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The Fast Track | November 3, 2015
Dr. Barry
I have studied diabetes for years…all primary care doctors have…but only recently have I been exposed to a concept that can really make a difference in the care of diabetics. One of my Signature MD patients sent me a link to Dr Jason Fung …a doctor with a “new” approach to treating type 2 diabetes. Immediately, I saw the rightness of the idea. There have been multiple new drugs in the past several years but they just increase our medication choices…they don’t have a meaningful impact on changing the lives of diabetics. When you become a diabetic you go on one med…after a bit you go on a second med…eventually many people go on an injectable agent…all the while monitoring their sugars, blood pressure and cholesterol levels routinely. We are treating the sugar number but not the underlying problem which is that your insulin levels are too high.
am talking now about the very common type 2 diabetes not the uncommon type 1 diabetes where they don’t make enough insulin. So, most diabetics have insulin resistance and high insulin levels. High insulin levels prevent you from burning fat, High insulin levels cause weight gain. High insulin levels keep your belly fat growing. High insulin causes salt retention and therefore raises blood pressure. So, high insulin levels bad. Now the current diabetic teaching is low carb, frequent small meals etc… Not bad advice but no where near the best advice for treating high insulin levels. To treat diabetes and prediabetes effectively you must get the insulin level lower. Turns out that this is possible and doesn’t require any strange new meds, treatments or therapies.
Ok, how much extra time in your day do you need for this new treatment? How much money will it cost? How many choices will you have to make each day? Special equipment? Extra doctor or professional visits? The short answers are that it frees you from too many choices. It will save you time. It will save you money. No special meetings or equipment needed. Do I have your interest piqued yet? Well, I am talking about intermittent fasting. Fasting lowers your insulin level back to normal. This allows you to start mobilizing the fat in your body. Fasting reverses all the metabolic processes that insulin resistance causes.
There are many many types of fasts…I have gently recommended the 5:2 diet for years….5 days a week you eat healthy…2 days a week you take in only 500 calories or less. This is simple, basic and reasonable. I recommend doing the two days in a row for best results but you can vary the schedule to suit you. The intermittent fast recommended by Dr Jason Fung involves skipping breakfast and lunch every day and only taking in calories from 6 10 pm at night. Yes, this flies in the face of all the recommendations that you should eat a big breakfast and or have 5 small meals a day. If you follow that advice, you will keep spiking your insulin and weight loss will be much harder. This advice certainly has not made a dent in our diabetic problem or obesity problem. With intermittent fasting you don’t have to make a decision as to what to eat for breakfast or how to manage eating lunch on the road etc.… You don’t have to spend extra time in the gym, buy special scales or tubs, or learn anything new about calories, fats, protein etc. The first few times are psychologically daunting but almost UNIVERSALLY people that do the intermittent fasting FEEL BETTER. More energy. More mental focus. Less stomach issues. As the doctor said on one of the many videos I reviewed for this issue, you can do the test of 1. That is , try it for yourself ..you be the judge. You don’t have to ask anyone else what happened to them or how they feel. You can try fasting for yourself and see for yourself and feel for yourself the benefits. “Oh I could never fast…it’s just too hard !” Really? A billion people fast for Ramadan, Hindus, Buddhists, and old fashioned Catholics all have experience with fasting.
I am not going to give you the play by play because it really is just that simple…black coffee and water only until 6 pm. Eat healthy or not for 4 hours then no food after 10 pm. There are many variations on the Internet. Start with Dr Fung on youtube and off you will go. By the way…this is not really some new fad or trend. Fasting has been around as long as we have. When people tell me that it’s impossible to do I refer them to the TV show…Naked and Afraid ..where strangers are put together in the wilderness for 21 days to survive. The vast majority of them never find anything to really eat and that has not prevented anyone from completing the challenge. They might get sick from drinking contaminated water but no one quit due to lack of calories.
You don’t have to need to lose weight, you don’t have to be a diabetic, you just have to want to feel better. If you are a diabetic on lots of meds it would be prudent to check with your doctor about which meds to cut back etc. Your doctor should be sympathetic to your efforts even if he is not familiar with fasting. If he can’t be bothered perhaps it’s time to upgrade your medical care. When I mentioned fasting to one of my colleagues he opined that he thought the idea made sense but that we couldn’t get people to go along with it. I have more faith in you than that.! Did I mention that people who do fast say they feel physically and mentally better!
Let me close with a few quotes about fasting so you know it’s not just me! “Humans live on one quarter of what they eat; on the other three quarters lives their doctor.” Egyptian pyramid inscription, 3800 B.C. “Fasting is the greatest remedy the physician within.” Philippus Paracelsus, one of the three fathers of Western medicine “Instead of using medicine, better fast today.” Plutarch, a Greek biographer and moralist “The best of all medicines is resting and fasting.” Benjamin Franklin Until next month…get well stay well…
Preach, Practice, Repeat | October 6, 2015
Dr Barry
I am trying to practice what I preach…I have always believed that good living will trump most medications. I am not saying you can treat all medical problems with diet and exercise but I am saying that lifestyle is more important than medications.
Look up the treatment recommendations for hypertension, heart disease, diabetes, arthritis, etc and the first line will say either diet and exercise or lifestyle modification which is really the same thing. Your doctor glosses over this because he or she has no control over what you eat or whether you work out…What we in the medical profession can control are the meds and you know we love our pills! We give out pills to help you sleep at night and then another pill to keep you awake during the day. One pill for your blood pressure and another to counteract the side effects. When you add in the supplements and the vitamins and aspirin many people find they are taking 10 pills a day or more. We can’t control you but we can control the pills we give you.
So, my mantra has been diet and exercise…exercise and diet…I read somewhere that to get the same benefit a person gets from statin drugs (the popular cholesterol lowering drugs like crestor, lipitor, zocor etc ) …the radical alternative that has the same benefit as the statins….eat more veggies ! Now I am talking about primary prevention here… If you have already had a heart attack, blocked arteries, stents, stroke, diabetes etc that’s secondary prevention and the statins are very important for those people.
The debate has raged however as to how important it is for the average Joe to take a statin. Some doctors think they are overprescribed while other doctors think practically everyone should be on a statin. The studies are reviewed all the time with different conclusions depending on who is doing the interpretation. The most recent recommendation regarding statin use involves using a risk calculation like https://cvdrisk.nhlbi.nih.gov/..If your 10-year risk is higher than 7.5% you should consider a statin. This number is calculated by putting in your sex, your age, your cholesterol number, smoking status , and blood pressure information.
So, I try to plug in my numbers and when I punch the calculation button I get an error message. It seems my cholesterol level is so high that the computer assumes that I mistyped the number. My cholesterol is so high that when I tried to get life insurance years ago the agent said…don’t bother to even apply. My response at the time was to show them my recent cardiac cath results which did not show any blockage. So even though my cholesterol was high…it was not sticking to my arteries. They didn’t care that I didn’t have blocked arteries …they only cared about the number on the paper…So I went on meds…got my number to where they wanted it and got my insurance. Of course I stopped the pills afterwards…I am not a pill guy if I can help it.
Fast forward to this month…From time to time I get chest symptoms. Could be anything…probably nothing but that’s not how I treat my patients. If you worry about some symptom and some test can give us information why not get the test? At least twice a year I will push myself past the limits of my endurance physically…usually hiking and skiing with the Clan Haswell. I would rather not keel over in the near future because life is great right now. My wife still seems interested in me and my professional work has never been more satisfying with Signature MD so I would like to stick around long enough to at least see how Iran, Greece and China all play out.
I told you that I took meds to get my cholesterol down…I didn’t stay on the meds…I don’t like meds and what I read says you can accomplish the same thing with the right diet and exercise program so that’s what I concentrate on. But am I being stupid not treating my high cholesterol? Are my arteries slowly and silently clogging up? In my favor is the fact that I am not a smoker or a diabetic ..that makes whatever cholesterol you have stickier. Also, my family history is good…neither parent having had an mi or stroke. So , do you go with a good family history and lifestyle or go with the population based scientific calculation. Well, you don’t have to be abstract about it…you can just measure the amount of blockage and act accordingly. So, last month, I went to St Joseph’s Hospital and had a heart catheterization. They snake a wire from your wrist or groin to your heart and inject dye to check the arteries. It’s an interesting sensation. Not pleasant but tolerable. Dr Simon and his team were very professional …not even giving me grief about my not wanting to take any sedating meds. I don’t like to alarm my wife and I figured if I skipped the sedating meds I could drive myself home. My wife is a working girl after all and no need to keep her from her job. Bottom line is that there were no real blockages. Maybe a little plaque here and there but no blockages that needed stents, balloon angioplasty etc. If that’s all the blockage I have after 57 years of genetically high cholesterol I am doing the right things!! Maybe the tequila has some role in keeping the arteries open but that’s another column altogether. Until we know for sure I am going to credit the exercise and diet. I feel a little vindicated with my diet and exercise mantra. I also think having a persistently optimistic attitude is also important but that may be more for my head than my heart. There is data to suggest that being happy…having a positive attitude ..is as important for your heart as it is for your head and I want to believe that as well.
The deal I made with the heart doctor was that if there was any plaque at all …any narrowing…I would go on the statins. I don’t like statins but a deals a deal. If they will only come up with a pill I could take Sundays only…that way I could be possibly compliant with doctors’ orders. Just because I think I am a good doctor doesn’t make me necessarily a good patient!
So, just like I preach and practice…if you worry about a possible problem and there is a test for it…why not find out for sure. You know I don’t like surprises or guessing. When it comes to your health you shouldn’t either. Never be afraid to be proactive with your health…It’s not wrong to say to your doctor… ”This is my symptom…this is what I read about it…this test seems to provide clarity…is there a reason I should not get the test?” Until next month… Get well… Stay well.
Get Yourself to the Fair | September 5 2015
Dr. Barry
I had an article ready to go but I was then reminded that the New York State Fair opens up soon. As a dedicated health professional I would be remiss if I didn’t have some diatribe against the artery clogging junk to eat at the fair. In fact, I know I wrote about this exact same issue previously…I could just go back and cut and paste and who would know or care. Sorry, that’s not the way I roll. This is fresh off the cerebral cortex stuff but it will be very familiar. If I am going to preach about the same lifestyle issues over and over again I better have that patter down pat…so to speak.
The important principles of how profound an effect that diet and exercise can have in your life and health don’t change but the ways to approach and illustrate them sure can. What can I say to those that don’t go to the fair? It boils down to this…anyone who doesn’t go to the fair is hiding something. That’s right, hiding something. Maybe they say, “It never changes,” but they are hiding the fact that they are too weak to make it around the fair on their own. Oh, maybe they are hiding the real fact from you but I think they are often hiding the reason from themselves as well…Not wanting to acknowledge their debilitated status. Maybe they say, “All the food there is unhealthy,” but again they are really hiding the fact that they have a hard time making food choices. If you call them on this they will say…no…I just don’t like the fair…to which I have always countered with, “What’s not to like?” but now I see I will have to ask, “What are you hiding?” All those people who say I went for 30 years in a row…What made you stop? Did you start doing something else instead?
The exaltation of the Fair is easy. First, is its proximity people! The damn fair is in our backyard and for that reason alone deserves a visit. As do the Zoo, the Everson, the MOST, Symphoria, Syracuse Stage, etc., but they are here year round. The State Fair is more ephemeral…here but a few days at the end of summer. Gone before you have even gone through your full list of reasons not to go. The Fair IS exercise! Walking, walking, walking…it’s exactly what I preach. You can walk miles at the State Fair and not see everything. There is indeed always something new at the Fair …maybe not something monumental but always something new. There is always a lot of educational stuff at the Fair and you know I preach about feeding your brain. Free music…and you know how I preach music therapy. The midway, the crazy deep fried “what-the-hell?”, the animal barns, the Native American area, all have their own allure.
The Fair IS diet! Rather it’s a chance to test and challenge your diet. If you plan ahead, you can easily modify your diet and exercise enough before and after the Fair that you can overindulge on your favorite fair food. Are you on some “diet” you have to adhere to rigidly to get results or do you have a “lifestyle” that allows you to go buck wild on the deep fry but then rein it in the next day. Why would you go to the fair and look for a salad?
That’s not just silly its insulting! I couldn’t find a green salad so I had to settle for the Blooming Onion!? People Please! Now, there is one caution about the Fair. If you are over 50 you are crazy to go on any of those vomitorium rides. You have had your brain jostled and giggled around enough already…don’t add insult to injury. Go ahead and do the Ferris Wheel and try your luck at one of the squirt gun games but avoid all the upside down, back and forth stuff if you want to stay out of the nursing home. So, overall the New York State Fair is good for your health. I will pit the walking against the fair food any day…the secret of course is to make it any day…any one day…not every day! Get out of your rut. Try something new. Try something that you “used to do.” Keep up those traditions whatever they may be….well ok…drunk and disorderly is not a good tradition but you know what I mean. Get yourself to the fair and challenge yourself!
Don’t You Remember! | August 3, 2015
Dr. Barry
The experts claim that one in three Americans will suffer from Alzheimer’s disease. Suffering is a relative word because honestly most of the suffering done with Alzheimer’s is the suffering of the caregivers as the patient themselves is usually unaware of their condition. You suffer through cancer…you suffer through depression…your family members are the ones that suffer when you have severe memory loss. Alzheimer’s is listed as one of the top 6 causes of death in America but before it kills you it takes a toll on you, your dignity, your family, your bank account, etc. Dementia is probably the #1 diagnosis in the nursing home and therefore at $8,000 a month, per patient, it’s probably one of the most expensive diagnosis to treat on a national level. Maybe one of those wildly expensive chemotherapy agents are more expensive but usually they’re used for 6 weeks or 3 months whereas dementia can persist for decades.
I don’t actually use the term Alzheimer’s much…It’s really a diagnosis that can be made with brain evaluation at autopsy and it’s just a name…I prefer to call it by the more practical and less charged name…memory loss.
That’s what I see and that’s what I try to treat. You could call it Alzheimer’s, you could call it Binswanger’s disease, you could call it Lewy body dementia, you could call it senile dementia, you could call it multi-infarct dementia but the bottom line is the person has a functional problem with their memory, usually short-term more than long-term. They might remember the name of their second grade teacher but they sure don’t remember where they left the car keys or that they wrote two checks to the cable company and one to the gas company. There are some new and up-and-coming brain scans that might help decide whether you have in particular the typical Alzheimer’s changes, but it doesn’t matter much since the treatments are all the same. There is no good reliable blood work to aid in diagnosis. Diagnosing dementia is like diagnosing Parkinson’s. It’s best done by the same observer evaluating the patient over time and seeing what changes occur. Unfortunately, in the modern doctor’s office the typical patient can get in and get out and be quite demented but not picked up by the doctor if he doesn’t ask the right questions. In an office visit with the doctor checking the blood pressure, checking the meds, checking the cholesterol and attending to any issues with the insurance company it’s hard to step back and ask “by the way can you tell me the name of the last 3 presidents? By the way can you remember these 3 words and draw me o’clock etc?” It is not particularly hard to do. You just have to have the time and interest… I have seen many people that were really having a lot of trouble with their memory before it was picked up by their healthcare professional because they didn’t think to ask the right questions. You don’t require a psychologist, or a neurologist, or any specialist to diagnose dementia.
So dementia is diagnosed by asking patients questions. You can use formal testing like the Mini-cog, or the MMSE, or the SAGE questionnaire, or you can diagnose it informally. Once you look for it, it’s not hard to diagnose. On the other hand many people have mild cognitive impairment and never go on to dementia and it is hard to determine who will progress and who will not, and that’s why it is best managed over time by the same professional doing serial observations.
Now, the treatment for dementia is unfortunately quite limited. None of the current prescription medications cause significant and sustained improvement in cognition. The best we can say is that these medicines keep the patient as they are, and delays deterioration, but even the most ardent user of these medicines, if they look at the literature, realize they lose their efficacy within a year or year and a half. I wanted to be known as a very aggressive dementia doctor and so when the NIH recommended that we use Aricept and then add Namenda that’s what I did. I happily told patient’s I was following the NIH recommendations proving to them that I was an up-to-date well-informed physician. The only problem was this combination didn’t really work well for the vast majority of patients I treated. There might have been a patient here and there that the family said they noticed some improvement temporarily, but it wasn’t common. Additional experience with these medicines over time has continued to disappoint. Not only did these drugs not make a big difference…they also had side effects. My experience has shown me that in point of fact the benefits are quite minimal and the side effects are real, not dangerous but real. I have had many patients stop these pills and either did not deteriorate further or improved off the medicines, so my view of prescription treatment for dementia has been leavened by experience over time. There are also 2 medical foods/nutritional supplements to treat dementia as well and they include Axona and Cerefolin NAC. I like the idea that there would be some vitamin you could use that might actually have a clinical effect because I think there are less side effects with these prescriptions then there are with the other drugs mentioned previously. Unfortunately, these nutritional supplements are not usually covered by insurance because they are considered vitamins but they are not available in GNC or Natur-Tyme as they require a prescription from the doctor. Once again although individual families will say this medicine helped or that medicine helped they have not been overwhelmingly successful. Worth a try: yes. Guaranteed to work: absolutely not. I have absolutely no confidence in any nonprescription supplements that are available in the nutrition stores and vitamin stores. Completely unproven and potentially dangerous! Show me a single study done in America using human beings that show some improvement in a double blinded study and I will happily change my tune. So unfortunately, our current armamentarium is quite limited when it comes to treating Alzheimer’s/memory loss and therefore we are left with trying to prevent it, which I think in the long run is much more important…
There are obvious risk factors for dementia and they include smoking, diabetes, hypertension, and being inactive. There are genetic risk factors as well but there is nothing you can do about your genes so we focus on the modifiable factors. So yes, you can directly diminish your risk of dementia by not smoking, not drinking excessive alcohol, controlling your blood pressure and controlling your sugar. I prefer to focus on the couch potato aspect because the studies show that this is one of the most important modifiable risk factors. Besides exercise helping your cholesterol, your blood pressure, your joints, your mood, your fall risk, etc. physical exercise cuts your risk of dementia. Mental exercises are also touted to prevent dementia but the evidence that supports that is very slim. Physically pumping more blood to the brain works…mentally challenging your brain hasn’t been shown to work. It just makes sense to me that if you can open up the arteries to your brain with exercise you can get a little better blood flow and therefore a little better function from the brain. Studies have not shown that mental exercises have a basic and lasting impact but studies have shown that physical exercise seems to be associated with a lower risk for dementia. The mature patients that I see on a regular basis would benefit from exercise for many reasons not just the dementia component. People may be afraid of a heart attack or stroke in some vague way but the fear of dementia seems to strike a stronger chord. They take it a little more personally because they know someone who’s had the problem. Still, knowing about it and actually doing something about it are two different things. Get up off the couch and take a walk regularly…walk over to the local Nursing Home and that will provide you much better motivation than I can with this article. If walking through the halls of the nursing home doesn’t motivate you to get moving while you still can nothing will!
So memory loss can be a terrible problem with life changing consequences for the entire family…meds so far have little effect…but you are not helpless against this scourge…In fact you don’t need special tools, expensive tests, or exotic supplements to ward off memory loss. You just have to move it or lose it. Move your body to prevent losing your mind. So what or who are you waiting for? Until next month…get well…stay well.
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!!