Sunday, June 27, 2010

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.

Thursday, June 17, 2010

Boston Celtics' Kendrick Perkins Knee Injury and Doctor's Xray Vision

Boston Celtics' basketball player Kendrick Perkins injured his knee during the NBA Finals against the Lakers when he landed awkwardly. Unable to weightbear, he left Game 6 not to return for the following pivotal Game 7.

Based on his mechanism of injury and his physical examination, his trainer reported that he tore his medial collateral ligament (MCL) as well as the posterior cruciate ligament (PCL). More amazingly, this was done without the help of a MRI! Since Perkins was unable to play the final game, there was no urgent medical need to expedite the test as regardless of the result, his season was already done.

How do doctors know what is wrong without xray vision or an imaging test? (Note that Perkins did get a xray, but xrays generally don't show ligament injuries). Is it guessing?

It's our medical training. Getting the right diagnosis relies mostly on the doctor able to accurately understand what happened and what symptoms you noticed. This often gives us a good idea what is going on. Afterwards, we do a physical exam that helps us hone down the number of possibilities to the right answer.

If Perkins had been a regular person playing basketball, he would have told his doctor the following:

I was playing basketball. Jumped up. Landed awkwardly. "I knew something was wrong...I didn't know exactly what it was, but I couldn't get up on my own. I couldn't walk. My whole leg was hurting, and the back of my knee was in pain. I heard something pop, but I didn't know what it was. It was just painful."

The doctor examining the knee would have noticed swelling, decreased movement, as well as significant pain on the middle aspect of the knee as well as some give or laxity.

Given the mechanism of injury, the history, and the examination, the likely injury is a medial collateral ligament (MCL) and posterior cruciate ligament (PCL) of the knee.

Yet the public is enamored with technology. Simply talking to a patient, thinking about the problem, and using our hands to examine patients can't be as good as fancy MRI. Don't these imaging tests give us the truth? Isn't more imaging better?

Let's put the doctor diagnostic skills to the test and compare to what the MRI shows. Getting the right diagnosis did not require expensive solutions. It requires listening and examining. More isn't necessarily better, yet the public believes it.

To fight the temptation of doing tests just for the sake of doing it, find a stellar doctor. The most valuable doctor is the one that is genuinely interested in you, and avoids ordering tests, procedures, and interventions when not medically necessary. He talks to you to understand what your problem is and performs an examination.

Let see if doctors got Kendrick Perkins' diagnosis right. Perhaps we really do have xray vision.

Tuesday, June 15, 2010

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.

Monday, June 7, 2010

Overtreated: More medical care isn't always better. Doctors must lead change.

The Associated Press recent article "Overtreated: More medical care isn't always better" reiterated a commonly known fact which is not understood by the public. This problem of doing more and yet getting little in return is a common issue which plagues the US healthcare system and was illustrated quite convincingly by Shannon Brownlee's book. Americans get more procedures, interventions, imaging, and tests but aren't any healthier.

In fact they are often worse off. Too many unnecessary back surgeries. Too many antibiotics for viral infections, which aren't at all impacted by these anti-bacterial therapies. Too many heart stents which typically are best used when someone is actually having a heart attack. Research shows that those that are treated with medications do just as well. As all patients with cardiac stents know, they also need to be on the same medications as well.

Eliminating unnecessary treatments is a good thing, particularly when it is based on science.

Already over the past year, cancer screening guidelines have been updated based on reviews of the latest medical evidence. Prostate cancer screening with blood test PSA does not appear to be helpful in determining which men have the life threatening aggressive form requiring treatment and which men have the indolent version which will never impact their health. Some medical experts have suggested that breast cancer screening with mammograms should be moved from age 40 to age 50 based on the review of studies.

You would think the public would be happier that they would be poked and prodded less as scientific evidence shows that it is safe to do so. We should want the healthcare system to be in the mindset of continual learning and not mired in old traditions just because that is the way it was always done.

Yet despite this reality, some people view this as rationing of medical care or the beginning of socialized medicine.

It's not. It's the time of rational medicine. Doctors need to lead the change and get away from the hype and more to the science. That is what patients really want. What is particularly disappointing is that overtreatment is well known and already profiled in various articles two years ago. Change is occurring very slowly. It is unclear why. Despite being bombarded with pharmaceutical advertisements, body scans, and easy access to medical information, patients still trust doctors the most for advice.

If we as doctors fail to lead, then patients will be left to figure it out themselves.

And they are already fearful.


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