Dr. Iliff’s 2013 Practice Newsletter/Rant

Raising Your HDL Cholesterol:  "Good" cholesterol, which transports fat out of your artery walls and protects against heart disease and stroke, has suffered from bad luck lately.  A promising drug failed in clinical trials, and now we find that niacin (which I rarely recommended because side-effects are intolerable to most of us), while raising HDL, doesn't add anything to the benefit of statin therapy alone.  Vigorous cardiovascular exercise remains the only effective tool; "will in a pill" fails again.

23 1/2 Hours: I'm putting this first, because if you don't do anything else as a result of picking up this letter, do this:  Go to doctoriliff.com, and at the bottom of the page you'll see PLEASE WATCH NOW!!! in red letters.  Follow those instructions carefully.  Once you've mastered the secret instructions included in that decoded message, Google The Simple 7.  Then take the assessment.  You've already mastered one of the 7-- the most important-- after putting 23 1/2 hours into practice.  Only 6 more to go!

Overweight or Obese? Many of you have struggled for many years with your weight, and all the complications it brings.  I've turned down requests from a thousand patients over the years asking for "will in a pill."  Qsymia, just coming on the market, is a combination of phentermine (a stimulant and appetite suppressant related to amphetamine, and part of the notorious "fen-phen") and topiramate, a seizure drug.  It appears to be safe and very effective.  So I'm going to give it a try, and I'll probably be sorry.  The dosing schedule is progressive and precise, and if you don't lose 5% of your body weight in 24 weeks, you don't get any more medicine.  No second chances.  Oh-- and it costs from $140 to $220 per month, depending on the dose you need, and your insurance won't want to pay for it.  Remember-- eating less and exercising more is healthier, and free, so no whining will be tolerated.

Two Really, Really Dumb Ways to Waste Your Health Care $$:  1. Go to a gynecologist (where you'll actually see a nurse) to get the Pap smear I would do for no added cost at your annual physical.  2. See a dermatologist (really, another nurse) for a 45-second skin-cancer screen that I do at every physical. 

The Explosion in Disability: You’d think we’d be healthier than ever, but we have seven times more Americans on disability now than in 1960.  What’s going on?  Obesity?  Malingering?  Unemployment?  Who knows?  My problem is that I’m getting more forms asking me whether a patient can sit longer than 15 minutes, or carry 20 pounds up stairs twice a day.  I don’t know the answer to those questions, so I’m not going to answer them any more.  Of course, I can testify as to your breathing capacity or hernia surgeries.  But all those subjective things are going to be sent to occupational medicine specialists. 

Cost and Quality in Medicine:  Research published in Health Affairs last spring showed that without clear information on quality, patients may assume that more expensive care is better care.  This showed up in the literature at the same time another study in California demonstrated that the cost for a routine, uncomplicated appendectomy and a 4-day hospital stay varied between $2000 and $188,000.  Obviously, this is insane.  Obviously, the latter appendectomy is not 45 times better than the former-- both patients went home alive, without an appendix.  Nevertheless, real patients-- when they were aware of the costs to see different clinicians-- perceived the low-cost docs to be substandard and avoided them.  This was true even of those patients with high-deductible health plans, who were paying the full cost of their treatment out of their health savings accounts.  However, when given information about care quality, patients willingly chose lower cost providers.  The problem for you patients is that you have no way to judge quality.  I may be cheap; but maybe I’m dumb, too.  Maybe I’m expensive.  I still may be dumb.  Here’s the only measure I know: 85% of my business is Blue Cross since I opened my practice in 1986.  I charge what they allow, like everybody else in town, so cost is not a variable.  However, every year until the end of 2008, when they quit sending us statistics, the overall cost of health care for my patients was 15-20% less than other family physicians in Kansas. There are only two possible explanations for this.  Either my patients have always been much healthier than those of other doctors, or there is something we are doing which keeps them out of the operating room, hospital, or morgue.  My guess is that the most important factor is easy access to me and my staff by phone or appointment.  Nobody ever has to wait months for a physical or days for a cough in our practice.  But here’s another irony: lacking information about quality, patients believe that the longer it takes to get an appointment, the better the doctor must be.  In fact, the opposite is true.  

The Communication Crisis of the Internet Age: At this moment, as I begin composing my 10th annual letter to you, my patients, I am surrounded by the following devices-- the iPad on which I am typing, my iPhone, my mobile land-line phone, my laptop, and my desktop.  The first four I can grab without stirring from my easy chair; the latter is ten feet away, and occupied by my wife at the moment.  Never, in the history of the world, have we had so many ways to communicate; and never, in my lifetime, has it been more difficult to get confirmation that a message has been sent, and received.  I've been through the age of telegrams, handwritten notes, mimeograph machines, rotary-dial telephones, Xeroxing, faxes, email, cellphones the size of a briefcase, beepers that will get me in New York City or the Grand Tetons, and now, of course, Facebook and Twitter.  I've drawn the line at the last two.  And yet never has it been more difficult to "close the loop"-- transmit important information, and know that it has been received, in a timely manner.  I know the reason.  It's not a mystery.  There are so many ways to be communicated to that we have collectively dug in our heels-- "No, I am NOT going to respond to one more jingle, beep, tweet, or honk!"  Patients call me at night or on the weekend through my answering service, I call them back, and get a voicemail message or answering machine.  I mean, YOU KNEW I WAS GOING TO CALL, DIDN'T YOU?  Therefore, although I understand your emotions, please consider answering your phone when I, or my office, call you.  We hate leaving a message about something important on voicemail, because we don't know if it's listened to, or for that matter, who's listening.  For my part, I can always be reached through the office number (271-6161) for OBs, and weekdays and every third weekend for everyone else.  Desperate?  My home phone is in the book.

Do I Take New Patients?  Every year I ask myself this question, and for a quarter-century the answer has always been Yes.  The reason is that I don’t take Medicare, Medicaid, or TriCare, and so every year I lose patients to those transitions as well as moves out of town.  2012 has once again been our busiest year ever, and at times the staff has started to feel the strain.  If I had to start restricting the inflow, what I would do is take only referrals from existing patients.  You already know the kind of character you’re dealing with, and you’re in a better position than the Yellow Pages or a newspaper ad to recommend people who would like what we have to offer: unlimited harassment, with a smile.  So if, at some time in the future, a friend or colleague asks if you would recommend them, that’s why. 

PSA, RIP:  After years-long analysis of data on tens of thousands of patients in Europe and America, it seems that screening for prostate cancer with the PSA blood test kills more patients (through complications from unnecessary surgery) than it saves (by detecting aggressive cancers early enough to cure them).  For more complete information, see "Prostate Screening" at the bottom of the page under "Iliff Family Practice".  In this regard, it's like the CA-125 antigen test which Gilda Radner promoted for detection of ovarian cancer, before she died of ovarian cancer.  What we need is a more specific screening test for the bad actors among these cancers.  Stay tuned.

Mammogram, RIP?  The preventive medicine "experts" are now doing the same kind of analysis on mammograms, and making the same noises-- we do too many unnecessary surgeries.  No conclusions yet, but I'm betting that the Forces of the Pink Ribbon beat back this attack on the Legion of Breast Squashers.

Controlled Drugs: Physicians are under increasing scrutiny about prescribing narcotics for pain relief.  Deaths from overdose, often prescribed, have doubled in the past decade.  The biggest problem is internet prescription mills in Florida and Georgia, but the Feds are squeezing them.  My problem is attempting to alleviate pain without producing an addict.  One approach is a "controlled drug contract," which I am requiring whenever you need more than 40 doses per month of narcotics (codiene, hydrocodone, oxycodone), benzodiazepines (Valium, Ativan, Xanax), or amphetamines (Vyvanse, Concerta, Adderall).  Don't take it personally; it's a response to the world we live in.  Addendum 1/27/2013 due to FDA ruling: An appointment every 3 months is now required for narcotic prescriptions.  I know; I don’t want to see you, either.  Blame the Gummint.

Pain Relief Without Narcotics: Start with extended-release acetaminophen 650 mg (Tylenol Arthritis), 2 pills every 8 hours.  Then, as long as you aren't diabetic or suffering kidney disease, add naproxen 220 mg (Aleve), 2 pills every 8 hours.  You can take both drugs at the same time.  That will handle almost all acute and chronic pain. 

Zolpidem (Ambien) Alert: The first week of January the FDA announced new recommendations for taking zolpidem, the most popular and effective prescription drug for insomnia.  The problem is that some people, especially women, metabolize it slowly, and it impairs their ability to drive the next morning.  The recommendation for women is a maximum of 5 mg per night.  Those of you who have been prescribed 10 mg can cut them in half with a pill splitter.  If you just don't get to sleep without 10 mg, use your judgment.  If you are in the least "slow" or tipsy in the morning, you should not drive.  Remember good sleep hygiene: no TV in the bedroom, use the bedroom only for sleep (not work), and read before going to bed. 

Pap Smear Frequency:  If your pap smears have been normal, every 2 or 3 years is sufficient.  Why the change?  We now know that cervical cancer is almost always the result of infection with the human papilloma virus.  If you're not infected, and sexually monogamous, your risk of cancer is exceedingly low.

BMI vs. Fat %:  The research world is in a tizzy because a study published in JAMA showed that people with a BMI between 25 and 30 (slightly overweight) live 6% longer.  The problem is clearly that BMI doesn't distinguish between fat and muscle weight, as I've been preaching for many years.  Don't worry.  Watch the fat % that we do on everybody every year.

What's New Politically for 2013: We've had our election, and ObamaCare is here to stay.  As I wrote last year, and in more detail in a Capital-Journal op-ed, it has its advantages.  Chief among them is the emphasis on preventive care, which follows the approach of all other industrial democracies.  Any screening test recommended by the U.S. Preventive Services Task Force-- including annual physicals, immunizations, mammograms, and once-per-decade colonoscopies-- will get first-dollar coverage without copays or deductibles, by January 1, 2014.  However, most insurance companies have already adopted this policy.  This is to encourage the early detection of disease and regular follow-up.  Those of you who have been patients for more than a couple of years remember that I used to recommend "database physicals" every five years under 50 years of age, and every two years over 50.  I haven't changed my mind about the cost-effective screening interval, but President Obama never asked for my advice.  I waited patiently, but still no calls.  So I have adapted.  Those of you who have to see me every 6 or 12 months for regular follow-up will now get a free "abbreviated physical", meaning you won't have to meet with Jackie for a pre-physical interview.  New patients, and old patients every 5 years or so, will still have to do the two-step with her so that I can catch up on your interval history.

What's New Medically for 2013: The pertussis (whooping cough) epidemic in Kansas and nationwide continues.  We've been trying to catch everyone who hasn't had the new  Tdap (tetanus, diphtheria, acellular pertussis) vaccination as you come through for physicals, because whooping cough is a rib-breaking, months-long annoyance for adults, and a death sentence for babies.  When I worked in the Stormont ER I watched one kid die of pertussis (the parents didn't believe in immunizations), and one is enough.  If you haven't had a "tetanus shot" in the last 4 years, you need the Tdap.   For reasons I haven't seen explained, we're also in the midst of a pneumonia outbreak that is now in its third year.  I used to see one case every couple of years.  Now I'm seeing a dozen annually.  For that reason, I'm also recommending a Pneumovax immunization if you're over 50.  Both of those are good for 10 years.  Finally, you ought to consider getting a Zostavax (shingles, herpes zoster) shot if you're pushing 60.  The chickenpox virus we all got as kids never dies; it just lives in your nerve endings forever, and pops out as painful blisters if your immunity ever wanes.  The Zostavax stimulates your immune system to boost antibody production.  The real problem with shingles is post-herpetic neuralgia, a severe pain which persists after the skin has healed.  The older you are, the worse it is and the longer it lasts. 

How Long Will I Be at the Office?  This is an era of busyness and multitasking, although evidence indicates that multitaskers often don’t do anything very well.  But never mind.  When you are scheduled for an appointment, you need to plan realistically.  Let’s start with the basics.  At our office, we ask you to show up on time for your appointment, not 15 minutes early.  That means that your appointment time is NOT the time I will walk into the room.  You’ll meet with the nurse first, and that is going to take 10 to 20 minutes, depending upon the number of issues we are addressing.  Add to that the time that I’m running behind, because rare is the day that no patient arrives late, or no visits take longer than they are budgeted.  Finally, add the time I spend with you.  So how much should you plan for?  A good estimate is an hour for a routine appointment, 1½ hours for a database physical, and 2 hours for a database and a treadmill.  We usually do better than that, but remember-- I’m not a dentist or an optometrist.  I let people talk to me, they’ve got the whole body for subject matter, and I can’t control the breadth and length of those conversations.  Anyway, try to be realistic about plugging these times into your smartphone, and we’ll all experience less frustration.

Give the Nurses a Break:  I have the best staff in the country-- no kidding.  I mean, they're not Mother Theresa, but she's dead, and worked in India.  There are two major time-wasters for them.  One you can't do anything about-- the stupidity of third-party payers screwing up my prescriptions with their stupid challenges and pre-authorizations.  I've been a fanatic for saving money from the get-go, and my reward is that my staff gets treated like every other medical office in the country.  There-- I feel better now.  I brought up the second issue in last year's letter.  If I give you six months of medicine, I want to see you again in 6 (six) months!  So if you're down to the last handful of pills  in your last refill, it's time to call for an appointment.  Failing that, you have to call office, somebody has to pull your record, the nurse has to call you back, you ignore the call, you call again, she calls back again, you answer, she agrees to give you 10 more pills and makes the appointment, she calls the pharmacy, they fill an expensive per-pill prescription, she has to write a note in your chart, and someone has to re-file the chart.  Doesn't that seem silly?  Overall, you're doing better.  Keep at it!

Use It or Lose It:  We’re approaching something like a fundamental law of the universe, documented scientifically.  For years we’ve known that the brain is more “plastic” than we realized: not just a blob of fat, it changes, it morphs, in response to stimulation.  New research shows that “gray matter”, the stuff we think through (not think with, but through-- we think with the soul, which, as Aquinas demonstrated, is not a physical body) expands and contracts as it is exercised.  That’s right-- just like a muscle does.  So all you aging crossword puzzlers, bridge players, and musicians: keep up the good work.  Just don’t forget that your body benefits from the same thing.  So keep walking, swimming, and gardening, too.  There is no age, and no disease, which does not benefit from daily activity.  If you can’t run or walk, bike.  If you can’t bike, swim.  If you can’t swim, crawl.  If you can’t crawl, roll.   

Media and Internet Update: For another year I am grateful to the Capital-Journal for Dr. Anthony Komaroff's advice column.  It is excellent and trustworthy, unlike Dr. Peter Gott, who was a fount of misinformation, some of it weird or downright bizarre.  May his column R.I.P.  Some of you still feel moved to apologize for sneaking a look at the internet for advice.  Stop worrying!  Everybody does it, and it's a good thing.  Sometimes you make your own diagnosis correctly.  Other times you confuse yourself, or get mislead.  Doesn't matter-- you're better off for having tried.  It's easier and quicker for me to disentangle truth from fiction that to start from scratch.

House Rental in Summit County, Colorado: Until 2008 I offered patients heavily discounted rental rates on my condo at Keystone.  I had to sell that to help my son contract a house to launch his construction company.  He now seems to be making it in that business, but in Christchurch, New Zealand; and I’m stuck with a house that was finished just as the Great Recession hit, and now won’t sell.  So if you want to have a family reunion near Keystone, Copper Mountain, or Breckinridge, the management company will let me give a 25% discount on a 7-day stay.  Go to keytotherockies.com, plug in your dates, and specify a 6-bedroom house.  That will get you to Ruby Ranch.  You can book the stay through the website, but you’ll have to call me to get the discount.

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