Doctor David Fisher's Blog

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David Fisher, MD, MPH: July 2009

House Calls Radio

House Calls Radio
Sundays at 10pm AM 560 WIND in Chicago

Thursday, July 30, 2009

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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Wednesday, July 29, 2009

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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Thursday, July 23, 2009

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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Tuesday, July 21, 2009

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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Tuesday, July 7, 2009

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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