What I’ve Been Reading

- Anyone wanting to sample the full range of opinion (and emotion) about health care in this country need look no further than Jerome Groopman’s review of Paul A. Offit’s book, The Quackish Cult of Alternative Medicine, and the comments, 81 in all, that appeared in a recent New Republic: http://on.tnr.com/1bKyvz2. Dr. Groopman, who is Chair of Medicine at Harvard Medical School and author of many articles and books, seems to be generally in agreement with Offit in dismissing most forms of alternative medicine, though he also points out the need for greater transparency in the medical profession, especially with respect to conflicts of interest.

      - Noreena Hertz’s frightening ordeal with a mystery illness led her to ponder the decision-making process in “Why We Make Bad Decisions,” http://nyti.ms/1b2EvSP. Here are a couple of salient quotes:

“If we are to control our own destinies, we have to switch our brains back on and come to our medical consultations with plenty of research done, able to use the relevant jargon.”

“One study of radiologists, for example, reveals that those who perform poorly on diagnostic tests are also those most confident in their diagnostic prowess.”

      - When it comes to staying healthy, which is more important, diet or exercise? This question is addressed in a short but useful article: http://bit.ly/1eANTjE. Briefly, it depends on your goal: if you want to drop a dress size or increase your energy, diet is the way to go; if you’d like to reduce your risk of heart disease, keep your mind sharp, or increase your libido, exercise is the better choice. The article includes specific recommendations in connection with each objective.

- These days there are a lot of doctor/bloggers. The stories they tell are often poignant and eloquently expressed. One that I just started reading is “In My Humble Opinion” by Dr. Jordan Grumet, an internist who practices in the Chicago area: 
http://jordan-inmyhumbleopinion.blogspot.com/

Searching for Healing 2000 Years Ago

On a recent trip my husband and I went to Bath, a lovely small city in the south of England. The place is name for the hot spring that has been an attraction for millennia. Bath was founded in 860. Legend tells that Prince Bladud became afflicted with leprosy. He was banished from court and made to look after pigs. The pigs too had a skin condition; Bladud noticed that, when they rolled in the hot mud, they were healed. He tried it himself and was cured of his disease. He went on to found Bath and become the father of King Lear. 

Centuries earlier, the Romans had been interested in the healing properties of the spring. In 50 AD they built a temple to Minerva, the Roman goddess of healing, and the Celtic god Sul. They also constructed a bath complex, with water supplied by the hot spring. Around these a settlement grew up known as Aquae Sulis, the waters of Sul. Today the remains of the temple and the baths are displayed in a wonderful museum, which includes sculpture, inscriptions, items lost when they were dropped in the water, and a skeleton of an ancient Roman with a reconstruction to show how he looked in life.

Some of the inscriptions are gravestones, a couple of them of Roman soldiers. These were young men by today’s standards, men in their twenties to mid-forties who died far from home. Roman soldiers formed cooperative associations that would pay for gravestones when one of them died so we now know their names, sometimes their ages, and places of birth. Did they come here hoping to find a remedy for war injuries or illnesses? I came away with a sense of how difficult life must have been for these people.

Today leprosy, also known as Hansen’s disease, is treated with antibiotics, anti-inflammatory drugs, and immunosuppressants.

Good News 2 – But Are Doctors Following the Recommended Protocols for Tests?

My doctor was concerned about the high BUN/creatinine ratio that showed up on my annual blood work. After looking back at a couple of years’ previous blood work results, she concluded that the number was going up. I looked back eight years in my own records and found that it had actually bounced around, although it was generally higher starting in 2008, when I amped up my exercise routines with interval work on the cross trainer. The original reading, taken on 7/19/13 was 36; a second reading, on 8/21/13 was lower but still high, 32. 

After the second high reading, I wanted to know what factors other than kidney disease could affect the test. My doctor’s office always tells me to fast before checking my cholesterol or blood glucose but does not give me any particular instructions relating to the BUN test. Yet it turns out that both exercise and diet the day before can affect its results. One website suggests not doing either cardio or weightlifting the day before. WebMD recommends not eating a lot of protein for 24 hours before the test. The day before the third test I heeded this advice; I did no exercise and ate virtually no protein. The third test showed a BUN/creatinine ratio of 19, within the normal range. Within the space of two weeks the number had dropped by one-third. If the BUN is so sensitive to extraneous factors, should it really be considered a reliable indicator of kidney health?

I’ve read that cholesterol tests too can be affected by what you eat the day before but no doctor’s office has ever cautioned me about this. Speaking of not following recommended protocols, both WebMD and Medline Plus say that, before your blood pressure is taken, you should sit quietly for at least five minutes. The medical staff I have dealt with recently never do this. Instead they take it while I am in the middle of a conversation with them. Then they tell me I have high blood pressure, which I know is not true because I take it myself at home; it’s about 105 over 60. I wonder how many people receive unnecessary treatment because medical tests are being improperly administered.

Capoeira

In the warm-up sequence in the Rushfit workouts there is one exercise based on capoeira, a Brazilian style of dance and martial arts. According to the wikipedia article, capoeira was invented starting in the sixteenth century, mainly by escaped slaves and their descendants. Here is a marvelous video clip of two master capoeiristas. There was a somewhat similar situation with yoga in colonial India; for some practitioners it was a martial arts program disguised as a self-improvement regimen.

Good News Part 1: DXA

One of the unnecessary scares at the time of a physical exam took place in 2003, the first year I had a DXA scan to measure bone density. I went to a testing center where an MRI was administered and later interpreted by a doctor. The results revealed significant bone loss in the lumbar spine and left femur. I was horrified. My PCP wanted me to take Fosamax; I decided to get a second opinion.

I went to the radiologist who did (and still does) my mammograms. The results on his machine were significantly better than on the first test. The radiologist explained that readings can differ from one machine to another. There is also a margin of error for any machine so that small differences are not considered significant. (Since 2003 I’ve had five DXAs since then and none has ever given results as low as the first one.)  The overall picture was not too bad. The reading for the spine was definitely in osteopenia territory, those for the femurs were normal.

In the succeeding years the picture has stayed about the same: osteopenia in the spine but no worse than before, some additional bone loss in the hips but just barely out of the normal range. Last year the spine was somewhat better, the femur readings a bit worse. This year the spine was back down but the right hip (the side with the shorter leg) had increased 3.7%. So the overall picture is that the numbers bounce around a bit but not much changes. After ten years, is it really worthwhile for me to continue with these tests?

Clearly, my body can still rebuild bone. To help the process along I’ve decided to increase my calcium supplement intake by 25%. I also take vitamin D and magnesium along with the calcium. There has been a lot of talk lately about people taking too much calcium. The theory is that the excess mineral can harden the walls of the arteries and contribute to heart disease. But how can we know whether a particular person is getting more than enough without a blood test? We’re all different. In my own case, I take well over the recommended amount yet my serum level is at the low end of normal. My blood pressure is low normal and my cholesterol readings are just fine. Instead of making sweeping generalizations, I wish the experts would recommend that people get themselves tested. That is the scientific way, after all.

A Blast from my Dental Past plus Coping with Medical Procedures

I emerged unscathed from my annual physical (more about that in future posts) but a few weeks ago I started getting worrisome messages from my mouth. Nothing hurt, but whenever I aimed the water pick at my upper right molars, there was blood. When it comes to problems with teeth, I am super-vigilant because my dental past is checkered, to say the least. 

From my early teens to my mid-thirties there was one crisis after another: large cavities requiring extensive excavation, abscessed molars, root canals, and extractions. Heredity and stress probably contributed to this and I probably could have taken better care of my teeth, plus the fact that I was a smoker then. When I moved to Bloomington somebody put me in touch with The SuperDentist. He got right to work fixing up the damage done by neglect and less-than-successful remedies by previous dentists. The SuperDentist (now retired, alas) is a master craftsman; when his patients would move to other parts of the country their new dentists would ask, “Where did you get that wonderful dental work?” After a few years, during which I also quit smoking and my stressful job, my teeth stabilized. Apart from replacing the occasional old filling, there was not much to be done. 

(Side Note: There has been a lot of talk about whether silver amalgam fillings can cause high levels of mercury in the blood. For decades of my life I had a mouth full of those fillings, most of them replaced now. I also worked for a dentist one summer and mixed up the silver amalgam for him. This year I had my mercury level tested and it was very low. If anyone would have been harmed by silver amalgam, you would think it would have been dental workers. In the years before they wore masks all the time, clouds of dust from silver amalgam would be in their faces for much of their work day. Has anyone surveyed them?)

Anyway, I went to my regular dentist and he cleaned out a little something under the gum. Two days later, the bleeding started again so I went to my husband’s periodontist. MHP surveyed the situation. The bad news was that this was the beginning of periodontal disease. The good news was that it was early enough that he could do a laser procedure – no cutting, no sutures – that should take care of it. Since I’m always in favor of getting out in front of impending problems, I said “Let’s do it.”

I’ve had so many medical and dental procedures over the years that I’ve developed a routine that helps to reduce stress and anxiety. First, I try to get a good night’s sleep the night before. The next day I don’t do any strenuous exercise but I do a stretching routine, like the ones in RushFit and P90X. This gets my circulation going, which helps me relax and will promote healing. I wear layers of comfortable clothes, including a light sweater in case the office is over-air conditioned. I bring along something small to read, like a cell phone or paperback book, that can stay in my lap. When I’m waiting for the appointment or sitting by myself in the treatment room I don’t want to be staring off into space worrying about what comes next. Finally, following a tip from my grandmother, I focus on what I’m going to do afterwards.

Compared with many of my past dental adventures, the laser treatment was a piece of cake. There will be follow-up after a couple of weeks and then at longer intervals after that. I’m actually glad to get established with MHP because he will keep an eye on things so that I can avoid periodontal problems in the future.

Why I Always Get and Keep Copies of Medical Test Results

Yesterday was my annual physical, a day I always anticipate with dread because it represents my annual battle with The Way Things Are in the health care business today. Inevitably this battle involves my doctor, a kind and intelligent person who has only my best interests at heart. She is the one I would want beside me in a medical crisis. But there is no crisis – I am perfectly healthy – and this year, like most years, I will have to prove it, by achieving normal results on various medical tests or by justifying any result that is out of line.

I might give up having an annual physical at all, except that I need refills of the two medications I take regularly: Synthroid for my hypothyroidism (no generics, please, we’ve tried that already) and Premarin, which I’ve taken since 1980 because I had a complete hysterectomy and want to stave off bone loss. So I go for my physical, get my blood work, mammogram, and DEXA scan, and deal with the consequences. 

An individual test result, looked at in isolation, can be misleading. In health care, as in most of life, context is everything. Unfortunately, because of the way medicine is practiced today, context is very limited or absent altogether. Most doctors don’t know their patients well; many don’t know them at all. Record-keeping systems are constantly changing which can lead to the loss, misfiling, or intentional destruction of older documents. One topic of conversation with my doctor yesterday was my high BUN/creatinine ratio. This is an item to be taken seriously because it is an indicator of kidney function. In my case, creatinine is a perfectly respectable .9 (normal range .5 to 1.3) but BUN or blood urea nitrogen is a whopping 32 (normal 7 to 20), resulting in a ratio of 36 (normal 6 to 25). On a more positive note, my GFR, another measure of kidney function, is 66, perfectly fine.

My doctor was concerned but I pointed out that the ratio, for me, has been high for years, maybe even decades. In the past doctors have attributed the high BUN to dehydration associated with fasting before blood work. “Still,” the doctor said, “it’s higher than last year and the year before. It seems to be going up.” We talked about whether I’m dehydrated  (no), whether the protein supplement I take could be affecting it, and she wants me to repeat the test on a day when I’m not fasting. I agreed.

My doctor only has test results for me going back a couple of years but I started getting and keeping copies in 2000 when my doctor at the time wanted me to take statins. After my appointment I went back through the file and found that the BUN/creatinine ratio has bounced around a lot; in 2005 it was 36! Protein in the diet can have an impact on BUN; cardiosmart.org, the website of the American College of Cardiology says, "Do not eat a lot of meat or other protein in the 24 hours before having a blood urea nitrogen (BUN) test." Exercise can affect it too. One website for weight lifters recommends not lifting weights or doing cardio the day before the test. (I had probably done both the day before this year’s.)

I haven’t had the mammogram or DEXA yet but so far this year’s flap has been relatively minor compared with the breast cancer non-event a few years back and the heart disease false alarm last year. Doctors devote their lives to helping others. In order to help as many people as possible they rely on test results and on generalizations based on large research studies. Since their time with individual patients is very limited, they sometimes interpret idiosyncratic variations as disease. In addition to a very real concern for patients, the prevalence of malpractice litigation inclines doctors to err on the side of caution.

I believe that having health coaches in doctors’ offices would do a great deal to reduce unnecessary testing and anxiety on the part of both doctors and patients. A health coach would have the time to review my medical records and know that my white blood cell count is sometimes low and that my BUN is always high. Instead of making assumptions about my physical condition based on my age and sex, a health coach could actually find out how many pushups I can do and what I eat for breakfast. The main reason to respect Western medical care is that it is based on science and science depends on accurate information about specific situations. A health coach who knows me could be a valued ally in my annual fight to prove that I am healthy.