Presidential Politics and Influenza Vaccinations

Recently a patient of mine expressed frustration with the presidential campaign, saying the other side wouldn’t listen to facts and just believed what they wanted to believe.

Knowing that she had repeatedly refused to get a flu shot, I asked her in that case if she’d like to get one, given that scientific studies have shown that the benefit outweighs the risk for most people. Although she hesitated, I unfortunately could not convince her.

When is DNR not DNR?

Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg
Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg

Patients are often encouraged to make wishes known with a living will or other instrument. If someone says they would not want resuscitation if their heart stopped, they are said to be DNR, as in Do Not Resuscitate, or more accurately DNAR, Do Not Attempt Resuscitation. Success rates one month after out of hospital cardiac arrests when CPR is performed are only about 4.9% to 9.2%.

In Washington State per a directive it often say,

“(a) If at any time I should be diagnosed in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand by using this form that a terminal condition means an incurable and irreversible condition caused by injury, disease, or illness, that would within reasonable medical judgment cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand in using this form that a permanent unconscious condition means an incurable and irreversible condition in which I am medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.”

For many patients this is reasonable, but not for all. No one lives forever, but even a generally healthy 98-year-old does not have a terminal condition. Many of my older patients tell me they are DNR, but most are surprised when I tell them their health care directive says they would want to have CPR and get shocked with a defibrillator if their heart stopped, as they do not have a terminal condition.

I think this is probably a failure of lawyers drawing up the health care directive to modify the language to what makes sense for their clients. I’m not a lawyer, but they might add something like:

(b) If I attain the age of 80-years-old, then I do not want to have my life artificially prolonged, other than using medications, including intravenous medications, and oxygen. An exception is that if I’m undergoing a procedure and develop a cardiac rhythm not compatible with life, then I would approve of an immediate attempt at shocking my heart back into rhythm if the physician deems there is a reasonable chance of success.

Just because a lawyer inserts boilerplate language, does not mean it cannot be changed.

Who Are You Calling Old?

Moth on bricksA local family medicine residency program sends second year residents to rotate through my internal medicine clinic. Reviewing the note that one of them wrote, I saw that he described my 66-year-old patient as, “Elderly, ” though did note that she appeared younger than her age. I let that young whippersnapper know that age is relative, and that I doubted he would consider 66 as elderly once he reached his 50’s!

A New Target for Food Companies

Image credit: <a href='http://www.123rf.com/photo_14942511_mature-satisfied-chef-smell-the-aroma-of-his-food-while-cooking-at-restaurant.html'>rido / 123RF Stock Photo</a>

Food companies use sophisticated science and psychology to get people to buy their food. Using combinations of salt, sugar, and fat, among other things, they entice us and cause actual addiction. Although many people are rightfully concerned given the levels of obesity, diabetes, and other health problems, I think they’re missing out on a segment of the population that might actually benefit from their craft.

Not infrequently do I see patients, often elderly, who have a problem many of us could only wish for. They have a poor appetite. This may be due to many factors, including diminished smell and taste, poor vision, and dry mouth. What they need is food meant to appeal to them.

One of the tricks used to sell us more food is vanishing caloric density. Foods like Cheetos, that quickly melt in the mouth, fool the brain  to think there are less calories than there really are, so people eat more of them. If you’re malnourished, that might be a good thing. The food engineers should create foods that people with a poor appetite will actually want to eat. Throw in some vitamins and fiber, and just maybe they would get physicians to recommend them.

Cataracts and Hip Fractures

A recent study showed that cataract surgery helps prevent hip fractures. It looked at a sample of Medicare patients with cataracts who did or did not have cataract surgery.  Those who had cataract surgery had a 16% less change of subsequent hip fractures than those who did not have the surgery, though the absolute difference between the groups was small, because hip fractures were not that common in either group.

The design of this study was not optimal. It would have been better to randomly assign patients to get cataract surgery or not, to eliminate possible biases, but such a study is not practical.

We treat osteoporosis with medications such as Fosamax (alendronate) and vitamin D, but that just decreases the risk of a fracture. It’s still important to prevent the fall. There are various things that can help, including physical therapy to improve gait (walking), good lighting, good shoes, lack of loose rugs, canes, and more. Add to the list cataract surgery for those affected. Not only will such patients improve their vision, but they may save themselves from a hip fracture that at best will lay them up for a while, and at worst kill them from complications of pneumonia or a deep venous thrombosis (DVT or blood clot) and pulmonary embolism (blood clot to the lungs).

Ask the Doc: Human Growth Hormone

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

Question:

I have been working out with a personal trainer with weight training and have been doing running on my own. I have been getting much stronger although I haven’t lost much weight. I asked the trainer why it takes longer to recover from a strenuous session at age 66 than it did when I was younger. She said that as we get older we have very little HGH in our system and that a small dose of HGH would help me recover quicker and she could push me harder. Would a small dose of HGH be beneficial for training? I know that testosterone creams etc. have a lot of side effects which are not good but how about HGH?

Answer:

Human Growth Hormone, or HGH, is a hormone that regulates growth, and decreases with age, as well as from obesity. It is one of many factors why, all other things equal,  66-year-olds aren’t as strong or fast, or recover as quickly, as when they were younger. With age lung function gradually declines, the cardiovascular system is less robust, testosterone levels fall in men, etc. In one of his movies, Warren Miller said something like, “If a 40-year-old says they sky as well as when they were 20, they are either lying, or they weren’t very good when they were 20!”

Human Growth Hormone is only approved by the FDA in limited circumstances, not including the normal decline with aging, and it’s expensive. It probably does build muscle, and for this reason is banned by the Olympics and some other sports institutions. It also has potential side effects.

Getting adequate sleep, regular exercise, eating healthy, and managing stress, are the most important things you can do to boost your growth hormone and improve your endurance.

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.

Surprising HIPAA Violation

The Health Information Portability Act (HIPAA) has criteria about not violating patient privacy, and potential harsh penalties for doing so. One needs to not only avoid saying a patient’s name to the public (meaning people not involved in the patient’s care), but not even to provide enough identifying information to allow someone to identify a patient. If you say you saw a 45-year-old male architect for diabetes, and there aren’t that many architects in town, you’ve probably supplied enough information for someone to figure out who you’re talking about.

I’m usually pretty conscious of it, and some of my colleagues are used to me ‘coughing’ “HIPAA” when they say a patient’s name aloud. One day, however, while eating lunch with my colleagues, I told the story of an 80+ man who came in complaining of a large bruise on his leg that he sustained after a fall when he tripped while running backwards. One of my colleagues said, “Was that Bob Smith*?”

“How did you know?” I asked.

“We go on the ski bus together and after he gets off he always runs backwards around the bus!”

*Not his real name, and yes, I got his permission to post this story.

100-Year-Old Marathoner

Fauja Singh completes Toronto marathon.

According to the Wall Street Journal, on 10/16/11 Fauja Singh completed the Toronto marathon, finishing the 26.2 mile race in over 8 hours. I hope that will inspire my patients to exercise. I’ve started telling my octogenarians to start training for a half marathon. Heck, I’m letting them off easy.