2006 Newsletter

Thanks for making us your choice for primary medical care.  As we enter our 20th year of practice, it remains a privilege and a joy to serve you.  And when I say “we,” I also mean Jackie Howard RN (also in her 20th year), 2005 Kansas Physician Assistant of the Year Scott For (19th year) and Diane Gordy RN (13th year).  Our goal is to get better, not just older.

What’s changed for 2006? 

1. Basic Training has hit the dirt.  This was a 12-week program of Saturday walking under my supervision.  Obviously, I wasn’t scratching where you found an itch.  If it is resurrected, it will be an “inpatient” program.
2. Keystone Rental:  Since I offered my condo for off-season rental to patients at half price, a number of you have shared our home.  Starting this spring, my son will be living in our condo while he starts building a house in Summit County.  Check back in 2007 for availability.
3. Hospital Rounds:  Last year I offered to make rounds on hospitalized patients by special request.  There wasn’t much interest in this service either, so I’ll only be rounding on obstetric and pediatric patients.  The hospitalists will handle the rest.
4. Breakfast of Champions: Although there is still an ongoing long-term research study on the benefits of vitamin E in the prevention of prostate cancer, the preponderance of research is demonstrating no benefit against cancer or heart disease.   Therefore, against the continued recommendations of the Cooper Clinic and RealAge.com, I’m dropping the recommendation.  Also-- one baby aspirin a day is dropped for females, but remains a recommendation for males.
5. Sledding at the Iliff Commons: I’m dropping attempts at email notifications.  Snow conditions are too unpredictable, and it always arrives the night before a busy day at the office.

What’s unchanged for 2006?  We take it personally when we lose a patient, or when one of you suffers a preventable medical problem.  Whenever that happens, I look back at the records to see what we could have done differently.  Sometimes the event is unsurprising, given the underlying medical problems.  Look: we’re all going to die sometime, and we have to accept that tragedy and move on.  What bothers me is a tragedy which didn’t have to happen.  In the great majority of instances, chart review reveals that the patient failed to follow recommendations for testing and treatment.   We all have to live with our choices-- what worries me is that I have not made my recommendations clear enough, or strong enough, to get through.  So I’m going to keep trying to get clearer, and stronger, starting with this blanket recommendation: If you smoke, STOP!  If you’re overweight, LOSE!  If you’re soft, EXERCISE!  There you have it-- all my medical wisdom in one line, and it hasn’t changed in two decades.  Beyond that, when we send you a card for your database physical (every two years over 50, every 5 years otherwise), make an appointment.  The yearly physical is a waste of time and money, but experience has taught me that this schedule flushes out medical problems on a timely basis.  LADIES!  A “female” exam is not a database physical!  A number of you have been confused about that, and I just figured it out this year.

Does preventive medicine work?  I recently received my annual performance report from Blue Cross, which is by far our largest insurance contract.  The figures represent the last 3 years of data, and show that our patients only consume 70% of the average health care dollars for patients of Kansas family physicians.  (The report shows about the same thing every year).   This means one of two things.  Either our system of service prevents medical complications through early detection and treatment, or we have become expert at refusing service at the front door to people who are sicker than average.  Since we never turn anyone away, I suspect it’s the former explanation.

The perils of risk assessment: If we were perfectly rational creatures, and if our wills were perfectly subject to our minds, life would be pretty simple.  As it is, we don’t understand things very clearly, and our emotions foul up the connections between our minds and wills even when we do.  This is the problem of risk assessment.  For example:  why do women flagrantly over-estimate the risk of dying from breast cancer, rather than heart disease, which is 10 times more likely?  Because breast cancer is a far more fearful disease, randomly striking young women with a potentially disfiguring and almost certainly uncomfortable treatment.  Hardening of the arteries kills later, quicker, and quieter.  That is one reason why it is easier to persuade women to get a mammogram than to start an exercise program (the other is that passive prevention is easier than active prevention).  There are many other examples.  Economist Steven Levitt, in the 2005 bestseller Freakonomics, points out that having a swimming pool in your backyard is 100 times more likely to kill a child than having a gun in your house.  That doesn’t mean the gun shouldn’t be locked up; but don’t forget to lock the back door, and the gate.   What’s the number one risk of premature death for people under 50?  Hint: if you don’t wear your seatbelts, it is completely irrational to spend a dime on disease prevention. 

With those considerations in mind, MY contribution to risk reduction centers around 3 conditions: Hyperlipidemia (high blood fats), Hypertension (high blood pressure), and Hyperglycemia (high blood sugar, or diabetes).  Any patient with any of these problems comes under special scrutiny in our practice: you’re one of the time bombs, with the explosions being strokes, heart attacks, blood clots in the lungs, kidney failure, blindness, and amputation (among other, more minor disasters).  For all of those problems, active prevention (your part) involves exercise and diet (yada yada yada), and passive prevention (my part) involves pushing pills.  In the literature rack in each room look for the one-page yearly update for each problem.  On it I will try to clearly summarize what the problem is, how it comes about, what our current treatment goals are, and what to watch out for.  Goal: No one dies before their time.

SpringForward 2006: Two years ago Dorothy and I co-hosted (with the Sunflower Striders) a race at the Commons on the first Saturday of spring.  Last year we expanded to 5 events: cross country and mountain bike races for experts and beginners, and a walk for anyone.  The walk is called Survival of the Fittest 5K METwalk, and a title that weird deserves an explanation.  Survival of the Fittest is a nod to Darwin by way of the New England Journal of Medicine, which in a 2002 editorial officially verified what I have suspected for a long time: that our exercise capacity has more to do with our longevity and quality of life than our weight, lipid level, blood pressure, or any other single disease parameter.  If you only know one number, it should be your peak metabolic equivalent (MET) score, which measures your exercise capacity.  This event will give it to you.  If you join us for a 5K (3 mile) walk on this hilly course, we’ll give you your peak MET and an estimate of your mortality risk relative to an optimally fit man or woman.  Pick up a  METs and Me sheet in the literature rack for an explanation of the concept, followed by a walking plan to safely get you shaped up over 12 weeks.  Then take a Springforward 2006 announcement and registration and join us at noon on Saturday, March 25th.  The $25 fee covers a donation to the Marian Clinic and a t-shirt with a place to record your MET score-- plus an upside-down map on the front to help you home if you get lost (attention: Jamie Prather).  Bring friends, grandkids, dogs, and/or bikes for this or other events.

Need help paying for prescriptions?  Check out the Partnership for Prescription Assistance, 1-888-477-2669 or www.pparx.org.  They have pretty liberal income limits and lots of drug companies participate.

Walkjogrun.net:  I just discovered this interesting website, which ranks up there with MapQuest and GoogleEarth for coolness and usefulness (by nerd standards, of course).  As part of your participation in METs and Me cardiovascular walking, you have to lay out a measured course which starts at your front door.  I used to do this using my car’s odometer, which is incredibly old-fashioned and unsophisticated.  Now I just go to this website, plot my course, and find out how long it is.  It’s real easy (duh! I’m using it).

My rant for 2006: I would like to think that I keep up-to-date on medical advances in my sphere of expertise.  Therefore I have become increasingly concerned about the unholy alliance between drug companies, researchers, and medical journals.  Every month there is a new story about faked results, influence-peddling, ghostwritten articles, or conveniently withheld data.  It’s getting so I don’t know what to trust, and the editors of major medical publications share this concern.  Medical research is hard to do right.  There are lots of variables which can accidentally screw up the results under the best of circumstances, which do not include deliberate falsification for financial gain.  I hope the research establishment will clean up its act.  In the meantime, rest assured that my recommendations are not for sale.  Except…
The sticky issue of drug samples.  There is a movement within the medical profession which advocates voluntarily refusing to accept samples from drug companies.  Research claims to show that whatever I think of my independent decisions, I’m really influenced by what’s on the shelf.  I’m willing to grant some truth to that claim.  However, I’m not persuaded-- yet-- for two reasons.  First, I’ve been an advocate of generic prescribing for so long that it’s a habit to try to save money on drugs.  That’s why I did the research on weekly prescribing of Lipitor which was published in the Journal of Family Practice.  Second, I may give away $500-$1000 worth of drugs every day.  That is saving either you or an insurance company a ton of money.  It’s a hassle to have to deal with the forms and stocking of samples every day, but at this point I think we’re better off as is. 

Homeopathic drugs:  I try to keep an open mind on other ways to skin a cat, but so far there is no evidence that homeopathic treatments differ from placebo in effectiveness.  That conclusion comes from a study of  110 trials each of homeopathy and conventional medicine from the University of Berne in Switzerland, covering 1995 to 2003.  So-- I don’t trust the conventional research much, but it’s better than nothing.  Nothing is what you get, so far, from the alternative medical universe. 

Teen fitness:  35% of 2,205 American teens flunked a treadmill test.  There’s a surprise.   And you know those earbuds for MP3 players and cellphones?  Kids are listening at 110 dB, or the equivalent of a loud rock concert.  Hearing loss is permanent.

TelaDoc: This new medical service costs $18 for registration and $35 for a phone consultation, with callback promised within 3 hours.  What am I doing wrong?  My callback is within 20 minutes, and free.