Friday, July 27, 2012

Too Much Medical Care?

More from the NY Times- I'm on a kick this week, I guess.

In this column, Tara Parker-Pope, the medical reporter/blogger who writes the "Well" Blog in the Times, critiques her daughter's medical care.  She describes how her daughter sprained her ankle dancing.  She took her to the pediatrician, who recommended the usual care (rest, ice, compression) and waiting it out.  It was not better after a month, so she took her to a sports medicine specialist.  That specialist ordered an MRI and sent her to an orthopedist.  THAT specialist took a lot of blood and did another MRI, and sent her to a rheumatologist.  THAT specialist did a bunch more tests...but the ankle still hurt.  At this point, Ms.  Parker-Pope called a halt to the merry-go-round, went back to the original sports medicine person, had her daughter get a steroid shot, and she was better in a few days.

She says, "I canceled all her appointments with the various specialists, and went back to the sports doctor. We discussed a new approach that focused solely on pain relief. He consulted with my daughter’s pediatrician, and they agreed on a treatment. Within days, my daughter’s ankle had stopped throbbing, and soon she was back to sports and dancing. The cost of this ankle injury had reached well into the thousands of dollars — I had lost track because it was all covered by my insurance."


I agree, her daughter was a victim of over testing.  However, I feel that the blame lays primarily on the shoulders of the author.  Her daughter's pediatrician suggested waiting it out- Ms. Parker-Pope initiated seeing a specialist after only a month.  That specialist then participated in my least-favorite specialist behavior- he referred the patient to another specialist.  This is rarely a good idea.  Why?  Because specialists often seem to not know what the scope of practice of a primary care doctor is.  A good primary care doctor can treat many conditions, including initiating a workup for juvenile rheumatoid arthritis, which is what I think the sports medicine doc was concerned about.  

I feel lucky that the vast majority of specialists that I work with respect my opinion enough to send patients back to me for continued workup.  This keeps care from getting too fragmented and allows me to put a stop to the endless merry-go-round of overtesting.


Tuesday, July 24, 2012

Breast is Best, Right?

The NY Times ran a piece yesterday about breastfeeding.  Not surprisingly, it has elicited a ton of comments.  The piece can be read in its entirety here.  I thought it made a lot of good points.

As any pregnant woman or new mom knows, the breast vs. bottle wars are alive and well.  Moms feeding their babies in public often are in a no-win situation- they either get the stink-eye for breastfeeding in public, or they get sneered at by the "lactivist" crowd for bottle feeding.  Yes, there are really people who describe themselves as lactivists.

The AAP recommends breastfeeding for the first 6 months of life, and then for as long after that as is comfortable for mom and baby.  There is plenty of research that shows the benefits of breastfeeding, both for the mom and the baby.  Some of the reasons are pretty founded in good, solid research, such as the decreased risk of breast cancer in mom and decreased risk of diarrheal disease in baby.  However, other benefits are more nebulous- claims such as higher IQ and lower rates of obesity are less clear-cut. Other benefits, such as more "bonding" between mom and baby are even harder to measure.  A very good article regarding the conflicting research results can be read here.

What it comes down to is this:  every woman has to decide for herself how to feed her baby.  It's no one's business but hers what she is doing and why she is doing it.  There is not an official list of acceptable reasons not to breast feed.  I've created a list of breastfeeding myths that I wish I knew about before I had kids:

Myth 1:  Breastfeeding Is Easy.

  • It's not easy.  People think that because it's "natural," it's easy.  There's a learning curve for both mom and baby.  I tell new moms that if they want to breastfeed, give it at least six weeks before giving up.  It does get much easier.  It truly does.  However, those first few weeks are tough.  Very tough.  I remember with my first that when I would finally get him to latch on, I would freeze, afraid to move a single muscle lest he pop off.  
Myth 2:  Breastfeeding Should Never Be Painful.
  • It hurts at first.  It really does.  It almost always gets better after a few weeks.  However, it is normal to have soreness and cracked nipples and all sorts of other pleasant ailments.
Myth 3:  Breastfeeding is Free.
  • Yes, technically, it's free.  However, unless you are staying at home and are available for every feeding for the first six months of your baby's life, there are hidden costs.  The majority of women go back to work six to twelve weeks after delivery.  If you're doing that, you need a breast pump.  A decent one will run you over $300.  And, you'd better get a decent one if you have any prayer of pumping enough milk.  You might have lost productivity from work from time taken out for pumping breaks.  You still need bottles and milk storage bags. 
Myth 4:  All women can produce enough milk.
  • Not true.  It's just not.  I'll tell you my personal experience.  I breastfed my first son for one year.  I went back to work after 12 weeks and pumped for 9 months after that.  It was a pain, but really not that bad.  I had no supply problems.  I never had to supplement with formula.  With my second son, for whatever reason, my supply was terrible.  Pumping became torture, as I would spend 20 minutes pumping and have an ounce or two to show for it.  I saw a lactation consultant.  I rented a hospital-grade pump.  I drank the stinkiest teas imaginable.  Nothing helped.  After about 6 months, I just gave up.  It seemed pointless.  At least 7/8 of each bottle was supplemented formula.  Once I gave up, it was such a relief.  I was finally able to concentrate on enjoying my baby, rather than obsessing about how to feed him.  Now, think about it.  If I, a mother with breastfeeding experience, a job that allowed me ample time to pump, sufficient funds for a lactation consultant, fancy pumps, and stinky herbal teas couldn't make it work- don't tell me that all women can if they just "try hard enough."
Myth 5:  Breastfeeding is crucial for the "bonding experience."
  • I'm bonded to both my kids.  Adoptive parents are bonded to their kids.  There are so many factor in the bonding process.  It really doesn't always come down to what your kid is eating.

Anyway, that's my opinion.  I encourage breastfeeding, but if someone is having a lot of trouble, or hates it, or just doesn't want to do it- well, that's fine too.  I firmly believe that a more important factor in a healthy, happy baby is a healthy, happy mom.  Let's face it- we'll have countless opportunities to feel guilty about how we raise our kids.  This shouldn't be one of them.

Thursday, July 12, 2012

Common Issues in Primary Care: It's more than just runny noses and strep throat

I've decided to start a series about common issues that a primary care doctor encounters.  As I browse the internet, I frequently see comments that reflect misconceptions about what primary care docs can do and manage.  These frequently run along the lines of, "If there's anything really wrong with me, I'm going to see a specialist anyway!"  Never mind that just about every public health study has shown that countries with more primary care docs and fewer specialists have better outcomes.  There are also numerous studies that show that the more specialists a patient has, the more fractured their care is and the worse their outcome.  See here, here, and here, for example.

I'm going to start this series by outlining a typical day in my life, during which I see an average of 30 patients.  Details have been changed to protect the innocent! Keep in mind- we have a "walk-in" hours from 8AM to 10AM, when people can drop in for quick visits without an appointment.

7:30 AM- Arrive at office, after dropping kids off at daycare.  Review upcoming schedule, making sure people are scheduled in appropriate spots for the right amount of time.  Review labs, phone messages, refill prescriptions, drink first cup of coffee.

8:00- Patients start arriving.

Patient 1: Here for a routine followup of his hypertension and high cholesterol.  Did his labs 2 days ago- I've already reviewed results.   He looks great.  No changes made, see him in 6 months!  Good start to the day...

Patient 2:  Walks in without an appointment.  Been coughing and has had sinus pain for 2 days.  Wants an antibiotic for sinusitis.  Exam is normal- she just has the cold that's going around.  Spend 5 minutes explaining to her why an antibiotic is not needed.  Sample of a sinus irrigation system given to her.

Patient 3:  Here for a followup of her diabetes, high blood pressure and high cholesterol.  Forgot to do her lab work.  Has not been checking her blood sugars at home.  Blood pressure not controlled.  Blood pressure medications changed.  Discussion about the importance of managing disease, checking sugars, doing lab work.  Follow up in 2 weeks to recheck blood pressure and review lab work.

Patient 4:  Walks in without appointment.  States has a UTI.  Urinalysis done in office is negative.  Patient is having severe pain with urination.  Gynecologic exam done- very consistent with herpes. Cultures taken, but I'm 99.9999% sure she has herpes.  Tears ensue.  Education regarding herpes and STDs given.  Medication started.  Discussed with her how to talk about this with her boyfriend.  Make a mental note to call her later to see how she's doing.

Patient 5:  Routine physical with a Pap smear.

Patient 6:  Here for a blood pressure check, looks good.  Follow up in 6 months!

Patient 7:  New patient.  Has not seen a doctor in 15 years.  Only here because his wife forced him to come in.  Feels fine.  Overweight.  Family history of diabetes in both parents.  I do a random finger stick blood sugar- it's 347.  He has diabetes.  Lots of education given.  Medication started.  Given a glucometer and taught how to use it.  Referred to a nutritionist.  Follow up appointment made for next week.

Patient 8:  Itchy rash.  Bad, bad case of poison ivy.  Steroids started.

I'm now about 2 hours into my day.  In between seeing these patients, don't forget that I have to dictate notes on each of them.  I'm keeping a constant eye on my "pile".

Patient 9: Can't hear anything.  Ears are totally blocked with wax.  Wax flushed out- patient can hear.

Patient 10: Reason for visit given as "insomnia."  Patient starts crying while I'm taking her history.  Finally admits that she is being varbally abused by her boyfriend.  Counseling referral set up.  Domestic violence resource information given.

Patient 11:  Knee pain.  Has been hurting for a few months.  Has completed 6 weeks of physical therapy and is no better.  MRI ordered.

I get interrupted by a phone call from another doc.  It's a local endocrinologist.  He's seeing one of my diabetic patients and has noticed that their heart rate is irregular.  Should he send her to the ER?  I tell him to send her over here.  She becomes...

Patient 12:  Exam and ECG reveal that she is in new-onset atrial fibrillation.  Her vital signs are stable but her heart rate is a bit rapid.  Started on a blood thinner and a rate control medication.   Referred to a cardiologist for follow up and potential cardioversion. Follow up with me in 2 days to see how she's doing.

Patient 13:  Here for a follow up of depression and anxiety.  Medication started 6 months ago.  Things are going great, but would like to stay on the medication.  Follow up in 6 months.

Patient 14:  Here to review labs.  Cholesterol is high.  Diet reviewed, suggestions for changes made.  Follow labs planned for 3 months from now.

Patient 16:  Here for follow up of her hypothyroidism, which I diagnosed 3 months ago.  Doing much better on medication.  Energy improved.  No changes made in medication, follow up in 6 months.

Lunch time.  Spent eating at my desk, reviewing results, returning phone calls.

You know, I was going to write out the whole day, but you get the picture.  I don't sit around all day seeing sore throats and colds.  I don't sit around just referring people to specialists.  If it's something I am qualified to take care of on my own, I'll do it.  If it's out of my league, I refer.  However, I love the fact that I'm the one that gets to make the diagnosis.  People walk into my office with a group of symptoms- I get to put them together and make the diagnosis.  That's what's awesome about primary care.  Do we make less money than many (most) other specialties?  Sure.  However, that's not because what we do is less valuable.  It's because the payment system is screwed up and rewards procedures more than thinking.

So, little by little, I'm going to write about common issues I encounter.  This is meant to be educational and perhaps help you to spark a discussion with your own doctor.

Don't worry, I'll still blog about running, my kids, and the ridiculous things I encounter behind the scenes at my office.

Friday, July 6, 2012

The slippery slope of "Providers."

I'm a physician. I'm not a "health care provider."  I hate that term. The insurance companies call me a "provider."  In a sense, it's true.  I provide health care services.  However, over the past few years I've noticed that the lines between different types of "providers" are getting more and more blurred.  Sometimes they're blurred to the point that patients don't even know what kind of "provider" they are seeing.  I often have patients tell me about their previous doctors, only to review old records and find that their "doctor" was a nurse practitioner or a PA.  I'll be reviewing lab tests that look kind of unusual, only to find that they were ordered by a naturopath.  And so on.  I'm not saying that there's not a place for everyone in health care.  I'm not saying that physicians are at the top of the hierarchy (trust me, most days I feel like I'm in the basement).  I'm just saying that patients deserve to know who is providing their health care and what their training is.

Here's an example- something that I've been reading about as a result of my interest in running.

On February 5, 2011, the annual Kaiser Permanente Half Marathon took place.  As is typical of large races, Kaiser was the main sponsor but outsourced the race management to a company called RhodyCo Productions.  It was an unusually hot day for February.  About 2 hours into the race, a 36 year old man named Peter Hass neared the finish line.  As he approached it, he collapsed.  Apparently, it took more than 20 minutes for an ambulence to arrive.  Other racers performed CPR.  Sadly, Mr. Hass died, apparently of a cardiac event. 

The City of San Francisco has now released a report regarding the events of the day.  You can link to the full document and read it.  There were obvious problems in communication and there did not appear to be enough ambulances present.  However- this stood out to me:


"There were several items listed in the EMS Plan for this event that were not adhered to by the permit holder for the event, RhodyCo Productions. For example, the number of EMTs at the starting and finish lines was insufficient, pursuant to EMSA Policy 7010. Additionally, chiropractic students were used as medical staff rather than EMTs or emergency medical personnel. The EMS Plan also stated that one MD would be stationed at the Medical Tent or at the event, which did not occur. Rather, a chiropractor from PCCW was provided. "

Whoa.  Double take.  Triple take.  There were no MDs present.  The production company was using students from a chiropractic college as "medical personnel."  What?  This can't be true, can it?  So, using the powers of Google, I investigated futher.  I found this.  For those of you who don't want to click, it's the RhodyCo Productions Emergency Procedures for the 2011 San Francisco/Kaiser Permanent Half Marathon. It states:

 "There will be Medical Personnel onsite at the START line till the last runner/walker passes.  There will be medical personnel at the Finish Line for both the 5K and Half Marathon till last walker/runner crosses the finish line.  There will be a minimum of 3 Medical Personnel mobile on the course during the race."

Sounds good, right?  Sounds like "medical personnel" will be ready and available.  Until you read a bit further, that is.

"Medical Personnel:  Palmer College of Chiropractic West Sports Council will provide event trained medical teams for the event (students are all CPR certified and have taken emergency response class).  The head clinician event day, Dr. Hal Rosenberg, (phone number redacted) will be onsite at the post-race Medical Tent."

Yup.  It's true.  They had "health care providers" present.  Except they were chiropractic students.  Even if they were real, live, actual chiropractors, they STILL wouldn't have been qualified to provide emergency medical services at a half marathon, unless they were also EMTs or paramedics.  But wait, what about Dr. Hal Rosenberg?  He's a doctor, right?  At least he would be overseeing the medical response team.  Right?  Right?  Except...not.  Yeah.  He's a chiropractor, too. 

It's true that running a half marathon is an inherently dangerous activity.  A distance runner is pushing his or her body to its limits.  Even elite athletes die during endurance events.  That's why all these events make you sign a liability waiver prior to participating.  However, this is what the half marathon website says about available medical support (from the 2012 race page- I'm not sure what the 2011 page said, but this is fairly typical):


Medical Support

  • Medical Support will be overseen by a Medical Director experienced in event medical response.
  • There will be a Medical Tent staffed with trained emergency personnel at the start line, at the finish line and in the expo area of the event.
  • Ambulances will be located at the start line, on the course, at the finish line and in the expo area.
  • There will be mobile Medical Teams at each of the 5 water stations and roaming the course throughout the race.
  • Medical personnel will be clearly visible, wearing a medical response uniform.
  • Race monitors on the course will be in constant communication with the Event's Medical Director. If there is a medical need on the course, please let one of the course monitors know as soon as possible and they will call for medical assistance.

Reading that, wouldn't a reasonable person assume that there will be physicians present?

Would having physicians present at this race have changed the outcome for Peter Hass?  I have no idea.  There's no way to know.  However, don't you think racers deserved to know that the "health care providers" at their endurance sporting event weren't physicians, but chiropractors and chiropractic students?  All health care providers are not created equally.

Wednesday, July 4, 2012

What to wear while running in hot weather

Happy 4th everyone!  The heat is on.  We've had temperatures well into the upper 80s and 90s for the past few weeks.  It's tempting to skip your run on hot days, but with the right clothes and gear, you can still keep moving.

Proper clothing is key.  Cotton, while soft and natural, is the devil when it comes to running in hot weather.  When you sweat in cotton, it gets sopping wet and stays that way.  This leads to chafing.  OUCH.  Look for synthetic fabrics.  Coolmax is one of my favorites.  It is soft and light.  As you sweat, it wicks the moisture away from your skin to evaporate rapidly.  Awesome.  Dri-Fit is another one.  However, most lightweight rayon or polyester will do fine.

Socks.  SO, SO important.  If you've ever run with a blister you know this. Again, cotton is evil.  Look for synthetic socks made of a wicking fabric.  My favorite are socks that are in a double layer- these are my favorite.  True, you can't pick them up at the dollar store,  but they won't break the bank, either.  Investing in a couple of pairs of these is well worth it.  I have 2 pairs and just rotate them.  Obviously, with 2 kids I'm doing lots of laundry anyway.

A hat.  Here are some good choices.  Look for a hat made out of a lightweight synthetic material.  These will wick sweat away from your head and hopefully keep it from running into your eyes.  If you get really hot, a neat trick is to dump water onto your hat and put it back on your head.  As it evaporates, it will cool you off nicely.

Sunglasses.  Look for a lightweight pair.  Now, you can spend a lot of money on a fancy pair, but it's really not necessary.  Just look for a light pair that has UV protection and fits decently.  I usually pick up a couple of cheap pairs at the drugstore.  I have a habit of constantly losing sunglasses, so I don't invest in anything expensive.

Sunscreen.  Need I say more?  High SPF, waterproof version.  Re-apply partway through your run if you are doing a lot of sweating.  Get something like this- a little travel size sunscreen with a carabiner so you can hook it onto your belt.

Finally- water.  Lots of it.  I'll do another post about hydration belts, but for now, just make sure you are carrying water!

Now it's time to get out for your run. Enjoy, because before you know it snow will be flying.