Mega Millions – What Would I Do?

Copyright (c) 123RF Stock PhotosWhen I walked into work this morning, our referral clerk called my name and asked if I wanted to buy a lottery ticket. The Mega Millions lottery had an estimated $640 million dollar jackpot and everyone else in the clinic had chipped in $3 to an office pool. I hesitated on principal as such lotteries are a losing bet. With the jackpot size and potential gain, it was not as big of a losing bet, at least, as usual.

She pointed out that if I didn’t participate, I might be the only one to show up for work on Monday. “You’d quit your job if you won?” I asked. “Well, I’d give my two week notice,” she replied. For the first time in my life, I handed over my hard earned money for a lottery ticket.

My definition of the ultimate in job satisfaction is whether one would keep one’s job after winning a large lottery. Steve Job, Bill Gates, Warren Buffet and many others could have quit their jobs a long time ago, but did not do so because they enjoyed working.

I wouldn’t retire if I won the lottery because I enjoy practicing medicine. But I would change how I work. I would see less patients per day and spend more time with each one. I’d take more vacation, and pay someone to do the paperwork.

So if I win then I won’t have to write this blog anymore. Wait a minute, I’m not getting paid for this in any case.  So win or lose, I’ll keep writing.

Ask the Doc: Statins and Exercise

On this site I’m unable to answer patient specific questions, but as time permits, may answer questions of a general interest.

Question:

Let me know what you think of this article. Strenuous exercise has not seemed to bother me taking Lipitor 20 mg for several years. However, I am wondering about the effects on my muscles as I am currently ramping up exercise both running and weight lifting. Will enough exercise improve my cholesterol level enough to quit taking Lipitor? Long term effects of Lipitor? I don’t know.
http://well.blogs.nytimes.com/2012/03/14/do-statins-make-it-tough-to-exercise/

Answer:

As the article points out, about 10% of people may experience muscle aches from taking statin medications such as Lipitor. It referenced an article that showed that rats were not able to exercise as long if taking atorvastatin (Lipitor), and they showed increased oxidative stress and problems with mitochondria, cell’s powerhouses.

You should always be careful when evaluating animal studies, as they may not apply to humans. Given other data, however, it would not be surprising if there was a similar problem in people who exercise and take statins.

The questions is what to do. As with most medications, one needs to balance the risks versus the benefits. Statins clearly save lives, but the degree of benefit depends on one’s risk. The more cardiovascular risk factors one has (hypertension, diabetes, hyperlipidemia (high cholesterol), smoking, family history, etc.), the more one has to gain from medication, and the more likely I would recommend patients tolerate side effects if we couldn’t come up with a better option. For someone at relatively low risk, a statin may not be worth taking if causing side effects.

I certainly always advocate diet and exercise to manage problems with cholesterol and triglycerides (fats). The problem is that for most people, it’s easier said than done, and people either just don’t make sufficient changes, or they don’t maintain them. Also for some people, their genetics are just too strong. With the wrong genes you may have a high cholesterol despite being thin, eating vegetarian, and exercising regularly.

Another option is to take coenzyme Q10 (CoQ10) or ubiquinone if you are taking a statin. It’s known that statins decrease this enzyme in the mitochondria and it may be the reason statins cause muscle pain and weakness. It is not proven to work, though the supplements appear to be safe. A study in Japan showed that pitavastatin (Livalo) did not decrease coenzyme Q10 nearly as much as atorvastatin (Lipitor). Whether it causes less muscle problems is unknown at this time.

For patients that I feel need medications to lower their cholesterol, yet are unable to tolerate a statin, or refuse to take one, I offer other alternatives, such as niacin (Niaspan, Endur-Acin, Slo-Niacin), colesevelam (WelChol) or ezetimibe (Zetia). There are pros and cons for each option. Sometimes people tolerate one statin, and not another, or may do better with a combination of a low dose statin and another agent.

So there’s no easy answer to your question. Different patients have different solutions.

Waiting Times and the Misery Index

Last month the Wall Street Journal ran an article, called the Wait-Time-Misery Index, about how frustrated people get waiting for deliveries or service repairs at home. Like when you need the cable company to come out and they say they will be there between 9:00 am and 1:00 pm. You have errands to run but your stuck. Companies such as General Electric and Verizon have been working to get the time windows from 4 hours down to 2 hours.

I understand the frustration, but when it comes to timely delivery (no puns about obstetrics here), doctors are held to a much higher standard. Patients often get upset or walkout if I’m an hour late, and sometime even if it’s only 15 minutes. The companies have difficulty delivering in a short time window because there are so many variables that they can’t always predict. They may get tied up in traffic, be delayed by weather, or a 30 minute service call turns in to a 2 hour one. But just like the companies, doctors have similar issues. A patient scheduled for a 15 minute appointment may have an hour’s worth of problems, and rescheduling isn’t an option. Or we may get unscheduled calls when a patient of ours shows up in the emergency room, or maybe a lab test comes back that demands our immediate attention. Just maybe the doctor themselves are slower than usual because they have a cold or were awakened 3 times the night before while on call.

I sympathize with patients frustration when I run late, and get frustrated myself because it means longer hours for me too, but I assure you that if I’m running late, it’s not because I’ve been playing golf.

Rush to Judgement

Conservative radio show host Rush Limbaugh recently launched an attack on Georgetown University law student Sandra Fluke. She had testified to house Democrats in support of mandates to provide contraceptive care in insurance plans. On his show two days later, Rush Limbaugh said that Ms. Fluke  was asking for taxpayers to pay her to have sex, and that made her a, “prostitute”.

Others have chimed in that contraception is a lifestyle choice and society shouldn’t have to pay for it.  Whether or not you believe women have the right to get an abortion, it’s a flawed argument. By the same reasoning, insurance shouldn’t cover heart attacks, strokes or cancer if the person smoked or was obese. It’s one thing to incentive healthy behavior, but Rush Limbaugh’s attack is either not well thought out in regards to its health care implications, it’s misogynistic, or it’s politically motivated.