American College of Physicians Internal Medicine 2012

I recently attended the American College of Physicians (ACP) Internal Medicine 2012 annual meeting, held this year in New Orleans. It’s a very large meeting with thousands of physicians attending. At any one time there are dozens of courses one can attend. I try to balance learning about subjects I have a particular interest in, with those that I’m less interested, and consequently have more to learn.

Among the talks I attended was a talk on genetics issues in internal medicine by Matthew Taylor, MD, PhD.  He discussed an interesting case of a 19-year-old woman who had been in good health who had lifted weights, used a hot tub then went swimming in a lap pool and was found unresponsive in 4 feet of water in 1998. She was resuscitated but died in the hospital 12 days later. An EKG done during the hospitalization was mildly abnormal with a prolonged QT interval. This was dismissed by most cardiologists as probably or not significant when asked to review the EKG. A subsequent genetic analysis of autopsy material revealed a genetic condition associated with a prolonged QT interval, which itself increases the risk of sudden death due to an arrhythmia. Further testing showed her sister, mother and maternal grandfather were found to have the same genetic condition. Most physicians would not even consider a genetic condition as the cause of a drowning, yet making the diagnosis may prevent family members from dying due to an arrhythmia with appropriate treatment.

I attended a talk by Holly Holmes, MD on discontinuing medications. It’s much easier to start a medicine than to stop one, yet medications carry financial costs and may cause side effects. She went over some cases and discussed strategies to decrease medication use. Amusingly she pointed out that not only did she not have any financial disclosures that might cause a conflict of interest, but that no pharmaceutical company would want to pay her to recommend stopping medications!

Besides the vast number of courses, there were also hundreds of vendors from pharmaceutical companies discussing new medications, companies selling books, equipment, massage chairs and gluten free products, and many just providing free information. There were recruiters looking for doctors, and more.

There was also the opportunity to interact with colleagues from around the world. I spoke with some physicians in Canada, and one from Saudi Arabia. I usually attend the ACP national meetings every few years and always come away having learning things that will help my patients, and feeling more invigorated about my profession.

Testing Tribulations

When I was an internal medicine resident, one of my staff attending’s, Dr. Charles Reasner, used to ask, “What is the indication for ordering a TSH?” This is a test of thyroid function (thyroid stimulating hormone), and he was asking what reasons should one order the test. His answer was to order it if you think about it. An overactive (hyperthyroidism) or under-active  (hypothyroidism) thyroid can cause many different kinds of symptoms, treatment is relatively easy, and the test is inexpensive. Thus he said if it occurred to you to order the test, then you should do so.

Unfortunately the Centers for Medicare & Medicaid Services (CMS)does not allow us to order tests based on intuition, even though numerous studies have shown that people often make their best decisions based on reasons they can’t explain. When a quarterback such as Peyton Manning throws a football to a receiver, he first has to make the decision what to do very quickly, while a 300 pound lineman is bearing down on him. Based on prior experience he can quickly survey the field and make a decision where to throw the ball before he could make a decision based on a logical analysis. He might not be able to explain exactly why he did something, but his skill and training contributed to making the right decision seemingly without thinking.

When physicians order a test, we have to associate a diagnosis. Presumably the main purpose is to prevent wasting money for ordering tests. Although there is no benefit in ordering a PSA test for a diagnosis of glaucoma, for example, this only catches errors in the test ordered or diagnoses associated, which probably doesn’t happen often. It’s a real problem though for ordering a vitamin D level.

Medicare no longer covers a screening test for vitamin D, even though perhaps 85% of patients in the United States are deficient, treatment is cheap, and it probably saves money in the long run. Once a patient is diagnosed with osteoporosis then a level is covered, but that’s too late. Plus in men a screening bone density test is not covered, so it’s a Catch-22 situation.

At least if not that expensive, physicians should be able to order labs because they think of them. Insurance companies and the government should trust our intuition.

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.

Acid Revelations – Acid Reducers and Asthma in Children

The Journal of the Medical Association recently published an article about the use of lansoprazole (Prevacid) for children with poorly controlled asthma. It had been thought that gastoesophageal reflux disease (GERD) contributed to asthma exacerbations because acid would come up from the stomach and get into the lungs.

By putting tubes down the nose and into the stomach and esophagus it was known that children often have reflux when they have breathing problems, even without having heartburn symptoms. Proton pump inhibitors (PPI’s) such as lansoprazole, omeprazole (Prilosec), pantoprazole (Protonix) and others, markedly decrease the amount of acid produced in the stomach. Even if the contents reflux into the esophagus (think of an old fashioned coffee percolator), there would be less irritation if it was less acidic.

In adults with asthma and reflux symptoms, studies have shown the PPI’s help their lung function. Despite lack of conclusive studies showing benefits in children, its use in them markedly increased between 2000 and 2005. It made intuitive sense and the medications seemed pretty safe.

In this study children with poorly controlled asthma without gastroesophageal reflux (GER) symptoms not only did not do better with lansoprazole, they had more adverse events with increased respiratory infections. There were also six times as many activity related fractures in those on the medication. Although it didn’t quite reach statistical significance because of the relatively small numbers, the PPI’s are known to be associated with osteoporosis in adults.

This illustrates the important difference in statistics between association and causation. Just because two things occur together, doesn’t meant that one causes the other, and even so, it doesn’t mean treating one will treat the other. There is an old joke of a man walking around carrying an umbrella on a sunny day. “Why are you carrying an umbrella when it’s not raining,” asked his friend. “To keep the tigers away,” he replied. “But there are no tigers around here,” his friend objected. “See, it works,” he answered.

The accompanying JAMA editorial called the use of proton pump inhibitors for asthma a case of, “therapeutic creep.” That’s using medications beyond what the scientific evidence shows. This is not necessarily wrong. For example I commonly recommend vitamin D for my patients even though we still don’t have definitive evidence. In such cases, though, it’s good to remember the limits of what we know and beware of potential risks. As Hippocrates reportedly first said, Primum non nocere – First do no harm.

Even my dog’s veterinarian suggested using using over-the-counter Zantac or Pepcid for reflux because my dog sometimes threw up on the rug. Now I don’t feel so bad that I ignored her advice.

Viewing Doctor’s Notes

Should patients be allowed to see doctor’s notes? Legally they can, but that doesn’t necessarily mean it’s a good idea. Patients would like to, but physicians are not so sure. People make strong arguments, but I think it’s really nuanced.

Physicians often write down the differential diagnoses. Say you’ve lost a little weight without trying. It could be a lot of things such as stress, cancer, an overactive thyroid, an ulcer, HIV AIDS, tuberculosis or a thousand other things. After asking a number of questions and doing an exam, I may decide that it’s unlikely that there’s any serious medical problem going on and prescribe a medication for depression. When I see you back in a month I’ll order additional tests if you have not responded as expected, and particularly if you’re still losing weight. But in my first note, I would have likely at least mentioned some of the diagnostic possibilities, and probably using medical terminology such as malignancy. I write these for a number of reasons. Mostly it makes for good care. Just in case it turns out to not be depression, when I look back at my prior note it will remind me of some of the concerns I had. It also provides a road map of what I was thinking if the patient has to see another physician, whether it’s because I’m on vacation, they have to go to the emergency room or see another physician. The note is also necessary due to malpractice concerns. Doctors are usually not expected to know the future, but the legal assumption is that if you didn’t write it down, it didn’t happen. If you don’t show that you considered the possibility of a serious condition, the presumption is it didn’t cross your mind.

Psychiatrists are allowed to protect their notes. Is that because their patients are too unstable to see their notes? Is it because the psychiatrist needs to record things that a patient may misinterpret? During the course of treatment they might have some insight about a patient’s problems, but not know whether their guess is right. By recording their thoughts they can later go back and review them, improve their diagnosis and treatment, and better help the patient. Well the majority of psychiatric care in the United States is actually provided by primary care physicians. There are not enough psychiatrists to treat all the cases of depression and anxiety. But primary care physicians notes are not similarly protected.

One measure of the benefit of a treatment is the number needed to treat. For example, one may need to treat 20 patients with a cholesterol medication for a year for every heart attack prevented. Conversely is the number needed to harm. Depending on age, it’s estimated that for about every 1500 abdominal CT scans, one person will get cancer as a result of the radiation. A good clinician will be correct the majority of time. How many patients will be harmed by reading chart notes (needless worry, additional tests that have their own risks and costs ordered because of that fear, physicians not recording important information for fear of it being read by a patient) for every patient that benefits?

I’m not embarrassed by what I write in a patient’s chart, but patients might be if they read it. Imagine a man asks a family member to review his medical records to see if they think he has been getting good care, given his recent heart attack. He probably forgot that a few years ago he spoke with me about sexual problems he was having.

The system I suggest would be a juried one. Patients could request their records, and in most cases the physicians would grant access to most or all of the record. If there was parts they did not want to show, they could explain why to the patient. If the patient did not accept the answer, they could appeal to a third party health advocate who would then decide whether it should be released or not. This would only apply to patients who are not bringing legal action. I think this approach would make physicians a little more comfortable, and lead to better patient care.

Medication Errors

Not infrequently Express Scripts, Medco, or other similar companies send a fax to alert me that my patient is taking two similar medications. Occasionally it’s intentional, but most of the time it means something went wrong.

Sometimes I change a patients’ medication to something similar to achieve better efficacy, to minimize side effects, or due to cost. Although I always put the changes in writing for the patient, telling them what to start and what to stop, this doesn’t always work. Patients may get an automatic refill of the original medication from the pharmacy or call it in when they notice a pill bottle is almost empty. Sometimes they go by a medication list they’ve generated, but not updated, rather than the printout I give them.

Sometimes patients end up on two similar medications after getting one from a specialist who doesn’t realize a patient is taking something, because the patient didn’t bring the list I gave them, and they don’t remember everything they take. For example I might have the patient on lisinopril for hypertension, and their cardiologist prescribes the similar benazepril.

A similar medication error happens when we tell patients to stop a medication and they don’t for similar reasons as above.

So the faxes are helpful when these things are caught, but it would be better if it occurred at the the time the prescription is sent to the pharmacy.  Ideally the pharmacy computer would automatically connect to the physician’s electronic medical record (EMR), particularly the primary care doctor, and compare medication lists. If they had medications to refill that didn’t match the EMR record, they would call to double check if the patient could not give them a good reason for the discrepancy. In addition, the pharmacy computer could keep track of all the chronic medications a patient has filled. If the patient doesn’t get the prescription refilled in a timely manner, their computer would query the physician computer to make sure it was still an active medication. If so they would call the patient (and maybe in the future talk to the patient’s medication list carried on their computer/mobile device) and remind them to refill their medication, assuming someone hadn’t stopped it, the patient was taking samples, or some other good reason.

If you use a program such as Quicken, you can download credit card and other transactions and reconcile them with entries you’ve entered. Comparing medications would be a similar process.

There are certainly barriers to such a solution. Electronic health records would need to have medication fields standardized, and there would need to be protocols to exchange the information. I’m not sure, but I think some of this already exists. Of course there are legal issues such as HIPAA.

As John Lennon said, “You may say I’m a dreamer, but I’m not the only one. I hope someday you’ll join us, and the world will be as one.”

Migraine or Sinus Disease?

A fractal suggestive of visual changes associated with migraines.

One of the more common reasons patients come to see me is because they think they have a sinus infection. Often they say they have pain in the sinus below their eye, nasal congestion, and may have drainage. They  tell me that they’ve had it before, and antibiotics help.

Careful questioning often reveals that they are really have a migraine headache. Typically they start as a teenager or young adult, and tend to decrease in frequency and severity in the 40’s to 50’s. They may occur on one or both sides of the head, and are often associated with nausea, sensitivity to light and sound, and sometimes people get blurred vision or see white spots or zigzag lines. Going to sleep helps. Migraines are more frequent in females and tend to run in families. If patients are unaware of a family history of headaches, I tell them to ask their mother, sister or daughter because they may just not have mentioned it.

Patients think antibiotics help because their headaches get better a few days after they start the medicine. But migraines generally only last 4 hours to 3 days if you don’t take anything. So the antibiotics get the credit, when none is due.

Sometimes the pain from a migraine goes into the neck, or it’s only felt there, and patients think they have a neck problem. They may go to a chiropractor or massage therapist before they see me.

Migraines are also confused for sinusitis because nerves from the brain that are activated with migraines can stimulate the nose to cause congestion. ‘Sinus Headaches’ was invented by Madison Avenue (or at least some advertising agency) to sell pills. Outside the United States, you won’t find such pills being advertized or sold. Some people truly have headaches from sinus infections, but many headaches thought to be sinusitis, are really migraines.

There are lots of ways to treat migraines, which I won’t discuss in this article, but first you have to get the diagnosis right.

If you have headaches or neck pain, be careful about telling your doctor that you think you have a sinus infection or neck arthritis. You may just convince them you’re right, when maybe you’re having a migraine.

Fine Tuning

A typical internal medicine patient has multiple medical problems, such as diabetes, hypertension and high cholesterol. Each visit I try and see if there is something to tweak. Perhaps the blood pressure is a little high or the cholesterol is not at goal. Maybe I can switch a medication to a similar one that recently went generic, or use a combination pill to simplify their regimen. I might correct the vitamin D deficiency I usually find, have them change their aspirin to an enteric coated one to lessen the risk of an ulcer, or try and persuade them to get a vaccination to prevent shingles. Most of us have room to improve when it comes to diet and exercise.

With each visit the patient is a little older, and on average, a little sicker. I hope my fine tuning, and occasional overhaul, will keep them going longer and healthier. In the rare visit where the patient has no complaint and I can’t find something to do, I feel like I’m forgetting something. The visit takes longer than it should as I struggle to come up with something other than telling them keep up the good work. That’s usually appreciated by patients, though.