“Please Give Me My Test Results (Not Just An Interpretation)” (posted 9/6/2011): A Relevant New Study

Last Sunday night’s edition of NPR’s “Sound Medicine” featured an interview with Tom Delbanco, MD, of Harvard Medical School about the OpenNotes Project, a new study by to find out what happens when patients have free access to their medical records, including doctors’ notes.  Although American patients have the legal right to see their medical records, doctors typically do not offer to share their visit notes with patients.

For one year, starting in the summer of 2010, 110 doctors in three diverse locations, suburban Boston, rural Pennsylvania, and inner city Seattle, regularly shared their notes with patients.  The study followed these doctors, as well as others who had refused to participate.  Initially, many doctors were concerned that the process would be too time-consuming, would confuse or frighten patients, or might expose doctors to more liability.  At the end of the study, however, not one of the participating doctors wanted to discontinue sharing notes with patients.

Investigators were surprised to find that patients of all ages, economic groups, and levels of education were enthusiastic about the process.  Some believed that it would foster trust and understanding and allow them to have more involvement in their medical care.  Others indicated that it might cause them to take their medications more regularly.  Fifty percent of patients said they might share their medical information with other people, such as family members or friends.

Dr. Delbanco characterized the process as a form of new medicine that will probably not be suitable for every patient.  He said that doctors will need to learn how to use this new tool wisely. 

Room For Improvement: the Wisdom of Tony Horton

Yesterday’s Wall Street Journal had a great interview/article by Kevin Helliker on fitness guru Tony Horton.  The online version comes with a 4-minute video.  Together they give you a good sense of the man we P90X users know and love.  The P90X workouts (X for “extreme”) are designed for people who are already in decent shape and want to advance to the next level.The series consists of 12 tough, briskly paced workouts based on a variety of different types of exercise such as weight lifting, plyometrics, martial arts, and yoga. 

One of the reasons why the program has been such a success is that Tony Horton is fun to watch; in each workout he wears at least five different hats.  He’s leading a group of three or four very fit young men and women in the studio and commenting on what they are doing.  He’s teaching the exercises to us, the viewers, while encouraging us to “Do your best – forget the rest.”  He’s delivering a steady stream of stand-up-like patter: jokes, impressions (Arnold Schwarzenegger, Forrest Gump), and silly faces.  He’s directing the cameramen (“You got that, Jer?”).  At the same time, he’s doing most of the exercises along with everyone else.  Once in a while he gets too many balls in the air and you can catch a trace of the speech impediment he worked to overcome.

Tony’s performance in these workouts is impressive and the workouts are effective but the essence of P90X is a certain attitude toward exercise.  Here are some of the high points:

• Fitness is not a goal but an ongoing process.  The idea is to find an exercise that’s too hard, work on it until it becomes easy, then find something even harder.
•  Everyone has physical limitations and parts of their body they wish were different.   One of the workouts actually features a guy with a prosthetic limb.  Tony talks frequently about his own weaknesses, like the knee shattered in a skiing accident.  Sometimes these become grist for the comic’s mill, as when he tells the cameraman, “Focus on my little calves!”
• Each individual will find some moves easier than others - the strong, muscular men in the class are not as good at stretching and Tony himself has trouble with balances - but the point is to keep trying so that you improve.

Ultimately, P90X seeks to produce not only a buff physique but an understanding, appreciation, and acceptance by each participant of what his or her own body will do, a wonderful gift from Tony Horton.

Why Work with a Personal Trainer?

I used to think that hiring a personal trainer was for celebrities who wanted to work out at home or for people who needed the motivation and structure of having someone oversee their workout.  Since I enjoy challenging myself and don’t mind going to the Y on my own, it seemed a needless expense.  Then in 2007 I read an article in the New York Times Magazine about how Dara Torres was trying a new approach to exercise using lighter weights and stability balls, focusing on stretching and movement as well as strength.  At that time there were few books or DVDs about this type of exercise so I went over to the recreational center at Indiana University and asked for a trainer. 

I was turned over to Bobby Papariella, who was finishing his undergraduate degree.  Over the next several weeks, he put together a routine that involved stability balls, a Bosu, and weights.  Some of the exercises he taught me are still part of my routine.  More recently I’ve been working with Greg Simmons, a world champion powerlifter, who coaches both student and professional athletes.  Greg and his wife Susan introduced me to the New Leaf program, which helped me get rid of the last few pounds I’d been trying to lose.  Greg is currently helping me with my balance, which has never been that good because of my uneven leg length, and with plyo, which is hard for everyone.  I’ve also worked with trainers I’ve met while traveling.  My husband and I have done a couple of workouts with Anne Tierney and Steve Sierra in Florida and I’ve visited Twist in Vancouver, BC.

Based on these experiences, I’ve concluded that there are a number of good reasons to hire a trainer:

• A trainer can help you set realistic goals and monitor your progress.  For me, seeing results is the best motivator.
• Nobody is completely objective about his or her own body.  A trainer brings a detached perspective and can point out particular areas that need work.
•  Some trainers make use of assessment tools that allow them to measure your current level of fitness and design a program that is appropriate for you.
•  Trainers can help you maintain proper form.  Particularly in strength training, good form is essential.
•  Working with a trainer gives you access to the information they have acquired about diet, exercise, and other fitness issues.  Trainers with degrees in kinesiology, like Greg and Susan, are likely to know about the latest scientific research in these areas.
•  And last, but not least, trainers can provide encouragement when the job of staying fit seems way too hard.

"Humana, I want my Premarin!"

This past Tuesday’s Wall Street Journal had an article about two important new web sites in the area of health care.  According to Health Journal writer Melinda Beck, “A start-up company, AdverseEvents Inc., has streamlined the FDA’s often impenetrable database and made it easy to search the adverse-event reports for more than 4,500 drugs, free and online.”  Another start-up, Clarimed LLC, has done the same for reports filed with the FDA on 130,000 medical devices….”  The new web sites created by these companies will be a welcome change for those of us who sift through the masses of information to try to get at the facts about available medical treatments.

During the past few days I have been in the sifting business myself.  Last June, when I turned 65 and went on Medicare, I selected Humana as my drug insurance provider.  For Humana, I should be a pretty good deal:  there are only two medications I take year-round and I rarely need any others.  The ones I take are Synthroid, because I’m hypothyroid, and Premarin, an estrogen-only form of hormone replacement therapy.  I started on Premarin in 1979 after a complete hysterectomy at age 32.  At first I resisted taking it, but my doctor at the time said that I needed it in order to maintain my bone density.  Over the past 30-plus years the pendulum has swung back and forth on HRT.  In 2002 the Women’s Health initiative study of estrogen-plus-progestin was halted when women taking the medication had 8 per 10,000 more cases of breast cancer than those in the placebo group. 

The publicity resulting from this study caused women to abandon HRT in droves, but not me.  Since I was taking an estrogen-only version, it wasn’t clear that these results applied to my situation.  Further research has led to a more nuanced view of the risks and benefits of HRT.  On the plus side, it lowers the risk of osteoporosis, diabetes, and colon cancer, as well as treating post-menopausal symptoms like hot flashes and mood swings.  In healthy women it may also help reduce atherosclerosis and inflammation, which can lead to heart disease.  This last part is of great interest to me because people in my family get heart disease.  On the negative side, there is a small increased risk of stroke and pulmonary embolism,  12 more cases of stroke per 10,000 and 6 more cases of blood clots in the legs, according to the Mayo Clinic web site.

A few weeks ago I ordered a renewal of my Premarin prescription.  Last week I learned that Humana has taken it off its formulary; they will no longer pay for it unless you get a prior authorization.  Instead, they are offering some version of Estradiol, a different form of estrogen therapy.  Right away I started doing research.  If Estradiol were basically similar to Premarin, as a generic would be, I might be willing to change.  They’re not similar, though, and there’s no generic for Premarin.  I looked at the comments of women who had taken one or both products.  The majority of reviews for both products were favorable but most women who had taken both preferred Premarin.

On Humana’s side, I can understand the rationale for discontinuing their coverage of Premarin.  Like other, older generation HRT treatments, its reputation was tarnished by the WHI study and its fallout.  Moreover, the current recommendation for prescribing estrogen treatment has changed; women are now advised to take it for a few years after menopause to deal with post-menopausal symptoms and then discontinue it.  Women with low bone density are steered toward bisphosphonates such a Fosamax.

For me, it is much too late to discontinue Premarin after a short time; I’ve been on it for almost 33 years.  I’ve been healthy during that time and am in better shape than the average 65-year-old woman.  I have no sign of heart disease and my bone density, though on the low side, is stable.  How much of this is the result of my Premarin use no one can say, nor can anyone predict whether I would do as well on some version of Estradiol.  Premarin, which has been around since 1942, has been studied a lot; it is a known quantity, both in general and for me personally.  Taking a new medication might cause subtle changes whose consequences might not be apparent for years.  I hope that Humana will reconsider its decision.  As a practical matter, medical research needs to deal with broad categories of people but medical treatment must be based on the specific needs of the individual. 

UPDATE 2/9/2012  My doctor's office told me that they faxed Humana's prior authorization form on 2/13/2011.  Today they made a follow-up call and learned that the fax number given on the form was not correct.  The form has now been faxed to the correct number.

UPDATE 2/10/2012  Humana has sent me a wall calendar with helpful reminders about taking my medicine as prescribed, etc. 

UPDATE 2/16/2012  After numerous conversations and several faxes among Humana, my doctor's office, and me, the request for Premarin has been denied twice.  I am now initiating an appeal.  Keeping me on Premarin seems like a win/win situation for Humana and me; without Premarin I might end up needing medication for both heart disease and osteoporosis.  Why is this so difficult?

UPDATE 12/11/2014 "Humana, I Still Want My Premarin - So I Wrote to Medicare" and the two sequels.

A Break in the Routine

Just before Thanksgiving I had cataract surgery.  The procedure turned out fine but the ophthalmologist who did the follow-up exams was extra cautious and told me not to do any strenuous workouts for three weeks.  When you’re serious about staying in shape, you try not to skip workouts because you know you will end up paying for it afterwards.  A week away from the gym is no big deal; two weeks means you have to backtrack a bit; after three weeks you have to really push to get back to where you were.

I do three “big workouts” per week.  These take a bit less than two hours and consist of 35 minutes of cardio (intervals on the elliptical averaging about 88% of maximum heart rate) plus some combination of weights, strength ball training, and plyometrics.  (I do this because I like to have rest days in between when my body can fully recover.)  I also do Ab Ripper X three times a week, usually on different days.  During the winter, if this is all the exercise I’m getting for the week, I add a DVD workout from P90X.  When it’s warm out, I work outside which gives me all the additional exercise I need. 

Since all of my normal workouts had been ruled out by the doctor, I decided to do slower, longer, more frequent cardio sessions.  I went to the Y four or five times a week and did a half hour walking on the track, following by 45 minutes on the elliptical at 80% of maximum heart rate.  I figured this would burn off most of the calories that my regular workouts did so at least I wouldn’t put on much weight. 

After three weeks I went back to my regular workouts but it was almost Christmas, when the gym is sometimes closed and delicious, high calorie foods are everywhere you go.  Around New Year’s I weighed myself and was thrilled find that I had gained only a pound or two.  Getting rid of that would be no problem, I thought.  Three weeks later I’m sitting here with that same pound or two of weight, in spite of regular workouts and sensible eating. 

This situation illustrates why it is important to look at both weight and percentage of body fat.  Here’s what I think happened.  Even though I was doing cardio and burning calories, I wasn’t lifting weights.  This meant that I was losing muscle mass.  Because fat weighs less than muscle, I lost muscle mass but didn’t put on much weight.  Now that I’m doing my usual routine I’m gaining muscle mass, which may initially cause me to put on a couple of pounds.  Eventually, though, the extra muscle will burn more calories and my weight will go back to where it was. 

Plyometrics and Agility Ladder Drills

Jumping, hopping, running up the stairs two at a time:  these quick, explosive movements are second nature to young children.  By the time I was twenty this sort of exercise seemed like way too much work.  A couple of years ago I decided to work on agility and quickness and discovered that exercise science has a name for this sort of training.  Plyometrics, as it is called, was invented in Russia by Dr. Yuri Verkhoshansky in the 1950’s as a way to improve power and jumping ability for the track athletes he was coaching.

A plyometric move consists of the rapid stretching of a muscle (eccentric phase) immediately followed by the rapid contraction of that muscle (concentric phase).  The web site  sport-fitness-advisor.com gives a clear description of how it works.  Research has shown that plyometric training, even in limited doses, can improve agility and quickness in a variety of activities.  I’ve been using several types of plyometric exercises in my workouts:  jumping jacks as part of the warm-up, hopping onto and off a small stool, and stepping onto and off a taller stool somewhere in the middle of the workout, and exercises with an agility ladder at the end.

An agility ladder is basically is series of slat-like plastic pieces spaced at regular intervals along two pieces of tape.  When laid flat, it can be used for a variety of drills including jumping and hopping routines, such as hopscotch, and stepping exercises that resemble dance steps.  I never was much good at learning dance steps and I suspect that the stepping routines are probably using an underdeveloped part of my brain, as well as helping my coordination and balance.  There are lots of good agility ladder drills on the Internet:  sport-fitness-advisor.com has some here:  http://www.sport-fitness-advisor.com/ladder-agility-drills.html.  There is also an excellent book devoted to both plyo and agility work, Training for Speed, Agility, and Quickness by Brown, Ferrigno, and Santana, which comes with a DVD demonstrating some of the exercises.

I’m not a real athlete and probably never will be, but I think that better agility and quickness can benefit me when I’m walking around, driving, and doing other everyday activities.  It also seems to help me move with more confidence.  Stepping exercises can be fun once you get over the initial, tripping-over-your-own-feet phase; plyometric routines are just plain hard work.  I recently watched the Plyometrics DVD that is part of Tony Horton’s extreme fitness program P90X.  The DVD features Tony, then 45, in the gym with three younger, very fit people.  Three-quarters of the way through all four of them are sweating and panting.  If it’s hard for them, it’s hard for everybody!

Supplements 1

When I was in my twenties and thirties I used to get lots of bruises on my arms and legs.  I started reading about what might be causing these and learned that smoking, stress, and drinking alcohol (yes, yes, and yes) can all deplete vitamin C.  I started taking a vitamin C supplement and there was less bruising.  This experience caused me to pay more attention to  nutrition. 

In those days I would sometimes visit my parents and notice how little they were eating; such a meager diet, I thought, couldn’t possibly provide all the nutrients they needed.  I suggested to my father that they take a multivitamin.  My father refused, saying his doctor had told him that a balanced diet provides all the nutrients a person needs.  Taking supplements, the doctor said, just produces expensive urine.  I believe that my parents’ final illnesses were both worsened by malnutrition.

Even after decades of research showing that vitamin deficiencies are common and that balanced diets are the exception rather than the rule, some doctors are still repeating this wrong-headed advice.  For these individuals, “The Nutrition Source,” which is part of the web site of the Harvard School of Public Health, should be required reading.  It provides clear, sensible guidance based on the latest research.  The article on vitamin D is especially valuable.  Inadequate levels of this nutrient are common, especially among dark-skinned people, the elderly, and those who live in cold climates.  Recent research has related vitamin D deficiency to a long list of serious illnesses from heart disease and cancer to depression.  

How can I tell whether I am getting enough of a particular nutrient in my diet? I ask my doctor to order a blood test.  When the results arrive, I ask for a copy and read it carefully.  Usually there will be a range of values that are considered normal next to the actual value from your own blood sample.  If my level is below the normal range, even by a little bit, I talk to my doctor about taking a supplement.  When it comes to test results, doctors tend to focus on numbers that are strong predictors of disease, such as high triglycerides or LDL (bad cholesterol).  A slightly low protein level may not even be addressed because it seems to pose no immediate threat.  In the long run, though, minor deficiencies may have a significant impact on the person’s health.  In my case, taking a protein supplement has helped to develop stronger muscles and to improve my overall fitness.