2009 Newsletter

Dr. Iliff’s 2009 Practice Newsletter

2008 in Review: This was a terrible year for anyone who lost a job, and a pretty bad year for all the rest of us.  In the past I’ve had fun with rumors that I was going to “retire” (as if I could have fun doing anything else full time), and joked that I’ll be right here in Fleming Place until I’m 70½, at least.  Forget that.  At the rate my retirement savings are going, I’m going to be buried with my stethoscope on.  But on a more positive note: What’s so bad about that?  Could anyone ask for more than to remain happily productive until the last day?  Hoping for a “Well done, thou good and faithful servant” on the next?  Happiness, rightly understood, is the proper goal of life on earth.  From a material standpoint, it requires just four things: 1. A productive occupation (whether or not we are paid for it); 2. Good relationships with at least a few worthy people; 3. Enough money to be comfortably supplied with food, clothing, and shelter, and free from the fear of losing those necessities; 4. Good enough health to enjoy the first three.  So whatever 2009 may bring, resolve to concentrate on what is important.  Thus endeth the lesson.  Now back to Health.

Points of Emphasis for 2008: Electronic prescribing has, in general, gone well.  There have been technical glitches which have wasted a lot of Jackie’s time, but we still think it will save time, and more important, eliminate inconvenient or dangerous errors.  By now all of your chronic medications are entered into our iScribe system.  What’s Your Mile? has been a failure.  I still think it’s a great idea, but I only have so much time to promote it to you.  If any of you have any ideas to make it easier or more accessible to test your own fitness level, please give me your thoughts.  In the meantime, you can still read about the test and enter your data on the Healthy Kansas website.  Unless you have a lifestyle which naturally lends itself to physical activity, you absolutely have to find some way to get supplemental exercise, and learn to like it.

Point of Emphasis for 2009:  Reducing the time my nurses spend on the phone unnecessarily.  I know it’s frustrating for patients to get a busy signal when you call.  It’s also frustrating to wait on hold to talk to a nurse.  Here are some random thoughts on this problem.

1. Remember that when you call almost any other medical office in town, you’ll get to leave a message for them to call you back.  This is more efficient for them, and may be more convenient for you, assuming they call back within a few hours, which they may not.  We don’t do that because we want to know what your problem is immediately.  Once we know, it may take a while to get it taken care of.  That’s OK.  But if you’ve got an urgent need (whether you know it or not-- sometimes we have to persuade patients that the need is urgent) we want to know that immediately, not tomorrow afternoon.  Accessibility is more important than having a smart doctor. 
2. A lot of nurse time is wasted when patients argue about routine medication visits.   This is not a problem for most of you, but I’m losing patience with repeat offenders.   I have made saving money a culture in my office.  I have always tried to use generic medications, without any stimulus from insurance companies.  I stretch the recommended intervals between follow-up visits when I think patients are responsible and their problems are well-controlled. (For example: the routine interval for diabetic medication checks is 4 months; most of my patients are seen every 6).  When I do that, I’m taking some tiny risk of a malpractice suit for the financial good of you and the whole system.  Here’s what irks me: When a patient waits until two pills are left in the bottle, and calls for a refill knowing that the refills are used up and it’s time for an office visit, the nurse has only two choices, both of them bad.  Either they get an immediate visit without labs, meaning that we will get the labs later and waste time following up by phone and maybe rearranging medicines or dosages after the fact; or the nurse has to waste time calling a short-term prescription to tide them over until an office visit can be arranged.  It’s even more draining when the nurse has to argue about the necessity of a visit at all.  Look: if you want to buy medicine off the shelf and manage your own care, move to Mexico!
3. Now that I’ve got the rant out of my system, let’s be positive and pro-active.  When you see that your medicine supply is nearing the end, and there are no refills left, call for an appointment and get the necessary labs drawn beforehand.  That way I will have the information I need when we meet, and you won’t experience so many busy signals.
4. Finally, realize that the “pharmacy benefit managers” for your insurance company try to torture doctors by requiring extra paperwork for expensive medicine.  In a just world, they wouldn’t bother practices like ours, because they can instantly recognize from their financial data that we’re the Good Guys.  Instead of harassing the docs who treat medicine like candy, they harass all of us.  That requires time on the phone-- sometimes a lot of time.  That means more busy signals, for no good reason.  So two requests: 1. Don’t get mad at the nurse if we can’t get you the medicine you need at a price you can afford; 2. If we ask you to fill out and mail your own paperwork, it’s not because we’re lazy.  We’re just tired of playing secretary, and have more important tasks at that moment.

Breakfast of Champions: At least once a year we make all of you measure your body fat.  Then we tape it to a sheet with some explanatory material, which includes what I began calling the Breakfast of Champions as a joke many years ago.  The title is a joke.  The substance is real.  Because I spent a lot more time the past year (reason?) answering questions about what vitamins I would recommend routinely, or whether I really mean what I wrote, let’s spend some time on this.  I really mean what I wrote.  There is a reason for everything on that list, but some of the reasons are better than others.  Here are the high points:

1. 2000 mg of vitamin C per day has the weakest rationale.  You’ll find it on health-maintenance websites, but it’s never be proven to prevent cancer or reduce infections.  It’s just an old friend for me.  I’ve been taking that dose for 30 years, and I don’t have cancer yet.  That doesn’t prove anything.  I haven’t missed a day of work for illness in 15 years.  That doesn’t prove anything, either.  But who knows?
2. 400 IU of vitamin E for men is still being investigated as a prevention of prostatism or prostate cancer.  The study is due in 2010.  In the meantime, I’ve been taking that for 30 years, too.  My dad had prostate cancer, but my PSA is low and steady.  I never have to get up at night to urinate, despite frequently enjoying a beer at bedtime.  That doesn’t prove anything either, but who knows?
3. A to Z multiple vitamin contains a bunch of trace elements which one authority or another thinks important.  You probably get enough of those in your American diet, but they sure won’t hurt you, and maybe your diet is weird.  Most interesting from the standpoint of breaking news is vitamin D.  There is emerging evidence that the benign but annoying muscle aches caused by statin therapy (simvastatin, lovastatin, Crestor, Lipitor) accompany low levels of vitamin D.  Why are so many aging Americans vitamin D deficient?  It may be that we’ve convinced all of you that sunshine causes skin cancer, and sunshine is by far the easiest way to raise your vitamin D levels (20 minutes of UVB rays produce enough vitamin D to meet all your requirements for a couple of weeks).  You get 400 IU of vitamin D in every pill.
4. 81mg aspirin for all males over 50 will produce enough anti-inflammatory effect to make sure the C-reactive protein is normal in most everybody.  People with low C-RP are at much higher risk of heart attack and stroke, and we don’t know who you are without testing, and Blue Cross won’t pay for the test.  So just take your baby aspirin.
5. 1000mg of fish oil (I don’t care what kind) is enough to raise the omega-3 fatty acids in blood vessel walls to a protective level in almost everybody.  We could test the levels in your blood to see if you really need it, but Blue Cross won’t pay for it, so just take your pill.  It will lower your triglycerides, too.
6. 3 psyllium seed capsules (Metamucil, Wal-mucil, many others) provides enough water-absorbing fiber to speed the flow of stool through your bowel, and lower the bowel pressure, to levels found in cultures where most of our bowel disorders don’t exist.  I know: you’re not constipated!  You probably are, by God’s standards (3 stools per day, no wiping necessary), unless you’re a vegetarian.  So just take your pills.  You’ll thank me when you’re 75, and every bowel movement isn’t an event worth announcing at the nursing home.
7. Finally, timing.  Why not Lunch of Champions?  First, because Wheaties was not the Lunch of Champions in my boyhood.  Second, because it’s the only time of day that’s still under your control (whoever heard of a “power breakfast”?).  Third, because if it isn’t the first thing down the hatch each day, fish oil will have you belching oil, and psyllium seed will make you bloat.

Paying Attention: Recently we lost another patient prematurely.  He was a really nice guy, and I always enjoyed his visits.  I take these things very, very personally.  It is a slap in the face, and I think about it every day for months.  It’s the worst part about being in family medicine: losing a friend, and wondering what I could have done to make a difference.  We always do an “office autopsy”, looking for what we might have missed.  One common denominator in almost all these cases is that the patient has failed repeatedly to do the database physical we recommend, and so he eventually died from a condition which we could have caught a long time ago.  Here’s a line from the movie Hardball: “The most important thing in life is just showing up.”  The application here is that you just have to show up, and we’ll do the rest.  For some of you, all that means is an Attaboy.  For others, it means a lot of work and a lot of pills.  But if you’ll do it, your family, friends, employer, insurer, and you, yourself, will be a lot happier in the long run.  Maybe, for males, I need to start asking for database physicals every two years starting at 40, instead of 50.  50 is fine for females, as long as you’re getting pap smears and mammograms-- heart disease hits a decade later for you.  That would mean some wasted money for guys who are healthy, just to have a better chance to wear down the resistance of the knuckleheads who really need it.  I don’t know.  Life’s full of tough calls.  In the meantime, ladies-- make that appointment for your man.  He won’t thank you, but it’s for his own good.

Family-Centered Maternity Care: I don’t advertise our practice in the Yellow Pages, or radio, or TV.  The vast majority of our new patients come from your recommendations.  I haven’t asked for those, but I appreciate your trust in our service, and we couldn’t exist without you.  Now I’m going to ask for something specific.  Dr. Laccheo, and several other local family physicians, are giving up OB.  It’s not that they don’t enjoy delivering babies-- but with C-sections more frequent, and lots of good obstetric specialists in town, they’re just not doing enough deliveries to stay good at it.  I’m not there yet, but my numbers are dropping.  Just because I enjoy delivering babies isn’t a good reason for recommending us to friends.  We have some advantages, the most important of which are convenience, cost, and continuity.  We don’t waste money on ultrasounds just to pad our net income.  We answer questions about other family members, and take care of other problems (don’t ask your obstetrician about that rash, or your sister‘s arrhythmia) during a one-stop-shopping visit.  We don’t schedule deliveries for “convenience”-- either yours or mine (deliveries between 35 and 39 weeks have recently proved to cause problems for baby).  And I deliver about 95% of mothers I’ve followed during pregnancy myself (obstetricians deliver on a call rotation).  I’m always on call for deliveries.  So if you know any candidates, I’d be glad to talk to them.