Sunday, March 27, 2011

Flu Activity, 2011 Weeks 10 and 11

There is one good outcome of the terrible weather this winter: people stayed home and didn’t share their germs. This, combined with an improvement in the immunization rate, has kept down influenza-like illness activity. It’s the end of March, and only Idaho has high activity. The rest of the country is quiet. The flu season might be over. 

What's In A Number?

It’s my habit to send all patients a copy of their laboratory evaluation, along with a summary of the important findings and recommendations. It’s not practical to discuss every value in a short letter (but of course, I am happy to meet with patients to do so). For patients who like to do their own research, the New York Times has an excellent interactive guide:

Even as I spent a lot of time discussing lipid profiles and the value of cardio-CRP levels with my patients, these are not my favorite tests. Analyzing some of the less glamorous assays can provide valuable clues to health and potential medical problems.

If I could run only one profile in my patients under 40, it would be the complete blood count. The absolute numbers are helpful; the ratios are even more so. Is my patient eating properly? Are there potential genetic problems we need to investigate (sickle cell trait, thalassemia)? Is my patient abusing alcohol, steroids or over the counter medications? Are environmental allergies a problem? Any parasites from that exotic vacation?

After age 40, I would add the comprehensive profile (Chem 24). These tests screen the liver and kidneys, which over time can start to show some wear and tear. We can see the cumulative effect of eating a less than perfect diet, consequences of medication (both ethical pharmaceuticals and non-medical), infection and metabolic disturbances.

Other tests can be very helpful for individual patients, and there always seems to be a test du jour. These days, I am ordering a lot of Vitamin D levels. There is a move to cut back on the number of PSA’s, and homocysteine is completely out of fashion. Unfortunately, there is no one test that can predict (or even diagnosis) disease. As I tell my patients – if such a test existed, wouldn’t everybody order it?

Wednesday, March 23, 2011

More Than Just Blood Sugar

With the diagnosis of diabetes, the first concern by the patient is control of blood sugar. It’s common wisdom that ‘tight’ control is key to reducing some of the bad consequences of diabetes, such as heart disease. There is increasing evidence that measures to control high blood pressure and high cholesterol may be even more important, and is the subject of a new article in Hypertension.

An accompanying editorial states, “Although diabetes remains a risk factor for atherosclerotic cardiovascular disease, the main focus of intervention needs to be directed to hypertension and cholesterol control in terms of reducing this risk, and treatment should most likely be completely independent of the presence of diabetes mellitus.”

Even the notion of ‘tight’ control is under review by the medical community. Certainly blood sugars consistently greater than 200 are unacceptable, but the risks associated with episodes of very low blood sugar must be considered. Getting the right regimen is a team effort and the patient needs to be an active participant.

In addition to medication, I cannot emphasize enough the role of diet and exercise in maintaining health. Food is to be enjoyed, but most of us should enjoy less of it. Food comes out of the ground – it’s not manufactured in a factory and wrapped in cellophane. No one ever got stronger just sitting in a chair; if you are in a chair, move what you can.

Diabetes may be the canary in the coalmine disease: since patients with diabetes receive close medical attention and are followed for a long time, we may be able to gain valuable insight on how to ward off other chronic medical afflictions.

Hypertension. 2011
Published online before print March 14, 2011, doi: 10.1161/HYPERTENSIONAHA.110.162446

Friday, March 18, 2011

Flu Cases: 8200 this year, more than 40,000 last year

This year’s flu numbers are much like what was seen in 2007-2008, according to the CDC’s Influenza Division. Last year the influenza attack rates were very high because of the lack of population immunity to the new H1N1 virus. The flu hospitalization rate this year is worst among young children and seniors, in contrast with last season, when many people in their 20’s were hospitalized with H1N1.

This year, circulating flu strains are well matched to the 2010-11 seasonal vaccine. According to CDC surveys, the adult percentage of immunization is 42%, up from 33% during the 2008-09 season. More than 70% of physicians are immunized. Immunizations are still available, as the flu season is expected to last until May.

There have been 115 flu-related deaths this year, compared with 1994 fatalities at the same point during the 2009-2010 season.

Monday, March 14, 2011

Flu Activity, 2011 Week 9

A real decline in activity across the country. Things are light in Connecticut, as well as the surrounding states. The data next week might indicate a real trend.

Some Whining

Just a few words of whining about the ways that insurance companies are driving me crazy. I am not solipsistic enough to think that I am the only one with complaints, but here are today’s aggravations:

A very large insurance company needs to ensure that I am recording the BMI (body mass index) in the patient chart as part of a HEDIS review. (If you are not familiar with HEDIS, Google it.) I have the data on hand so it takes about five minutes to complete the survey. I then attempt to fax the completed document to the secure receiving fax machine. No go – not a working number. Over the next few hours, I make several more attempts to submit the data. I felt no urgency to complete the task, but I simply wanted it off my desk. The next day I call the person listed as the project manager. Of course, the contact telephone number is the gateway to voicemail hell. But a miracle does occur – we receive a return telephone call. Several telephone volleys later the transmission problem is revealed: the receiving fax machine is out of paper. This very large insurance company prides itself on cutting edge data mining – and it’s using a fax machine without a memory? And collecting data on paper? Shouldn’t there be an app for that?

A very large pharmaceutical management company will only allow my patient to have thirty days of a blood pressure medication at a time, even though the prescription was written for ninety pills. This is an inexpensive, generic product that the patient has been taking for a long time. A trip to the pharmacy once a month is inconvenient and a waste of gasoline. An overdose is unlikely, and it’s even less likely that my patient would sell the pills or otherwise misuse them. The management company agenda is clear: collect a co-pay every month and while waiting for the pharmacy tech to return from break the patient will stock up on peanuts, magazines and small electrical appliances. My suggestion to the patient: just pay the retail price of $10 for ninety pills and completely bypass the insurance company.

An aside: mail-order pharmacies present their own challenges. My favorite: a patient who received his shipment of five medications quickly after we submitted the electronic prescription. Imagine his surprise upon opening the package: no lids on the containers and 450 loose pills in the padded envelope. 

Sunday, March 6, 2011

Flu Activity, 2011 Week 8

Still not much influenza-like-illness in Connecticut last week, even as our surrounding states show increased activity. Wilton has reported 13 confirmed cases this season, and Westport has 28 cases. Norwalk, has reported 133 cases. The largest number of cases in the state is reported by Stamford (174 cases). Rather than assuming that Stamford truly has more cases, it might be that the public health officials are doing a better job of tracking illness. 

News from Consumer Reports

The cover story in March Consumer Reports,  “What Doctors Wish Their Patients Knew,” contains valuable insight into improving the physician-patient relationship. I certainly agree that forging a long-term relationship leads to better care (and I hope, better health). Research suggests that patients who frequently change doctors have more health problems and spend more on health care than patients who have a consistent relationship.

The top complaint by physicians about their patients is non-compliance with advice or treatment; most doctors in the CR survey stated it affected their ability to provide optimal care. If patients are having side effects, are unsure if they are following instructions properly or experience new or recurrent symptoms it is important to contact the physician. It’s also important to keep follow-up appointments, especially if there has been a change in medications or treatment plan.

Physicians would like their patients to be smart online researchers. Rather than enter the name of the condition in the search engine box, go directly to a few reliable sites. (There are several listed on the “Health Resources” page on my website If there is information online that you would like to discuss with your physician, just print out the relevant parts. According to CR, doctors are not convinced that online research is helpful to patients. I disagree - but be aware that there are many motivations for posting information on the web. Be wary of links paid for by advertisers.

A related article in March CR is “Best Buy Drugs.” The take home message is that sometimes older pharmaceuticals work just as well as newer drugs and may be safer. They are almost certainly less expensive. Doctors know that money does not grow on trees; our job is to match the right medication to the right patient.

I believe that the foundation to a good physician-patient relationship is communication. Each new dialogue builds upon the foundation of previous conversations.