Newsweek - Just Say No! - One Word Can Save Your Life. Too Simplistic. Doctors Need to Help.

Newsweek has a very provocative and yet incredibly too simplistic piece for the public and patients on its cover story - One Word Can Save Your Life: No! - New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.

The piece is actually well written and highlights facts that have been apparent for some time.  More intervention and treatment isn't necessarily better.  Having a cardiac catheterization or open heart surgery for patients with stable heart disease and mild chest pain isn't better than diet, exercise, and the prescription medication treatment.  PSA, the blood test previously suggested by many professional organizations, isn't helpful to screen for prostate cancer, even though the value of the test was questioned years ago.  Antibiotics for sinus infection?  Usually not helpful.

Certainly doctors do bear part of the blame.  If patients are getting routine colonoscopies sooner than every 10 years or are getting them despite being quite a bit older (80 and older) and frail, then clearly patients should say no to more care.  More isn't better.  (Whether a patient has the conviction to do so is another story.  When my auto mechanic says it is time to change the brakes or change the oil, who am I to say no?)

But the overtreatment and overuse of medical technology does not just fall on the doctors.  It is also the patients' and the public's perception of what is the right care.  Whether this perception was shaped by doctors, the media, movies and television shows, or patients comparing notes is hard to say, but the reality is patients have a certain expectation of what should be done which often is in stark contrast to the right thing to do.  For low back pain, many patients simply want a MRI and avoid an examination or visit.  After all, isn't the truth in the MRI?  Isn't talking to a patient and examining his back, knee and ankle reflexes, evaluating for joint strength and sensation simply from a by-gone era that is antiquated in the 21st century?  Do patients know the limitations of our understanding not in the history or physical examination honed by generations of doctors before us, but the shiny new piece of technology rolled out annually by General Electric?  As Dr. Michael Lauer, a cardiologist of the National Heart, Lung, and Blood Institute noted in the piece, “Our imaging and diagnostic tests are so good, we can see things we couldn’t see before...But our ability to understand what we’re seeing and to know if we should intervene hasn’t kept up.”

Doctors who do provide the right care, which often is low tech and common sense, might be viewed as denying care.  If a patient has chest pain which is easily treated with a statin (cholesterol lowering) drug and beta-blocker and a cardiologist is not needed for further intervention, do you think the patient or the family will feel more relieved or more anxious?  If a stress test isn't offered to an otherwise healthy middle aged man as part of a physical (or at a minimum an EKG) and yet is offered the identical tests as part of an executive physical, do you think the public at large will feel better or worse in not having the tests, which are correctly noted in the article not proven to save lives?  (It is ironic that although fantastic experts are quoted in the piece including Dr. Steven Nissen, a cardiologist at Cleveland Clinic, his organization offers executive physicals, which you guessed it provide many of these tests and interventions to paying clients.  Though the results of the majority of the tests are normal it is that remote possibility that something might be wrong and the basis of the testimonials on the website that have the public clamoring for more testing and treatments).

In today's society where news is disseminated as sound bites or tweets, I am concerned about the unintended implications this Newsweek story will bring: patients will say no to everything.  Based on a well written, though not entirely balanced article, patients will anchor their decisions to default to no based on this small piece of information.  It has already occurred with vaccinations.  As the National Committee for Quality Assurance noted in its 2010 State of Health Care Quality report, childhood immunization rates for those in private insurance has actually fallen compared to those in public insurance (Medicaid) plans.

Childhood vaccination rates in 2009 declined by almost four percentage points in commercial plans.
   
A possible cause of this drop is commercial plan parents may refuse vaccines for their children based on the unproven, but increasingly popular, notion that vaccines cause autism. Celebrity activists are outspoken advocates of this view. Interestingly, we see vaccination rates in Medicaid – the program serving the poor – continuing to steadily improve.  

“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said NCQA President Margaret E. O’Kane. “All of us in health care need to work together to get better information to the public.”
The State of Health Care Quality Report examined quality data from over 1,000 health plans that collectively cover 118 million Americans.

Because of the complexity, nuances, and ever changing nature of medicine, patients more than ever need doctors to lead and be firm on what works and what does not.  The anecdotal quote by a doctor who opted not to have a mammogram should be taken as one person's opinion and not a recommendation for all women to do the same.  Having patients say no or expecting them to make the right decisions for themselves and family is not how the country will get better care.  A recent NY Times piece by Dr. Pauline Chen titled Letting Doctors Make Tough Decisions could not have been more timely.

... a new study reveals that too much physician restraint may not be all that good for the patient — and perhaps may even be unethical. While doctors might equate letting patients make their own decisions with respect, a large number of patients don’t see it that way. In fact, it appears that a majority of patients are being left to make decisions that they never wanted to in the first place….

The challenges appear to arise not when the medical choices are obvious, but when the best option for a patient is uncertain. In these situations, when doctors pass the burden of decision-making to a patient or family, it can exacerbate an already stressful situation. “If a physician with all of his or her clinical experience is feeling that much uncertainty,” Dr. Curlin said, “imagine what kind of serious anxiety and confusion the patient and family may be feeling.”

Medical choices are not as obvious.  Today the vast amount of information and choices are overwhelming.  The easy and natural thing to do is to run away or bury our heads in the sand, or simply say no when decisions are complex. 


The Newsweek article concludes -

Many doctors don’t seem to be getting the message about useless and harmful health care. Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help. Arthroscopic knee surgery for osteoarthritis is performed about 650,000 times a year; studies show that it, too, is no more effective than placebo treatment, yet taxpayers and private insurers pay for it. And although several large studies, including the Occluded Artery Trial in 2006, have shown that inserting a stent to prop open a blocked artery more than 24 hours after a heart attack does not improve survival rates or reduce the risk of another coronary compared with drugs alone, the practice continues at a rate of 100,000 such procedures a year, estimate researchers led by Dr. Judith Hochman, a cardiologist at New York University. “We’re killing more people than we’re saving with these procedures,” says UT’s Goodwin. “It’s as simple as that.”

Actually, I think doctors are getting the message as Dr. Atul Gawande noted in the June 2009, New Yorker piece Cost Conundrum.  Doctors are compensated more to do more.  Even medical students get the message.  Increasingly more are becoming specialists as reimbursement is far more lucrative in doing procedures than it is to simply talk and counsel patients.

The Newsweek piece tries to simplify the problem too easily by hinting to patients that saying no is a good thing rather than challenging patients to have an open-minded, important and thoughtful conversation about the advantages and disadvantages of having certain tests or treatments with their primary care doctor.  Of course since fewer medical students want to do primary care, my job and those of my colleagues in family medicine and internal medicine just got a lot harder.

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.

Brittany Murphy's Death - Learnings About Consumer Driven Healthcare and Pneumonia

Actress Brittany Murphy, age 32, died unexpectedly in December 2009 as a result of pneumonia. An autopsy report noted elevated levels of medications, like Vicoprofen, which contains the narcotic hydrocodone and other medications, the anti-histamine chlorpheniramine and L-methamphetamine which is found in decongestants. The hydrocodone in Vicoprofen can cause sedation and was used by the actress to treat menstrual cramps. The other medications are often used for symptom relief from respiratory infections.



Her husband noted that Murphy "was on an antibiotic and was taking cough medicine." Yet it is unclear if she was actually under the care of a doctor at the time of death. Other reports noted that the "star had been feeling ill prior to her death and had scheduled a doctor’s appointment on a Wednesday or Thursday — days before her Sunday death."

Her husband had been ill a week before and recovered so it was certainly reasonable for the actress to care for herself at home.

So what can we learn from this tragic and untimely death?

First, even in the 21st century pneumonia can kill despite our advanced antibiotics and medical technology. Among adults in 2000, there were about 135,000 hospitalizations due to pneumonia, and 60,000 cases of invasive disease, which included 3,300 cases of meningitis. Of those patients with the aggressive invasive disease, 14 percent were fatal.

Bacteria is becoming more resistant to medications as antibiotics are overused in treating viral infections, like colds and sinusitis, as well overuse in food production and livestock.

Patients at risk of pneumonia, elderly, young children, those with compromised respiratory systems (emphysema, asthma) and immune systems (diabetes) should ask their doctors about the pneumonia vaccine. 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.

The type of vaccine administered varies depending on the age of the patient. 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.

It's unlikely Murphy would have needed a pneumococcal vaccine based on her medical history, which was otherwise healthy except for anemia, which is not unusual among women who are menstruating. However, according to the autopsy report the coroner noted a history of diabetes which alone would have been a reason for vaccination.

Second, it is unclear what dosages Murphy was taking of each of the listed medications. Certainly taking too much of any medication can be problematic particularly with hydrocodone and the chlorpheniramine. Both can cause sedation. The former drug can cause respiratory depression and decrease the drive the breathe, which can be fatal when taken in high doses.

Again it is unclear if she was under the care of a doctor at the time of her illness. Her husband notes that she was taking an antibiotic for a flu like illness. Yet, antibiotics are not appropriate for viral illnesses like the flu. Based on information from the coroner's report, the antibiotic clarithromycin which is used for pneumonia, was prescribed to her on November 17th, 2009, a month before the actress died. Was she ill before her December illness?

Finally, the assistant chief coroner noted that her death was "preventable".

Could Murphy have known how sick she was and how urgently she needed to seek medical care? It would been perfectly natural for her to have assumed that since her husband was recently ill and subsequently recovered that she would have done so as well. Isn't that what many of us do?

With increasing healthcare costs, many healthcare advisors are touting consumer driven healthcare as a way to slow medical expenditures. The theory goes that by having patients shoulder more financial responsibility on when to seek medical care and when they can safely skip advocates believe as a result people will make smarter choices and lower healthcare costs.

This is quite concerning.

Murphy, who arguably didn't have a financial barrier to seek care yet was quite ill, didn't get timely medical care. One wonders if individuals facing $50 to $100 office visits who might be equally as sick would simply stay home as well. At best, they might delay care and then subsequently end up in the emergency room or hospital not only requiring a lot more care but also a significant amount of out of pocket costs in the hundreds to thousands of dollars. At worst, they could die and have a death that was preventable.

Consumer driven healthcare, which is coming soon to you, requires that patients educate themselves in a way unprecedented than the past. Perhaps if Murphy had reviewed the symptom checker at the American Academy of Family Physicians she would have demanded an earlier appointment. (According to the coroner's report, Murphy was complaining of shortness of breath).

Instead of winging it, patients in these health insurance plans must educate themselves otherwise they are truly taking their lives into their own hands.

And the ignorance could be deadly.

(Sadly, her husband, Simon Monjack, age 39 was found dead today at home. Preliminary reports indicate he died of natural causes. Certainly he could have died from a broken heart).

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.

More information about the H1N1 vaccine can be found at the CDC website.

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.