Too Much Testing

Patients who receive diagnostic tests for the purpose of reassurance don’t feel less worried in either the short or long terms, according to a very large analysis of fourteen clinical trials.

When the physician believes that the probability of a disease is low, there is no additional benefit in running the tests “just to be sure.” The reassurance of a negative tests offers comfort that can last as little as a few hours – “a fleeting sense of relief” – instead of long-term assurance. Ordering more tests is not the best response to the worried well.

Testing is sometimes offered in an attempt to wrap up a problem in just one visit, responding to patients concerns about increasing office co-pays and larger deductibles. This is false economy: the analysis shows that it requires testing 16-26 patients to avoid one repeat visit, and the tests cost $250 to $500 per test, therefore the health care system is spending between $4000 and $16,000 to prevent a $100 primary care visit.

There are currently evidence-based guidelines for testing for common conditions. More testing is not better medicine. Now – if only malpractice lawyers would get on board ….

Too Much Caffeine

One third to one half of all teens and young adults consume energy drinks regularly and nearly one half of deployed military personnel report daily use. These drinks are loaded with caffeine. A single cup of coffee has 100 mg of caffeine; this results in a blood level of 1-2 mcg/mL. The usual caffeine content of an energy drink is 80 to 140 mg but some have double that level. A potentially level dose of 3000 mg caffeine (80 mcg/mL blood level) can be reached by consumption of 12 highly caffeinated drinks within a few hours.

There are many ingredients in energy drinks and reading the label might not reveal the entire story. Guarana, also known as Brazilian cocoa, is a South American plant that contains the caffeine compound guaranine. One gram of guaranine is equal to 40 mg of caffeine, but it’s typically not included in the total caffeine count.  It’s like having caffeine with caffeine.

These drinks are particularly dangerous when combined with alcohol. The combination is believed to lessen the effects of alcohol but actually lessens the perception of impairment and encourages greater alcohol consumption. The combination of alcohol and energy drinks is associated with an increase of risk of riding with or being an intoxicated driver as well as the risk of committing or experiencing sexual assault. These drinks are marketed as dietary supplements and are exempt from most regulations.  Many states have banned the sale of premixed alcohol/energy drinks.

A reasonable goal for adults is a maximum of 500 mg of caffeine daily. This is only 30 ounces of coffee – a Starbucks Vente is 20 ounces, a Dunkin Donuts medium hot coffee has 14 ounces but the large iced coffee has 30 ounces. Children and adolescents have no need for any caffeine at all.

Saving Primary Care

The people who make health care policy are not too worried about getting into to see a doctor. They have insurance and know a lot of physicians or know people who know a lot of physicians who can make a telephone call. Not everyone has that access.

With the onset of the Affordable Care Act, many more people will have some kind of medical insurance. However, they might not have access to a doctor. The United States has too few primary physicians. There are many reasons for this, but like many problems this can be solved with money. Alan Sager, PhD, of Boston University School of Health has a proposal to make primary care more attractive for doctors: raise their incomes to match those of subspecialists. According to Dr. Sager, diverting 3% of healthcare spending to primary care would allow more parity in income. (Other countries spend 10% on primary care.)

This is very different than loan forgiveness, another proposal for enticing medical students to enter primary care. If a person owes $200,000 of medical school debt, that is only a one year salary differential between a general internist and an interventional radiologist.

An increasing number of primary care doctors are not accepting Medicare patients – funding is at the pleasure of the Congress. Private insurance company payments are highly prejudicial against primary care physicians even as the doctors are expected to (in addition to taking care of their patients) coordinate care, ensure continuity and appropriateness of care and hold down costs.

Primary care doctors are desperately treading water – and may soon be drowning. It doesn’t matter how many doctors one knows: the phone will not be answered. 

You Are What You Eat

Two news stories in the past two days caught my eye, reinforcing my belief that you are what you eat. The benefits of the Mediterranean diet have been widely touted but now there is good statistical evidence that a diet rich in olive oil, fruits, vegetables, beans and nuts will reduce the risk of heart disease and strokes. The merits are there even if one doesn’t lose weight and adds to the benefits of taking medications to lower blood pressure and cholesterol. The participants in the study avoided commercial cookies and pastries and limited their intake of red meat and dairy products. Wine could be enjoyed with meals.

Gluten intolerance, once rare, is now becoming almost commonplace. There is a growing body of evidence that manufactured food given to infants and small children may play a role. Breast-feeding beyond six months seems to convey life-long protection from celiac disease along with many, many other benefits. It appears that sticking with simple grains that are minimally processed is a good idea for people of all ages.

In my opinion, food comes out of the ground. What emerges from a factory wrapped in plastic is not food. Animals should be treated with respect. If you choose to eat meat/fish/chicken, those animals should be well-fed, be allowed exercise and slaughtered humanely.

Michael Pollan: "Eat food. Not too much. Mostly plants."

One in Eight

One is eight American women will have a personal encounter with breast cancer. A young woman far more clever than I is blogging about her experience. For PG-13 to R rated real time reports, read this.

Should the Annual be every year?

The ‘yearly’ physical examination is an opportunity for the patient and physician to spend focused time on health maintenance and disease prevention. If a recommended preventive service is missed one year we can catch up at the next visit. The visit also nutures the patient-physician relationship.

For women, there are 21 measures that earn a A or a B rating as showing evidence for effectiveness in maintaining health or preventing disease.  Mammography is the 22^nd measure. What is NOT effective is an annual pelvic examination.

As we attempt to better allocate our health care dollars, we need to think about what procedures are supported by evidence and which are performed merely out of habit. There no clear reasons to perform a yearly pelvic examination in women who have no symptoms and for whom a Pap test is not due. In 2012, Pap test guidelines were resolved to recommend a standard cytology examination every three years. In women between the ages of 30-65 the testing interval can be increased to every 5 years if the HPV test (done at the same time as the Pap test) is negative. No need for testing in the asymptomatic woman after age 65.

Many women believe that that pelvic examination screens for ovarian cancer; sadly, this is not true. Also, pelvic examinations are not needed to start or continue oral contraceptives.

There is evidence that many women avoid routine care because of the dreaded pelvic examination. These women are denying themselves the chance of obtaining a personalized program to help stay well. 

Staying Healthy: Recommendations for Women

Iron Deficiency

Iron deficiency is the most common nutritional disorder worldwide; the low blood counts that result can be caused by inadequate iron intake, decreased iron absorption, increased iron demand and increased iron loss. Iron is a building block for making new red blood cells.  

The diagnosis of iron deficiency is quite straightforward with some simple blood tests. Once the deficiency is identified, the goal is to determine the cause. Excessive menstruation is a common cause in premenopausal women. In men and postmenopausal women blood loss via the gastrointestinal tract is suspect. The first step in evaluating the GI tract includes upper endoscopy and colonoscopy. These tests will both look for source of blood loss and celiac disease. The tests will need to be repeated if initially negative and the patient doesn’t respond to treatment. 

The initial treatment is oral iron, which can truly be a tough pill to swallow. Common side-effects are chest pain, nausea, diarrhea and constipation. Side-effects are less when iron is taken with food, but the iron may not be as well absorbed. Certain medications (stomach acid blockers) are associated with decreased absorption as well. Intravenous iron may be considered if oral therapy is not effective in raising the blood count. 

Since the red blood cells carry oxygen, a very low blood count can be life-threatening and the patient will be transfused. There is no universal guideline as when to transfuse – the clinical condition will determine the threshold. In pregnancy, the health of the fetus is a concern.

 

Iron-rich foods