I wish I had a better story to tell you about why I am typing this with one hand (and some help from Dragon Dictate).
A shark attack would be interesting. An assassination attempt would be intriguing. Skydiving mishaps always make for good copy. An out-of-control quad copter that turns on its master would be entertaining (and would come complete with a grim, potentially viral, video).
No, the reason I am now one-handed is a little more prosaic than those scenarios.
I had finished my last shoot after a long reporting trip to Japan and the Philippines and was stacking the Pelican cases brimming with TV gear onto my cart. As I tried to bungee cord them into some semblance of security for movement, one of the cases toppled onto my left forearm. Ouch! It hurt, but I wasn’t all “911” about it. It was painful and swollen but I figured it would be okay without any medical intervention. Maybe a little bit of denial?
The next day, February 13, things seemed status quo. It was sore and swollen but seemingly no worse. Then, that night, things got worse. Both the pain and swelling increased.
So on the morning of February 14, I asked the hotel for a referral to a doctor and went to see him right away. While my concern was already growing, the look on his face when he saw my forearm got me a little more nervous.
The doctor told me he suspected that I might be having an Acute Compartment Syndrome. I had to Wiki it, but in essence it is an increase in pressure inside an enclosed space in the body. This can block blood flow causing a whole host of serious, life-threatening consequences.
He had me admitted to the hospital. Over the next few hours, I endured probably the longest, most painful experience I could ever imagine. My forearm developed some dusky discoloration, but more alarming was the numbness. I could not feel my forearm!
The doctor recommended an emergency fasciotomy to relieve the pressure. This is a gruesome enough procedure on its own, but the he was clear that the problem was progressing rapidly and there was a clear and present threat to my limb.
Continue reading “Just a Flesh Wound”
Filed Under: THCB
Tagged: Acute Compartment Syndrome, Emergency amputation, Fasciotomy, Miles O'Brien, Wellness
Mar 3, 2014
When it comes to high blood pressure treatment in the elderly, the plot continues to thicken.
Last December, a minor controversy erupted when the JNC hypertension guidelines proposed a higher blood pressure (BP) treatment target (150/90) for adults aged 60+.
And now this month, a study in JAMA Internal Medicine reports that over 3 years, among a cohort of 4961 community-dwelling Medicare patients aged 70+ and diagnosed with hypertension, those on blood pressure medication had more serious falls.
Serious falls as in: emergency room visits or hospitalizations for fall-related fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In other words, we talking about real injuries and real patient suffering. (As well as real healthcare utilization, for those who care about such things.)
How many more serious falls are we talking? The study cohort was divided into three groups: no antihypertensive medication (14.1%), moderate intensity treatment (54.6%), and high-intensity treatment (31.3%).
Over the three year follow-up period, a serious fall injury happened to 7.5% of those in the no-antihypertensive group, 9.8% of the moderate-intensity group, and 8.2% of the high-intensity group. In a propensity-matched subcohort, serious falls happened to 7.1% of the no-treatment group, 8.6% of the moderate-intensity group, and 8.5% of the high-intensity group. (Propensity-matching is a technique meant to adjust for confounders – such as overall illness burden — between the three groups.)
The methodologists in the audience should certainly read the paper in detail and go find things to pick apart. For the rest of us, what are the practical take-aways?
Continue reading “Clinic: A Cautionary Note About the Risks of Blood Pressure Treatment in the Elderly”
Filed Under: THCB
Tagged: Blood Pressure, Geriatrics, Leslie Kernisan, Telemonitoring, Wellness
Feb 28, 2014
Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.” There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand. That is no longer true.
Now we have published data on many vitamins and we can say that for most people they do not work. More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.
For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much. Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.
When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.
To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”
Bill’s response, he lack of trust in my advice, disturbs me at several levels. He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.
Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin. They do not prevent or fix anything. Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.
More importantly, there is increasing data that people taking a multivitamin may become less healthy.
Continue reading “That Vitamin There Could Kill You”
Filed Under: OP-ED, THCB
Tagged: alternative medicine, Cancer, doctor/ patient relationship, James Salwitz, multivitamins, practice of medicine, Wellness
Feb 25, 2014
T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.
He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.
A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.
He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.
The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.
His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.
T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.
Continue reading “What If Your Employer Gets Access to Your Medical Records?”
Filed Under: THCB
Tagged: Al Lewis, data breaches, Employers, personal health records, Privacy, Vik Khanna, Wellness, workplace wellness programs
Feb 19, 2014
With the exception of rare and particularly bleak days, I don’t tend to think of myself as a moron — nor, as far as I can tell, do those who know me well and love me. I will hazard a guess that neither you nor those who love you think of you as a moron, either.
So let’s be bold, proffer one another the mutual benefit of any disparate doubts, and declare: We are not morons!
I propose, then, that this be the year we stop ingesting as if we were. Still with me? Let’s find out.
On the matter of morons, I think they are very much the exception rather than the rule. I have met a lot of people over my years. I’ve taken care of many patients over decades and come to know their intimate thoughts as the privilege of doctoring uniquely allows and requires. So I know firsthand that most of us are endowed with our fair portion of both sense and sensitivity. Formal education, the color of a collar, degrees and credentials don’t distinguish us nearly as much as some might like to think. In most ways that matter, most people have that practical brand of folksy wisdom and intelligence that serve most handily on any given day.
And yet, as a matter of routine we are fed a steady diet of both food and food for thought as if we were abject morons. That’s how it’s served to us — but of course, only we get to decide whether or not to swallow such insalubrious slop. It’s a New Year, and time for new chances. Here’s our chance to stop the slop.
On the matter of common sense, I have been driven many times over the span of my career to lament the fact that it isn’t nearly common enough. But as just noted, I think it really is — in most areas. We apply it routinely to finances, home care, our careers and our families. We just turn it off when captivating promises about effortless weight loss, miraculous vitality, or age reversal waft our way. The result, of course, tends to be that even as we get fatter, sicker and older, we get poorer — spending our sensibly earned money on a senseless parade of false promises.
Continue reading “Please Don’t Feed the Morons!!”
Filed Under: Uncategorized
Tagged: alternative medicine, David Katz, junk food, Morons, Nutrition, Obesity, paleo diet, Wellness, Whole Foods
Feb 9, 2014
Any confusion over the recent news of cholesterol guidelines in the U.S. is perfectly understandable. On the one hand, the guidelines suggest that nearly half the population should use statins to stave off heart attacks and strokes. On the other, use of the drugs is not with potential side effects and, to many, will offer no substantive benefits. The controversy highlights a problem mired in an outdated way of thinking about health care and the doctor-patient relationship.
Guidelines came about after generations of physicians wanted to bring something more than “opinion and experience” to the patient’s bedside. In the late 1960s legislation for the U.S. Food and Drug Administration was amended to call for a demonstration of efficacy and an assessment of benefits and risk as prerequisite to the licensing of any pharmaceutical. Modern clinical science resulted, first slowly and now with an avalanche of clinical trials, each pouring forth outcome data galore.
The Burden of Clinical Data
Clinicians are expected to stay current with this wealth of information. The modern medical curriculum instructs all budding physicians on how to evaluate the quality and the clinical relevance of all such contributions to the body of clinical science. Because some (or perhaps many) find this exercise overwhelming, there are organizations—many academic and some without any discernible relationships with purveyors that could pose a conflict of interest—that attempt to bundle the information in a fashion that might be relevant to particular physicians or physicians in particular specialties. Some of this bundling is quite systematic, some quite helter-skelter.
Occasionally there is a contribution to the literature that offers an unequivocal advantage for a particular patient group. More often, the bundlers are faced with a heterogeneous literature that often demonstrates little, if any, efficacy. Faced with these circumstances, biostatistics has offered up many a method to impute more value to the literature than is apparent at first blush. The result is that all this bundling adds to an enormous and ever-expanding secondary literature.
What is the clinician to do?
Continue reading “How Clinical Guidelines Can Fail Both Doctors and Patients”
Filed Under: THCB
Tagged: American College of Cardiology, American Heart Association, cholesterol guidelines, clinical guidelines, Nortin Hadler, Physicians, practice of medicine, Robert McNutt, Wellness
Jan 30, 2014
Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s partnership with ThinkWellPoint. Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.
I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.
Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.
According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.
Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?
I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.
This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.
Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.
Continue reading “The Flu Shot and a Patient’s Right to Choose”
Filed Under: THCB
Tagged: Flu vaccine, FutureMed, Jennifer Anyaegbunam, prevention, public health, Wellness, WellPoint American Resident Project
Jan 25, 2014
THCB is excited to announce the first official e-book release from THCB Press, “Surviving Workplace Wellness” by contrarian Wellness industry observers Al Lewis and Vik Khanna.” What exactly is the “Wellness industry” anyway? How scientific is the “science” behind wellness programs? Are stop-smoking programs a good idea? Should your company really be paying to send employees to the gym?
Should you be using technology to help your employees monitor and understand their health? You may not always agree with the authors (we certainly don’t here at THCB world headquarters, where Al and Vik have started more than a few food fights) but we still think you’ll find this title a provocative examination of many of the fundamental assumptions underlying prevention and wellness today.
You can order your digital copy from Amazon.com here at the discounted price of $9.99. If you’re a healthcare insider trying to understand the controversies facing wellness or a conscientious wellness professional trying to get a handle on developing a program that works for your employees, this is the e-book for you.
Be sure to look out for upcoming releases from THCB Press in the months to come. If you’d like to be placed on the THCB Press mailing list to be notified of upcoming new releases, send us an email with “update me” in the subject line. Author inquiries and partnership requests should go to this same address. — John Irvine
Continue reading “Good News! A Workplace Wellness Vendor Saying You’re Sick Means You’re Probably Healthy”
Filed Under: THCB
Tagged: Al Lewis, corporate wellness, eBooks + Downloads, Surviving Workplace Wellness, THCB Press, Vik Khanna, Wellness
Jan 25, 2014
The two columns by Bill and Emma Keller about Lisa Bonchek Adams unleashed fury this week from supporters who questioned the manner in which Adams, who has metastatic breast cancer, “lives her disease” through her blog and Twitter feed.
Amid reams of articles, blogs, tweets and Facebook posts, patient advocate and breast cancer survivor posted Liza Bernstein grabbed our attention for posting a brilliant yet simple observation. Responding to an article in Gigaom, Bernstein noted that Bill Keller wrote this of Adams:
“Her digital presence is no doubt a comfort to many of her followers. On the other hand, as cancer experts I consulted pointed out…”
And Keller went on to describe what those experts thought.
Bernstein and other e-patients know well that Lisa Adams is an expert. In her response, Bernstein said that while Adams “is not a doctor or a researcher, [she] is a highly engaged, empowered, and educated patient who, as far as I know, has never shared her story lightly.”
Perhaps unintentionally, Keller’s supposition that Adams is a “comfort” to other patients compared with the analysis he provides from “cancer experts” marginalizes what people like Adams bring to others affected by cancer.
Continue reading “In Praise of Lisa Bonchek Adams, Breast Cancer Expert”
Filed Under: Uncategorized
Tagged: Brian Loew, Cancer, e-patients, FutureMed, Inspire.com, Patients, Social Media, Wellness
Jan 16, 2014
The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.
This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).
Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.
Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.
Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.
Continue reading “Dr. Aetna Will See You Now”
Filed Under: THCB
Tagged: Aetna, Al Lewis, Belviq, Disease Management, Obesity, Pharma, Qysmia, Vik Khanna, Wellness
Jan 15, 2014