Tuesday, December 16, 2014

A Question for Doctors: Are Sick Patients More Important Than Healthy Patients Who Are Trying to Stay Healthy?


Now that I am in my late 60s I often worry that I am losing it. Incidents involving misplaced keys or forgotten grocery items take on an enhanced importance. But when I tell myself to step back from the panicky emotion and look at the present situation in a larger context, I can recall that I used to make the same mistakes in my 20s and 30s. It’s not so much actually losing it but anxiety about losing it that is at work here.

For doctors and medical administrators, anxiety about what might happen can cause temporary blindness to what is actually happening. In my conversation with the Medicare doctor it was clear that he was extremely concerned about harm that might come to women when estrogens were prescribed inappropriately by their doctors. For example, the WHI 2002 study did show that older women with existing heart disease should not be initiating hormone replacement therapy. In order to protect those who should not be taking estrogens, Medicare has erected a series of hurdles that must be negotiated each year by all patients wanting to take these medications (and their nurses and doctors). This situation means that many women who could avoid menopause symptoms (and possibly be helped by beneficial side effects) are excluded from taking a drug that could improve their quality of life and might actually extend their lives (depending on what current and future research shows).

The same reasoning seems to be at work in our current version of preventive medicine, which applies treatments and test to millions of healthy people so that a few can avoid illness. Jeff Wheelwright discusses this situation in an article entitled, Risky medicine: Misunderstanding risk factors has led to massive overtreatment of diseases people don’t have and probably never will.” If 100 people are treated with statins for 10 years only 4 will be saved from having a heart attack. For every 1000 women regularly screened with mammograms over the age of 50 one life is saved. Often overlooked is the fact that these interventions harm a certain number of healthy people.

The medical community needs to take a step back and ask itself questions like these:

- Is it more important to protect the sick or to maintain the healthy?

- How many healthy people are we willing to put at risk in order to spare one person
     from disease or death?

- How many healthy people are actually being harmed by any given intervention?

- To what extent can we accommodate the needs of both groups?

- How much is all of this costing?

Doctors dedicate their lives to helping patients. From med school onward they learn to interact and empathize with those who are suffering from illness. In the larger world, however, most of us, most of the time, are healthy. If that were not the case, no health care system could ever take care of all of us.When medical policy decisions are made,­ healthy people who are trying to stay healthy need to become part of the calculation.

What Happened Next

Continuing... 

Like many people who live far outside the Beltway, I tend to think of Medicare as an undifferentiated part of a faceless federal bureaucracy. After writing the letter, I kept it around for a couple of days, then sent it off to Marilyn Tavenner’s e-mail address on Thursday, December 11, in mid-afternoon.

That evening I received a call from Humana saying that my request for Premarin had been approved for one more year. This year my doctor’s nurse had requested the drug for me twice and been turned down twice. After that, I had had to file a grievance; my doctor and I each wrote a letter to Humana. One of those last two attempts had succeeded. This sequence of events is pretty typical of our experience in the three years we have been doing this.

In response to my e-mail to Medicare, I expected to receive a form letter or, at most, an e-mail from the PA of a PA well down in the food chain. I was therefore quite startled to find a message, sent the following morning, from a doctor at Medicare saying that someone would be in touch with me. If I wanted to speak to him directly, he said, I should e-mail my phone number. I wrote back and told him that, since I had received the approval from Humana, the immediate situation was resolved but that I was frustrated at having to go through this process each year and concerned that, at some point, I might not be able to get this medication at all. I included my telephone number but said that I didn’t necessarily need to talk with him.

Minutes after that message went off, the phone rang. It was the same Medicare doctor. Not expecting an important call, I had been playing a brain game on the computer. I had to scramble for a few seconds to get rid of my headphones so I could focus on what he was saying. Our conversation was quite friendly, although we were approaching the issue from different vantage points. His primary concern was to reassure me that I would always be able to get Premarin, although it didn’t sound as though the appeals process would be going away anytime soon.

When I asked why there were so many obstacles for women wanting to use this medication, he said that Medicare wants to be sure that doctors and patients understand the risks involved; some doctors prescribe estrogens for patients who really should not take them. I said that some doctors refuse to prescribe these drugs, even for women would benefit from using them. After WHI 2002, many women were persuaded to stop hormone therapy. (One woman I know had terrible problems with insomnia; another is now taking a bisphosphonate for bone density, which poses its own risks.) We agreed that it would be better if there were some way of providing easier access for women who can and are willing to take estrogens, while discouraging those for whom it is truly a risky drug. He thought that electronic records might make it easier to do this.

At the end of our conversation I had the sense that the Medicare doctor had really heard what I was saying and would continue to think about it. Whether any actual changes will come about is, of course, another story.

Monday, December 15, 2014

"Humana, I Still Want My Premarin – So I Wrote to Medicare"

December 11, 2014

Marilyn Tavenner, Administrator
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244

Re: Problems Getting Medication

Dear Ms. Tavenner:

Recent advances in the field of medical genomics demonstrate the wide variations from one person to another and point to the need for a more individualized approach to health care. In spite of these developments, the advice issued by Medicare to insurance companies continues to rely on large studies that make generalized recommendations for diverse groups of individuals. I am a 68-year-old woman with no heart disease, cancer, or diabetes; I do powerlifting, cardio, and P90X workouts. Yet according to Medicare’s current approach, the recommendations for me would be the same as those for a woman my age with heart disease and diabetes.

This one-size-fits-all approach comes back to haunt me each year when I have to ask Humana, the provider of my medications, to make an exception and allow me to take Premarin, a drug that I have been taking for 35 years since I had a complete hysterectomy at the age of 32. Apparently Medicare tells Humana that Premarin is a high risk medication that should not be given to patients 65 and older. Will Medicare and Humana compensate me if I go off Premarin and get osteoporosis, hot flashes, and other symptoms of menopause? Of course not.

Medicare’s recommendation is evidently based on WHI 2002, a study that did not deal with estrogen-only therapy, was poorly presented to the public, and whose results have been called into question by subsequent research. I have written about this in my blog post, "When Emotion Trumps Science: the Latest on Hormone Therapy," http://bit.ly/18RqHfB. To give just one example, a Danish study reported in the British Medical Journal 10/09/2012 reached this conclusion after observing 1006 women:

 After 10 years of randomised treatment, women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, without any apparent increase in risk of cancer, venous thromboembolism, or stroke.

So estrogen is not only preventing menopause symptoms for me but may also be protecting against heart disease, which runs in my family. In spite of these more recent results, Medicare continues to behave as though WHI 2002 were the final word on HRT and even to generalize its findings to cases like mine (estrogen-only versus estrogen-plus-progestin) to which they are not relevant. There has been little acknowledgement of the harm done to women by the study and the way it was presented to the public. Millions of women have suffered menopause symptoms needlessly and have been denied the possible benefits of estrogens. Some scientists at Yale believe that as many as 50,000 women may have died prematurely of heart disease between 2002 and 2011 because of discontinuing estrogen-only therapy.

I do not have any major illnesses and I rarely get sick at all. My good health has probably already saved the health care system thousands of dollars. It would seem to be in everyone’s best interests to allow me to continue what I have been doing. I hope that you will be able to help me with this situation. I have heard from other women who have had the same experience. Thank you for taking the time to read this message.

Yours sincerely,

Gretchen Kromer

Saturday, November 8, 2014

Don’t Call Me Spry!

“Aging is for people who don’t know better.” This Tony Horton quote came to mind as I read Alison Gopnik’s column in today’s Wall Street Journal (“A More Supportive World Can Work Wonders for the Aged.”) The article highlights the demeaning language that is often applied to old people and the negative impact of those messages on their condition. Gopnik contrasts the experience of people 60 to 99 years old in a Yale study who were exposed to positive (though unconscious) ideas about aging and saw their physical functioning improve

Yet even the word “spry,” which was treated as a positive adjective in the study, carries with it the patronizing implication of “pretty good for your age.” Disparaging talk about aging is sometimes encountered in medical offices. “You can’t expect to be able to do what you could do when you were younger,” said one orthopedist to a very athletic woman in her forties. With all due respect to doctors in general, this is presumptuous nonsense. Some of us are fitter and in better health than we were as sedentary young adults. As a thirty-year-old, I couldn’t do even one pushup; now, at age 68, I can do at least forty. I’m not spry, I’m strong!

Much of the mental and physical deterioration traditionally considered to be an inevitable part of aging is actually a consequence of improper diet and inadequate exercise. Diet-wise, it’s important to get enough vegetables and fruit and enough protein. If you can’t or won’t buy and prepare lots of vegetables, drink vegetable juice. There are low sodium varieties at the store or you can make your own. Even if you eat vegetables anyway, drinking juice is like having extra insurance. And, drinking juice, any kind of juice, at least three times a week was associated in a Vanderbilt University study with a 76% lower risk of developing Alzheimer’s disease.

For years, my annual blood work showed that my protein was a bit low, yet my doctor never suggested a protein supplement. These days I have a protein smoothie in the mid-morning (recipes here) and a take an enzyme supplement that helps me to digest protein. The proteolytic enzyme also helps me to recover from injuries more quickly. Take protein supplements or eat protein bars to maintain muscle strength. Keeping muscles strong is one of the most important (and most underrated) contributors to a good old age. Strong people can pursue a greater variety of activities and are less likely to be injured if they have an accident. Also, the heart is a muscle; what’s good for the other muscles is likely to be good for the heart as well.

Keeping muscles strong means that exercise, especially weight lifting, is essential. But there are other types of movement that also need to be practiced and maintained, including flexibility, balance, explosive movement (plyo or jump training), and cardio. When it comes to cardio, older people are often told that a little swimming or walking around the neighborhood is enough. My own experience has been that you have to work a lot harder if you want to stay in really good shape. Everyone’s body is different but my particular body requires 33 minutes of intervals on an elliptical twice a week, averaging 85% of maximum heart rate. (I use a heart rate monitor.) For exercise overall, it takes about a little over an hour six days a week for me to feel comfortable and get a good night’s sleep.

Finally, I think it’s important to keep doing things for myself. Once you’re retired, to farm out tedious chores and errands to someone else seems like an attractive idea. After all, you’re retired, you should take it easy, right? Wrong! I don’t necessarily love grocery shopping or house cleaning but doing those tasks means that I am taking care of myself. The more I delegate the workings of my day to other people, the more I will have the sense that I can’t do those jobs anymore, almost as though I have become a child again. Doing things for myself helps me to maintain a sense that I am capable and in control of my own life. In this world there are only two things that I actually own: my physical body and my time. If I take care of one, I will have more of the other.

Thursday, October 30, 2014

Is There a Role for Fitness Professionals in Health Care?

About six months ago a friend of mine started having trouble sleeping. He was being kept awake by a nagging pain under his rib cage. During the day when he was standing or sitting up the pain was barely noticeable but at night it was enough to disturb his rest. It was also worrisome because he had had cancer surgery a number of years earlier.

He went to his primary care doctor, who ordered an ultrasound and blood work, followed by a HIDA scan to check for gallbladder problems. All of these came back negative. Still concerned, my friend sought out a GI specialist, who, after verifying that he was not experiencing any digestive symptoms, told him that this was not a GI matter but muscle-related. Both doctors felt around his abdomen and found nothing; neither had anything further to suggest to help him get a better night’s sleep.

By coincidence, I had been seeing a certified massage therapist who works with athletes. When I described the situation to her she said immediately, “That is a herniation of the iliopsoas muscle and I’ve seen several of them recently.” When she examined my friend she was able to feel a lump about the size of a quarter where the muscle belly protruded through an opening in the muscle band. In a standing position, she explained, the muscle was pulled flat and the hernia would retract into its proper place; but lying down caused the tear in the muscle band to open up and the hernia to bulge out like a balloon, creating a pinching sensation. After several sessions with the therapist, my friend was able to sleep again. What to do in order to prevent a recurrence? Strengthen the muscle so that it is less likely to tear.

The tests at the hospital had done nothing for my friend but generate medical bills and expose him to radiation. The real answer was waiting at the gym. There are a number of common and disabling injuries where muscle weakness is implicated as a contributing factor, such as rotator cuff tears and carpal tunnel syndrome, yet few doctors talk with their patients about the importance of maintaining muscle strength. Isn’t it time for physicians to collaborate with fitness professionals for the benefit of patients?

Wednesday, September 24, 2014

Having Respect for Limitations – in Medicine and in Life

Recently, I heard the story of a bright and ambitious young woman who aspired to be a physician. She finished pre-med in college but, as she started to get to know more doctors, she found that many were addicted to alcohol or drugs or just plain angry. She decided that she didn’t want that kind of life and went on to a different career.

In an earlier blog post I talked about some of the stresses on doctors today. ”The vast majority of physicians are sincere, caring people who are doing their best to treat too many patients in too little time. … Doctors work impossible hours; they are harassed and talked down to by insurance providers; and they must protect themselves (at great cost) against lawsuits for malpractice.”

What I see in the way medicine is practiced in the United States today is a lack of respect for limitations, both of the individual medical practitioner and of the field of medicine itself. As more and more patients are stuffed into doctors’ schedules, communication is limited, treatment is standardized, and subtle nuances are overlooked. All of this sets the stage for medical errors that arise, not from incompetence or a lack of caring, but from too little time for listening attentively and framing a careful response to the patient’s situation.

In addition to schedule constraints, physicians are limited by their individual education and experience. Diagnosis is too often guided by what tests are available and commonly applied rather than by the patient’s own medical history (which the doctor may not have had much time to review). In some cases, unfortunately, doctors’ training has predisposed them to believe that the solutions offered by modern medicine are always to be preferred and that if modern medicine doesn’t offer a solution to the patient’s problem, there is no solution. This school of thought often involves a blanket rejection of all supplements, traditional remedies, and alternative treatments.

When I was in my late forties, juggling a career and graduate classes, I tore something in the back of my shoulder. It was quite painful and, as the weather got colder, it got worse until I was having trouble sleeping. My doctor recommended over the counter anti-inflammatory remedies and then a course of therapy with a clinic run by the local hospital but none of it helped. After about six months of this, with no other option but surgery, I decided to try acupuncture. My doctor was scornful, “All that does is stimulate endorphins.” Over a couple of months, the injury healed; after that, I did stretching myself to restore normal movement in my shoulder. My doctor was so impressed that she later sent at least one other patient to the same acupuncturist.

I have enormous respect for modern medicine, which has probably saved my life a number of times, but modern medicine doesn’t always work and doesn’t have much to offer in some areas. Most athletes will tell you that there is little to be done for any but the worst soft tissue injuries. Rest, Ice, Compression, Elevation are what doctors and trainers alike will recommend; the body just needs time to heal itself. Another weak area is the wide range of food allergies and sensitivities and other digestive disorders termed “irritable bowel syndrome.” Doctors can’t do much about these so they don’t give them much attention, but for affected patients these conditions can lead to long term malnutrition.

Fortunately, there are remedies out there. Acupuncture and massage can accelerate the healing of soft tissue injuries; probiotics and enzyme supplements benefit many people with ill-defined digestive disorders. Unfortunately, most doctors won’t have anything to do with these therapies because they are not part of the standard canon taught in American medical schools. Doctors may also be motivated by fear of a malpractice lawsuit if harm comes to the patient.

A lack of respect for limitations, both the human limitations of doctors and the practical limitations of medical science, creates hardship for both doctors and patients. We need to find an approach to medical care that is more respectful of the individual and more open to therapies outside the conventional realm of medical care.

Wednesday, September 10, 2014

What I Like About mytrainerbob

If you’re already in decent shape and want to take it to the next level, the Bob Harper workouts are a good option. These are challenging, businesslike programs packed with a variety of well-paced exercises ̶ no jokes or funny voices and not much down time here. Based on the reviews in Amazon, I selected and tried a total of four DVDs, all of which have improved my condition, though not necessarily in ways I expected.

I started out with Totally Ripped Core and Total Body Transformation. Both of these came out in 2011 and are similar in format. Both come with shorter routines to do when you have less time. In both cases the first half or two-thirds of the workout is not too hard, working mostly with light or medium weights, the last third is difficult-to-almost-impossible, using body weight, isometrics, and jumping. My abs were pretty strong before I started so the Bridge series near the end was actually a relief. The planks and other isometric exercises were good for me because I don’t normally do much of those. The hardest move for me was the side plank lifting the top leg and holding it up. At first I couldn’t do this at all but now I can. For both of these workouts, I saw the most change in the muscles in the back of my body and my outer legs, abs not so much. The benefits you get from any workout depend on where you were strong to start with.

Total Body Transformation is billed as “the hardest workout ever” but for me Body Rev Cardio Conditioning is even tougher, working with a heavier weight (as well as a light one), more balance moves, and a generally faster pace. I don’t see this so much as a cardio workout, because my heart rate doesn’t get up and stay up high enough for long enough, but more as an intense workout with weights and body weight. I haven’t totally mastered this one yet but I’m working on it. BRC and Kettlebell Sculpted Body both appeared in 2010. The kettlebell workout features the GoFit contoured kettlebells that have flat sides and a vinyl coating that make them more comfortable to use than the traditional round variety. KSB is fifty minutes of squats, lunges, and lifts combined with pushups, mountain climbers and jumping jacks for a tough workout emphasizing the swinging weight of the kettlebell.

The first three workouts show Bob with a class. In each of them the standouts are women ̶ Shaela Luter in Totally Ripped Core and Total Body Transformation and Roxanne Mari in Cardio Conditioning ̶ and some of the men struggle. Kettlebell Sculpted Body features the amazing Stephanie Czajkowski, who manages to keep her sense of humor in spite of the hard work and some mischievous needling by Bob. Are the workouts designed this way because the intended audience is women? I don’t know.

I only have a couple of minor quibbles with these workouts. One is that at times they are unrealistically hard. At certain points you see form starting to fall apart because these very fit twenty-somethings are simply worn out. The other is that Bob doesn’t do all of the moves himself. I find it more impressive when the teacher actually does most or all of the workout with the class. Of course this makes it impossible to monitor and comment on how people in the class are doing.

Bob Harper is one of the trainers on The Biggest Loser. Since I never watch the show, I had no particular impression of him one way or the other. Last year, when contestant Bobby Saleem was agonizing about whether to tell his parents about his homosexuality, Bob supported him by telling him (and everyone else) that he is gay. I thought that this sacrifice of personal privacy by a celebrity was an extraordinarily generous act.
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