This Week's Health Headlines

Drinking Coffee or Tea May Reduce Risk for Diabetes
Black Pepper and Curry: Two Great Tastes that... Fight Breast Cancer?
Volunteering Keeps Older Minds Sharp
FDA Panel Makes Major Change in Cholesterol Drug Recommendations
Meeting Spiritual Needs Improves Quality of Life for Dying Patients

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This Week's Health Headlines

Relief for Sufferers of Cluster Headaches
Study: Most Hospitalized Patients Don't Know Their Medicines
Study: Doctors Leave Gaps When Talking to Patients About Their Cancer
Discovery Could Lead to Pill That Makes Curly Hair Straight
Kissing a Frog Won't Get You a Prince, But It Could Get You Sick

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This Week's Health Headlines

CDC: H1N1 Vaccine Has Proven Safe So Far
French Scientists Create Human Skin Using Adult Stem Cells
NIH Opens Federal Funding for Embryonic Stem Cells in Spite of Ethical Concerns
Slim-Fast Recalls All Products Due to Non-Lethal Toxin
Weight Loss Eases Sleep Apnea in Obese Men
Study Says Loneliness is Contagious

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Oregon state registry for end-of-life wishes: a good idea?

Oregon recently launched a state registry for patients who sign a form known as POLST (Physician Order for Life-Sustaining Treatment).  This transferable order set allows patients to give specific instructions on the treatments they would or would not want in certain situations.  For example, a patient may opt for or against resuscitation for cardiac arrest, for or against IV antibiotics, or whether or not to place a feeding tube in different scenarios.  The POLST orders go beyond most states' DNR (do not resuscitate) orders, which only apply in the event of cardiac arrest.  POLST allows a patients to direct their care even when they have become to ill to express their wishes.

One of the biggest problems with advance directives is that emergency crews or hospital staff cannot locate the documents in a crisis, the time when the expressed wishes are most crucial.  Unless medical personnel have a verbal or written directive from the patient, we are obligated to perform certain procedures like intubation and mechanical ventilation, which many terminally ill patients do not want.  POLST tries to ensure that wishes are honored, but even in states where POLST has been implemented, relying on a paper form has its risks.  This program in Oregon would allow medical personnel with a password to instantly access the POLST record electronically, even if the paper document cannot be found.  Many times I have encountered situations when a patient was in a crisis, unable to speak, and we could not locate the advance directive or power of attorney.  Too often the patient had something done that went against his or her expressed wishes, simply because those expressions were not available when needed.

I understand concerns that people may have about an electronic record of private and personally held wishes that can be used to direct medical care.  I believe that this system would give more control to patients, not less.  If you take the time to document your wishes, shouldn't they be available to health care personnel in a time of crisis?  The registry is purely voluntary; Oregon residents are not required to participate. There is no coersion to choose one option over another; patients may direct care however they see fit, even to request all available treatments or procedures be given under any circumstance. While I do not agree with Oregon's policy on legalized physician-assisted suicide, I believe that a voluntary electronic registry of patient wishes is a helpful addition to the health care system, and I hope that more states adopt such a program.

As I have said before, the best way to ensure that your wishes are honored is to name a Power of Attorney for Health Care.  Read more here.

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This Week's Health Headlines

Exercise makes you hungry, but it also makes you feel full
New theory on multiple sclerosis stirs excitement
H1N1 flu leads to spike in pneumonia, and new vaccine recommendations
How much salt should you cut out to cut your stroke and heart risk?
Depression may increase risk of leaky bladder in women
US diabetes cases to double, costs triple by 2034

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Engage with Gravy, then Engage With Grace

I have blogged before about the importance of sharing your end-of-life wishes with someone you trust.  Thanksgiving is the perfect time to have that conversation as you gather with family.  The fine folks at Engage with Grace have put together a slide of 5 questions that will make this process easier.

If you have the gizzards to bring up these questions at the Thanksgiving dinner table, you deserve the Myles Standish Award for Bravery.  Even so, I find that once the ice is broken, these conversations can be quite cathartic, and you and your family will feel like you accomplished something important at Thanksgiving besides overloading on poultry and dozing off into a tryptophan-induced haze.  So, after you engage with gravy, Engage with Grace this holiday.  You can thank me later.

...would love to hear your comments on how it goes...

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This Week's Health Headlines

Learning while sleeping: Not so crazy after all?
Low-carb or high carb?  Both diets seem to help
Diet drug linked to increased strokes and heart attacks
Doctors say low pay for diabetes care shortchanges patients
Swine flu infections dropping, but more to come?
Certain foods proven to reduce colon cancer risk

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The "Million Med March"

Today I attended the Million Med March held in cities across the US and here in Chicago.  It was sponsored by Docs 4 Patient Care, a grassroots organization of physicians, healthcare professionals, and concerned citizens who want to reform health care while preserving the integrity of the patient-physician relationships we enjoy in this country.  I didn't know much about the group before today.  There weren't exactly 1 million doctors at Chicago's rally today- maybe 200-300.  Even so, there were some important messages.  Here is a summary of what was said, and my reflections on the event.

1. We are blessed to live in a country where the exchange of ideas is protected by law.

It was a privilege to gather with like-minded people today and express my views on an issue that I care about.  Few nations on earth protect, and even encourage, free and peaceful assembly to promote a cause.  The police who were present were not there to break up our meeting, or even monitor what we were saying, but to protect our right to assemble.  I'm not a big "rally" guy, but I appreciated the chance to participate today with no risk to my personal safety, my job security, or my family's well-being. 

2. Doctors are bad protestors/activists.
Today's rally lacked the energy that I have experienced at other public events.  It was not because the doctors present do not believe strongly in sensible health care reform.  I think most physicians, in an effort to provide their patients with the best, evidence-based medical care, get used to just falling in line with the latest recommendations and "standard of care."  Protests do not come naturally.  That, combined with the even-tempered personalities often found in physicians, makes us bad activists.  We are not a "rah-rah" crowd.

Most of the doctors I talk to are not in favor of the current health care bill.  Most of them also feel there is not much they can do to impact the health care reform efforts in Congress.  Part of that is due to the fact that very few doctors were actually invited to participate in the process.  The American Medical Association (AMA) supports the bill, but it represents less than 30% of doctors.  (Many AMA members are newly graduated physicians who have not taken time to cancel the free membership they received as a medical student.)  Another reason doctors don't feel we can have an impact is that, for whatever reason, we tend not to rally together.  Perhaps it is the self-sufficiency we learned in medical school and residency training.  It may be that we are too busy to ask each other to participate in an event seen as an "extra" thing.  The laws prohibiting physicians from forming a union also prevent us from uniting around a cause.  I am proud of those physicians who attended today.  As one physician and speaker put it, "I wasn't going to come today because I have a busy practice, a family, and few minutes to spare, but then I realized, that is why I needed to come today, because health care reform is going to affect all of those things."

3. The introduction of a public option will lead to government-run health care.
Even if this is not the stated intention, offering a government-subsidized health insurance plan to all will eventually destroy private health insurance as we know it.  The argument for the "public option" says that health insurance companies need a competitor to "keep them honest" and the government needs to provide this competition to prevent abuse.  Sounds great, but since when did the US government compete with its own people?  One enters a competition for one reason: to win.  That means that the clandestine goal of the government-run plan is to make private insurance companies into losers.  Since a government plan does not have to remain profitable to stay in existence, it will play by different rules.  Since its inception in the 1960's, Medicare has operated at a $37 trillion loss, yet it is bigger than ever.  No private company can "compete" against a beauracracy that bulletproof.

4. The "opt-out" provision in the Senate bill is a sham.
To create the impression that the public option is not being forced upon us, the Senate included language that will allow individual states to opt out of offering the public option.  What is not publicized is the fact that states who opt out will still pay the same taxes as states who opt in.  They will incur the same costs but no benefits.  It's doubtful that any states will opt out of the plan, since they cannot opt out of the cost.

5. Estimates of the bill's costs are grossly underestimated.
You have probably seen the CBO estimates of a $849 billion price tag for the current health reform bill.  The CBO numbers are based on a ten-year projection.  Since the changes to the health care system are slated to take place in 2013, the estimates only include 6-7 years of costs, but they include 10 years of increased taxes that will start immediately.  In other words, three of those ten years are income-only years for the program, with no costs.  Let's say you move into a house in June and paying six months of mortgage payments of $1000 each.  Would you then assume that, since you paid $6000 for your mortgage this year, that you would pay $6000 again next year, and your payments would only be $500/month?  Of course not, because you failed to take the entire year into account, but that is essentially the way the CBO is projecting the costs of this health care plan.

Plenty more was talked about today, and I encourage you to read as much as you can and get as involved as you can.  To learn more about today's event, visit Docs 4 Patient Care.

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This Week's Health Headlines

Frequent Neti pot use could cause sinus infections
Reduced muscle strength associated with Alzheimer's disease risk
Get instant diagnosis by coughing into your... cell phone?
ER waits worsening, especially for those in a true emergency
Are chemicals in plastics making boys more feminine?

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Nonpartisan Agency says House Bill will reduce Senior Care

In June, I wrote about why the proposed health care reforms will end up reducing benefits for seniors.  This week, a major nonpartisan agency agreed.  Today's Washington Post has a story about the report from the Centers for Medicare and Medicaid Services.  It reads:

"The report... found that Medicare cuts contained in the health package approved by the House on Nov. 7 are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether."

Read the full article here.

Good intentions do not always equal good results.  Congress needs to consider the unintended consequences of asking our health care system to do more with less.  As the Post article explains, the weakest and most infirm could still end up out in the cold.  We need different solutions to the problems with our health care system than the ones currently being proposed in Congress.  The bill offered by the Republicans, while not perfect, offers more common sense solutions, like giving incentives to individual States for reducing their numbers of uninsured, increasing tax benefits related to Health Savings Accounts, and at least addressing problems with medical liability.  Before the Senate votes on health care reform, let your Senators know that the current proposals are a bad prescription for America.

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Dennis and Me

I had the chance to attend a live broadcast of The Dennis Miller Show at Navy Pier.  I took it upon myself to grant him an honorary MD, since laughter heals and he is one of the best.  Listen here.

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This Week's Health Headlines

Are "green" products really green?  Not always, according to study
Eating too fast contributes to weight gain
Breakdown of the House Health Care Bill
Experts: H1N1 spread is outrunning vaccine
Study: Surgeons-in-training need a work week of more than 80 hours

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This Week's Health Headlines

CDC: Kids' deaths from H1N1 jump to 114
New injection could cure snoring
Survey: Doctors performing Pap test too often
High cost of malaria medicine costs millions of lives
Down syndrome births decline as more moms abort

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This Week's Health Headlines

President Obama declares H1N1 a national emergency
Knee pain?  Don't rest, exercise
Doctor's group: media sex and violence threatens kids
Food labeling program halted over FDA warnings
Rotavirus season shortened since introduction of vaccine

Read more....

Natural sleep aids in pregnancy

Tuesday morning on WMBI a caller asked if there was something safe that her daughter could take in her 7th month of pregnancy to help her sleep.  In the midst of a busy morning of calls, I gave her a kneejerk response by recommending the antihistamine diphenhydramine, the active ingredient in Benadryl.  This approach is safe, as diphenhydramine is a pregnancy category B medication (meaning that studies in humans have proven it to be generally safe for the unborn child).  However, I did not take the opportunity to discuss other natural remedies, as well as behavioral strategies for sleep in the later stages of pregnancy.  My response brought to light one of the problems in our health care system, namely, that the increasing demands of insurance companies and health care systems force doctors to rush through an office visit, and we often fall back to the old playbook of the most commonly recommended pharmaceutical solution, rather than exploring other 'natural' and behavioral remedies. I felt like I did the radio equivalent of a rushed office visit on Tuesday. Thankfully, I have the opportunity to follow up and explore those alternatives here.

Sleep patterns are clearly altered for pregnant women as they approach the birth of their baby.  The expanding uterus presses on the surrounding organs, making it difficult to last the night without having to get up to empty the crowded and shrunken bladder.  The sheer discomfort of the expanding abdomen, and the often corresponding back pain, make it difficult to sleep comortably, especially if the woman is used to sleeping on her stomach.  I believe that the disturbed sleep can help prepare an expecting mom for motherhood.  Once the baby is born, new moms are called upon to spend odd hours nursing and caring for their baby.  Every new parent knows that while their newborn may sleep 18 out of 24 hours, the sleep usually comes in 90-120 minute spurts followed by 1-2 hours of wakefulness.  Furthermore, newborns tend to have an opposite sleep cycle after birth, spending more time sleeping during daytime hours and more time awake at night.  In a way, the woman who has to adapt to irregular sleep patterns is being trained for the physical demands of early motherhood.

That being said, there are some simple ways to improve sleep during pregnancy.  The basic behavioral recommendations to improve sleep still apply.  Try to wake up and go to bed around the same time every day.  Avoid caffeine in general, but especially in the afternoon and evening.  It is important to continue to drink plenty of water during pregnancy, but try to limit your intake for 2-3 hours prior to sleep, and be sure to empty your bladder fully before bed.  Many women state that sleeping on the side and placing a pillow between the legs provides additional comfort.  Continuing to exercise during pregnancy is safe, and regular exercise has a positive impact on sleep.

Regarding "natural" sleep aids, some are safe in pregnancy and some are not.  It is important to remember that herbal and 'natural' remedies are not regulated by the FDA, so they can claim anything they want on their packaging without having to prove their claims with scientific studies.  Also, the FDA does not test the products to ensure that the ingredients listed on the label are actually contained in the supplement.  Some of the more popular sleep aids are below.

Melatonin is a chemical that resets the body's 24-hour clock, called the Circadian rhythm.  Pregnant women have naturally lower melatonin levels, and these lower levels may be important to the baby's development.  Therefore, I would not recommend melatonin durnig pregnancy.

Chamomile is commonly used to make tea that is used by many as a sleep aid.  Most would consider chamomile tea to be safe, but probably not the more concentrated chamomile oil.  I can safely recommend chamomile tea during pregnancy.

Valerian is an herb that has a mild effect on the body and is one of the safer herbal sleep aids, however, there is conflicing evidence about whether it is safe during pregnancy.  Therefore, I would play it safe and not use valerian during pregnancy.

5-HTP is a supplement used for depression that can also aid in sleep.  It affects serotonin levels, and while many doctors consider serotonin-altering medications to be generally safe in pregnancy, we do not have convincing evidence that it is completely safe.  Therefore, I would not recommend 5-HTP.

Kava was once a popular herbal supplement used for anxiety symptoms and insomnia.  Many problems with kava have been uncovered, including its harmful effects on the liver.  I do not recommend taking kava for any reason.

Tryptophan is not available as a supplement but is present in turkey, cheese, nuts, beans, eggs, and milk.  High levels have induced fetal tumors in laboratory animals, so seeking out tryptophan in high doses is not advised.  The amount of tryptophan in a glass of warm milk would be safe, and it may be enough to assist with falling asleep.

In summary, about the only "natural" sleep aids that I recommend are warm milk or chamomile tea.  Making some behavioral changes may also help with sleep during pregnancy, but in the later stages, it is probably unrealistic to maintain normal sleep patterns.  If you find yourself wide awake and frustrated as your due date nears, take a moment and pray for your baby.  It's a great way to prepare yourself spiritually and emotionally for the arrival of your child, while your body trains itself physically for more sleepless nights ahead.

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Feature on Albert Schweitzer Fellowship website

The fine people at the Albert Schweitzer Fellowship recently invited me to participate in their "Five Questions for a Fellow" feature on their blog Beyond Boulders.

Read the article here.
Read more about Albert Schweitzer here.

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This Week's Health Headlines

Manufacturers come up short in expected H1N1 vaccine production
FDA warns H1N1 products purchased over internet could be phony
More MRI scanners may lead to unnecessary back surgeries
FDA approves another vaccine for virus that causes cervical cancer
More progress in the fight against breast cancer
Pregnant women with back pain might benefit from acupuncture of the ear

Read more....

This Week's Health Headlines

Chronic fatigue syndrome linked to a little-known virus
Exercise improves survival in chronic kidney disease
Another big step taken in adult stem cell research
Feelings of being wronged may worsen your recovery from whiplash
Trying to quit smoking?  Texting may help
Cruising in a convertible could harm your hearing

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The 411 on H1N1

Here it is: the breakdown you've been looking for on the flu vaccines.
Who should receive them?

First- the regular seasonal flu vaccine, available now.
You should get the flu vaccine this year.
The only people who should not are infants less than 6 months, people with an egg allergy, and people with a previous reaction to the flu vaccine.

Next- the H1N1 vaccine, available in the next few weeks.
The following groups of people should get this vaccine:
Pregnant women
Children age 6 months to 18 years
Caregivers for children this age
Young adults 18-24
Health care workers
People age 25-64 with a chronic medical condition
(Examples include diabetes, asthma, COPD, and autoimmune conditions)

People age 65 and older are at lower risk for H1N1, so they are not recommended for the vaccine until the higher priority groups are inoculated.  Sometime in December or January, people age 65 and older may be recommended to receive the H1N1 vaccine.

The H1N1 vaccine will be available as a nasal spray and as a shot.  Pregnant women cannot receive the nasal spray because it contains a live virus.  It is safe for everyone else except those with a compromised immune system (as in HIV).  Children under 10 will require 2 doses about 4 weeks apart.  Everyone else will need only one dose.

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This Week's Health Headlines

Scientists extend lifespan by blocking protein
Most babies born this century will live to 100
Yoga may decrease age-related "dowager's hump"
Yet another benefit of vitamin D- it prevents falls
Combination of generic drugs cuts heart risk by 60%
Federal WIC program finally allows use for fruits and veggies
Skinny friends could wreck your diet
Treating your kids to too much candy could land them in... jail?

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This Week's Health Headlines

Think it's swine flu? Don't go for the rapid test
Antidepressants during pregnancy linked to heart defects in baby
Study: No evidence to support routine PSA testing for prostate cancer
Fear of back pain may increase your risk for back pain
Poor math skills may worsen diabetes control
Low vitamin D may be deadly for older adults

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This Week's Health Headlines

First H1N1 vaccine in US will be a nasal spray: CDC
Deadly mosquito-borne illness heading to US
Unhealthy habits could cost men 10 years of life
Steroid injection may help restore vision when eye veins are blocked
Daily dose of aspirin may cut colon cancer risk
Scientists discover cure for color blindness

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This Week's Health Headlines

Eating meat in middle age may help preserve later abilities
Even a little smoking increases breast cancer risk
Docs stressed out when patient unable to communicate wishes
Sleep specialist says sharing a bed is 'bad for your health'
New test can determine if you really need antibiotics
Health reform will prompt need for many more primary care docs

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House Calls Episode Two

"House Calls" airs Sunday night at 10pm on AM 560 WIND and streams live at 560wind.com. In addition to the latest health headlines, I will address the topic of H1N1 flu. My guest is Donald Thompson, MD, Senior Medical and Public Health Program Director in the Center for Infrastructure Protection at the George Mason University School of Law in Arlington, Virginia.

Episode Two Action Steps:

1) Prepare to utilize hand sanitizer liberally this flu season. Purchase some bottles for you and your family to have with you at all times.

2) Do not touch your eyes, nose, or mouth until your hands are clean.

3) Get the regular influenza vaccine, available now at your doctor's office or other locations (unless you have a contraindication like egg allergy or previous adverse reaction to the vaccine).

4) Get the H1N1 vaccine when available (likely late October-early November) if you are in one of the recommended groups:

a) Pregnant women

b) Household contacts and caregivers for children younger than 6 months of age

c) Healthcare and emergency medical services personnel

d) All people from 6 months through 24 years of age

e) Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza (these would include asthma and other lung disorders, and conditions causing immunosuppression such as HIV or certain cancers).

5) If you get sick with fever, aches, cough, and congestion ("flu-like" symptoms) stay home and limit your exposure to people until 48 hours after your fever is gone.

6) If your fever is over 103, you are unable to eat or drink, or you are having severe vomiting or diarrhea, seek medical attention. These are risk factors for dehydration, a major cause of morbidity and mortality from the flu. You should also seek medical attention, of course, if you are having difficulty breathing.

7) Don't panic. Common sense will get us through this!

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Chicago Tribune article on "End-of-Life Conversations"

Today's article by Barbara Brotman in the Chicago Tribune gives an excellent representation of what advance care planning conversations might look like at the end-of-life. Of course, advance care planning can occur at any stage of illness, and does not always have to address things like Do-Not-Resuscitate orders or refusing other invasive measures. It could simply cover what you value when it comes to your health care, and who you want for your Power of Attorney.

The article also explains more about Someone to Trust and what we are trying to accomplish in Chicago.

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This Week's Health Headlines

People with skinny thighs die sooner, study finds
Scientists discover why broccoli is good for your heart
Late night snacking is worse than you think
Reduction in residents' work hours linked to more patient complications
Researchers discover three new genes linked to Alzheimer's
Antioxidants best when obtained from food, not pills

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House Calls Episode One

House Calls Radio debuts this Sunday evening Sept 6th at 10pm on AM 560 WIND. In addition to the latest health headlines, we will discuss the topic of advance care planning. My guest is Dr. Martha Twaddle, director of the Midwest Hospice and Palliative Care Center.

Show #1 Action Steps
1) Choose the person you would trust to make health care decisions on your behalf if you become unable to express your health care wishes.
2) Ask that person if they would be willing to act as your health care power of attorney.
3) Download the Durable Power of Attorney for Health Care form. (Here's the Illinois form if you live in my home state)
4) Complete the form and have a witness sign it. You may also have your chosen agent sign the form but it is not required. No notary or attorney is required. You may choose successor agents in the event your primary agent is unable to fulfill their responsibility.
5) Make copies of the form.
6) Keep two for yourself, give one to your power of attorney, one to your physician, one to your successor agents (if applicable), and one to your lawyer (if applicable).
7) Have a conversation with your power of attorney about the things that are important to you when it comes to your health care. If you need help with this, make an appointment with your physician specifically to discuss advance care planning and ask for at least a 30 minute appointment. Bring your power of attorney with you. In Chicago, you can find a trained facilitator to help you with this process at Someone To Trust.

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This Week's Health Headlines

Muscle mass, not fat, leads to stronger bones
New study breaks down reasons heart attacks more deadly for women
Help for irritable bowel syndrome: soluble fiber, not bran
Larger waistline increases asthma risk for women, even with normal weight
Worry about losing job more stressful than actually losing job
AHA has harsh warnings about sugar intake

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This week's health headlines

Even a little exercise can extend life span
Study: end-of-life discussions improve mood in cancer patients
US sets new record for life expectancy, but still lags behind many countries
Study shows lost people really do walk in circles
The doctor will IM you now: online counseling helps depressed patients
CDC to college students: Curb swine flu by wearing surgical masks while... kissing?

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This Week's Health Headlines

Popular sports creams do little to help the pain
Flu drugs not useful in children according to British study
Slippery bathrooms cause many injuries in kids
TV viewing linked to high blood pressure in children
More depressed Americans opting for drugs over counseling
You may think better on sunny days

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This Week's Health Headlines

Tanning beds proven to cause cancer
Blue dye used in M&M's may treat spinal cord injuries
Morning sickness tied to higher child IQ
Good relationship with caregiver may slow Alzheimer's disease
Is "Organic" food healthier than conventional food?
CDC publishes recommendations for who should receive swine flu vaccine

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The document that is more important than a living will

Have you heard the radio advertisements for legal firms that will send you a FREE living will? Have you heard them promise that if you call now, you can save even more money because they will include a FREE Health Care Power of Attorney? Sounds great, doesn't it? What they don't mention is that these documents are already available for free, and you don't even need a lawyer in order to complete them.

The most important advance care planning document, and the one everyone should have regardless of age, is the Durable Power of Attorney for Health Care (DPAHC). This is the document that names someone to make decisions on your behalf if you ever are in a situation where you cannot express your own wishes. Most people, when asked, know immediately which person they would trust in that situation. It is important to name this person in writing, because state laws vary, and without the proper paperwork, it is possible that someone other than the person you want would have authority over your health care if you could not express yourself. For example, I recently admitted a patient to the nursing home whose granddaughter cared for her at home for many years. The patient had become very ill and could no longer express her own wishes, but she had expressed her wishes to her granddaughter during previous conversations. Unfortunately, they never completed a Power of Attorney for Health Care. The patient's estranged son arrived on the scene and began to demand a course of management that went against the patient's wishes. In spite of the granddaughter's protests, the nursing home was obligated by law to follow the wishes of the son, because Illinois law gives adult children priority over grandchildren for decision making authority when there are no papers. Such a scenario could have been avoided had my patient completed her DPAHC and named her granddaughter.

If you live in my home state of Illinois, the official DPAHC form can be downloaded for free here. Most other states make their forms available as well, and you can find them by doing a web search for "(your_state) power of attorney for health care". Once you have the form, you simply need to identify your person of choice, fill in their name and contact information, and sign the form. In Illinois, you will need one witness to also sign the form. You don't need an attorney, and you don't need a notary public. You don't even have to have your decision-maker sign the form. I still recommend this, because the person you choose needs to know of the important responsibility you have given them.

There are other sections of the form that allow you to express specific wishes, such as a procedure you definitely would or would not want, or specific organs you would want donated. It is not necessary to fill out these portions, though it may be helpful for your decision making agent to know this information. However, he or she is not obligated to follow what is written there. That is why the best approach is to have a conversation about your wishes with the person you trust. This will give them the opportunity to ask you questions and to see and hear directly from you what is most important about your individual wishes.

Another advance directive is the living will, which gives you the opportunity to state that you would not want to be kept alive artificially if you contracted a terminal illness and doctors believed you had no hope of recovery. This document also gives you the opportunity to define specific courses of action. I have run into problems with this document and I do not find it as useful as the Power of Attorney. One problem with the document is that you can fill it out and never tell anyone. If you were to become very ill, unless someone has a copy of your living will, it may never be followed. It is much more powerful to have a living, breathing advocate (your Power of Attorney for Health Care) who understands your wishes and can help guide your doctor through the myriad of possible scenarios that can occur if and when you become ill. I do not have a living will, but I do have a Power of Attorney for Health Care. I know the President told us recently that he and his wife have a living will, and that it is important to have one, but I think it is far more important to have your Power of Attorney for Health Care.

Once you have filled out your advance directive, keep a copy for yourself, give a copy to your decision maker, and give a copy to your doctor. There is a movement to standardize these documents and make them more accessible across health care systems. In Chicago, a large coalition called Someone to Trust is working to accomplish this goal for the first time in a large, multiethnic city. Google Health recently added a section where you can scan and store these documents so you can authorize your agent or doctor to access them in time of need. If you feel comfortable using this service it is a good resource.

For more information on Advance Care Planning, visit the website for National Health Care Decisions Day.

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My "conversation" with Rush Limbaugh

Today while driving between nursing homes, I heard Rush Limbaugh talking about the health care reform bill's Advance Care Planning Consultation section. He, like some other conservative talkers, was complaining that the government was mandating these consultations as a way to usher patients towards an early death in order to save money. In my previous post I explained why this was an unfair characterization of Section 1233, and that it makes sense to reimburse doctors for the time they spend talking with patients and families about their health care wishes. I decided to call in, and I actually got through. "Dave in Chicago, you're next.." Rush said.

I explained that I was a physician, and that there are many aspects of the current health care reform bill that I disagree with, but that this provision was actually a good idea. I said that I often take extra time to ask my patients about choosing their power of attorney and about their end-of-life care wishes, and that it was smart of Medicare to encourage these conversations by providing a small reimbursement to doctors who initiate such discussions, since the current structure requires doctors to essentially offer this service for free. I started to explain that the bill actually does not mandate these conversations between doctors and patients, nor does it mandate their content. Then I realized that Rush was talking and my voice was turned off. He once again incorrectly insisted that the bill will mandate a consultation promoting "death care," a term he claimed I had used. He said that I was welcome to have those conversations with my patients, but that anyone who had a doctor like Dave in Chicago who insisted on talking about "death care" should find a new doctor. I tried to protest but quickly realized that my voice was turned off and that our "conversation" was over.

Rush Limbaugh's reaction to my call was a stark reminder that many people completely misunderstand palliative medicine and end-of-life care. While he railed on about doctors being mandated to discuss death with their patients, I could sense an underlying fear, perhaps about his own mortality. Death is inevitable, and one of the greatest gifts I can give my patients is to help them look ahead to possible scenarios and to express their thoughts and wishes about their medical care while they are still able. Those of us who practice this skill do not attempt to usher our patients toward an early death for the sake of utilizing fewer health care dollars. All too often I have watched patients and families undergo painful and invasive treatments which are unlikely to extend life or provide any healing, simply because they felt they were obligated to submit to such treatments. No doctor had ever laid out the real picture, that their prognosis was poor and their choices were limited by their disease. They needed to hear that their realistic options had shifted away from the best course for avoiding death to the best way to maximize the quality of life remaining. They needed to know that there was another path, and they probably needed to hear that from a doctor. Many doctors avoid these conversations because they are uncomfortable or awkward. Doctors who talk about death with their patients are brave.

I do understand the fear that more government-sponsored health care will lead to rationing and could result in seniors being denied services simply because of their age. That is a real concern. It is a reason I am not in favor of more government involvement in health care. However, please do not make the same mistake Rush Limbaugh made today and equate coversations about end-of-life care with promoting "death care." Expressing your wishes to your doctor, and asking about options if and when you become ill, serves to promote patient choice and control, not take away from it. I still think government-run health care is a bad idea, but as long as Medicare pays for most seniors' health care, I think it is admirable that they are looking at ways to make it easier for doctors to assist their patients with advance care planning.

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Reimbursing doctors for discussing goals of care with their patients- finally, a good health care reform idea!

Part of the proposed health care reform bill that I like is the idea to reimburse physicians for having an "advance care planning" discussion with their patients once every 5 years. This is something I do with my patients often, and I have wished many times that Medicare would recognize the value of this skill, and the time it takes to perform it, by offering specific reimbursement for the discussion. Unfortunately, some Republicans are saying that supporting a patient-physician conversation about goals of care and end-of-life options will "start us down a treacherous path toward government-encouraged euthanasia". I disagree.

Section 1233 of HR 3200, the proposed health care bill, is titled "Advance Care Planning Consultation". It allows a physician to be reimbursed for leading his or her patient in a discussion about the patient's wishes in certain medical situations. I find these discussions to be very helpful for patients and doctors. Patients have the chance to think through different scenarios and ask questions about what to expect. They also have the opportunity to put these wishes in writing, and to select a surrogate decision maker for a situation in which they are unable to express their own wishes. Doctors can gain insight into their patient's preferences so that, when they become ill, the doctor knows better how to care for them. Family members are often involved in these discussions, and the process helps prepare the entire family for unexpected events so they don't have to panic in a crisis. These discussions often occur around the time of a new diagnosis, a serious change in condition, or a change in living situation such as a move to a nursing home.

The bill does not mandate these discussions, as some commentators and even congressmen have suggested. It simply rewards clinicians for taking time to assist their patients with advance care planning, if they chose to do so. The bill also does not mandate the specifics of the conversation. It mentions many of the standard treatments that are discussed in an advance care planning session, such as intravenous antibiotics, artificial feeding and hydration, and hospitalization. The bill does not mandate what is said or decided about these issues; it simply allows that they can be part of a conversation that would qualify as advance care planning.

My only concern about a bill like this is that it recommends: "An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title". I am a staunch supporter of palliative care and hospice, when appropriate, but in states where physician-assisted suicide (PAS) is legal, the phrase "continuum" could be used to mandate that physicians offer this option to their patient in any advance care planning discussion. However, the bill states that this discussion can include such an explanation, not must, so the bill as it is currently written would not mandate offering PAS even where it is legal.

Though I have many problems with HR 3200, and I hope it does not pass in its current form, I am encouraged that reformers are recognizing the value of advance care planning, and that they are considering reimbursing physicians for taking time to providing this valuable service to their patients.

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Health benefits from Chia seeds

A caller to my Tuesday morning appearance on WMBI asked a question about chia seeds, and I had to admit that I did not know much about what they had to offer. If you're like me, the word "chia" conjures up images of pet-shaped terra cotta pottery with green sprouts. It turns out that eating chia seeds can have some positive health benefits.

Chia seeds contain a high amount of omega-3 fatty acids, which are beneficial for brain and heart health. Chia seeds apparently contain more omega-3 per ounce than flax seed. Chia seeds also contain some calcium, and high levels of magnesium. The recommended dosage of chia is 2 tablespoons per day. They can be eaten straight, mixed in water, or ground and added to baked goods like muffins. As with any supplement, it is important to remember that these are not regulated by the FDA, so if you are going to purchase chia seeds, try to do so from a reputable source.

I was unable to find any major medical studies on chia. It has been reported to benefit those with diabetes, but so far there are no studies to back this up. I expect that some studies will emerge over the next few years, especially now that Dr Mehmet Oz mentioned chia seeds on the Oprah show.

While some have suggested chia seeds as an alternative treatment for hair loss, I do not recommend this course of action.

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This Week's Health Headlines

Active children go to sleep faster
CDC: All children should get the regular flu vaccine this fall
Up to one in four Americans could get swine flu
Six lifestyle changes that reduce men's risk of heart failure
Obesity rate for preschoolers holds steady at one in seven

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Does Your Doctor See Dollar Signs in Your Kid's Throat?

If you watched President Obama's press conference Wednesday night, you may have come away with the impression that doctors are often thinking about how much money they can earn from your illness as they make decisions about your health care. Here are his comments from the transcript at CBS News:

"Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out....Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference."

In my experience, this dynamic rarely happens in primary care. Sure, if you are seeing a specialist whose earnings are based on performing one or two highly specialized procedures, he or she is more likely to recommend that you have that procedure. In the vast majority of cases, however, doctors are not calculating what decision is going to earn them the most money. For one thing, repayment schedules are so complicated these days, that it is difficult for doctors and medical office managers to know if and when they will be reimbursed at all for a day's work. Many insurance companies' payment schedules, including Medicare and Medicaid, are designed to pay only a percentage of what the doctor actually bills, so even if a doctor wanted to figure out how much he or she would make based on a specific decision, it would be nearly impossible to do so in today's system. (If you've ever seen a hospital bill that your insurance company paid, and you were shocked at the numbers, you should know that the hospital and doctor probably only received a percentage of what was actually billed, and they were forced to mark up the fees in the hopes that what they are actually paid would at least cover their costs for the hospitalization or procedure).

For President Obama to imply that doctors are performing unnecessary surgeries on children for their own financial gain is an insult to the medical profession. The very procedure that he referenced disproves his own theory. Tonsillectomies have dramatically decreased over the past 2 decades because doctors recognized that removing a child's tonsils did not prevent infections like it was once thought. Therefore, ENT specialists and pediatricians stopped recommending tonsillectomy as often because it became clear that the risk of the surgery, though small, outweighed the potential benefit in most cases. Financial factors played no role in this trend. Practice guidelines published by doctor's associations are always rooted in data about patient outcomes. If a procedure or treatment produces good outcomes, it is recommended. If it does little to help patients or is too risky, it is not recommended. The doctors I know and work with attempt to follow these guidelines as closely as possible, whether or not they will benefit financially. Practicing medicine is a lot different from practicing law, where lawyers can bill an hourly rate for just about everything they do. I hope President Obama is not relying on his background in law as he conjectures about what doctors think when they look in your throat. Your doctor is almost certainly thinking about what decision will help you the most, and not what will help his or her pocketbook.

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More thoughts on health care reform

I am not an economist; I do not claim to understand the complexities of the health care market, nor can I accurately predict how the proposed health care legislation will impact our nation's health care industry. However, many aspects of the proposed reforms make me uneasy.

1) Creating a centralized oversight committee in Washington puts too much power in one place. This group of doctors and other professionals will be making decisions about what treatment or procedure is appropriate for what person at what age or stage of their illness. Those decisions should remain between you and your doctor, not a committee in Washington. Further, many of the decisions will inevitably be made for political rather than medical reasons, as swarms of lobbyists and special interest groups will exert their influence over this committee to obtain results that benefit their own self-interest instead of the patient's. Imagine, for example, the frenzied efforts of drug companies to sway the government-approved formulary to choose their medication over their competitor's. Billions of dollars and tens of thousands of jobs could be at stake. Such far-reaching power over the industry will lead to corruption, no matter how well-intentioned the President or his oversight committee may be.

2) Like it or not, health care is a business. That cannot be changed, and attempting to change it will lead to laziness and stifled creativity. The most successful businesses succeed because they provide their services better than anyone else. In a market system, a business cannot survive unless it stays one step ahead of its competitors. Incredible innovations in health care technology and health care delivery have come from the opportunity to compete and succeed in a competitive market. Introducing more government-supported players into the market will dilute creativity and distort the field of innovation. Private health care companies must provide quality health care within a limited cost, or they go out of business. A universal government health plan has no survival accountability; if it fails to control costs or deliver quality services, it can simply be bailed out with more tax dollars. There will be no real consequences for poor performance, and therefore, I fear that the federal government's health care bureaucracy will become more and more bloated and eventually crowd out private health care companies that have to play by the tougher rules of a free market. Furthermore, competition among health care providers is the factor most responsible for the high level of patient satisfaction that exists in this nation (I believe our system needs reform, but I also believe that claims of imminent collapse and widespread dissatisfaction with our system are vastly overstated for political gain). One of the leading indicators being looked at by doctors, hospitals, and insurance companies is patient satisfaction. This is because patients can, for the most part, choose who will provide their health care. I believe the proposed reforms, despite President Obama's promises to preserve choice, will actually limit patient's choices, and the health care industry will begin to care less and less about patient satisfaction when their clientele no longer have the option of going to the doctor across the street if they are dissatisfied.

3) While I do not think tort reform would answer all of our health care problems, leading experts from diverse political backgrounds agree that the medical malpractice industry is draining resources from our health care system. Yet, no attempt was made in the proposed reform to address this issue. If we are really trying to control costs by any means, shouldn't tort reform be part of a broad health care reform package?

Though I have not read the 1000 page House bill, I will say that I am encouraged in hearing about increased funding for Federally Qualified Health Care centers that provide much of the health care in areas stricken by poverty. I am also encouraged by the proposal's promise to redirect resources toward prevention and primary care. Even so, I think the overall philosophy of increasing government's involvement in health care will have disastrous results.

As an alternative, I have read much of Senator Tom Coburn's proposed plan, and I agree with much of it. He is a physician and he understands the importance of preserving the doctor-patient relationship, something I think the President's plan will damage even further. Sen. Coburn also understands the value of having doctors and insurance companies compete for patients, and attempts to preserve that dynamic in his plan. Links to the entire bill or a summary can be found here.

It will be interesting to see how this unfolds and I would love to hear what you think.

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This Week's Health Headlines

CDC downplays swine flu fears
DASH diet combats mental decline
Bottle-feeding moms may be overfeeding their kids
Boys with unusual names end up in jail more often

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This Week's Health Headlines

Study finds Omega-3 not helpful in slowing Alzheimer's

Seniors should hit the weights

Key to living longer- eat less
Obesity linked to same-sex parent
Stress can cause weight gain
Asthma drug may help restore sense of smell

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Antacids and "Rebound" Heartburn- can you get hooked?

This morning on WMBI I talked about a recent study on the popular Proton Pump Inhibitor (PPI) medications and their potential to cause "rebound" acid reflux. This could lead to a dependence on these medicines. Many callers and e-mailers have questions about this. If you are on these medicines, should you stop them? If so, what is the best way to stop? Is there any risk to staying on the medicine?

The PPI medications are commonly known as Prilosec, Prevacid, Nexium, Aciphex, and Protonix. The generic names have the common ending "-prazole". These medicines block the stomach's production of acid. They are useful for people with acid reflux disease, or gastroesophageal reflux disease (GERD). This class of medicines is one of the most commonly prescribed group of drugs in the world. Many doctors prescribe them the first time their patient reports symptoms of heartburn. Some of these drugs are now available over-the-counter without a prescription.

The problem that is now coming to light is this: it turns out that while these medicines are in the system, the stomach responds by attempting to crank up acid production. When the medications are stopped, the floodgates open and heartburn symptoms return, possibly in a more severe form than previous. This study actually placed people with no heartburn symptoms on a PPI medication for two months, and when the medicines were stopped, the patients with no history of GERD developed symptoms of heartburn within a few weeks.

So what are the implications? First, if you are on a PPI, there is no documented long-term risk of staying on the medicine. That being said, it is best to use these medications for the shortest time possible in order to avoid the "rebound" effect. The recommended time frame is 2-3 weeks, in order to treat a severe flare-up of GERD. During that trial, there are lifestyle modifications that should be tried. These include limiting the intake of alcohol, tobacco, caffeine, and spicy foods. Stress can also contribute significantly to GERD.

If you are already on these medicines, and you have been taking them for some time, talk to your doctor about stopping. One way to do this is to wean yourself off by cutting your dose in half, then going to every other day, then every third day, etc. Do this over the course of 4-6 weeks. What may happen, as suggested by this study, is that your symptoms may return when the dose is reduced. I would encourage you to try to ride this out over 1-2 weeks, because the stomach may re-calibrate its acid production on the new lower dose. This may need to occur over several weeks and multiple, step-down dose reductions.

For those who cannot manage their GERD through lifestyle modifications (mentioned above), another medication option is ranitidine (brand name Zantac). This medicine is available over the counter in a 75mg tablet. The maximum dose is 150mg (two tablets) twice a day. Start by taking one tablet at night, go to two if needed, and then add a morning dose if necessary. It is safe to start on the ranitidine while you are weaning yourself off the PPI's, and this may help with any "rebound" heartburn you may experience.

There is a group of patients that should be on PPI medications for life. These are people with something called "Barrett's esophagus". This occurs when the acid reflux is so severe that it causes tissue damage to the esophagus. This damage can progress to esophageal cancer and can be deadly. Barrett's esophagus is diagnosed by esophagealgastroduodenoscopy (EGD), a test in which a GI specialist passes a small camera down the esophagus and can look at or biopsy the tissue. Anyone with a positive test should stay on PPI's. For the rest of us, it seems best to limit the use of these medications.

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This Week's Health Headlines

Antacid use may lead to dependence
Panel to FDA: restrict acetaminophen even further
Could coffee reverse Alzheimer's?
'Self-help' might make you feel worse

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I Bumped My Head- Now What?

The recent death of famed pitchman Billy Mays was tragic (he convinced me to spend $19.95 for not one, not two, but six tubes of "Mighty Putty"). He apparently died from heart disease, but initial speculation blamed his death on a head injury he suffered during a rough airplane landing the night before. While the head trauma seemingly did not cause Billy May's death, it raises the question: what worrisome signs should I be looking for if I bump my head?

Bleeding in the Brain

Head injuries can be lethal from something called a hematoma. A hematoma develops when there is bleeding in the brain. There are two main types: epidural and subdural. The brain is surrounded by a tough layer of tissue called the dura. When the skull suffers an impact blow, the brain shifts and collides with the skull, causing shock to the tissues. This is known as a concussion. Depending on the severity of the blow, concussions range from mild (with symptoms lasting only a few hours) to severe (confusion, nausea and headache lasting for days). Most concussions are not deadly, but bleeding in the brain can be.

An epidural hematoma is a collection blood that develops between the outer skull and the dura layer. This type tends to develop quickly and can be deadly within hours. Actress Natasha Richardson died of this type of hematoma, which she suffered during a skiing accident. Symptoms include severe headache, vomiting, a sudden change in vision, profound lethargy, and confusion. An epidural hematoma will show up on a CT scan of the head within minutes of the injury. Brain surgery must be performed within hours to removed the blood and stop the building pressure from killing brain tissue.

A subdural hematoma occurs beneath the dura, between the dura and the brain. It tends to develop more slowly. In fact, someone with a subdural hematoma may not show symptoms until days after the initial injury. A CT scan performed within minutes or hours of the injury may be normal. The symptoms are the same as with the epidural: severe headache, vomiting, a sudden change in vision, profound lethargy, and confusion.

What to Watch For

If you suffer a head injury, seek medical attention immediately if you have the following symptoms:

- Severe headache that does not get better with acetaminophen (Tylenol) or ibuprofen (Motrin/Advil)

- Vomiting (especially if it is what we call "projectile" vomiting- when it is very forceful)

- Blurry or double vision. Some concussions, which are not life-threatening, can produce mild blurriness for a few hours. If the blurriness is severe or does not resolve within a few hours, seek medical attention.

- Irregular pupils. If the pupils are different sizes, you need to be evaluated.

- Extreme drowsiness. Many concussions produce a "tired" feeling. However, if all you want to do is go to sleep, and people around you can get you to rouse or wake, they need to take you to the ER. It is also advisable during the first 24 hours following a head injury to have someone wake you every 2-3 hours, just enough to rouse you. If they can't wake you at all, it's time to visit the ER.

- Confusion. This is a major red flag. If you are saying oddball things (more than usual), confused about time or place, or just babbling nonsense, this likely indicates a serious problem.

Lastly, a word about prevention. Wear a helmet when biking, rollerblading, riding a motorcycle, or playing contact sports. It is well worth the trouble.

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One Good Decision can Lead to Another

There are many foods that are healthier than cereal bars (like fresh fruits and vegetables), and I am not endorsing Nutri-Grain products, but I am a big fan of their new ad campaign. Watch their commercial here and be inspired to make a small change today.

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This Week's Health Headlines

Bone density tests not needed once osteoporosis meds are started
Diet high in red meats and dairy linked to pancreatic cancer
FDA approves generic morning-after pill for girls 17 and under
One in 25 deaths worldwide blamed on alcohol
Right ear is better for hearing

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A Simple Cure for Vertigo

One of my favorite Alfred Hitchcock movies is Vertigo. Jimmy Stewart plays the detective who becomes an unwitting foil in a complex murder scheme, then goes too far in orchestrating a second chance to absolve his gnawing guilt for failing to save a woman's life. The twisting plot and gripping finale will make your head spin.

And speaking of spinning heads, your head was made to spin without causing you to lose your balance. This happens thanks to a delicately designed system contained in the inner ear. The semicircular canals are three looping arcs that sit behind the eardrum and are oriented in three separate planes. They contain fluid which moves as we move, triggering the movement of tiny hairs that line the inner surface. These hairs send messages to the brain, letting it know the direction our body is oriented in space. This allows our brain to coordinate our eye movements, blood pressure, and depth perception so we do not lose our balance. This video illustrates the role of the canals in maintaining our equilbrium (Notice: the audio is in German, but this was the best video I could find that accurately demonstrates the function of the inner ear).

This is a wonderful system until it malfunctions. Those who have experienced vertigo know how severely debilitating this condition can become. Even the smallest head movement or change in position can literally send the walls spinning. Vertigo is often accompanied by nausea, sweating, and feelings of wanting to faint. The fact that you can sit up, lie down, and turn around without launching into these symptoms is often taken for granted unless you have experienced a bout of vertigo.

The most common cause of vertigo is Benign Paroxysmal Positional Vertigo (BPPV). This temporary condition is caused by irritation of the interior canals and the tiny hairs that deliver information to the brain. The nerves are overstimulated and send faulty data to the balance center, causing our brains to think we are spinning when we are not. The Mayo clinic offers a succinct description of BPPV.

Often the irritation is the result of tiny stones or sediment that collect in the canal fluid. This sediment can be removed from the canals by a technique called the Epley maneuver. By manipulating the head through a series of positions, the force of gravity is used to draw the sediment out of the canals. Your doctor can perform this maneuver, but it is something you could do at home as well. Though you can do this yourself, I recommend recruiting as assistant, just to ensure you do not fall off the table or bed. The technique is demonstrated in this video. Each successive position will likely reproduce your symptoms if you truly have BPPV. The video instructs the patient to wait 30 seconds between positions; in reality, you should wait until the dizziness resolves and then quickly move into the next position.

If this technique does not solve your vertigo, see your doctor. There are medications that can help with the symptoms, and there are other causes of vertigo besides BPPV that your doctor can diagnose.

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Where President Obama is wrong about health care reform

I don't have all the answers to health care reform. American medicine is a complicated web of economic, political, and social factors. I believe that everyone engaged in this debate wants the best health care for the most people; we just disagree about how to accomplish that goal. President Obama's recent statements about Medicare tipped me off that he is about to damage our health care system in ways that may not be reversible.

Medicare Advantage- standard or scapegoat?
His comments were about the program called Medicare Advantage. This is a program that works like an HMO. Patients who are Medicare-eligible enroll and reassign their Medicare benefits to an insurance company. The government then pays the insurance company a set amount per month to manage that patient's health care. Patients pay lower premiums (regular Medicare still requires patients to pay 20% of most of their own health costs), and patients must navigate their medical care through their primary care physician, who oversees everything and generates referrals for procedures or visits to specialists.


The insurance company contracts with doctors and hospitals to provide the care. If they do a poor job of efficiently managing a patients' medical care, they lose money. Let's say Medicare pays $700 per month for a patient. If that patient ends up having a $3000 hospitalization that month, the insurance company loses $2300 (and often passes that loss along to the doctors and hospitals in the form of reduced reimbursements). If, however, the doctors keep their patients healthy and out of the hospital, or help them avoid invasive (and therefore expensive) procedures, they have money left over at the end of the month. The doctors and hospitals who figure out how to manage their patients' care at the lowest cost have an incentive to do so. For example, if I meet certain clinical goals with my Medicare Advantage patients (things like improved blood sugar readings for my patients with diabetes, improved blood pressure readings, timely immunizations, etc), then I will qualify for a year-end bonus from my employer, Advocate Health Care. If I don't help my patients meet these goals, then no bonus for me.



For those who are concerned that this arrangement motivates doctors to withhold care, one of the largest factors we measure is patient satisfaction. Our scores go down if our patients' satisfaction goes down. Also, because there are many insurance companies, doctors and hospitals who accept Medicare Advantage, patients who are unhappy with their treatment can always switch providers. Another potential concern about this program would be that insurance companies will only accept healthy patients under this arrangement, but Medicare adjusts payments based on diagnoses and severity of illness, in order to encourage providers to take all patients, both healthy and sick.


The bottom line: Medicare Advantage sets a goal for health care costs, and then encourages doctors, hospitals, and insurance companies to work together to stay within that cost. Those who do it the best will keep more patients and will see financial benefits at year's end.


Obama's flawed philosophy

Here's where President Obama comes in. He wants to eliminate Medicare Advantage. His reasons reveal what I believe to be a flawed philosophy towards our health care system. According to Obama, Medicare Advantage "overpays insurance companies" and leads to "wasteful spending." Here's what irks me about that. Let's say that Medicare pays a capitated rate of $500/month per patient to the insurance/doctor team. (This is an oversimplification, but works for the sake of example). And then let's say that I work hard to keep my patient's healthcare costs to $400/month. I do this by spending more time with my patients emphasizing prevention, making extra phone calls to make sure their treatment is working so they don't end up in the ER, and arranging for family meetings to discuss advance care planning so patients avoid unwanted treatments and procedures. The resulting $100/month cost savings is my financial incentive to control my patient's costs. In many ways, it makes it possible for me to spend the extra time, since Medicare does not directly reimburse for phone calls or family meetings. What bothers me is that President Obama looks at the cost per month for this patient and thinks the $100 is "wasteful". He naively assumes that the patient's costs could have been managed within $400/month under regular Medicare, that pays according to what doctors/insurance companies bill (the "fee-for-service" model). He sees Medicare paying $500/month when they could have just paid $400. He fails to realize that my patient's lower cost per month was the result of my hard work, which was motivated, in part, by the opportunity to earn some extra money for being efficient and effective. When Obama labels this financial incentive as "wasteful" and "overpayment" he suggests that doctors, hospitals and insurance companies should be expected to control their patient's costs with no additional incentive for doing so. In today's world of declining reimbursements and increasing malpractice insurance rates, this is an unreasonable expectation.

By President Obama's own admission, any financial profit gained by health care providers who manage their patients well and keep costs down is considered "wasteful." His comments reveal a philosophy that resists, and may even resent, any financial gain by those who succeed at providing health care efficiently. This philosophy demonstrates a gross misunderstanding of human nature. It is a philosophy that could damage, and perhaps destroy, America's excellence in health care.

One factor more than any other has made American innovation in health care the envy of the world. That single factor is competition. Here in the USA, the business entity that does anything better than its competitor will achieve success. Competition drives creative solutions in all fields, including health care. The hospital that provides the best care at the lowest cost will end up with patients lining up outside its doors. The pharmaceutical company that invents a drug easier to take, and with better results, will take over the market. The medical school that develops innovative training techniques will get the best and brightest applicants. There is nothing obscene about success in a health care market; indeed, it is the potential for success that drives new innovators to enter the field and achieve personal goals, financial or otherwise, while improving health care for patients.

President Obama must understand human nature enough to understand this. Very few enter the health care field (or any field) on purely altrustic motives. There is always an underlying desire for personal success in the field that one loves. Yet, Obama naively labels financial incentives in health care as "wasteful" and "excessive." These statements frighten me, as Obama pushes for health care reform. Introducing more government into health care will skew the competitive market away from free enterprise, away from opportunities to develop innovative solutions, and towards more paperwork, beauracracy, and waste. The nursing home environment, where I spend the majority of my time, is one of the most heavily regulated sectors of health care. I am not against regulations; some rules are necessary to protect the vulnerable. However, the efforts required of doctors, nursing home staff, and administrators, in order to keep up with the documentation for state and federal regulations, drains nearly all of the patient-focus out of daily care. Nursing home employees are often more concerned about keeping their charts and documents within regulations than they are about caring for their patients. This is not a knock against nursing home staff; they are some of the most caring people I know. This is simply an example of what a large beauracracy does to any industry.

Stop cursing profits
Any health care reform must preserve the opportunity for people and organizations to compete on a level playing field in the health care market. The introduction of a wide-reaching "public option" for health insurance will, by its nature, limit these opportunities. Government subsidized health care will not be under the same pressure as private health care providers. Private companies must generate a profit in order to survive. This forces people to work hard, innovate, and contain costs. Governments that can simply print or borrow money do not need to generate profits. There is no pressure to perform well. This leads to laziness and lack of care, and costs tend to expand. President Obama should stop cursing insurance companies and innovators who earn money by introducing solutions into the health care market. He should not naively assume that injecting more government into health care will somehow bring equality and order. I believe it will have the opposite effect. I believe more government involvement in medicine will reduce health care quality for most Americans, will ultimately limit access to care for most Americans, and will discourage our best and brightest from entering the field of medicine. I hope and pray that the administration and Congress take a measured approach before increasing federal involvement in health care, because once government expansion occurs, it is very difficult to retract.

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Use Listerine to fight... mosquitoes?

Some of you have possibly seen the e-mails going around that tout Listerine as an effective mosquito repellent. I decided to try it myself and... it seems to work. Most mouthwash products contain eucalyptus oil, which is known for its insect repelling properties. The only caveat: because the concentration of eucalyptus in the mouthwash is much lower than in commercially available repellents, the Listerine must be sprayed more frequently to keep up the effect.

Instructions:
Make a solution of half mouthwash and half water in a spray bottle.
Avoid spraying eyes and nose (not toxic, but irritating).
Spray body or any area, like your deck, where you don't want mosquitoes.
Repeat roughly every hour.

Read a NY Times article on Listerine as repellent here.
One more disclaimer: mosquitoes are drawn to the heat of your body and the odors you give off through your skin. Some people just happen to give off more attractive odors to mosquitoes. In those people, this is less likely to work. I hope it works for you!

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This Week's Health Headlines

Small study shows green tea may slow prostate cancer
Nestle voluntarily recalls raw cookie dough
Nearly one quarter of suicides linked to alcohol
Many women fearful of cancer screening: study
Taking the stairs to fight obesity

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Lessons from a Broken Alternator

About 2 weeks ago, the "Check Engine" light began to appear each time I started my car. When this happens, my emotions go through several stages. First, denial. "There's probably nothing wrong, the light is just malfunctioning." Next, anger. "I don't have time to take my car in! Doesn't it know this is a crazy week for me?!" Then I move into bargaining. "OK, car, if you can hang on for one more week, I'll make sure to never again go over 3000 miles before changing your oil." And finally... well, back to denial. "Hey, the light went off- I knew nothing was wrong."

So I continued in my happy state of blissful ignorance until today. While crossing the mile-long bridge on I-294, the engine died. Uh-oh.

I shifted into neutral, and pulled to the shoulder. My first step was to justify myself for not taking my car in to the mechanic. How could I have foreseen this, right? Next, I called the motor club to arrange for a tow truck.

"What town are you in, sir?" came the voice at the other end. I looked around. I could explain where I was on the interstate, but I had no idea in which southwest Chicago suburb I currently sat. Even my high tech GPS and smartphone couldn't tell me. Then I remembered the old-fashioned Chicagoland map book my wife had given me, "just in case." I opened the book to my current location, and I wasn't sure whether to laugh or cry as I spoke the name of the town to the motor club assistant.

"I'm in Justice," I told her. Though I drive through it (or over it) nearly every day, I never knew there was a Justice, IL. I started to laugh. I happen to believe that God orchestrates all events in our lives, even the most mundane, and I was deeply amused at the thought of God allowing me to break down and land in Justice after ignoring my car's warning signs. Justice indeed. There are consequences to actions and inactions, whether we want them or not.

Waiting for the tow truck, I pondered the other warning signs that many of us ignore. They occur in relationships, in our occupations, and in our health. I'm not usually big on the "your body is like a car" analogies, but there are a number of "Check Engine" warnings that our bodies give us that should not be ignored. Sometimes these warnings will appear for a while and then disappear, like my dashboard light. Don't assume that means the problem has gone away. You should see your doctor if you experience any of these warning signs.

Excessive fatigue. I don't just mean getting tired after a long day or a particularly busy week. If you find yourself feeling unusually tired all the time, it is not normal. It could be caused by a thyroid problem, low blood counts, or other more serious health conditions.

Unexplained weight loss or gain. If you changed your diet or exercise habits and notice a change in your weight, don't worry. But if your lifestyle has not changed and you are suddenly lighter or heavier by more than 10% of your previous weight, you should see your physician.

Bleeding. Occasional nosebleeds are common, especially in the winter. Gums somtimes bleed with brushing, especially in the setting of gingivitis. Hemorrhoids can cause blood to show up on the toilet paper or occasionally on your stool. These types of bleeding are not concerning, but other types are. Blood in the urine, excessive bruising, dark, tarry or purplish stools, or coughing blood are all conditions that require immediate attention.

Sudden change in mental status. If you or a loved one starts behaving in ways that are uncharacteristic, such as forgetting something that was previously second nature, getting confused, or losing inhibitions and behaving completely out of character, it's important to be assessed by your doctor.

Chest pain. There are many causes for pain in the chest. Unfortunately, we cannot easily determine the cause without sophisticated medical tests. A person having some indigestion may feel exactly the same as a person having a heart attack. For that reason, everyone who seeks medical attention for chest pain will receive a battery of tests to rule out a cardiac cause. Chest pain caused by a heart attack, or heart disease, does not always fall into the typical pattern of crushing pressure in the center of the chest radiating to the jaw or the arm with accompanying nausea, sweating, and shortness of breath. Sometimes it can present as simple abdominal pain. This is especially true among women, older adults, and people with diabetes.

Changes in a skin lesion. Most skin abnormalities are benign. They may grow at a very slow rate, but otherwise, benign lesions remain mostly the same in their color, shape, and behavior. Skin lesions that are worrisome have irregular borders, diverse colors, and they will change more rapidly. They sometimes itch or bleed as well. If you notice a skin lesions that exhibits any of these characteristics, see your doctor quickly.

Sudden flashing lights. We all see "floaters" and other visual disturbances throughout our life. This is normal. Sudden, bright flashes of light, especially when moving the head around, could indicate a detached retina. This is an emergency that needs immediate attention.

Persistent fever or night sweats. Fever that lasts more than 3 weeks, as well as night sweats, could be an indication of a serious infection.

Thoughts of suicide. This is often a sign of severe depression. People who are depressed may sometimes wish they could just go to sleep and not wake up, or they may feel like they would not mind if they were in a car accident and died. That is different from suicidal intentions. If you spend time planning how you might kill yourself, seek the help of a doctor or therapist. The worst thing to do is not tell someone.

Worsening exercise tolerance. If you find that you are no longer able to endure the workout that you are used to doing, that could be a sign of a heart or lung problem. Seek attention if you are unable to exercise at your usual pace for no obvious reason.

This is by no means an exhaustive list, but it is a start. I hope this helps you determine when it is important to see your doctor. By the way, while waiting for the tow truck, a rainbow appeared over my head, reminding me that even God's reminders of justice are an act of mercy.

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