August 24, 2012 | 5:43 pm

Get Your Flu Shot

Posted by Albert Fuchs, M.D.

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Wikimedia Commons

Temperatures are dropping. Children are returning to school. (Parents are elated.) Families are planning a last summer outing on Labor Day. It must be time for flu shots.

This season’s influenza vaccine has shipped from manufacturers. Our office just received them. So it’s a good time to remind ourselves that the flu can be fairly nasty and that the most reliable way to protect yourself is the influenza vaccine.

The flu shot is recommended for everyone over six months of age. It’s especially important for the groups below.

• People who are at high risk of developing serious complications like pneumonia if they get sick with the flu. This includes:
• People who have certain medical conditions including asthma, diabetes, and chronic lung disease.
• Pregnant women.
• People 65 years and older
• People who live with or care for others who are high risk of developing serious complications. This includes:
• household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease.

The following groups should not receive the vaccine.

• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• Children younger than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)
• People with a history of Guillain–Barré Syndrome

Follow the links below to learn more about the flu. And get the shot now, before the flu season starts.

Learn more:

Seasonal Influenza (Centers for Disease Control and Prevention page)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention page)
Google Flu Trends

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

August 17, 2012 | 12:27 pm

The Anatomy of a Shortage

Posted by Albert Fuchs, M.D.

Image credit: Angry Doc
angrydr.blogspot.com

“If you think health care is expensive now, wait until you see what it costs when it’s free.”
– P.J. O’Rourke

I distinctly remember that in first grade I had an idea of breathtaking wisdom and profundity. Candy should be free. You may have had a similar thought at the same age. This idea was supported by an incontrovertible rationale, namely that I really liked candy. Tragically, it only took a moment for my parents to expose a flaw in my otherwise revolutionary scheme. They suggested that if candy were free, no one would bother making candy. All candy makers would do something else that allowed them to make a living. Thus exposed to the painful realities of life, I put the thought out of my head for about forty years.

But now I realize that modern bureaucracy makes my vision more possible than ever. Candy makers obviously won’t work for nothing, but they could be paid to give away candy by a national program (Candycare or maybe the Affordable Candy Act). Employees through their work could contract with third party payers (like Blue Candy) to pay for their candy needs. Thus candy would still be free to the consumer and no first grader would ever have to be denied his gummy bears.

Complications may still arise in this ingenious scheme. Prices, after all, play a critical role in marketplaces. They reflect the resources consumed and risks taken in producing a product. They force consumers to make important decisions about what they need and what they can do without. And they encourage conservation. The only reason we don’t all buy the most expensive product in any class of products (cars, houses, shoes, whatever) is because we’d rather do something else with the money we save. Prices also give producers a powerful incentive to improve quantity and keep prices low, that is they cause competition between producers.

In the absence of prices, all these details become corrupted in our otherwise idyllic candy utopia. Customers would demand more candy than they ever ate before. They may simply eat more candy, but much would just go to waste. If it’s free, no one will stop to think about whether they really want another Snickers bar. Attention to quality would also decline for two reasons. Consumers would not be able to pay more for better candy, so they would have to be satisfied with whatever they got. And candy makers would no longer have to compete since they would suddenly have all the business they could handle.

There would be a dramatic imbalance between supply and the very high demand. Economists call this imbalance a shortage. Long lines would form at candy stores and supplies would not last until the end of the day. Lots of people who previously were content paying for their candy would now not be able to get any. And though the costs to the consumer would be zero, the cost to society would keep escalating as candy makers would consume ever more resources trying to meet a bottomless demand. In a few years candy would become both mediocre and, for society, disastrously expensive.

Sounds familiar?

Healthcare in general, and especially primary care, is operating in exactly such a system. I’ve been writing for years (see links below) about the shortage of primary care doctors that will happen as the baby boom ages. But with the implementation of the Affordable Care Act (ACA) looming in 2014 the shortage promises to worsen dramatically and is receiving some media attention.

An opinion piece in the Wall Street Journal warns that 30 million people will acquire health plans starting in 2014. The article predicts “the result will be gridlock.” Waits for care will lengthen, and many practices will close to new patients. The author predicts that concierge medicine will grow rapidly as patients flock to doctors who promise them attention and access. I urge you to read the very sobering article.

A recent Medical Economics article asks how an influx of 30 million patients will impact primary care. New physicians certainly will not be trained in time. The article suggests various bureaucratic solutions and states “nurse practitioners know they are about to be elevated in the national healthcare dialogue.” This is jargon for “patients should not expect to see a doctor.” The article warns that in Massachusetts, a leader in experimenting with universal health insurance, only half of primary care practices are accepting new patients.

Finally, The Doctor’s Company, a medical malpractice insurance company recently released a survey of 5,000 physicians to measure doctors’ opinions and thoughts about the coming ACA implementation. 60% of respondents thought that the increased patient volume will hurt the level of care they can provide. 43% said they are thinking about retiring in the next five years. And nine out of ten said they would discourage friends and family members from pursuing a career in medicine.

Sooner or later we will be forced to rediscover the credo that there’s no such thing as a free lunch. Shifting costs from one person to another doesn’t lower costs. A central plan to make something affordable always makes it unaffordable.

Until then, patients should find a primary care doctor who they really like. They should do so right now. And they should ask frankly how he or she plans to handle the coming wave of newly-insured patients. And now that I’m thinking of it, they should buy him some candy.

Learn more:

John C. Goodman: Why the Doctor Can’t See You (Wall Street Journal Opinion)
Affordable Care Act brings influx of patients (Medical Economics)
Nine Out of 10 Physicians Unwilling to Recommend Health Care As a Profession, Exacerbating Anticipated Physician Shortage (The Doctors Company press release)

My previous posts on the primary care shortage and the economics of healthcare:
Rescuing Primary Care
More Match Day Misery
Rational Rationing
Torpedoing Primary Care
The Healthcare Meltdown
On Being Doc and Being Happy
Will Primary Care Survive?

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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August 10, 2012 | 12:51 pm

Preventing Falls in Older Patients

Posted by Albert Fuchs, M.D.

Image credit:
MaineHealth.org

Falls are the most common cause of injury in adults 65 years or older. About one third of adults in that age group fall at least once per year, and 5% to 10% of those falls result in a broken bone, a laceration, or a head injury. Injuries sustained due to falls can cause a permanent decrease in mobility and independence.

The harm that results from falls is much harder to treat than to prevent. One way to prevent the harms due to falls is to test for and to treat osteoporosis. Another way is to try to prevent older people from falling in the first place.

In the current issue of Annals of Internal Medicine, the US Preventive Services Task Force reviewed the existing evidence about various methods of fall prevention and recommended that all adults aged 65 or older who are at increased risk for falls receive vitamin D supplementation and exercise or physical therapy.

Who is at increased risk of falling? Very simple assessments that are easily done by primary care doctors can identify these patients. Patients with a history of falls, a history of mobility problems, or poor performance on a simple walking test are likely to fall in the future.

The fact that vitamin D supplementation prevents falls in older patients is not new. (I wrote about it two years ago.) The mechanism by which it does this is unclear. Perhaps it helps muscle strength or balance. But it’s a simple and harmless intervention. Exercise and physical therapy are also well-established methods to improve balance and mobility and help patients stay on their feet. And of course exercise has lots of other benefits.

A home assessment for fall risks by a geriatric case manager can also be helpful, though the USPSTF did not find enough evidence to recommend this for all older adults. Making sure that loose rugs are either secured or taken away, that stairs are well lit and have rails, and that grab bars are available in bathrooms can help someone with imperfect vision or imperfect gait stay stable.

So if you have a loved one who is stumbling occasionally, make sure her doctor knows. Some vitamin D and some physical therapy may make a big difference.

Learn more:

Scientists Weigh In on Fall Prevention (NY Times)
Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement (Annals of Internal Medicine)
The Most Recent Celebrity Vitamin: D (My post in 2010 summarizing the current evidence about vitamin D supplements)
Tai Chi Improves Balance in Patients with Parkinson’s (My post in February about Tai Chi for fall prevention)
The timed Get-Up-and-Go test (The Society of Hospital Medicine)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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August 3, 2012 | 10:38 am

West Nile Virus Cases at Eight Year High

Posted by Albert Fuchs, M.D.

Photo credit:
Wikimedia commons

It’s summertime! Summer is the perfect time for swimsuits, outdoor grilling, throwing Frisbees, and contracting dangerous untreatable viral infections.

West Nile is a virus that is transmitted by mosquito bites. Four out of five people infected with West Nile Virus have no symptoms and never feel sick. About one in five infected people develop fever, headache, body aches, vomiting, or a rash. Less than one in a hundred will develop serious neurologic complications such as inflammation of the brain or inflammation of the tissues that surround the brain. Some of those people will have permanent neurological deficits, and some will die.

The Centers for Disease Control and Prevention (CDC) issued a press release this week warning that more West Nile Virus cases were reported in the US this year than at any time since 2004. 241 cases have been reported this year, including four deaths. Most of the cases have been in Texas, Mississippi, and Oklahoma, but a handful have been in California.

There is no specific treatment for West Nile Virus infection, and no vaccine. So the only way to battle this illness is prevention.

The CDC information page on West Nile Virus has some useful common sense advice about avoiding mosquito bites and eliminating mosquito breeding sites. They suggest the following.

• Use insect repellents when you go outdoors.
• Wear long sleeves and pants during dawn and dusk.
• Install or repair screens on windows and doors. Use air conditioning rather than leave unscreened doors or windows open.
• Empty standing water from items outside your home such as flowerpots, buckets, and kiddie pools.

So stay away from mosquitoes this summer. Because this advice is about all we can do for West Nile Virus.

Learn more:
West Nile virus disease cases up this year (CDC press release)
Severe West Nile Cases Rise (NY Times)
CDC: Most cases of West Nile virus reported since 2004 (CBS News)
West Nile Virus (CDC information page)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment