children, vaccinating them will make it less likely they can carry it and give it to vulnerable infants.

The other story was about raw cow milk and how 15 people became ill and one woman became partially paralyzed! This frankly is unbelievable and sad. Louis Pasteur, the famous French scientist, who figured out that organisms invisible to the naked eye caused diseases, was also the one to understand and learn how to kill them and make things like milk safer for consumption. This is where the word- pasteurized - came from.

• The raw milk came from Alexandre Family EcoDairy Farms, which supplied the product to 115 customers.
• The county's Department of Public Health suspects at least 15 people were sickened by Campylobacter, a common bacteria found in domesticated animals. The department has confirmed three cases, and are awaiting test results for the other 12.
• Alexandre EcoDairy voluntary stopped its raw milk program June 15 after learning one of its customers was hospitalized. That woman later became partially paralyzed by a rare disorder often associated with Campylobacter infection.

In a high-tech world where many of us wish for simpler times, we must not forget that these more natural methods had major problems as well. The leading cause of death about a hundred years ago was due to infectious diseases. Like the example of measles, just because we don't witness illness or problems ourselves doesn't mean that the problems still don't exist. Many of the reasons we live longer than generations ago is because of high immunization rates and more sterile and hygenic food processing techniques. Are some of the foods perhaps less natural and less safe than the past because of pesticides and hormones? Hard to say, but in that case, purchase organically grown products. Don't ignore basic common sense.

Here's the other question. If people became ill because of an accident or food poisoning, then I don't think anyone would argue we should take care of them. However, what if a person out of ignorance gets ill from a very preventable infection, should we as a society pay of their healthcare? If the woman, who is partially paralyzed doesn't regain full use of her body and requires resources from the community, is that fair for the rest of us?

Why Don't Adults Get Vaccinated?

It's kind of depressing to keep reading about how our healthcare system fails to do the basic preventive tests and interventions that doctors and researchers know that can keep us healthy and lead productive lives. Here's another example in Time magazine's article Why Don't Adults Get Vaccinated?

A survey of 7000 adults found that most could only name the flu vaccine and that the hepatitis A, B, the shingles vaccine, the pneumococcal vaccine, the diphtheria, tetanus, and pertussis vaccine, weren't mentioned as easily.

Excerpts from the article:

• Just 2% of adults have had the new combo shot for tetanus, diphtheria and pertussis (better known as whooping cough), even though pertussis rates in adolescents and adults have soared in the last 20 years. The disease, a major child killer before the childhood vaccine was introduced, can cause coughing so forceful it breaks a patient's ribs or leaves him vomiting.
• Despite clamorous public debate and high-profile media coverage about the first cancer vaccine, which protects against the human papilloma virus, only about 10% of young women reported receiving at least one dose of the three-dose vaccine.
• Vaccines should be a cornerstone of preventive medicine. "They can prevent serious illness and death. They can save money and help keep us healthy, and at work and able to take care of our families, says Schuchat, who is also director for the CDC's National Center for Immunization and Respiratory Diseases. "We obviously have a lot of work to do and it involves literally rolling up our sleeves."

What perhaps is more disturbing is that many adults aren't vaccinating their children.

These reports only illustrate the increasing importance that you must take charge of your health and ask and even demand preventive tests and interventions you need to stay healthy and live longer as it is clear that our healthcare system won't do it for you.

Vaccine against "infant killer"

Doctors in Macau, which is near Hong Kong, want the government to pay for the pneumococcal vaccine to protect against Streptococcus pneumoniae. The bacterium dubbed "infant killer" claims nearly 50 children per hour in Asia. The bacterium is already resistant to many antibiotics. Unfortunately the cost of the vaccine is out of reach for many in Asia.

Lui Kin Man, president of the Macau Paediatric Society, said childhood vaccination against the bacteria was important in southern China because treatment was especially difficult.

"In our region, like Hong Kong, Macau and Taiwan, bacterial drug resistance is very high, and pneumococcal (bacteria) is resistant to drugs like penicillin and erythromycin," Lui said in a telephone interview.

"Mortalities (caused by the pneumococcal bacteria) are higher in developing countries and mostly from pneumonia. Of all pneumonia deaths, 40 percent of them are caused by this bacteria," Lui said.

In the United States, prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

In America, children are routinely offered this vaccine. Recommendations by the Centers for Disease Control suggest that for children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

With immunization, parents don't need to worry that there children will contract the illness or a bacterium that is resistant to many antibiotics. Yet, in this country many parents question the importance of vaccinations as doctors and parents a world away wish they had the opportunity to immunize.

Adult Vaccination Update

As it does regularly, the CDC revised its recommendations for adult vaccinations. Now adults who are worried about shingles or zoster, which is a very painful skin eruption that typically occurs in older adults, can get vaccinated at 60 years of age. Also new is the recommendation that all adults without proof of immunity to the chicken pox (varicella) virus should get vaccinated.

Not sure what immunizations you need? Print out the adult vaccination schedule and have your doctor explain. It's the easiest way to make sense of the alphabet soup of immunizations. In the 21st century as an increasingly number of bacteria are more resistant to antibiotics and viruses exist that can cause debilitating illnesses, vaccinations continue to have a role in keeping people healthy. Most of us immunize our children. Adults deserve the same level of care. Talk with your doctor the next time you see her.

Better Screening Test for Cervical Cancer - Are Pap Smears Obsolete?

Very exciting news about the war against cancer. A published article in the New England Journal of Medicine found that screening for the human papilloma virus (HPV) was far more accurate in detecting cervical cancer than the current PAP smear.

Highlights from the article.

The HPV test, which looks for the virus that causes cervical cancer, correctly spotted 95 percent of the cancers. The Pap test, which checks for abnormal cells under a microscope, only found 55 percent, according to researchers at McGill University in Montreal.

The Canadian study, which was government-funded, included 10,154 women ages 30 to 69 in Montreal and St. John's, Newfoundland. The women got both tests. Still to be determined is the best way to start using the HPV test by itself and what follow-up action to take after positive results, the researchers said.

Dr. Carolyn D. Runowicz, who wrote a journal editorial, noted that the two studies used a different kind of Pap test, not the liquid-based technology used in the U.S, which may be more sensitive The results of a British study that used liquid Pap are due to be presented in November.

"We're not ready for prime time. We're moving in that direction. But we're not there yet," said Runowicz, a former president of the American Cancer Society.

Troubling Trend of Avoiding Vaccinations in Children

A recent article noted how more parents, skeptical about the value of vaccinations and worried about the linkage of immunizations with other problems like autism, are using religious grounds to be exempted from mandatory childhood vaccinations.

This troubling trend is fortunately relatively small. Highlights from the article.

• The number of exemptions is extremely small in percentage terms and represents just a few thousand of the 3.7 million children entering kindergarten in 2005, the most recent figure available.
• In 1991, a religious group in Philadelphia that chose not to immunize its children touched off an outbreak of measles that claimed at least eight lives and sickened more than 700 people, mostly children.
• And in 2005, an Indiana girl who had not been immunized picked up the measles virus at an orphanage in Romania and unknowingly brought it back to a church group. Within a month, the number of people infected had grown to 31 in what health officials said was the nation's worst outbreak of the disease in a decade.

I understand the parents' concerns. I also am more concerned that people have forgotten how many of these illnesses, like polio, measles, mumps, were debilitating and devastating in the past and that generations of adults, through the use of vaccines years ago, have avoided those complications or premature and preventable deaths.

This past winter, I saw first hand how powerful and effective vaccinations are. When I examined one patient, in his late 30s who was vaccinated against influenza, he felt well in a day or two despite having the flu. This was in stark contrast to other patients in their early 20s, who weren't vaccinated, felt miserable, stayed in bed for days, and wanting to die (they didn't of course). If you've had the flu, you know what they mean, fever often up to 103 to 104 F and every muscle, joint, and bone aching relentlessly. On follow-up months later, the latter group all without hesitation planned on getting the flu shot this fall, even though they are not required to based on current vaccination guidelines.

With recent reports about the rise of bacteria that are resistant to all antibiotics resulting in 19,000 deaths and the findings that cervical cancer is caused by the human papilloma virus (HPV), individuals skipping vaccinations maybe missing opportunities to stay healthy.

Those who cannot remember the past are condemned to repeat it.
* George Santayana (1905) Life of Reason vol. I, ch. XII Charles Scribner's Sons

Enough Flu Vaccination to Go Around - Just Do It

The Centers for Disease Control announced that for the 2007 - 2008 flu season, there are plenty of vaccinations to go around. According to CDC:

Every year, flu infects up to 20 percent of the population, causes the hospitalization of 200,000 people and kills 36,000.

People 65 and older are most likely to get vaccinated, 69 percent during the 2005-2006 flu season, the latest count available.

But that's still well under the national goal of vaccinating 90 percent of seniors — even though Medicare provides flu shots for free.

Just over a third of 50- to 64-year-olds are getting vaccinated, and just 30 percent of high-risk younger adults, CDC found.

The vaccine is recommended for anyone over 50 or under 5; people of any age who have asthma, heart disease, weakened immune systems or other chronic illnesses; and pregnant women.

From personal experience this past season, I diagnosed more confirmed flu cases that in the past. The impact of flu vaccination became clear when I examined one patient, in his late 30s who was vaccinated, feel well in a day or two despite having the flu and then saw others in their early 20s, who weren't vaccinated, feel miserable, bed bound, and wanting to die (they didn't of course). On follow-up, the latter group all without hesitation planned on getting the flu shot this fall.

Perhaps you should to, especially if you are a health care provider.