December 30, 2011 | 12:58 pm

Do You Want to Read What I Write About You?

Posted by Albert Fuchs, M.D.

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All patients have a right to a copy of their medical record. In practice that right is rarely exercised. It usually means submitting a request in writing, paying a fee for photocopying, and waiting weeks for someone to copy and mail the records. The development of electronic medical records has the potential to revolutionize patients’ access to their records, making it possible for patients to review their records securely whenever they want from any internet-connected computer.

But would patients want that? Would it improve their care? Would it help or hinder their doctors’ work?

An interesting study aims to answer these questions. The pilot program, called OpenNotes, approached primary care physicians working for three health care systems in Boston, Seattle, and rural Pennsylvania. These physicians were already working in organizations that used electronic health records. Some of these records already had features that allowed patients access over the internet to their medication list or to their laboratory test results, but none offered patients a chance to review doctor notes. The study proposed to give patients access over the internet to their physician notes for one year. All the physicians in the three locations were invited to participate but had the option of declining. Only the patients of participating physicians were given access to their notes.

We won’t have the actual results from the OpenNotes project for another year. This issue of Annals of Internal Medicine published the results of questionnaires completed by the physicians and the patients prior to the study. The questionnaires asked the physicians and patients about their expectations of how patient access to notes will impact care, and about the potential benefits and harms of this access.

The difference in the answers between physicians and patients was surprising. The authors of the study expected younger and more educated patients to be more optimistic about the project, since these patients would be more technologically savvy and feel they deserve greater control over their care. Actually most patients, regardless of age or education, were very optimistic that the project would be helpful to their medical care, would help them understand their care better, and would give them more control over their care.

Physicians were much more restrained in their optimism. Doctors who opted into the program were obviously more optimistic than doctors who declined to participate, but many doctors in both groups expressed concerns that access to progress notes may increase anxiety and confusion among patients. It’s easy to imagine a patient presenting with symptoms which could be due to many different diseases. Doctors routinely document the many possibilities that will be tested and excluded or confirmed. Many of those possibilities are terrible diseases that will turn out not to be present. Will patients want to know before the test results are available all the scary possibilities? Patients expressed very little concern that reviewing progress notes will make them more anxious or confused. Is that because they are psychologically sturdier than doctors fear, or because patients are naïve about what they’ll be reading?

An accompanying editorial in the same issue describes the experience at M.D. Anderson which has already been offering all its patients online access to their entire medical record, including doctors notes. The editorial states that the M.D. Anderson experience has been largely positive. Patients appreciate having access to their notes, and feel better educated about their disease and treatment. They claim that impact on physician workflow has been minimal.

We’ll find out the results of the OpenNotes project in a year. As healthcare in general moves away from paper records, patients and physicians will have to struggle with balancing transparency with discretion, openness with privacy, and empowerment with guidance.

Learn more:

Patients Want To Read Doctors’ Notes, But Many Doctors Balk (Shots, NPR’s health blog)
Do you want to see what doctors write about you? Apparently, you do (Booster Shots, LA Times health blog)
Inviting Patients to Read Their Doctors’ Notes: Patients and Doctors Look Ahead (Annals of Internal Medicine article)
Access to the Medical Record for Patients and Involved Providers: Transparency Through Electronic Tools (Annals of Internal Medicine editorial)

Tangential Miscellany

The nice folks at the American College of Physicians Internist blog are republishing some of my posts. You’ll be happy to know that the fame hasn’t affected me yet.

I wish you a prosperous, healthy, and happy 2012!

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.

December 23, 2011 | 1:18 pm

Don’t Put Unsterilized Tap Water Up Your Nose

Posted by Albert Fuchs, M.D.

I like introducing you periodically to some of the stranger and more dangerous germs out there. It’s a good reminder that nature isn’t just full of daisies and rainbows, and that the most lethal dangers we face are natural.

This week’s news presents a terrific example. Meet Naegleria fowleri. Naegleria fowleri is an amoeba, a single celled parasite that lives in warm bodies of fresh water, like lakes and rivers. Its nickname is the brain-eating amoeba. Isn’t that nice? (My nickname is Al.)

Before we find out why Naegleria (neg-LE-ria) is in the news, let’s get some background.

Infection with Naegleria is very rare. There have been 32 reported cases in the U.S. in the last ten years. Drinking water contaminated with Naegleria is perfectly safe, as Naegleria does not cause infection when swallowed. Naegleria only causes infection when contaminated water goes into the nose. Most cases have occurred in people swimming in fresh water lakes and rivers, frequently in southern states and usually in warmer weather. Some cases have also occurred in swimming pools that were not chlorinated.

When infection occurs, the amoeba crosses from the nasal sinuses into the brain and causes a disease called primary amebic meningoencephelitis (PAM) in which brain tissue becomes inflamed and is destroyed. As any neurologist or fan of zombie movies will confirm, destroyed brain tissue is bad. PAM is almost always fatal. It’s a good thing it’s so rare.

This week, a new mechanism for acquiring Naegleria infection came to medical attention. A woman in Louisiana became the second in the state to die this year from Naegleria that was likely acquired through the use of a neti pot. A neti pot is a small container shaped like a genie’s lamp that is used to flush water up the nose to clear nasal congestion. Many people with nasal allergies or colds prefer irrigating their noses and sinuses rather than taking decongestants. This is an important reminder that nasal irrigation should always be done with sterilized water – water that has been boiled or filtered. Unsterilized tap water is not safe for nasal irrigation. Remember, Naegleria in drinking water is perfectly safe, unless it’s flushed up the nose.

The Louisiana Department of Health published a press release warning of the potential danger of using neti pots with unsterilized water. The alert reminds us that neti pots or other nasal irrigation systems should be washed between uses and allowed to air dry. This effectively kills any amoeba in the equipment.

So if you are going to flush water up your nose, either buy sterile saline from your drug store, or boil some tap water first.

Finally, should we worry about swimming in lakes or rivers? Perhaps, but not because of Naegleria. Of the tens of thousands who swam in bodies of fresh water in the last decade in the U.S. only 32 developed Naegleria infection. During the same time period, there were over thirty thousand deaths due to drowning.

Learn more:

Neti pot danger? Two die from amoeba infection (Booster Shots, LA Times Health Blog)
Second Neti-Pot Death From Amoeba Prompts Tap-Water Warning (Shots, NPR Health Blog)
North Louisiana Woman Dies from Rare Ameba Infection (State of Louisiana Department of Health & Hospitals)
Naegleria, Frequently Asked Questions (Centers for Disease Control and Prevention, Parasites)

Tangential Miscellany

Lighting the darkness is a major theme of Hannukah. The holiday falls close to the winter solstice, when nights are the longest, and it always includes the night of a new moon, when the night is darkest. Increasing numbers of candles are lit every night and the menorah (candelabra) is placed by a window to be visible from the outside. It is a conscious rebellion against the cards dealt to us by nature. As the world gets darker, we illuminate our small corner of it and push back the night.

I hope in the last year my posts have illuminated a few dark topics for you. Thank you for reading. To everyone celebrating, Merry Christmas and Happy Hannukah!

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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December 16, 2011 | 8:28 am

The Final Chapter

Posted by Albert Fuchs, M.D.

“Soon I will rest, yes, forever sleep. Earned it I have.”—Jedi Master Yoda

I have some bad news for you. You’re going to die.

Not soon, I hope. But for the foreseeable future the death rate will remain one per person.

This week a patient pointed me to a wonderful article by Ken Murray, “How Doctors Die”. Dr. Murray, a USC Family Medicine physician, argues that doctors faced with terminal illnesses very frequently forego aggressive care and die peacefully at home, while other patients are subjected to invasive, painful, and futile care at the end of life. I urge you to read the article. In fact, you might want to read it first and then return to this post.

All doctors have seen cases of patients receiving invasive, aggressive, futile care. Some cases involve not just care that is unlikely to help, but care that has been shown in studies not to help, like feeding tubes placed in patients with dementia, or CPR performed on patients dying of cancer. This is a calamity because it subjects patients who are frequently frail and in the final days of their lives to gratuitous suffering without any potential benefit. Worse, as if the suffering of the patients’ disease was not bad enough, the suffering due to futile care is inflicted by physicians. Though Dr. Murray also highlights the astronomical cost of futile care, I think the economic argument is unnecessary and counterproductive. These cases are a calamity even if the care was free. Patients should understand that we are appalled at such outcomes because of the harm done to patients, not because of the wasted resources.

Dr. Murray describes the problem well and recommends the path frequently chosen by physicians when they themselves are ill – hospice care, a focus on quality of life, and death at home. But how do we convince patients that this is best? Many patients believe that medical technology is omnipotent, and that recommendations for hospice care amount to giving up. Other patients, bewildered by the complexity of healthcare delivery, suspect that doctors have a financial motive to withhold lifesaving care. These misunderstandings can only be reversed if there is trust between patient and doctor.

Doctors, of course, share much of the blame. Ordering another test, recommending another procedure, and prescribing another medicine are all easier than giving a patient and her family terrible news. Maintaining a false hope is easier than explaining that this illness will be the last.

The best patients can do is to tell loved ones their wishes in advance, and develop a long-term relationship with a doctor they trust.

The best doctors can do is be honest when things are dire, and recommend against futile care with patience and compassion.

“May you die well.”—Klingon benediction

Learn more:

How Doctors Die (Zócalo Public Square)

My previous posts about end-of-life care:

When Less Care is More

A Dose of Realism about Advanced Dementia

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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December 9, 2011 | 4:41 pm

A Reminder to Dump Your Multivitamin

Posted by Albert Fuchs, M.D.

The Medical Letter is a biweekly publication which publishes the most unbiased reviews of medications. It is not supported by advertising and prides itself in giving objective evidence-based information. I think it’s mandatory reading for anyone with a prescription pad. Several of my posts have been inspired by Medical Letter articles, and this week they’ve come through again with a review of vitamins titled “Who Should Take Vitamin Supplements?” The article reviews in detail the clinical trials which have tested the effects of the most commonly taken vitamins. I summarize these below.

Vitamin E supplements have been shown to increase the risk of prostate cancer, not to decrease the risk of stroke or heart attack, and not to decrease the risk of eclampsia in pregnancy.

Beta-carotene is a precursor of vitamin A. A randomized trial in smokers found that a high dose beta-carotene supplement significantly increased the risk of lung cancer. Another randomized study in asbestos workers showed that supplementation with vitamin A and beta-carotene led to higher lung cancer rates than placebo.

Vitamin D is essential in older people in preventing fractures and falls. Many people with limited sun exposure are deficient in vitamin D.

Vitamin C has been shown not to prevent the incidence of cancer, strokes, or heart attacks. It does not significantly decrease the risk of developing a cold or significantly improve cold symptoms. High doses can predispose to kidney stones.

Vitamin B12 deficiency is common in older patients and can lead to anemia and nerve dysfunction.

Folate should be taken by all child-bearing-age women to prevent neural tube defects in their babies. Folate supplementation has no known benefits in men.

Vitamin B6 supplementation has been proven not to decrease the incidence of strokes, heart attacks, or any cancer.

The authors conclude:

“In healthy people living in developed countries and eating a normal diet, the benefit of taking vitamin supplements is well established only to ensure an adequate intake of folic acid in young women and of vitamins D and B12 in the elderly. There is no good reason to take vitamins A, C or E routinely. No one should take high-dose beta-carotene supplements. Long-term consumption of any biologically active substance should not be assumed to be free from risk.”

That last sentence deserves our attention. Many people assume that even if vitamins aren’t helpful, they are at least harmless. The Medical Letter reminds us that this assumption should be tested, and when tested is sometimes proven false.

Learn more:

More Than Half of Americans Take Dietary Supplements (My post in April on multivitamins)
All my previous posts on various vitamins
Who Should Take Vitamin Supplements? (The Medical Letter article, issue 1379, only by subscription)

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

December 2, 2011 | 5:49 pm

Niacin Much Less Helpful in the Age of Statins

Posted by Albert Fuchs, M.D.

Niacin has been getting some bad press recently. A brief retrospective of Niacin’s rise to prominence will help us understand its recent fall from favor.

Niacin is also known as vitamin B3 or nicotinic acid, a molecule that we need in tiny quantities in our food. As far back as the 1950s it was known that niacin in higher doses reduces blood levels of cholesterol. At that time our understanding of heart disease was in its infancy and there were few effective medications to treat or prevent cardiovascular disease.

From 1966 to 1969 a trial called the Coronary Drug Project (CDP) was conducted that would prove to be niacin’s finest hour. The CDP enrolled patients who had suffered a prior heart attack and randomized them to placebo or niacin. My understanding of those years suggests that all the patients wore paisley shirts, had very long hair, rioted outside political conventions, and landed on the moon. The trial showed a reduction in strokes and heart attacks of about 25% in the patients receiving niacin. The CDP findings from over 40 years ago are the strongest suggestion we have that niacin helps prevent cardiovascular disease. The important thing to remember about the CDP is that many of the medications that are now used routinely in patients with heart disease, like aspirin and certain blood pressure medicines (beta blockers) were used rarely then. But that’s not surprising. After all, back then we thought that polka dots and hair were attractive in any quantity. Can you dig it?

Fast forward twenty years. The paisley and polka dots were replaced by skinny ties and Ray-Bans. The first statin, lovastatin (Mevacor), appeared on the market in 1987. My regular readers know that statins are a family of cholesterol-lowering medications which have been extensively proven to prevent strokes and heart attacks. Statins are also the most potent reducers of LDL, the cholesterol molecule most linked to stroke and heart attack risk. Meanwhile, other medications like aspirin and beta-blockers were proven to extend life and prevent heart attacks in people with prior heart attacks. The management of heart disease was progressing by leaps and bounds, and mortality from heart disease has been decreasing ever since.

So statins rapidly overshadowed niacin for management of cholesterol, and for good reasons. Niacin has side effects that are more difficult to tolerate, it lowers cholesterol less, and the evidence of its ability to prevent strokes and heart attacks is largely from one study – the CDP. Nevertheless, niacin has continued to be prescribed, largely because it has one benefit that statins don’t have. Niacin elevates the levels of HDL, a cholesterol molecule that is associated with lower heart attack and stroke risk.

This year a large trial called AIM-HIGH attempted to answer whether niacin taken with a statin is superior to a statin alone in patients with cardiovascular disease and low HDL. I wrote about the AIM-HIGH study in May when it was completed but before the full results were published. The full results were finally published two weeks ago. (You may want to read my May post for details about the study and for a more detailed explanation of LDL and HDL.)

The study enrolled patients with known cardiovascular disease with low HDL and randomized them to two groups. One group received a statin (simvastatin, sold under the brand Zocor) and niacin. The second group received simvastatin and a placebo. The niacin group had lower LDLs, higher HDLs, and lower triglycerides than the placebo group. But surprisingly there was no difference between groups in the rate of strokes and heart attacks.

What does this mean? Why didn’t better cholesterol numbers translate to better outcomes?

The first possible explanation (which I offered in May) is that low HDL is simply a marker of heart attack risk, not a cause. This is the same reason that putting an ice cube on your thermometer on a very hot day won’t make you feel more comfortable, since the thermometer reading is a marker for your discomfort, not a cause. Another explanation is that niacin alone does have some benefit (as shown in the CDP) but that the benefit of more modern medications is much greater. And that in the presence of statins and aspirin and other proven medications, niacin may not offer any additional advantage. Both explanations may be true.

So we’re likely seeing the waning days of niacin use. It may remain a reasonable option for patients who can’t tolerate statins. For the majority of patients who can tolerate statins, niacin has no value.

Learn more:
No Benefit From Niacin for Heart Patients in Study (US News)
Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy (New England Journal of medicine article)
Niacin at 56 Years of Age — Time for an Early Retirement? (New England Journal of Medicine editorial)
Needed: Pragmatic Clinical Trials for Statin-Intolerant Patients (New England Journal of Medicine editorial)
Niacin Does Not Prevent Strokes or Heart Attacks (my post in May about Niacin)

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

November 23, 2011 | 8:18 am

Reflections on Gratitude

Posted by Albert Fuchs, M.D.

For each new morning with its light, For rest and shelter of the night, For health and food, For love and friends, For everything Thy goodness sends

Thanksgiving By Ralph Waldo Emerson

It’s been a difficult year for many of my patients. Some have had catastrophic health challenges. Many businesses are still struggling. Some marriages are fraying. Many of us are very unsure of what comes next.

When things look irredeemably hopeless, when I have nothing but bad news to give, when I really wish someone else was the doctor for one day, that’s when I am reminded what an extraordinary job I have. I am privileged to be a part of people’s lives at their scariest, most personal, darkest times. I hear their anxieties, their confessions, and their secrets. I do my best to help, and to assemble a team of specialists to do the many things I can’t do. But ultimately all help fails.

And the one thing my patients teach me again and again when things are at their worst is gratitude. I hear about the love of family, the comfort of happy memories, the joy of looking back without regrets. In the most desperate situations when I would expect panic or grief, I hear gratitude.

Tomorrow is the day to remember all of our abundant blessings. We all have so much to be grateful for. This year I’m especially grateful to my patients for allowing me to make a living doing what I love, and for reminding me constantly of the importance of gratitude.

As is my annual tradition, I hereby lift all my patients’ dietary restrictions for one day. I wish you happy feasting in homes filled with cheer and joy! Happy Thanksgiving!

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

November 18, 2011 | 5:54 pm

Yoga Or Stretching Helps Chronic Back Pain

Posted by Albert Fuchs, M.D.

Everyone hates stress, and for good reason. Stress makes us miserable. Perhaps for that reason, stress is blamed for virtually every disease for which the cause is still unknown. Later, when we discover the true cause, we find that it is unrelated to stress. We thought stress causes stomach ulcers before discovering the bacterium that is the true culprit. We thought stress caused heart attacks before a study comparing high-stress to low-stress individuals showed that this wasn’t true. Stress causes gray hair? Nope. Genes cause gray hair. Irritable bowel syndrome is probably the next disease on this list. We’re close to sorting out what causes it, and when we do, we can stop blaming stress.

So stress causes misery, which is bad enough, but we should be careful not to scapegoat it for other ills.

A study in the Archives of Internal Medicine last month adds another illnesses for which stress may not be relevant.

Chronic back pain is common and has no universally effective treatment. Lots of patients swear by yoga, and for many with chronic back pain it seems to improve their symptoms. Is this simply because the exercises stretch their backs and legs, or is the breathing and meditative component also helpful? After all, countless people attest to the stress-lowering properties of yoga. Shouldn’t less stress decrease chronic pain?

To test this question, researchers enrolled over 200 patients with chronic back pain and randomized them to three groups. One group attended weekly yoga classes. A second group attended weekly stretching classes. A third group was given a self-care book teaching exercises for low back pain and was asked to follow the book’s instructions independently. All the patients had their functional status and pain levels measured by periodic questionnaires.

As expected, the yoga group did better than the self-care group. But surprisingly, the yoga group did no better than the stretching group. This suggests that the benefit for back pain from yoga is entirely related to the stretching, with no additional improvement from the meditation and breathing exercises.

That’s not to say that the breathing exercises and the meditation don’t feel good, which might be reason enough to do them.

So chronic back pain may be another illness that doesn’t have as much to do with stress as we thought. But stress makes us unhappy and strains our relationships. That’s reason enough to find ways of managing stress.

The holidays are around the corner, which for some of us are particularly stressful. So when you’re feeling very anxious and want to tell a loved one who is annoying you “You’re giving me an ulcer,” remember that he’s not. Take a deep breath and say something like “You’re not giving me an ulcer, a heart attack, or gray hair, but I wish you’d stop anyway.”

Learn more:

Yoga, stretching both ease chronic back pain: US study (Reuters)
Yoga May Help Low Back Pain. Mental Effects? Not So Much (Wall Street Journal)
A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain (Archives of Internal Medicine, abstract available without subscription)

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

November 11, 2011 | 10:14 am

Difficult to Digest Carbohydrates Implicated in Irritable Bowel Syndrome

Posted by Albert Fuchs, M.D.

Irritable bowel syndrome (IBS) is a chronic condition marked by abdominal pain, bloating, and alternating constipation and diarrhea. There is no specific test for IBS and other more serious diseases like celiac disease and inflammatory bowel disease can cause similar symptoms. The good news is that when a doctor has ruled out these more serious diseases and diagnosed IBS the patient can be assured that her illness is chronic but not progressive or life-threatening. The bad news is that IBS symptoms can be quite miserable, and at their worst can interfere with work and life activities.

Myriad treatments are used for IBS, and as with any disease with myriad treatments, that means that none of them are consistently effective. I wrote five years ago about a trial that showed modest success using antibiotics for IBS but even that trial did not show an improvement in the majority of patients.

A new theory proposed by researchers in Australia holds that IBS is caused by certain sugars that are difficult to digest. These sugars pass undigested through the small intestine and are fermented by bacteria in the colon. This releases carbon dioxide which causes bloating and pain, and draws water into the colon which causes diarrhea.

These carbohydrates are called FODMAPs, which stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols, which just means small sugars that can undergo fermentation.

FODMAPs are present in lots of foods. (This Wall Street Journal article has a handy table with a list of foods high in FODMAPs and low in FODMAPs.) So eliminating them entirely requires some drastic dietary changes. Nevertheless, the Australian researches published a study in last month’s issue of the Journal of Human Nutrition and Dietetics in which patients were randomized to standard care or to a FODMAP-free diet. About half of the patients in the standard group had symptom improvement, compared to about three quarters of those on a FODMAP-free diet.

Gastroenterologists who are promoting this theory recommend that patients try a FODMAP-free diet for six to eight weeks and then slowly reintroduce FODMAP-containing foods to determine what quantities they can tolerate. Unlike food allergies, complete abstinence is not necessary. It’s just a matter of reducing the FODMAPs below whatever threshold causes misery.

Some caveats are necessary. The study was quite small, and it was not blinded since it’s impossible not to know whether your diet is being restricted radically. So the results should be treated as suggestive but preliminary. Still, for those with severe IBS symptoms a FODMAP-free diet may be worth a try. It may be inconvenient but it’s certainly safe and the worst that could happen is that it won’t work.

Learn more:

When Everyday Foods Are Hard to Digest (Wall Street Journal)
Very Restricted Diet May Reduce Symptoms of IBS (WebMD)
Irritable Bowel Syndrome (National Library of Medicine information page)
An Oral Antibiotic Reduces the Symptoms of Irritable Bowel Syndrome (my post in 2006)
Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome (Journal of Human Nutrition and Dietetics, abstract available without subscription)

Tangential Miscellany

If you appreciate the right to speak as you wish without fear of censorship or punishment, the right to wave a sign declaring your displeasure with how much income the top 1% earn, the right to occupy public places and protest Wall Street and be generally tolerated, if you value these rights, then thank a veteran. Happy Veterans Day.

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