Virtual Colonoscopy? Just Say No

The Center for Medicare and Medicaid Services -- CMS -- is asking for public input on whether virtual colonscopy - CT scanning of the colon -- should be a covered benefit in Medicare to screen for colon cancer.

In early 2008, the American Cancer Society (ACS) added virtual colonoscopy as well as stool DNA testing on its list of suggested screening methods for colon cancer. Screening for colon cancer is recommended for all adults 50 years and older. Besides these two options, the others are:

• fecal stool testing (FIT or FOBT) annually
• double contrast barium enema every 5 years
  
• flexible sigmoidoscopy every 5 years
• colonoscopy every 10 years

While I understand why ACS recommended adding virtual colonoscopy to its list, I don't agree with them. Although it is not as invasive as a sigmoidoscopy or colonscopy since patients lay on the CT scanner table while an x-ray technician works the machines to allow xrays to peer into the body, the colon preparation as well as the insufflation of air to distend the colon, is still required. Also, there is exposure of radiation which increasingly a question doctors are facing. Is doing a scan worth the risk of radiation exposure and potentially higher risk of cancer?

More importantly, if a colon polyp or growth is seen on the virtual colonoscopy, patients still need to have an invasive procedure - sigmoidoscopy / colonoscopy - to do a biopsy or removal of the lesion in question. At least these procedures don't involve any radiation as the instrument is essentially a fiber optic cable.

With the healthcare crisis upon us and the nation asking itself what is affordable and reasonable and what is not, CMS hopefully will not recommend virtual colonoscopy to be added to its list of covered benefits. While the technology is attractive, there are other proven screening tests that albeit uncomfortable are life-saving and don't subject people to unnecessary radiation.

Weight Loss? It's About the Calories.

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

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

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

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

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

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

Multivitamins Not Worth the Money - Except...

Interesting, yet hardly surprising story that in most cases multivitamins are NOT worth the money.

The source is from an article from the Annals of Internal Medicine specifically:

• the 161,808 postmenopausal women enrolled in the Women's Health Initiative Study that took multivitamins there was no protective effect from common forms of cancer, heart attacks, or strokes.
• during the eight years of observation, the numbers of deaths were the same between women who took and did not take vitamins.

There were situations, however, which are still every important vitamins are taken. These are:
* Folic acid supplements in women who are pregnant or plan to become pregnant can help to prevent serious neural-tube defects that affect the baby's brain and spine.
* Supplements that contain more vitamin D and calcium than is present in regular multivitamin pills can help older men, and especially women, avoid osteoporosis and bone fractures.
* Supplements of vitamins C and E, beta-carotene, zinc, and copper may slow the progression of vision loss in people with early macular degeneration.

Check with your doctor to see if multivitamins are necessary or a waste of your money and time.

Book Review - Innovator's Prescription: A Disruptive Solution for Health Care

Brilliant. Far and away the best book on health care reform.

The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

For those trying to navigate the increasingly frustrating, confusing, and expensive health care system as it current exists, Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System would be the perfect guide book.

Secrets to Preventing Heart Disease

I recently gave a talk to discuss how to keep the heart healthy and avoid heart disease. February is designated as heart health month. Heart disease is the leading cause of death in both men and women. Yet within our country, there are doctors who consistently treat their patients to the latest research such that for their patients, heart disease is no longer the leading cause of death! In fact, their patients chance of dying from heart disease is 30% less than those of other doctors and hospitals in the same communities.

Their secret? Knowing your numbers and then treating them. Risk factors for heart disease include the following:

Age
Gender
Cholesterol
Blood Pressure
Smoking Status

The older you are, the more likely you will have heart disease. In terms of gender, men will tend to have heart disease at an earlier age. Women will see their risk gradually increase after menopause (average age of menopause is age 51).

Cholesterol is a risk factor, but needs to be determined in the context of the above risk factors. An excellent heart risk calculator is the 10 year risk calculator. Punch in your numbers. (Patients who have diabetes or a previous history of heart disease don't use this calculator because you should already be on cholesterol lowering medications called "statins"). The calculator is from data generated from the Framingham heart study, the nation's longest heart study.

Those with < 10 % risk, continue lowering your risk by dietary changes and exercise. Those with 20% or great risk, contact your doctor immediately and find out if you should start taking cholesterol lowering medications, blood pressure medications, or quit smoking as a 1 in 5 chance of dying from a heart attack or having one is pretty high! Those between 10 to 20% should see their doctor and ask what more can they do to lower risk.

Need more? Here's the secrets to preventing heart disease courtesy of Kaiser Permanente.

The Doctor is In - Sacramento ABC Channel 10

Thanks again to Sharon Ito and the ABC Sacramento affiliate channel 10 for having me on their Live Online. The 30 minute interview goes by very fast! For those of you who missed it, the video is below. Also Sharon does an excellent summary of what we discussed which included whether it is too late for the flu vaccine (yes) and ways to afford prescription medications.



SACRAMENTO, CA - If you haven't had your flu shot yet, you can still ask your doctor for one, but it may not be especially effective, said Monday's Live_Online guest Kaiser family physician, Davis Liu, MD.

Liu told viewers the flu vaccine usually takes two weeks to take effect and flu season typically peaks in February and March. Liu said patients were better off washing their hands thoroughly in order to avoid germs. In fact, Kaiser has already closed its flu shot clinics.

Liu said you know you've come down with the flu if you're suddenly overcome by chills, muscle aches and fever. If you call your doctor within a day or two of your symptoms, several prescription medicines are available that can shorten the flu's duration by a day or two. The flu often lasts five days to two weeks.

Liu also gave some suggestions on how to save on prescription medicines. He said patients need to be upfront with their doctors and let them know that money is a consideration. Liu said patients need ask whether a medication is needed in the first place, and if it is, whether a cheaper generic drug can be just as effective. The doctor said patients need to shop around and determine which retailer offers the best price on specific drugs.

The doctor said surveys show the average doctor's visit lasts only 18 minutes, with the doctor interrupting the patient within 23 seconds.

Liu said to make the most of their limited time with a doctor, patients need to prepare a list of their most important health issues. In his book "Stay Healthy, Live Longer, Spend Wisely," Liu wrote, "If at all possible, I recommend tackling no more than four concerns in your office visit, especially if the four are new problems never before evaluated by your doctor. The goal is not to cram in as many problems as possible in a visit, but rather to get the most out of the visit by getting an accurate diagnosis and treatment plan. The aim is quality, not quantity."

You can view the entire interview by News10's Sharon Ito in the Live_Online archive.
News10/KXTV
Copyright 2009 / All Rights Reserved

Save Money on Health Screenings - President of American Academy of Family Physicians Wrong

The NY Times published a new section titled Patient and Money, which is particularly timely as individuals and families facing reduction in income or in some cases losing jobs are having the difficult choices between basic necessities and health care. Their piece titled "Health Care You Can't Afford Not to Afford" unfortunately was wrong. Particularly the perspective of Dr. Ted Epperly, the president of the American Academy of Family Physicians.

As a practicing board certified family doctor, I strongly disagree that screening tests can be safely skipped for months which is what Dr. Epperly was quoted as saying. The reason they are called screening tests because we do them when we feel completely fine and have no symptoms. Research has consistently shown that these do save lives. Whether the American Cancer Society gave him some criticism for his comments (he acknowledges that “The American Cancer Society wouldn’t like me saying so,” Dr. Epperly said, “but you can stretch out those tests when you need to.”).

Yet, in the same article he highly recommends that people get an "annual physical" done which research also consistently shows isn't worthwhile! From the article "If you’re due for your annual physical, for instance, and you feel fine, you can wait a few months before forking over that hefty co-payment. Even children, once they are past vaccination age, can skip a check-up or two, as long as they are healthy and at a normal weight." Indeed, having an annual physical done randomly is no better than taking your car for a check-up when it is running perfectly well. What do you think your mechanic will say? Everything is fine. Randomly dropping by your auto dealer is different than taking your car in for a scheduled maintenance.

Knowing when you must get checked is far better than just dropping in on an annual physical. If Dr. Epperly means an annual physical is the only way you can figure out if you are obese, need to be screened for high blood pressure, or diabetes, then that's different. (Those on prescription medication for conditions like high blood pressure, high cholesterol, heart disease, diabetes should be checked annually). But for the most part, most of us who are healthy and aren't on medications can figure that out ourselves. The trouble is in our busy lives how do we remember to take a time out and assess our health? Do it at New Years or every year on your birthday.

When should you go in and what tests should you ask for (if your doctor forgets to remind you or is squemish about screening for colon cancer - only those readers 50 years and older, possibly younger in people with family history of colon cancer) can be found in Do the Right Thing Regularly and Repeatedly - Preventive Screening Tests and Interventions for Adults. Helpful websites to keep you healthy and well in addition to figuring out when to see your doctor are right here.

For decreasing drug costs, I would add that Walmart and Target's $4 /$10 medication option is a great one as many high quality medications are available. I would also add that Consumer Reports has a free website called CRBESTBUYDRUGS.ORG which lists the best medications for
the money.

For your symptoms, understanding when to see the doctor and when you don't need to is as simple as going to the American Academy of Family Physicians website - www.familydoctor.org and clicking on the symptoms check link - Search by Symptoms.

Also realize that giving doctors a good medical history about your symptoms prevents us from ordering too many tests / imaging studies which cost money and time. Unfortunately, if you simply tell us that your back hurts and are unable to say what makes it better or worse, what the pain feels like, how long it lasts, if you've had other symptoms with it, among other important information, doctors meaning to help will prescribe medications and do tests which may not help you get better, but hurt your wallet more. This is particularly challenging as doctor visits are getting shorter and doctors, research shows, cut patients off in 23 seconds.