Tuesday, October 27, 2009

Why I Chose to Get the H1N1 Vaccine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are you?

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

How Effective Are Generic Drugs?

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

For many however, generic is perfectly fine.

Sunday, October 18, 2009

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

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

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

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

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

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

The op-ed piece follows.

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

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

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

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

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

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

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

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

Sunday, October 11, 2009

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

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

Sounds like a lot, doesn't it?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday, October 5, 2009

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

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

They are wrong.

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

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

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

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

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

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

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

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

Thursday, October 1, 2009

Breast Cancer Awareness Month - Truths and Myths You Must Know

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

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

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

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

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

Screening for breast cancer begins by doing a self breast examination monthly. Learn how to perform a breast self exam (BSE) correctly at 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.


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