Posted by admin …
Drop Dead! | July 2, 2015
Dr. Barry
I often use this line…“I like you…I hope you drop dead!!” Immediately, most people are, of course, taken aback until they think about it for a bit. I didn’t say drop dead right here and now. I said drop dead…eventually. Think about it for a minute and you will find yourself…reluctantly as always, agreeing with me. What are your eventual options? You could just keel over shopping or at dinner OR end up dying after a long and difficult fight with cancer. You could just die quietly in your sleep OR spend your last days drooling over yourself demented in the nursing home. Now, with this perspective I think you’ll agree that a short painless expiration is preferable to a long lingering finish. In essence…dropping dead, when you consider the other options, is quite desirable.
What brings this issue to mind this month are two separate articles in the medical literature recently as well as my wife having to take a CPR class for her new job. I have been feeling pretty good about my medical pronouncements recently because things that I have been saying for years are finally making front page news in the Journal of the American Medical Association and in the New England Journal of Medicine and in the Cleveland Clinic etc…From Charles Krauthammer writing in the Washington Post about the dissatisfaction of doctors, to articles in JAMA about how diabetic care has to be personalized to the patient, to articles in the NEJM about the difficult issue of pain management with chronic opioids, and including two articles regarding CPR.
The first article was about improvements in CPR but when you drilled down to the actual numbers what you find is that even in the best of hands out of hospital resuscitation gives you less than 1 in 10 chance of surviving to the hospital. Note this is not intact survival. It’s having a heart beat when you reach the emergency room. “Survival” often means living with major brain damage. The 1 in 10 chance is of course very optimistic…the more realistic number is that less than one person in 20 will survive long enough to reach the emergency room doors. They never talk about the part wherein most people who have been successfully resuscitated are never the same again. This is not the way I want to go!
Let me take a moment here because I know a lot of people are going to respond angrily to this article. They’re going to say they saw someone or know someone who was successfully resuscitated. Well, it’s got to work right sometime but I think when someone collapses in the store people rush to pound on their chest… they could have just had a faint or a seizure…but in the stress and urgency of the moment they get CPR even if they don’t really need it…then they wake up and it’s a “save from CPR.” Don’t take my word for it…ask any ambulance attendant or an emergency room nurse about the effectiveness of CPR. How often do people with no heartbeat get successfully brought back to life with no significant deficits?
Also, don’t get me wrong I am a big believer in defibrillation but not CPR. If someone collapses due to very irregular heartbeat called ventricular tachycardia or ventricular fibrillation…hooking them up to the defibrillator can restore a regular rhythm quickly and easily and the person will usually not have significant brain injury. This is a whole different kettle of fish from pounding on someone’s chest so hard which, if done properly, causes rib fractures and other injuries even as you try to save the person’s life.
The second article on CPR was an editorial commenting that even in the hospital with the plethora of trained personnel the survival to get to the ICU was only 20% and again these are people who survived just to be transferred to the ICU. They don’t give out the figures for the extent of brain damage. This article said we should be doing less CPR in part due to financial considerations because the last 90 days of people’s lives can be frighteningly expensive but my rejection of CPR is not based on finances. I am a doctor not an accountant. My point is that there is a time and a place for everyone to be born and for everyone to die. For us to attempt to intervene usually does not end well for the patient nor for the family for that matter.
I call for a respect of death. If you are religious, the line I would use is to say “If the Lord calls you home which He will do eventually, and He gives you an express pass by having you collapse suddenly and painlessly in your sleep let’s say…Why would you or anyone else want to delay it?” If you’re not religious, I point out the basic facts that when your heart gives out your brain and kidneys usually follow and instead of a dignified moment of silence for you as you pass you get instead days or weeks of slowly worsening in the intensive care unit until some doctor’s sad duty is to suggest to the family it’s time to turn the machines off and let the patient meet their end peacefully. It doesn’t have to be that way. We should have a better respect for the quality of healthy living and not try to deny aging or death. Of course this is a hard sell in a country obsessed with youth and looks. We have all kinds of celebrations when people give birth and I’m not saying we should celebrate death but we certainly should acknowledge it in a less desperate manner than we do today.
Again there are always exceptions and cold water drowning etc. may justify CPR but for the run-of-the-mill patient who collapses in the parking lot I personally don’t feel that I am doing them any favors when I perform CPR. I know it’s very unlikely to result in any quality time for the patient. For a doctor trained to help people, not taking action is difficult but I’ve learned through a fairly long career so far that sometimes the best action is no action.
As you know CPR, until recently, has involved pounding on the chest and attempting to breathe for the person but the American Red Cross is abandoning the concept of breathing for the patients stating that pounding on the chest alone produces the same results as pounding and breathing. I propose to you that the reason they abandoned the breathing part of CPR is because it doesn’t work well, but then again I don’t believe that the pounding on the chest works well either. If a procedure works only one time out of 20 that to me is not successful.
You know I love my mama but I hope she passes quickly and painlessly when her time finally comes. Making someone a Do Not Resuscitate or having a MOLST form or Health Care Proxy gives patients the chance to have some say in what’s done when they get sicker. Making someone a DNR doesn’t mean put them in a corner and ignore them. It means that when it’s obvious to health professionals and family alike that the end is near we treat the patient with dignity and not as a piece of meat. That people are given the option to die at home or in a comfortable setting surrounded by their family and friends, not being subjected to what I think is cruel and unusual punishment in a frantic environment during their final moments.
Many times my job as a geriatric specialist is to tell people that less may be more. Maybe you need less medicines. Maybe you need less testing at a certain age. Maybe we should look ahead and make plans for that final day whenever that might come. That’s something that each patient and doctor should decide together. You didn’t have any choice about how you came into this world but at least here in America you have plenty of choices about how you’re going to go out. A little planning done ahead of time can make a huge difference.
No Butts About It! | June 3, 2015
Dr. Barry
I received a lot of responses to my Bitch Bitch Bitch column from last month. One person asked me if was ever going to write about real medical issues as the column is labeled Preventive Medicine. So here you go Stan!
There’s a new player in town…cancer town that is. That player is a test called Cologuard. Colon cancer is the second leading cause of cancer death in men and women so it’s obviously important. This is not some obscure disease we are talking about like the Pustular Psoriasis of Von Zumbusch or the Spreading Depression of Laeo. This is a disease that is killing someone in your family or your neighborhood. And colon cancer is not a quick easy death. There is much we can do to you and for you before the end. The NIH spends roughly 270 million dollars a year just funding studies of colon cancer. This figure does not include the detection of cancer, the treatment of cancer, etc. How do you put a number on the emotional toll of cancer? So, it’s a big deal when we have a new approach to detecting colon cancer.
First, some facts and figures regarding colon cancer. The average American has a 5% risk of colon cancer in their lifetime. Another way of stating the same thing is that one person in 20 will get colon cancer. Men get cancer more than women but we don’t know why.The last year for which we have firm statistics is 2012 and approximately 25,0000 women and 25,000 men died of colon cancer that year. Cancer deaths are going down because of improved detection primarily from colonoscopy as far as we can tell. 90% of colon cancer incidents occur in people aged 50 and over. That’s why most people started having a screening colonoscopy at age 50. The important thing is to find the cancer while it can be excised simply without needing chemo or radiation, etc. Currently the #1 way to do this is with colonoscopy.
A colonoscopy is the insertion of a flexible lighted periscope into your rectum and looking into your colon for any kind of cancerous or precancerous lesions. It’s not cheap. It’s uncomfortable enough that for most people it requires a sedating injection. The prep which is required for the test is often considered the worse part of the whole procedure. You need to get cleaned out so the doctor can see enough to be sure he didn’t miss anything. Many people dislike the prep more than they dislike the procedure. If the preparation isn’t good enough the colonoscopy might have to be repeated and / or they might resort to using an older technique like a barium enema. There is a new technique called the virtual colonoscopy which is basically a barium enema and a CAT scan but I never recommend this because #1 it is a lot of x-ray exposure, #2 the doctor could miss something and therefore you suffer because of a misdiagnosis, or #3 the radiologist could and often does say he thinks it could be a polyp and therefore you have to have a colonoscopy anyway. With virtual colonoscopy you still have to do a similar prep so virtual colonoscopy doesn’t work for me. There have been, up to now, a couple of other options including testing the stool for blood in the doctor’s office or in a take home preparation. I have given out well over 1000 of those packets and only got about 10 back, so that scenario has not played out well either. Testing for blood is not the same as testing for cancer.
Now for the new guy in town, and that’s Cologuard. Don’t get me wrong …colonoscopy is still the “gold standard.” That’s the test I get. But for people that are unwilling or unable to have a colonoscopy there is a new technique that’s called Cologuard. It involves simply sending a sample of your stool to the company where it is tested 11 different ways for any evidence of cancer. The test is 92% sensitive in the detection of cancers and that’s a very good number in medicine. The test is not perfect but neither is colonoscopy. The test report comes back simply negative or positive.. if it’s positive you need a colonoscopy…if it’s negative you are probably ok and can discuss what to do next, and when, with your physician. So if you have been neglecting getting your bowels checked for cancer it’s time to bring this article to your doctor and ask him what they think of this test and if it is for you. The test is for average risk people…it’s not meant for people who are known to be at increased risk for cancer, like people with a family cancer syndrome or patients with a history of colitis. Hopefully your doctor is familiar with the test and maybe a life will be saved. What a great way to start the summer. Until next time …get well and stay well.
Bitch Bitch Bitch | May 1, 2015
Dr. Barry
Can I bitch and whine for a column? Join me in my world this month and you might have some insight into why there are fewer and fewer doctors going into primary care. I’m not talking about the vast difference in reimbursement between primary care and specialists. I’m talking about the hassle factors and frustrations of being a primary caregiver.
Forget about the fact that the insurance companies are charging 10-15 % more each year but I haven’t had a single raise in years and have absolutely no negotiating power. I am board certified in two specialties with over two decades of experience but that’s not worth a penny extra to the insurance company. Recently one major insurance company in the area came to the office to review our mammography screening rates. Our results were at the top of the scale, well above the average and far above the worse performing physicians. What do we get for our superior care.? Nada…Zip…Zero. Why not at least publish this to the paper or to the patients with your insurance so they can see the individual doctors performance and judge for themselves who they want to see? What a shocking concept…giving patients real informed choices. Instead the high quality and low quality is all mixed together and patients really have no idea about quality measures.
First it’s the insurance hassles. There are many different health plans and I have to hire a whole billing dept to sort through the different plans and deal with their individual convoluted coverage. These plans will cover shingles shots…these plans won’t . These plans cover this test…those plans don’t. Impossible to keep straight in your head. I have to hire another staffer to fight with the insurance companies to get authorizations for MRI’s, stress tests, etc. Now some high school graduate with a checklist is saying the stress test is not covered because we used the term “chest pressure” not “chest pain”. So now I have to get on the phone personally to speak doctor to doctor to get this straightened out. Imagine doing this multiple times every day of the workweek.
Likewise the insurance companies have their own strange and arcane rules regarding drug coverage…This company will cover these meds…that company will cover completely different meds for the same medical problem. They send us multiple faxes daily alerting us to possible drug interactions with our patients even if the possible reactions are rare or trivial . We have our own computer system that warns us of serious interactions. They send us notices when our patients don’t fill their refills as if I have any real control over that. Each year the plans can change what drugs they cover so the same patient with the same medicines may have the insurance company change their coverage yearly. I can assure you this is not based on the quality of the meds or the benefits of the meds…it’s made on a $$$$ basis only.
Test results are another area of tremendous stress for the primary care doctor. Forget about the patient that gets sent for a test but doesn’t show up. You decide to skip a mammogram this year and if you get a breast cancer somehow it’s my fault . I can send you reminder after reminder to get your colonoscopy or mammogram.but if you still don’t get the test it’s still my fault. Trust me that’s how the courts look at it. Telling you to get a mammogram is not enough. Scheduling the mammogram for you is not enough. I have to stay on your case until it gets done or I am liable . At some point the patient has to take some responsibility but thats not how the courts see it. But the real hassle with test results is that the radiologists refuse to read any test as yes or no anymore. When I started in medicine…the radiologists would issue a simple report..”Chest X Ray showed pneumonia”. “Chest X Ray normal” Now almost universally the reports hedge their bets …”Could be pneumonia…could be cancer…could be a variant of normal” Almost all reports we get now suggest further more expensive testing which may or may not require further testing or more testing down the road. This is very frustrating for the doctor and even more frustrating for the patients. “How many tests am I going to have to do to get an answer?!” The test report may give me an answer about a specific issue but raise another one. “The spot seen on the x ray is shown to be nothing serious but on this scan I see a possible cyst on the liver”. The radiologist will suggest more expensive testing now and or in 3-6 months which may or may not give a real answer and further testing could reveal new incidentalomas that have to be addressed. Patients get mad at me for all this testing but if we don’t check every possible problem out it could be you that suffers and me that gets sued. Not good for either one of us.
Noncompliant patients are another source of frustration to the doctor. Patients just don’t understand how seriously we take the doctor patient relationship. If we see patients regularly ..if we are in regular contact , then any potential problems can be followed and there are less complications down the road. When you let patients go for years without being seen any little problem from the last visit could grow into something serious or catastrophic. So when we send you three separate written requests to schedule an office call and also call you at least twice and get absolutely no response we have to discharge you from the practice. One of the negative reviews we have on the internet addresses this. The patient complained that she was fired just because she never responded to our calls and letters. I’m not the publishers clearinghouse…I am contacting you for a reason and all you have to do is call us to stay in communication. Yes, it’s my business and I do think I know what’s right for you healthwise including how often you should be seen. We can discuss this and work out a mutually agreeable program but not if you never respond. No response = discharge letter. Another complaint about our office on the internet involves the no show fee. If you give me any notice at all…any kind of notice..even the same day ..there is no charge. But if you blow off a scheduled and confirmed appointment there are consequences. Lawyers charge by the minute when you call them. I just want you to keep your appointment and if you don’t you have to pay a no show fee. If I miss an appointment with my massage therapist or my Saxophone instructor I pay the full price for their time. That’s the right thing to do but not according to the guy who bitched about our no show policy on the internet.
I just took my annual recertification for malpractice. It’s always a depressing experience. Basically they remind you that each and every office call could lead to a major lawsuit. It’s also not the obvious problems like chest pain that the doctor is sued over…What you and the patient think is just a sore throat or arthritis of the back could turn into something potentially life threatening so there is no real “easy “ office call. Patients bitch if they think you are not taking their complaint seriously. Patients also bitch if you take their complaint seriously and suggest referrals to specialist. Look what position that puts me in…It’s crystal clear that the main reason doctors get sued is “failure to diagnose”. The main defense against failure to diagnose is referral of the patient to a second opinion. I would think patients would be appreciative of a medical office that was willing to be thorough and get a second opinion but judging by the mostly anonymous complaints I get they really don’t appreciate it. I tell my Nurse Practitioners to not hesitate to get a second opinion or do a referral if they feel it’s necessary. I would rather have a patient bitch about too many referrals than a widow complaining that we were not thorough enough!
Thanks for letting me give you a little glimpse of what the modern doctor has to deal with. Is it any wonder that more and more doctors just want to be hospital employees or work in a large group setting where they might be insulated from some of the hassles? Of course I’m sure they have their own unique hassles as well.
So, these are all the reasons primary care medicine is not the same anymore. The hassle factor is driving more and more doctors to chose other specialties and to retire early. Yes, even with all the hassles and decreased reimbursement and rising expenses doctors still make a good living but that’s not a primary reason why I went into medicine. My interest in people and their medical problems hasn’t diminished. I still think I can make a difference. Of course, changing part of my practice to a personalized care service certainly has helped to ward off any doldrums. Despite all the hassles I still love going to work everyday. I hope you do as well! Until next month, get well….stay well.
Improved Healthcare or Documentation Boondoggle? | April 2, 2015
Dr. Barry
We use an electronic medical record in our office. It’s managed by a national company and it has helped in some ways with record keeping but it has as many drawbacks as it has advantages.
We can use the EMR to keep better track of your medicines and when and how often you have been seen in the office. Its nice to be able to bring up a patients labs or results from another physician with a touch of a few buttons. Its very helpful when I am on call and have to access the record from off site. It eliminates the issues of poor penmanship. On the other hand, the EMR generates so much useless information that really important stuff gets lost in the midst of the records. Just look at the records we get from the local emergency rooms…The sheets we get documents that the patient was educated about seatbelts and flu shots but its very hard to find out what really happened during the visit. What did the patient complain of ? What tests were done ? What diagnosis did the doctor come up with? This important information is getting harder and harder to find in the record. I think this is dangerous. When we get a transfer from the Hospital to the Nursing Home the record can have pages and pages of nursing notes and vital signs but often doesn’t have a complete problem list and a coherent narrative of what transpired in the hospital. This is dangerously obfuscatory. Things are going to get missed and thats never good for patient care.
Likewise we get records from prior doctors when we see a new patient. Often we receive 60-80 pages of records to review. Most of these pages are incomplete or blank or have info regarding a sore throat visit from a decade ago. We have to wade through all these pages to find out basic but vital information like …When was the last mammogram? When was the last tetanus shot? This is sabotage !! It would only take three minutes for a person to really pull out the important information and just send that part. I don’t know if its laziness , I don’t know if its because the office can charge 75 cents per page. I don’t know if its because the doctor just can’t be bothered as the patient has transferred care. But I do know its dangerous.
The other problem with the EMR is that it takes away face to face time with the doctor. Unless the doctor documents after the visit or uses an assistant called a scribe the modern encounter with a health care provider has them spending some time looking at you and some time looking at and dealing with the computer. Have you had that experience in the doctors office where the doctor or nurse practitioner barely looked up from the computer screen ? Doctors spend time “populating” the record to make sure they don’t get in trouble with reimbursement from the insurance companies. If the doctor checks off the boxes saying they reviewed the family history and / or reviewed outside records they get paid better even if those sections are not relevant to the visit. For example …it doesn’t really matter that your grandmother had breast cancer in order to treat your sore throat.
Also, the EMR presents me with a damned if you do and damned if you don’t situation. If you just pick and choose from the preselected lists in the EMR it can make the record look very vanilla, very programmed, machine generated. Can you tell if the doctor really examined the patient? Is the person missing a few fingers on his hand but the record doesn’t mention this?
I try to get around this problem by always adding something personal to the record. I type something in that clearly shows details of the encounter and personalizes the record. This too gets me in trouble from patients that prefer the record to have nothing personal in it. People will get mad at me for putting in information about their lives that I think are important but they don’t want “someone” to see it. If you have stress in your life that is effecting you so much that you have come to me for pills or other treatment I think it’s better if the record has details of this and it helps on the next visit when I refer to the actual cause of the stress not just the symptoms. I still prefer the “personalized” record over the “vanilla” record because I think the more you know about people the better you can care for them. We are not cattle…people are very different one from another and I think that should be reflected for better or worse in your record. I had a lady who said she was the victim of “Demonic Abuse” Now I don’t know what that means but if it’s somehow important to the patient then I think there should be a place for that in the medical record. You know me…I did ask what that meant but the patient declined to elaborate. She eventually called me and asked me to take that out of the record because whenever she went to a specialist she got some weird looks. I told her I can’t change the old record but would take it out of future visits. So you can indeed get in trouble by trying to personalize the record. Of course the government which insisted that doctors pay for and use EMR’s also is threatening to punish doctors if the records look too “cut and pasted” .
We have, and I think most primary care offices have, many patients who travel South for the winter. I tell all my patients to come by and pick up a travel package. This includes their last full physical, the last office call or two, the last ECG and labs. This is really all the emergency room or clinic needs. This usually comes to less than 10 pages and really has all sorts of important info including your meds, allergies, surgeries, etc.This is precious information and can save you time , money and possibly avoid unnecessary tests and surgeries. You can’t be expected to remember all this info on your own even when you are healthy. Imagine trying to recall details of your family history whilst you pass a kidney stone. I have been told by multiple patients that the travel package proved very helpful to the patient and their snowbird caregivers. Your doctor should give you this for free but even if they charge 75 cents a page its worth it. Beware the cd/disk. Its great for the radiologist to give you a copy of the images from a test you had. This may be very useful for the Orthopod across town who wants to see the actual images not just the report about the images. On the other hand , If I run a HIPAA compliant office , I must be very careful of any cd /disks that may contain some hidden virus so I really shouldn’t use my regular computer to try to view your images. I have extensive experience in reading Xrays of your chest and CT scans and MRI’s of your brain and can read a skeletal x ray for obvious fractures but I am very unlikely to find more than the radiologist or to disagree with him based on my reading of the images. Some physicians provide their patients with a disc with all their records on it. This is even worse for me than paper records since at least with 100 pages of paper I can go over each page and mark it off as reviewed etc but with a disc you don’t know how its organized, I don’t know if I have a program that will access the files. Again , precious information is obscured by a lot of unimportant data. Sabotage again !
So, the EMR is here to stay…unfortunately the many systems out there do not communicate well with each other so its not anywhere as useful as it could and should be. I know we will get there eventually but tomorrow would be nice. Some day all your information will be available on your phone, your watch, or the implanted chip you will someday have. The implanted chip and universal health care are still not ready for prime time. Until then , if your doctors office uses an EMR , get access to the patient portal so you can review your own records and at least make sure the basic information is correct. Take charge of your health. Take care of your body. Take even better care of your mind. Get well. Stay well. Be an active participant in your care!
MARCH MADNESS | March 9, 2015
Dr. Barry
I honestly don’t know much about basketball. My son considers me a failure, in part, because I don’t really pay attention to most organized sports like basketball and football. I would rather be doing the activity than watching someone else do it.
If I was younger I would be applying for American Ninja or Wipeout but those are really individual events not team events. So, when people talk about March Madness I really have very little to contribute to the conversation. I do know madness when I see it. Madness to me is doing the same thing over and over again and hoping for a different result. Albert Einstein said the same thing. Madness to me is someone saying every day “ I really ought to blank”, “I know I should blank.” “It would be better for my health if I blanked.” Fill in the blank with lose weight, quit smoking etc. Saying the same thing over and over again but never actually taking action… that’s madness to me… That’s why I find the Upstate Medical Center advert so amusing. Their catchphrase is “knowing changes everything.” You and I know that knowing changes nothing. Doing changes. Doing makes a difference. We have to figure out a way to get you from knowing to doing. That’s not easy stuff. That happens also to be the most important thing you can work on with your health. You can work on your blood pressure alone. You can work on your cholesterol alone. You can work on your diabetes without the help of anyone else. But it’s very difficult for people to change themselves/ their behavior on their own. As I often relate to patients, most people don’t have enough tools in the toolbox to achieve the results they want on their own. If they had those tools they would probably already have used them. There has been work done on how to motivate people but mostly by the marketing divisions of big companies like FORD and Proctor & Gamble. To get you to change toothpaste, fabric softener, etc.
Work has been done by the medical profession as well but it’s really limited because it involves real conversation between patient and Doctor and thats not happening much anymore. You come in for a blood pressure check visit and also have questions about a rash, etc., and it’s all the provider can do to check your meds, review your blood pressure and evaluate your rash in the allotted 15 minutes. How is the provider to really engage you about changing aspects of your life and your health in this environment? Unfortunately this is just not happening. Changing behavior requires work. Changing behavior takes effort. It’s very hard to get rid of a habit or form a new one. Hard, but not impossible and there are some guiding principles to work with. Number One principle is that if you want to eliminate a habit you will have much more success if you substitute a behavior not just try to eliminate a behavior. Instead of having that cigarette or that extra plate of cookies after dinner, you might take a walk or write a letter. Substitution helps change habits. Number Two principle is to make yourself accountable. Accountable to a group like weight watchers or AA. Making yourself accountable to friends, family, health team has been shown to work on your psyche in a way that reinforces your motivation to change. My experience with the technique called motivational interviewing has shown me that we really can’t change other people, we can only help them change themselves. This comes from having conversations where people’s prior successes are supported and their rationale for change is explored in a non-confrontational environment… The doctor telling the patient “You really should lose weight and get more exercise” patently doesn’t work, hasn’t worked, and is unlikely to work in the future.
However, talking with people so that they can themselves express their concerns and desires sometimes tips the scale in the balance favoring change. It often takes more than one conversation. It certainly takes more than 1 visit every 3-6 months. So yes, change is possible and change is difficult but change it is possible and can be supported by a variety of tools. People roll their eyes when I ask them about what tools they have in their toolbox change-wise but I think having a varied toolbox is critical. Not every tool works for every patient. Not every tool is right for every problem. Many people have preconceived notions about what tool works for them and what will not. I tell people let’s open up the full toolbox and look around and see what might work for you. Let’s not have preconceived notions about what works and what doesn’t. If we want to achieve some change that is losing weight, quitting smoking, etc., we have to be open to doing something new, trying something new, doing something different. Hypnosis, acupuncture, motivational CDs, all might help you change your thought process and therefore your action process. Cognitive behavioral therapy, personal trainers, visualization techniques all can help facilitate change. Since none of these tools involve shots, pills, x-rays, needles, or dyes why wouldn’t a person explore/consider these tools? I learned a great expression in yoga class one day. The instructor reminded us to guard your thoughts because thoughts become feelings. Guard your feelings because feelings become words. Guard your words because words become actions. Guard your actions because actions become habits. Guard your habits because habits determine character. Guard your character since character determines destiny. Maybe it’s a little wordy but I do like the sentiment. Essentially it relates back to the fact that it all begins with your mind and you have control over that in the way no one else does. Link your desire to change with one of the tools of change and let’s see what happens. Until next month get well and stay well.
Why Prevention Matters | February 7, 2015
Dr. Barry
My last few columns have been rather personal…I thought you might enjoy the more scientific side of Dr Barry for a column or two. Since I make my living trying to talk people into taking better care of themselves I thought I should review with you the real enemy…its not the insurance companies, the government etc…its what will kill you prematurely and what you can do to make a difference. The cdc says that 30% of cancers, heart attacks, strokes etc are preventable. Other sources say that you can make an even bigger difference than 30% but thats still a huge number compared to what you can get from pills etc.
What’s killing americans? If we don’t know what is killing us we don’t know what to focus on in your health. We are looking for opportunities to cut down your risks of the top killers through lifestyle modification / behavioral intervention. There is something we can impact on for all of these. Below is the very latest data from the CDC as to the top causes of death in America each year (Cause/Number of People).
Heart disease: 596,577
Cancer: 576,691
Chronic lower respiratory diseases: 142,943
Stroke (cerebrovascular diseases): 128,932
Accidents (unintentional injuries): 126,438
Alzheimer’s disease: 84,974
Diabetes: 73,831
Influenza and Pneumonia: 53,826
Nephritis, nephrotic syndrome, and nephrosis: 45,591
Intentional self-harm (suicide): 39,518
So, lets look at these issues one by one and see which ones we can have an impact on.
Heart DIsease…the number 1 killer!!! We can intervene with changes in blood pressure, cholesterol levels, smoking status, diabetes control, diet and exercise and meds… heart disease is of course also in part genetic but we cant do anything about this component…yet!
Cancer… There are a lot of different recommendations from different organizations but the most common cancers.breast, lung, colon, skin, prostate, bladder, have screening tests which can be done at the appropriate intervals. Yes we can survey for cancer but we can also try to impact your cancer risk with diet and exercise and stopping smoking.
Chronic lower respiratory disease is basically smoking and pulmonary fibrosis. Between Chest X Rays and Spirometry ( breathing tests ) we can get a good measure of your lung status. Since this category really is COPD / Emphysema / Chronic Lung DIsease… this is another modifiable lifestyle issue since most of this is smoking related. It doesn’t matter how many times you have failed to quit smoking in the past there is more we can do here if you want it !!
Stroke… the modifiable risk factors here are smoking, hypertension, diabetes, and cholesterol. All of these we can work on and modify.
Accidents…Driving assessment…fall risk /evaluation…Alert bracelet… Need for physical therapy…carbon monoxide detector…staying off the roof after the age of 70 etc.
Dementia…You can have your memory assessed using nationally validated tools, but this is just checking for the problem. The most important intervention you can take to prevent memory loss seems to be exercise. Physical exercise is most important and mental exercise may be helpful as well. Medications have heretofore been widely used but have had only marginal results overall. So the name of the game remains prevention!
Diabetes…The single most important issue in managing your diabetes is your commitment…to diet…to exercise…to taking your meds… so much of this is under your control and therefore modifiable.
Flu and Pneumonia…You should have a list from your doctor regarding your shot status. I believe in routine immunizations. When an injection can cut down your risk of dying from one of the top causes of death for as long as 10 years…I want that shot. Luckily those shots are the flu shot and the pneumonia shot.
Nephritis…basically kidney failure… still affects lots of people and there are well recognized modifiable risk factors…Once again being: smoking, cholesterol, hypertension, diabetes…easy to measure…easy to work on…easy for you to make a difference in your outcome.
Suicide… What a terrible thing that 40,000 people decide to kill themselves every year. Did you know that each year there are more suicides than homicides. Unfortunately we don’t have a strong mental health care system in this country…Depressed or anxious? Here…take a pill. See a counselor and come back in 3-6 months. Hard to make a change in your mental health with this system. Again, I think people need more time to work out their problems with a professional than we are giving them now under our current system. Change is hard and changing your feelings is hard and it comes from inside…not outside. Yes, once again I think the right diet and a good exercise plan will make a difference in how you feel and what you think.
So, we have reviewed the top killers. You can take action regarding all of them. You can make a difference in your health. It makes me laugh when I hear Upstate’s commercial…“knowing changes everything”, because knowing doesn’t change a damn thing. You KNOW you should quit smoking…you KNOW you should lose weight…doing something…taking action…that changes things. How to help people make those changes…take that action, etc. That should be a very high priority for every health care professional you see. Nothing wrong with hunting deer or rabbits but what about hunting down and killing your bad habits!! Now there’s a challenge!!
Time Is On Our Side (Once Again) | Jan 7, 2015
Dr. Barry
I have just made the biggest change in my medical practice ever. I feel like I am waking from a long slumber where doctors are struggling to work harder and harder for less, and professional morale is at an all time low. A company called Signature MD helped to rouse me from my professional lethargy, and once again I am excited at the prospect of being able to deliver even higher quality health care than I am now. I will have a chance to really practice at the top of my game. Once again I think I will be able to really make a change in people’s lives. I am excited about finally being able to make a difference.
I’m also nervous because this is a fundamental change in my practice. I am adopting a Personalized Care Program in which a limited number of my patients will receive enhanced services, more detailed management of their health and wellness, and a focus on Preventive medicine.
At the core of this new program is time. I’ll have more time to devote to each patient. In effect, I’ll be acting as their Life Coach.
I really don’t have a better term for it yet, but I think Life Coach conveys my intent. Any good healthcare provider, and we have many in Syracuse, can handle your blood pressure, your diabetes and your sore throat. This is midlevel provider stuff, which is important but doesn’t need my skill level. I want to actively follow a smaller number of patients and really provide them more oversight and attention.
Frankly, we all should have this kind of relationship with our doctor, but we will never have it without a program like the kind offered by Signature MD. The healthcare system has been changed into an assembly line with a different healthcare provider for each visit, not enough time allowed for meaningful consultations, and where the standard of care has devolved to some pills, some tests, and then it’s on to the next patient in line.
Walmart says they want a healthcare clinic in every store and want to be the number one provider of medicine in a few years. You don’t have to scour the national news for changes in health care. Look at what has happened to North Medical Center. Clinics aren’t bad…but I don’t want to practice assembly line medicine. Signature MD’s Personalized Care Program will give me the opportunity to spend quality time with patients, including the time to follow the patients when they are hospitalized at any of the local hospitals.
When we doctors turned over your hospital care to Hospitalists (in-house staff healthcare providers), it was a good for the doctors but really not so good for the patients. As a patient, you want the medical professional that knows you best to see you when you are sick, whether that’s in the office or in the hospital. But it’s most important in the hospital when you are most vulnerable to mistakes and miscommunication. Signature MD will give me the time to manage all that and actually be there to assess you in person, and to communicate directly doctor-to-doctor with the physician charged with your care in the hospital.
Yes, there is a fee for all this extra service, but however, because I believe that the health of every single person that enrolls in the program will be improved, I think it will be worth the fee. I think your health is worth it. I think you are worth it. I realize that this program will not appeal to everyone. Some people won’t see the value in a sustained and engaged relationship with their doctor. Some people are young enough, healthy enough and or self-directed enough that they don’t really need the program. Some people simply won’t want to pay an extra fee. I don’t fault them for not taking advantage of this program, but I am hearing from a few people that are faulting me for working on being a traditional doctor again.
By “traditional” I mean having the time to really listen and establish a relationship with each individual patient. I have heard from and respect those who are opposed to this new program. However, I have been given an opportunity to fundamentally change my practice in such a way as to make me feel that I am actually making a difference again. What an opportunity. What a risk. But I just had to take it because the price – better health care for my patients and better job satisfaction for me – was worth it.
This will not be a one-size-fits all, cookie-cutter program. What’s important in healthcare differs from patient to patient. What’s obvious is that this isn’t being addressed in the world of 10-minute office calls. We are just bandaging the problem with these visits and not really focusing on what’s causing the underlying problem in the first place. I cannot get a person to quit smoking or lose weight with a couple of office visits. Complaints of anxiety, depression, insomnia or chronic pain are not treated with a pill and a referral to a specialist. We can do better than this…but we need more time.
The new Signature MD Personalized Care Program gives us the time we need to make a difference. This doesn’t mean that I will be making patients get more tests done. If anything, I could actually end up recommending less testing. Whatever testing that I do recommend will be accompanied by written explanations of all my suggestions as well as comparisons to the national guidelines.
Now, for those people who choose not to sign up for this Personalized Healthcare Program, there are still plenty of options in our office available to you. Starting next year all of my patients that choose not to sign up will be directed to my Nurse Practitioner Zoryana Bozak, who will handle all the routine office calls and physicals. She will be working directly with me and whenever your medical problem needs my direct attention, I will be there for you. If it is a routine visit, if it is a routine visit, you will see Zoryana. If it’s not routine, you still see Zoryana first, or another one of our excellent providers, who then will get me directly involved whenever the situation warrants it. If you feel you need or want to see a physician, we still have Drs. Knudsen and Manfredi taking new patients.
I didn’t get into medicine to see as many office calls as possible. I got into medicine because I enjoyed the intermixing of the sciences and dealing with people’s problems and personalities. I have lifted my head up from the din of visit-after-visit where I don’t know if I am making a difference to say, “Wait a minute. This isn’t how it’s really supposed to be. This way is not really allowing me time to change peoples lives.” There must be a better way. The new Personalized Care Program that I’m offering is the wake-up call to a better way. At last, time will be on our side.
Driving Me Crazy | Dec 15, 2014
Dr. Barry
One of the most delicate parts of my job as a doctor is the conversation about whether the mature patient should still be driving. You know the folks…they brag that they never had a ticket or an accident but can’t walk steadily and reliably across the parking lot.
How can you claim you are “safe?” Look at you…your vision is not great. Your hearing…well the less said about that the better…you can’t turn your neck more than a few degrees due to arthritis…you can’t really feel your feet can you? Your strength, focus, coordination, endurance, etc. are all far from peak and you still say it’s fine for you to get behind the wheel of two thousand pounds of steel and plastic and gasoline. All WE can think about is you hitting some kid or plowing into the school bus and the whole thing being quickly engulfed in flames. And it will be our fault because we should have somehow forced you to stop driving.
The scope of the problem? The CDC says that of 2009 there were over 33 million senior drivers on the roads. Fatal crash rates start to rise at age 75 and rise up sharply after age 80. This doesn’t always mean they have more accidents but they get more injured from the accident. 500 senior drivers nationally are injured every day in America. According to the Insurance Institute for Highway Safety drivers over 75 years of age have higher per mile accident rates than middle aged people but still LESS than younger drivers.
First, this whole sticky wicket of senior driving safety becomes mute once the self-driving cars finally arrive. “Car, take me to church, hairdresser, my kids’ house,” etc. How great will that be?! Just say where you want to go and sit back and read, relax, take a nap, make a phone call without worrying about driving distractions. That’s something I will pay extra for when it’s available. I am not saying everyone has to let the car drive them…the tread heads, as my sister Marijo refers to them, will say it takes the joy out of driving, etc. so let them stay behind the wheel but make them pay extra for it because in the end it will not be as safe as letting the computer do it for them.
Until that happy day we must wrestle with the personal and public issue of who should be driving and for how long. Should women be tested more often than men? When do you start testing…only after an accident? Retest everyone at age 80? Of course someone will say testing is racist or sexist. None the less…if you ask me about your ability to drive a car I am going to give you my stock response and no one likes it! If you wonder about your ability to drive, go see the specialist…go take a driving test. You can use the DMV but you can also call one of the driving schools and they will evaluate your driving. Taking the refresher classroom course absolutely doesn’t count. Under my benevolent Caesar-like leadership the rule will be established that everyone will be tested every five years. You can do the DMV or you can do it privately. This puts to rest the issue of who to test and when. We test everyone…regularly. Commercial drivers will be tested yearly. If you are 95 years old and pass the test the car keys are yours! And of course did you notice my solution also provides jobs in both the private and public sectors! I wonder what will happen to all those couples where the husband is demented but the wife lets him drive because she hasn’t in years and he is indeed a better driver. That makes me mention that all you older ladies that let your husbands drive all the time…it’s likely you will outlive your husband and it’s a mistake to stop driving just because right now things are easier. Keep your skills up!
So you don’t think your mom should drive anymore…you do know that taking away her driving is like stabbing her in the heart with a dagger. Maybe that nice carving knife she got your husband for Christmas…that’s it…the very one, and remember to come up under the ribs. You want to set off indoor fireworks? Just try working in “you should probably give up driving” into casual conversation. The fact is that you are robbing her of her independence. It might be what you think is the right thing to do but it is not likely to be appreciated. This doesn’t usually go over well. It’s a sure trigger for depression…akin really to the loss of a spouse. And I am supposed to make that better with a little white pill?
Sometimes one of my roles as a physician is to be the bad guy…to take the blame. Much better to be mad at me regarding getting some help in the home or mad at me for telling you not to drive…rather be mad at your family member. I routinely refer patients for driving testing but they never go…I am pretty sure they are afraid of taking the test and not passing. I can’t force them to stop driving. I can’t force them to take the test. I can only offer my advice and insight. What I cannot do is notify the DMV if I think you are unsafe behind the wheel. It is a violation of your confidentiality. So you are safe in bringing up your driving concerns but I am always going to be on the side of personal freedom. Now, while I can’t report you to the DMV your family or for that matter anyone who wants to can. Although the NY DMV says on their website that a physician can report a patient my lawyers tell me this isn’t true. There is a form you can fill out that will prompt an evaluation of the person’s driving skills.
Although my periodic retesting scheme makes sense to me as long as the current system allows seniors the right to drive I don’t think we should infringe on this right unless and until something happens…the fender bender in the mall…the garage door frame…and yes, even some of the worst sort of accidents…your freedom and independence are important enough for this risk. In the end, it comes down to common sense like not driving at night…not driving long distances to new places…extra care when backing up…keeping your cell phone available but not in use, etc.
So let’s keep giving our seniors the benefit of the doubt when it comes to staying independent when driving. When trouble finally happens, an independent reevaluation of driving skills takes the emotion and guilt out of the decision.
Don’t forget the fair. You owe it to yourself and the grandkids to go. Stop with the negatives and enjoying the sun, the sites, the wild food, the music, the exhibits, the petting zoo, the Iroquois Indian Village…how can you have this great attraction in your backyard and not support it and enjoy it!
It’s Time to Stop Wining | Dec 15, 2014
Dr. Barry
It’s the December issue and I usually spend it exhorting you to spend a little extra time on the friend and family part of your health equation. To get out and do stuff…whether it’s Lights on the Lake…going out to just one of the seasonal shows at the Palace Theater…going Cross Country Skiing at Highland Forest…we have covered this ground and you should be picking up your phone to make arrangements. You’re going to say…let me at least read through the rest of the article and then I will make the calls. Here’s the problem…I know you…you have good intentions but at the end of the article you are just going to forget about it. So, it’s much more important to stop now and at least make one new plan than to read through this article…you can always come back to the article…you probably won’t make a new plan unless you start right now.
Well, we are all deeply flawed individuals as my colleague, Dr. Manfredi, likes to remind me. So let’s get on with the article. Did you think I misspelled whining at the top of the article? No, I really do mean it’s time to stop wining. For more than 5 years our office has been quietly giving out a bottle of wine to our patients who had appointments around Xmas time. We appreciate our patients and thought it was a nice touch…giving a gift of health. It’s well known in the medical community that a modest amount of wine is good for your health…of course there are the exceptions and therein lays the problem. With exceptions come problems. With problems come headaches. Headache cause us to say it’s time to stop the gifting, at least for now.
Let me elaborate…we want to do something nice for the holidays but not if it’s going to make people mad at you, give you new legal issues and potential liabilities, take up too much time and money. Frankly the money part of the equation was not the main reason we are stopping the giving of the wine. We had people complaining that they did not like our choice of wine. We had people complaining that they were good patients but did not come by around Xmas but surely they deserved a bottle. We don’t want to give a bottle to a person with a history of alcohol trouble but what if the person says “I have been proudly sober for 10 years but I see other people leaving with wine and I wouldn’t mind bringing the bottle over to my sister’s house for the holidays.” People would come in for a problem…have a recheck for the problem three days later and want another bottle of wine! Frankly when we had so many people expecting a bottle like we were some assembly line it isn’t a nice healthy surprise anymore. It’s lost the magic. It’s lost the meaning of the gesture. So, no more wine from Preventive Medicine Associates. Please don’t take it personally.
Instead of giving individual gifts of wine, we will spend the money on several local projects including supporting the Maria Desantis Xmas show at the Palace Theater. It’s a great show for the young and old alike. The reason for the season is all about the Birth of Jesus…but anyone of any religion can understand this is a time of year to enjoy with friends and family. You should absolutely watch some version of Scrooge each year. If you can’t take something important away from this story you are beyond help…and I know you and there is still some hope for you. Well, I for one have not given up on you.
Another way we at Preventive Medicine Associates will show our gratitude to our patients is in support of some local family that needs help during the season. We have done this for years already but this year we can bump it up a few notches. We will put some smiles on some family faces this year.
So please understand that we thought that the wine gifting idea had run its course. I wanted to give out little jars of horseradish because along with garlic and ginger it is one pf the best things you can put in your mouth but there was surprisingly little support for the idea around the planning table. So we are doing more for the community in general by sponsoring the Desantis show and by being Secret Santa to some families. Hopefully you will understand and agree with our decisions and motivations. Wishing you a healthy and happy Christmas.
Now is the time to make those family Christmas plans and don’t forget Maria Desantis at the Palace Theater Sunday Dec 14th. Next month…why and how I hope to fundamentally change my practice of medicine. Stay tuned.
Ride On! | Nov 10, 2014
Do you mow your lawn? I cringe when I drive around and see people mowing their lawns and weed whacking without hearing protection. Don’t they know what they are doing to their hearing? How can they get used to that clamor? I am all for full employment for their audiology (hearing aid) colleagues but I would rather get my hearing aids at age 80 than age 60. Hopefully they will be cheaper, better, and/or covered by insurance by then so as so many baby boomers will be deaf that they will insist on coverage. Riding the lawn mower has saved my life. Well, maybe not saved my life, but certainly has changed my life. I dare say that only the beatudinous (WHAT????) vision that is my wife has had a more positive influence in my life than sitting on my lawn mower.
When we moved to Lafayette in 1999 I bought a new riding mower and I have a fairly big yard and it can take me just under 2 hours once or twice a week, depending on the temperature and the rain, to get the job done but at that time is spent more inside my mind than on top of that tractor. So, it’s not the actual task of mowing the grass that has helped me so much as the time spent listening to lectures on my MP3 player. I have listened to lectures from the Teaching Company about Ancient Greece and Rome, about the history of medicine and about music appreciation, etc. the lecturer makes or breaks the course and there is none better than Professor J Rufus Fears but he limits himself to historic stuff. Too bad because he could read the phonebook and make it interesting. The history of medicine lecturer was okay but of course the subject matter was important to me so that was pleasant listening. The lectures on music appreciation and sentence writing are so much denser and the speakers seem to drone on and I haven’t gotten through those series yet. Right now I am working on less history and more introspective stuff from the Mind Valley Academy. Stuff about meditation, quantum jumping, positive visualization and and positive vibrations.
Sure I will just listen to music from time to time but I can listen to music anytime and with the lawn mower I know I have a solid block of time to try to mentally absorb something. It’s like reserving a block of time to devote to a book you’re reading…I don’t want to read it in 10 minutes dribs and drabs. I want to have time to really get a few pages into the story…get up in there…immerse myself in the story…and you can’t just dp that in a few minutes here and there. Same thing with the audio lectures…I want to listen to the whole block…not just five minutes at a time.
So I think I have learned something about the world around me and hopefully about the world inside my head and who amongst you can say they are doing that on a regular basis. Hold a second…you can…anyone can. MP3 players like iPods are pretty cheap and if you can’t figure out how to get files on someone in your family surely can or you can YouTube it!
Having your mind engaged while your body is doing some repetitive task can only make the time go by faster and perhaps you will feel better at the end. Surely there is some subject you have an interest in…besides fantasy football and fishing…expand your mental horizons, not your waistline.
So far no one has asked the question about what I am doing the rest of the year when the grass is not growing. Well, I am listening to less lectures I can tell you that. On the other hand it gives me a chance to relax and enjoy when I am skiing or snowmobiling. You can’t have your mind on “go” all the time but you should try to get it in go some of the time.
Continuous Quality Improvement as they call it in the Industry. Taking Care of Business as Elvis Presely used to say.
My colleagues at the University Hospital have a slogan that says “Knowing changes everything.” With all due respect, that’s not true at all! Everyone knows you should quit smoking. Everyone knows you should get more diet and exercise. Knowing doesn’t change everything. Action changes everything. “Change gonna come” said the great Sam Cooke. Are you going to bring change to your life? You know it starts and ends with you. Maybe you will give thanks this season for your good health and spend a little energy making sure you stay healthy. Change a little something…in your diet, in your habits, in your thought process and see how you feel.