Dr. Iliff’s 2018 Practice Newsletter/Rant

What Foods Will Kill You: From a "cardiometabolic" death list (700,000 Americans croaking from heart attacks, strokes, and type 2 diabetes), here are the top threats, starting with the most dangerous: 1. Excess sodium (I haven't touched a salt shaker in 50 years)  2. Insufficient intake of nuts and seeds (my lunch is almost always almonds or peanuts)  3. High intake of processed meats (I love filet mignon, hamburger, and chicken, but never touch bologna)  4. Low intake of seafood omega-3 fats (while I occasionally eat salmon, I take a fish oil capsule every day).  Now, if I stroke out this year, all of you can have the last laugh.

Am I Going to Retire?  I get this question every day.  Is it something I ate?  No, no, no.  I'm going to die with my Crocs on, probably in or on the way to the office.  However, I won't be delivering the first baby in Topeka in 2018, as I did the last two years.  Gave up obstetrics last summer, after a couple of thousand newborns and no stillbirths.  Quit while you're ahead, my father always said; and I won't miss the 2 a.m. summons to the hospital.  Still, it's kind of sad.

Opioids and Pain Control:  The 8th most influential article in the Journal of the American Medical Association this year was a study which should have been done a long time ago.  It was elegant in its simplicity.  The authors randomized 411 consecutive ER patients with severe upper arm pain (average of 8.9 on an 11 point scale) to treatment with 3 narcotics (Percocet, Lortab, and Tylenol 3), or a combination of acetaminophen and ibuprofen.  The narcotic combinations were no better than Tylenol and Advil; in fact, Lortab and Tylenol 3 were considerably less effective.  This confirms what I've been saying for years, to wit:

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 ibuprofen 200 mg (Advil), 3 pills every 8 hours.  You can take both drugs at the same time.  That will handle almost all acute and chronic pain.  Next stop: tramadol 50 mg (prescription) every 8 hours.

Narcotics, Professional and Personal Experience:  I have a number of patients, usually suffering back pain, who have been on narcotics for years.  They are addicted, but functional and comfortable; they aren't the folks who you read about who are dying of overdoses, usually with illegal narcotics laced with fentanyl.  It is unnecessary, in my opinion, to make them undergo the pain of withdrawal and adjustment to some other regimen.  On the other hand, I have become much more hesitant to prescribe narcotics at all, based on the evidence above.  On the other hand, when I experienced severe sciatica many years ago, I couldn't get out of a recliner without Percocet-- with it, I didn't miss a day of work.  So I dunno.  Real life and research don't always square with each other.

More Bad News About Obesity and Perception:  In the past 3 decades, Americans have steadily gotten fatter.  Over the same period, the number who are trying to lose weight has steadily dropped.  The conclusion is that we are getting comfortable with being fat.  In a vain attempt to counter this perception, I often drag out an old black-and-white picture of a KU class in the 1950s.  The kids all look like models.  I've pretty much given up harassing my patients about gaining weight, except for my many diabetics, who are slightly more motivated as I threaten them with insulin in their future.  Anyway, research shows that if you have had to choose between being skinny or fit, fit is more important.  So I won't stop urging you to take a hike.  Come to the Iliff Commons, if you haven't already.  The prairie, woods, and hills are four-season beautiful.  Google Maps will get you there.

More Bad News About Kids and Electronics:  Children who are allowed to use cell phones and computers before bedtime experience less sleep, lower sleep quality, more fatigue in the morning, and a higher body mass index.  Add to this the experience of school counselors, who claim that social media is a major source of bullying and school fights.  Oh, for the good old days of playing pickup basketball and gigging crawdads in Brush Creek after school.  I'm either nuts or terminally nostalgic.  C'mon, parents.  Be the adult in the house.  Grandparents, weigh in here!  You'll have to deal with more chaos, mess and noise, but it will be worth it.

And Yes, That Was My Son James who was named a “Distinguished Kansan” for being co-founder of a company that produces virtual reality video games.  Whoever said “the apple never falls far from the root of the tree” was mistaken.

More Good Parenting Practices, Rapid Reading:  1. Up to 1/3 of children will suffer anxiety disorders before the age of 18, starting as early as preschool.  Best approach is to gently encourage them to face their fears, rather than protecting them.  2. Measles has increased 19-fold in Texas between 2002 and 2016 due to "vaccine deniers," who are a public health hazard not only to other children, but their own.  3. Want to prevent a childhood crippled by allergies?  Get a dog, let your kids play in the dirt, introduce them to peanut butter at 6 months-- our genome is mostly derived from bacteria and viruses, a well-exercised immune system is the best defense against asthma, eczema, infection, and cancer.  Humans were not engineered to live in a bubble.

Gym Rats-- Cardio or Kettle Balls?  According to the Wall Street Journal, gyms are switching from machines for cardio or weight workouts (ellipticals, treadmills, steppers, bikes, rowers, universal gyms, Bowflex) to free weights and "functional" exercises (CrossFit, Jazzercise).  My opinion is that anything raising your heart rate for at least 20 continuous minutes is a good thing.  A lot of this is just fad and fancy, and I'm always suspicious of trends, because trendy people aren't known for their persistence.  So, although I will always prefer the outdoors, I have an elliptical, rower, and Bowflex for bad weather and convenience.  My only caution is that I see a lot of chondromalacia (grooves in the cartilage on the underside of the kneecap) among active women these days, because wide-set hips (made for baby delivery) pull the female kneecaps to the outside during quadriceps exercise.  Guess what?  Squats and lunges are a popular "functional" exercise, and I suspect that's the source of the problem. 

Flu Vaccine-- Lets Get Real: "Every time I get the flu vaccine I get sick."  Right.  And everyone in the Topeka health care system gets the vaccine every year, and the system doesn't shut down because of illness.  So you must be special!  Congratulations.  "But I never get the flu."  Right.  On average, an unvaccinated adult will only get the flu every 40 years.  That's because your neighbors get the vaccine, so we don't have an epidemic.  You're a free rider!  Congratulations.  Some years ago (against my advice) schools began mandating a very expensive chickenpox vaccine because 4 kids a year died of chickenpox.  Since 2010, between 12,000 and 56,000 people die every year of influenza in America, and 140,000 to 720,000 are hospitalized.  No, the vaccine isn't perfect; it is developed based on a guess about the strains circulating in SE Asia and heading our way.  However, those of us who get the vaccine every year have some cross-protection against a rogue strain, and we also experience less illness from other types of viruses.  So there you have it.  Make your choice.  I'm not wasting any more space or breath on the subject. 

Another Battle We're Losing:  Americans drank an average of 201 calories per day in 2016 in the form of soda and fruit juices.  That adds up to about 20 extra pounds in 12 months, of completely unnecessary sugar, and it’s rising every year.  The beverage industry really seems to have tried to reverse the trend by promoting artificial sweeteners, but sales of diet drinks keep falling.  Nevertheless, patients frequently wonder if aspartame and its cousins are dangerous.  No, they're not.  Unnecessary, but not dangerous.  Fat is dangerous.  Diabetes is dangerous.

Medicare and Me:  As my fellow oldsters know, our office hasn't participated in government programs since 1996.  That's why I love my practice, while half of the physicians in America hate theirs.  That's why I can look you in the eye instead of checking boxes on my computer.  When I get daily updates about problems with Medicare, I just ignore them, leaving me free to concentrate on my craft. Twenty years ago our practice started charging two flat rates in cash for patients over 65 without commercial insurance: $75 for an office visit, and $125 for a physical.  We've never adjusted those fees for inflation.  As a result, they no longer cover the cost of my overhead, which runs around $360 per scheduled office hour.  That means I lose money when I see old friends in my age group.  Therefore, for 2018, I'm boosting those charges a little bit, to $85 and $150, to cover my expenses.  I hope you understand.  We really like you. 

Medicare and You:  What are you really paying for Medicare?  It's hard to understand, as Dr. Laccheo and I discovered when we came of age.  Let me see if I can simplify the finances.  Part A covers hospital charges, and the premium is FREE and automatic at age 65, for everybody.  So how much financial exposure do you have for Part A deductible, Part B (doctor and outpatient) premium and deductible, and Part D (drugs) premium and deductible?  It depends on your income.  For people earning less than $85,000 per year (almost everybody), those add up to $3600 per year.  (It could be up to $8000 if you earn more).  If you want to sign up for a supplemental policy through a private insurer (Part C), it could be $0-- but, of course, you'll have to make monthly payments to the insurer.  No matter how you look at it, Medicare is the cheapest, best insurance in America, because your children and grandchildren are paying a lot of your REAL cost through higher premiums than they deserve.  That is, it's welfare for old people, including old people like me who could afford to pay their fair share.  Sorry to be so blunt, but that's the fact.  LESSON: If you EVER hear a Medicare patient complaining about how much they have to pay for medical services, remind them that they are on welfare, and to be grateful for all the plumbers and secretaries in America who are subsidizing their joint replacements and stents. 

Special Note About GoodRx:  Your prescription might cost less than your insurance copay with GoodRx, but you will have to ask for the cash price from the pharmacy clerk.  They won’t give away money voluntarily.

Heartburn:  I have information sheets with more information in the exam rooms, but here are the basics:  1. Don’t eat after dinner, or within 2 hours of bedtime.  2. If that doesn’t solve the problem, take an antacid at bedtime.  3. If you still suffer, buy a pair of GI bed blocks and put them under the head of the bed.   4. Next, try Zantac at bedtime.  5. Finally, Nexium.

Plantar Fasciitis:  1. Never go shoeless at home; I recommend Crocs.  2. Stretch your calves daily.  3. Buy gel heel cups for your work shoes.   4. Advil daily   5. Ice your heels for 20 minutes before you sit down after work or exercise.  6. Custom orthotics

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