January 11, 2013 | 11:31 am

This Year’s Flu Season Isn’t Mild

Posted by Albert Fuchs, M.D.

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Photo credit:
CDC

The last two years have graced us with atypically mild flu seasons. This year we’re not so lucky. The flu season seems to have started early, and at least on the East Coast is quite severe. This week Boston has declared a public health emergency as their emergency departments became swamped with flu cases. In Pennsylvania, a hospital erected a tent outside its emergency department for the increasing number of flu patients. The number of flu cases is increasing in California too, though we may be a week or two behind the wave of illness that has struck the East.

What should we all do to avoid getting sick?

• Everyone over 6 months (except for a few exceptions) should get the flu vaccine.
• If you get sick, stay home except to get medical care.
• While sick, limit your contact with others as much as possible.
• Wash your hands frequently with soap and water or with hand disinfectant, and avoid touching your eyes, nose, and mouth.

There are antiviral medicines that can decrease the duration of the flu. They are only recommended for people who are likely to have serious complications from the flu – pregnant women, older people, or people with chronic illnesses. If you are in those categories, contact your doctor at the first sign of flu symptoms. Antiviral medications are more effective the earlier they are started.

The season hasn’t peaked yet, and may turn out to be just moderate. We’ll know in a few weeks. In the meantime I recommend a little social distancing until the worst is behind us. Stay a couple of feet away from people. Say hi with a friendly wave instead of a handshake. Write an IOU to be redeemed in the spring for the hug and kiss with which you usually greet a friend. She’ll thank you if it turns out either of you is about to get sick.

And get your flu shot.

Learn more:

Flu Season Strikes Early And, In Some Places, Hard (Associated Press)
As Cases Spike, Flu Season May Be Peaking In Boston (Shots, NPR health news)
Number of NYC flu cases higher than in past years (Wall Street Journal)
Google Flu Trends for Los Angeles Seasonal Influenza: Flu Basics (Centers for Disease Control and Prevention)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention)
Hospital Opens Emergency Tent in Midst of Increasing Flu Cases (NBC Phiiladelphia)

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.

January 4, 2013 | 3:37 pm

Many Women Who Don’t Need Them Are Still Getting Pap Tests

Posted by Albert Fuchs, M.D.

Cervical cells collected in
Pap tests: normal cells on
the left, precancerous cells
on the right.
Ed Uthman/Wikimedia
Commons

My regular readers know that I frequently bemoan the fact that we have no effective way to test for most cancers, and that in many cancers early diagnosis does not improve survival. Cervical cancer is one of the few exceptions. Since Georgios Papanikolau developed the test named after him, the Pap test has dramatically reduced the incidence and mortality of cervical cancer.

More recent advances have shown that cervical cancer is caused by human papilloma virus (HPV), a sexually transmitted infection. Specific testing for HPV is now frequently performed in addition to the Pap test, and a vaccine against the most dangerous strains of HPV is likely to further decrease cervical cancer incidence.

We also now understand that the changes that HPV cause are detectable years before cervical cancer occurs, so the interval between tests can be quite long. Current recommendations are for all women between the ages of 21 and 65 to have a Pap test every three years. If HPV testing is also used, women over 30 can be safely tested every 5 years.

Women over 65 who have been previously tested and have had normal test results are unlikely to benefit from further testing. Also women who have had a total hysterectomy (surgery in which both the uterus and cervix are removed) do not need further Pap tests, because they don’t have a cervix. (An important exception is women who have had a hysterectomy because of cervical cancer or pre-cancerous changes.)

This week brings us evidence of too much of a good thing. The current issue of Morbidity and Mortality Weekly Report (MMWR) published a survey of women over 65 and women who have had hysterectomies. It asked them if they had a recent Pap test. Two thirds of women over 65 answered affirmatively as did 59% of women who have had hysterectomies. I found that as surprising as if 59% of bald men were still going to their barber regularly. It’s hard to know what’s behind this behavior. These women can’t benefit from the tests they’re undergoing. Perhaps this is a manifestation of long-established habits for both the doctors and the patients. Another possible explanation is that some of the women surveyed are simply wrong. The study didn’t actually check medical records, and some of the women may have thought that they had been tested when they hadn’t. Obviously, the most pernicious possibility is that many doctors are still recommending useless testing to patients who trust them. (If Medicare paid for haircuts one wonders how many bald men would still go to their barbers, just for the attention and social interaction, and how many barbers would sent reminder postcards to their bald patients.)

So if you’re between 30 and 65 and are having both Pap tests and HPV testing and your results have been normal, give yourself 5 years between tests. And if you’re over 65 and your tests have been normal, or you no longer have a cervix, congratulate yourself for permanently escaping cervical cancer and feel free to forego further testing.

Learn more:

Pap Tests For Cervical Cancer Are Often Wasted (Shots, NPR health news)
CDC: Women with hysterectomies getting unneeded Paps (USA Today)
Cervical Cancer Screening Among Women by Hysterectomy Status and Among Women Aged ≥65 Years — United States, 2000–2010 (MMWR)
Announcement: Cervical Cancer Awareness Month — January 2013 (MMWR)
US Preventive Services Task Force recommendations for cervical cancer screening
My post in 2009 summarizing the recommendations for Pap tests: Should You Have a Pap Smear?

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 28, 2012 | 4:46 pm

On the Passage of Time

Posted by Albert Fuchs, M.D.

Sunrise. Photo credit:
Wikimedia Commons

The sun will come up tomorrow.
– Little Orphan Annie

But in a trillion tomorrows the sun will become
a red giant and extinguish all life on earth.
– astronomers

If you’re reading this, you’ve completed another loop around the sun. Congratulations.

Marking space is easy. Walls, fences, lane dividers, buoys, flags, are all ways of communicating that the space over there is different than this space over here. Marking time is harder. We need holidays, calendars, events to remember that what comes after is different than what came before. While we can revisit places, we can’t revisit times.

So as the rightmost digit on the calendar is about to be incremented, it’s a good time to reflect on the successes and the setbacks of 2012 and to make realistic goals for 2013. The only thing about 2013 about which I am certain is that we’ll only get to do it once.

I wish us all a prosperous, healthy, and joyous 2013!

Learn more about time:

Dave Brubeck, one of the greatest Jazz composers ever, died in 2012. Here is a link to his best known song, from the album Time Out, which was a collection of experiments with different time signatures.
Dave Brubeck Quartet – Take Five (5 minutes)

How is it that the past is so different from the future? Why can we remember 2012 but not 2013 (at least yet)? Why can’t you uncook an egg or unburn a match? Those with a background in science know that the answer relates to the Second Law of Thermodynamics. I’ve seen no better discussion of this fascinating question targeted to a general audience than the following lecture by Richard Feynman.
Richard Feynman – The Character of Physical Law -Lecture 5 -The Distinction of Past and Future (46 min)

Lucius Annaeus Seneca: On the Shortness of Life

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 21, 2012 | 1:59 pm

Niacin: Ineffective, and Now with Fewer Side Effects!

Posted by Albert Fuchs, M.D.

Photo credit:
Wikimedia commons

I haven’t written about niacin for over a year, and like a misunderstanding of the Mayan calendar that won’t go away, niacin is in the news again this week.

You can catch up on the old news by reading my previous posts (links below) but here’s the story in a nutshell. People with high levels of a cholesterol molecule called LDL tend to have more strokes and heart attacks than people with normal LDL levels. People with low levels of a cholesterol molecule called HDL tend to have more strokes and heart attacks than people with normal HDL levels. (Does that mean that LDL causes strokes and heart attacks or that HDL prevents strokes and heart attacks? Nobody knows.) We've long known that taking niacin raises HDL and lowers LDL. That should be good, right? And in fact a study called the Coronary Drug Project in the 60s and 70s showed that in patients with a previous heart attack, taking niacin modestly reduced the risk of another heart attack.

More recently, many other medications have been proven to prevent strokes and heart attacks – aspirin, statins (a family of cholesterol reducing medicines), and beta blockers (a family of blood pressure medicines). These medicines are now in widespread use. Statins especially have very solid evidence that they greatly decrease the frequency of strokes and heart attacks, and now that some of them are available generically they are used extensively. Last year, the AIM-HIGH trial tried to discover whether patients with a history of cardiovascular disease and low HDL had better outcomes by taking niacin with a statin than by taking a statin alone. They didn't  The rates of strokes and heart attacks were the same in both groups, strongly suggesting that in the age of statins, niacin has no additional benefit.

Now, when faced with a medication that has no benefit, I typically decide not to prescribe it, but not the folks at Merck. They were thinking “How can we decrease the side effects?” Why it would be valuable to decrease the side effects of a medicine without benefit is a mystery that only Mayan astronomers are likely to solve. In any case, the most common and bothersome side effect of niacin is facial flushing, so Merck came up with a tablet in which they combined niacin and a second drug, laropiprant, which prevents the flushing. This combination medicine, called Tredaptive, has been in use in Europe since 2007.

A large trial designed to win FDA approval for Tredaptive ended this week. The results won’t be formally published for some time, but Merck has already released some important tidbits. The study randomized over 25,000 patients to Tredaptive and simvastatin or to simvastatin alone. The patients were monitored for over four years. There were no differences in rates of strokes or heart attacks between the groups, but the Tredaptive group had an increase of a “serious adverse event” the details of which Merck has yet to release. In an unusual move, Merck has asked European physicians not to start new patients on Tredaptive.

This new finding should throw a wet blanket on the few remaining niacin enthusiasts. Niacin use has declined since the AIM-HIGH study and now should decline further. It has no benefit in the vast majority of patients who can tolerate statins.

Learn more:

Why Merck's Niacin Failure Will Scare Drug Researchers (Forbes)
Merck Says Niacin Drug Has Failed Large Trial (New York Times)
Merck: Niacin Drug Mix Fails To Prevent Heart Attacks, Strokes (NPR Shots)

My previous posts about niacin:
Niacin Much Less Helpful in the Age of Statins
Niacin Does Not Prevent Strokes or Heart Attacks

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 7, 2012 | 5:10 pm

Flu Season Hits Earlier than in Recent Years

Posted by Albert Fuchs, M.D.

Flu incidence by week
(CDC)

This year’s flu season seems to be starting earlier than usual and is getting more intense by the week. The Centers for Disease Control (CDC) reports in its weekly summary of flu surveillance that flu cases are increasing across the country. California still is showing only sporadic flu activity, but 8 other states report widespread activity and 15 others report regional activity.

The CDC reminds us that it’s not too late to protect yourself and those around you by getting a flu shot. The vaccine is recommended for everyone over 6 months of age. And the CDC also has other helpful suggestions for preventing flu transmission. If you’re sick, stay home and limit contact with others. Avoid touching your eyes, nose, and mouth. Cover your coughs and sneezes with a tissue. And wash your hands frequently.

I've seen no randomized studies suggesting that lighting candles, singing songs, or eating latkes decreases transmission of flu, but I recommend it anyway. Happy Hanukkah!

Learn more:

Unusually Early Flu Season Intensifies (NPR Health)
Situation Update: Summary of Weekly FluView (CDC)
Google Flu Trends for Los Angeles
Key Facts About Seasonal Flu Vaccine (CDC)
CDC Says “Take 3” Actions To Fight The Flu (CDC)

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 30, 2012 | 6:41 pm

When it Catches on They Won’t Call it Concierge Medicine

Posted by Albert Fuchs, M.D.

Photo credit: Liz Ramos-Prado
One more illustration

The idea that patients are better off paying their doctor directly and using their insurance only for unaffordable catastrophes is gaining some traction. With implementation of the Affordable Care Act looming in 2014 many patients are looking at their doctor’s already crowded waiting room and wondering how their care will be impacted when their doctor is responsible for even more patients. And doctors who even now are swamped and frustrated with insurance bureaucracy are wondering how much worse things will get when they have less time for more patients.

Yesterday Bloomberg Businessweek published an article which asks “Is Concierge Medicine the Future of Health Care?” The headline lifted my spirits because of its happy presumption that healthcare has a future. The article interviews several concierge doctors. It makes the important point that practices in which patients pay doctors directly are now thriving at many different prices. From practices charging tens of thousands of dollars a year targeted to the very affluent to practices charging $50 per month for blue collar workers, doctors have found that they can take better care of patients by caring for fewer of them and by concentrating on practicing medicine the way they were trained, not by focusing on what’s covered by a policy.

The article brings up some very common criticisms of concierge medicine that deserve to be answered.

One objection is that concierge medicine leads to a two tiered system in which the affluent get attentive care and everyone else doesn't  That’s nonsense. The whole point of the article is that direct-pay care is working at many different prices and that some of the practices are targeted to middle class patients. There are already many more than two tiers of healthcare – the County system and Medicaid for indigent patients, private HMO insurance, staff model HMOs, PPOs, direct-pay practices, etc. How many tiers are there in other marketplaces, like food, housing, or clothing? A practically uncountable number. One characteristic of robust marketplaces is that they offer goods at widely varying prices. That means that those who need to save can still afford some access to the marketplace but those who can afford more can get better comfort, or better quality, or more reliability. I can get across town for the price of a bus ticket or the price of a BMW. (I ride my bike.) How many tiers is that?

Another objection is that by shrinking their practices to only those who can afford them, doctors who switch to the concierge model are exacerbating the coming primary care physician shortage. Of course the opposite is true. The physician shortage in primary care is fueled by the fact that people aren't choosing to go into primary care. Nothing will attract more students into primary care than examples of happy doctors who are making a living practicing in a way that is both ethical and enjoyable. Concierge doctors are not the cause of the shortage; we’re the fix. What would the critics prefer? That we stay in the insurance model and tell medical students how miserable a career in primary care is? That we drop out of medicine all together?

I think the main barrier to even faster growth of concierge medicine is the name. Another problem is that the insurance model is so entrenched in our understanding that we now think of getting routine care through insurance as the “regular” way it works. We don’t have a name for it anymore. If someone says “I saw my doctor” we just assume that someone else paid for it. If she says “I saw my concierge doctor” we understand that she paid herself. But it should be the other way around. We don’t have a word for an accountant or a plumber or a lawyer who gets paid directly by his clients. They’re not concierge accountants or concierge plumbers or concierge lawyers. We need to get to the point that paying a doctor directly doesn't deserve an adjective before the noun “medicine”. Paying your doctor is just medicine. Having someone else pay for you is insurance medicine.

The Buisnessweek article quotes Josh Umbehr, a concierge doctor in Whichita.

“Health insurance should work more like car insurance,” says Umbehr. “We have car insurance for all the big stuff, but we pay for gas, tires, and oil changes ourselves.”

He's right. I wish I’d thought of that.

Learn more:

Is Concierge Medicine the Future of Health Care? (Business Week)
Dealing With Doctors Who Take Only Cash (NY Times)
Dollars to doughnuts diagnosis (My 2008 op-ed in the LA Times that explains why I got out of the insurance model) 

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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November 21, 2012 | 11:21 am

Giving Thanks

Posted by Albert Fuchs, M.D.

I’m grateful that I have a home.

I’m grateful that my home has electricity and heating.

I’m grateful that I have work.

I’m grateful that I love what I do.

I’m grateful that I’m healthy enough to attempt a 77 mile bicycle ride this weekend.

I’m grateful that tomorrow I will be gathering with lots of loved ones to eat more than is prudent and to count our innumerable blessings.

I hope you will do the same. 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 16, 2012 | 11:48 am

Revenge of the Parasites

Posted by Albert Fuchs, M.D.

Malaria parasites inside
human red blood cells
(Photo credit: Wikipedia)

Malaria is a life-threatening illness marked by high recurrent fever, shaking chills, and severe headache. Though malaria is now treatable, even with treatment it sometimes progresses to coma and death. Survivors frequently suffer recurrent symptoms and can be debilitated. The World Health Organization estimated that in 2010 there were 216 million people infected with malaria. Hundreds of thousands of them died, though precise estimates are lacking.

Malaria has plagued people for tens of thousands of years. It may have contributed to the decline of the Roman Empire. Very little was known about malaria until the late 1800s when the parasite that infects the red blood cells of malaria patients was first observed under a microscope. Later work discovered that mosquitoes were responsible for transmitting the parasite from person to person. Since that time malaria control has involved a combination of mosquito control, avoidance of mosquito bites, medication to prevent infection, and medication to treat infected patients. Despite advances in all these fronts, malaria remains a tough adversary. It was the most dangerous health hazard faced by U.S. troops in the South Pacific in World War II. As many as half a million troops were infected.

In the second half of the twentieth century as developed nations became more affluent, malaria elimination was a marker of their progress in public health. Mosquitoes were sprayed. Standing water was drained. The U.S eliminated endemic malaria transmission in 1949. Greece did the same in 1974. That doesn't mean that there were no cases in the U.S. (or Greece) since then, but that all the cases were imported. People who were infected abroad would travel to the U.S. and become ill here, but no one has been infected in the U.S. since 1949.

Well, forty six years later malaria is regaining lost ground. This week the Wall Street Journal reported that endemic malaria transmission has returned to Greece. That means that infected mosquitoes are infecting people in Greece for the first time since the 70s. In the past two years there have been over 50 endemic cases of malaria in Greece and over 100 imported cases. So far there have been no deaths.

Since its economic collapse three years ago, Greece’s public health system and its mosquito eradication efforts have been hard hit. The nation’s ability to care for patients and to prevent infection has been hobbled by worsening scarcity of resources and financial uncertainty. In response, the U.S. Centers for Disease Control and Prevention (CDC) has released an outbreak notice advising travelers to take precautions to prevent mosquito bites when traveling in Greece. Travelers to the agricultural regions of Evrotas should also take prescription medications to prevent malaria.

My friends who were born in the U.S. sometimes think that human progress is inevitable and irreversible, that the human condition can only improve over time as if propelled upward by some natural law, like water flowing downward. I was born in Romania, so I know that this isn't so. I know that a modern affluent country can be utterly ruined. If you have friends from Iran or Cuba, they’ll tell you the same thing. (If you don’t have friends from Iran or Cuba, make some. Then beg to be invited to their homes for a meal. In both cases, the food is delicious.)

Perhaps the return of malaria in lands from which it was eliminated is a sign of the local cracking of the thin veneer of civilization. Perhaps it is a very late marker of societal collapse or of fiscal profligacy. If that is the case, it may be wise in the next few years to bring insecticide and mosquito nets to Italy, Spain, Portugal, and eventually, to California.

Learn more:

Health Scourge Hits Greece (Wall Street Journal)
Malaria in Greece (CDC Outbreak Notice)
Malaria (Wikipedia)

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