Sunday, May 31, 2009

Participatory Medicine will Change the Health Care World as we Know it!

One of the reasons eDocAmerica exists is to empower patients to take more control of their own health care. A wonderful group of people, patient advocates, physicians and other professionals alike have created a broad platform for this "e patient" movement, called Participatory Medicine. This group was originally assembled by Tom Ferguson, MD, an esteemed colleague who died after a courageous battele with Multiple Myeloma, and has since continued to meet. They created an excellent blog site, that anyone who is interested in this subject should visit regularly.

Participatory medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (healthcare professionals, patients, caregivers, etc.) as integral to the full continuum of care. The ‘participatory’ concept may also be applied to fitness, nutrition, mental health, end-of-life care, and all issues broadly related to an individual’s health. This group is forming a society, the Society of Participatory Medicine and, soon, there will be a web site where interested parties can join and "participate" in the discussion. The society's first president is Alan Greene, MD, author of popular Pediatric website In addition, the Society is founding a new journal, the Journal of Participatory Medicine. The Journal will bring together the best available evidence and examples of participatory medicine to:
a) Make a robust case for its value to people – sick or well –, advocates, and health professionals
b) Serve as a meeting place and rallying point for those at the leading edge of participatory medicine
c) Engage, inform and include those who have been involved in, or practicing, participatory medicine. We aim to advance both the science and practice.

The mission of the Journal is to transform the culture of medicine to be more participatory; and we believe that doing so, as the saying goes, will take a village – perhaps even a large metropolitan area! JPM constitutes a major investment of time and talent in community development. The journal will be entirely electronic, using the Open Journal System platform of online publishing. Yours truly, along with Jessie Gruman, the founder and president of the Center for Advancing Health (CFAH), an independent, nonpartisan Washington-based policy institute funded by the Annenberg Foundation, the W.K. Kellogg Foundation and other foundations, will serve as Co-Editors in Chief of this new journal. We expect to publish our first issue of the Journal sometime in the fall of this year.

This is an exciting group of talented, engaged people who have the capacity to create something that will make a major difference in our health care system. eDocAmerica has a powerful collaborative opportunity here to participate with other key individuals and groups to help change health care!

Your comments and opinions are always welcome...

Friday, May 29, 2009

Is it Time to Rethink Aspirin?

Aspirin? - Yes, I should take that to prevent heart attack and stroke, right??
Well......perhaps. A new study (called a meta-analysis), the largest comparative trial of its kind, shows that being overzealous about aspirin use for prevention of initial heart attack and stroke may be unsubstantiated.

Specifically 95,000 subjects were evaluated in this series, producing 1671 strokes and heart attacks in the aspirin group and 1883 in the control group. Aspirin was associated with an absolute reduction of 0.06% heart-related events per year. Correspondingly, aspirin did not significantly reduce ischemic (non-bleeding) stroke risk, but researchers noted a borderline-significant increase in hemorrhagic (bleeding) stroke. Aspirin also increased the incidence of bleeding outside the brain. Overall, aspirin was not associated with a significant reduction in vaascular death.

What does it mean? The advantages of aspirin in low risk patients are scant. As cardiovascular risk factors (like smoking, high cholesterol, high blood pressure, diabetes, family history of early stroke/heart attack) pile up, aspirin gains a bit more support, though there is a modest associated bleeding risk.

We will be following this data and it's analysis further. In the meantime, it may be reasonable to discuss things with your doctor, or perhaps cut aspirin dosing to the appropriate lowest dose (81mg in most patients).

Want the original? See Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009 May 30; 373:1849. We will post the appropriate link after publication to make it easier.

Monday, May 18, 2009

Overcoming your Headaches

One of our most revered faculty members, Lee Archer, MD, a neurologist, provided a copy of the handout he gives to his headache patients. With his permission, I adapted it for use with my own patients. I thought it was so good that I asked him if I could publish it on my blog so that others could benefit from his advice.

Headaches are incredibly common and usually frustrating for providers. It has become increasingly evident that chronic or frequently occurring headaches are often virtually impossible to identify as either "migraine" or "tension" headaches and often simply are called "chronic headaches". Treatment often becomes a revolving door of trying new medications that sometimes work, but more commonly don't. And, even worse, many headache patients gradually simply become dependent on addictive pain medications just to try to cope with their often daily discomfort.

But, there are some really basic things about dealing with chronic headaches that we should never forget to try. So, without further ado, here is his advice:

Ten Steps to Overcoming Your Headaches

There are some things that everyone can do to help their headaches. There are a number of things you can besides just take medication to help their headaches. If someone follows all of these directions, the need for prescription medication is often dramatically reduced if not eliminated.

1. First and foremost, taking pain medication everyday is definitely not a good idea. Daily pain medication tends to perpetuate headaches. This is true for over-the-counter medications like Excedrin and BC powders, as well as prescription medications like Fiorinal, Midrin, and “triptans” like Imitrex, Zomig, Relpax, Frova, etc. Exactly why this occurs is unclear, but it is a well established clinical finding. Anyone who takes pain medications more than twice a week is in danger of perpetuating their headaches. Occasional usage of pain medications several times in one week is permissible, as long as it is not a regular pattern. For instance, using pain medication several days in a row during the perimenstrual period is certainly permissible.

2. Regular exercise helps reduce headaches. Exercise stimulates the release of endorphins in the brain. These are chemicals that actually suppress pain. I encourage people to aim for at least 20 minutes of aerobic exercise (like walking or swimming) five days a week if not daily. In addition to helping reduce headaches, this also will prolong your life because of the beneficial effects on your heart.

3. Stress reduction is a definite benefit in reducing headache frequency and severity. Headaches are not caused by stress alone, but can make most headaches worse. There are no easy answers for how to reduce stress. If it is severe, we can consider referral to a therapist for help.

4. Too much or too little sleep can trigger headaches. Pay attention to this, and note whether or not you are tending to trigger headaches from sleeping too little or too much. People differ as to how much sleep is “right” for them.

5. Caffeine can precipitate headaches. I encourage patients to try stopping caffeine altogether for a few weeks, and we can decide together whether or not caffeine might be contributing. Abruptly stopping all caffeine can trigger headaches, too, so try to taper off over a week.

6. NutraSweet (aspartame) can cause headaches in some people. If you are drinking multiple servings/day of beverages containing NutraSweet you might consider trying to stop that, and see if your headaches respond.

7. There are some other foods they may trigger headaches in some people. Usually people learn this very quickly. For instance, red wine will precipitate migraines in many people, and chocolate, nuts, hot dogs and Chinese food triggers headaches in certain cases. I generally don’t advise omitting all of these foods, unless you notice a pattern where these foods are causing headaches.

8. If I give you a prophylactic medication for headaches, you should take it daily, as prescribed. If you have trouble tolerating it, please let me know and we can consider using something else. No prophylactic medication works in every patient with headaches. Generally, each of the medications works in only about 60% of people. Therefore, it is not uncommon to need to try more than one medication in any given patient. We must give any of these medications at least four to six weeks to work before giving up on them. It generally takes that long to be sure whether or not a medication is going to work.

9. Keep a calendar of your headaches. Use a standard calendar and mark the days
that you have a headache, how severe it is on a scale of one to ten, what you took
for it and how long it lasted. Also note anything that you think could have
precipitated it. By keeping this over time we can tell if our efforts
are helping.

10. Riboflavin (vitamin B2) 400mg daily helps prevent migraines in many people. It
comes in 100mg size tablets, so you will need to take four of them each day. You
can add it to anything else we try. You do not need a prescription for it.

Do you have chronic headaches? If so, I challenge you to apply these ten principles, then come back and provide a comment on this blog post!

Thanks and good luck!

The Measure of a Life Well Lived

When it’s all said and done, when the piper has played his last note, the farm is well and truly purchased, the bucket come to rest, and the fat lady’s final lyrical note but a fond memory, what is the yardstick we use to measure the worth of our lives? Do we tally up bank accounts to see who won? There will always be someone whose net worth is greater than the next guy’s. Mine, unfortunately will not even be a contender for that particular prize. Maybe we could compare the grandeur of our cars. Mine is a clunker well past its warranty, but it holds a lot of good memories. My car’s value is not in its blue book value, but in the memories it holds. So if memories are more important as a measure of a life well lived than monetary possessions, how do we measure memories?

We should measure the worth of our memories by those who will carry them on after we are long gone. How many people have you positively touched in your life? How many of those were a lasting, memorable touch? How many of those went on to touch others because of your actions? This is your measurement. This is your legacy.

Randy Pausch touched millions while he lived, and continues to have a positive impact on people’s lives today. I’ve included a video clip of his address to the graduates of Carnegie Mellon University. I think everyone should watch this clip at least once in their lives. And stay tuned through the end when he carries his wife off stage and gives her a beautiful kiss behind the stage. Your relationships with the special people in your life are what really matter when it’s all said and done. This is what people will remember. Not the degree you earned, not the handy little nest egg you managed to build, not even the size of your office - although it seems very important now.

And when it is your time and they record the important stuff on your tombstone, what will it say? Your name that your parents chose, you didn’t have anything to do with that. Your birth date, again, more your parent’s business than yours. And your death date. You shouldn’t decide that either. No, the only thing you have to show for an entire life is the dash between the dates. And how many of us make it a hard, fast dash to the finish line? So this entire life that is summed up by a mere dash etched in granite is where we insert the memories of the relationships, the love, the life, the passion, the person.

“Even though our culture puts a strong emphasis on attaining wealth and fame, pursuing these goals does not contribute to having a satisfying life. The things that make your life happy are growing as an individual, having loving relationships, and contributing to your community," says co-author Edward Deci in a news release about his article, Achieving Fame, Wealth, and Beauty are Psychological Dead Ends.

So when it’s all said and done, let’s have no regrets on our way to the top of the ivory tower of our choice. Let us be remembered as a person who had a positive impact on others, who loved and lived life to the fullest, and made the most of the time we had. Play on piper. Ours will be a mighty dash. We’ll measure up just fine.

Friday, May 8, 2009

Missing Someone Special on Mother’s Day: Coping Strategies in Action

Mother’s Day is just around the corner and web pages and blogs are full of gift idea do’s and don’ts for your mother. I won’t go there. I think the topic has been covered quite nicely by better shoppers than I could ever hope to be.

You’ve also, no doubt, been bombarded with the plethora of tear jerker emails cautioning you to spend time with your mother while you can. She’s older than you, you know, and may not last until next year for you to make it up to her if you miss this Mother’s Day. That topic’s been covered too.

I’d like to talk with you a little bit about how to get through Mother’s Day after you’ve lost your mother. And I especially don’t want to forget the reverse situation; how to cope with Mother’s Day if you have lost a child, the hardest pain of all to overcome.

So how do you survive this Sunday if half of the equation is missing? You could hide under the covers until Monday. The protective property of the blanket works for monsters under the bed, why not against monsters of the heart as well? You could ignore that the day has any other meaning and treat it like any other Sunday, but that tends to backfire with a nasty trap of emotions smacking you back into reality the hard way at the worst possible time. Don’t let it catch you off guard; the day is coming whether you are ready for it or not. Or you could cry in your beer (over 21, please), but that just makes your eyes red and dilutes the beer.

Here are some coping strategies for bereavement:

Talk about it with a friend or family member you trust to handle the sensitive and powerful emotions you feel towards Mother’s Day

Realize that Mother’s Day is only one day out of the year and it has been commercially blown out of proportion and this too shall quickly pass

Be around friends who understand and can help you cope with the day

Acknowledge it can be a hard day and distract yourself with a movie or something that has a positive and endearing memory of what this day was initially designed to represent

And remember that your mother will always be your mother no matter where she is. And the same goes for mothers who have lost children. Once a mother, you will always be a mother even if you can no longer hold them in your arms.

If you are an eDocAmerica participant, you can send a message to the ePsych Psychologist for individualized coping strategies. Many people use this helpful option with good results whether it’s Mother’s Day or not.

All comments welcome.

Monday, May 4, 2009

When Pigs Fly: Dealing with the Swine Flu Jitters

Remember the old adage, "that'll happen when pigs fly"? Well, the swine flu is floating around.... Does that count?

If so, we have nothing to worry about with the swine flu; it's merely a symptom. The real things you need to worry about are all of the "that''ll never happen" things that are about to come true. Like Carrot Top winning a Nobel Prize or the Rams winning the Superbowl, or a black man being elected president. Oh wait, that's already happened and I voted for him. See? It's already started. What will happen next? Will Angelina stop adopting kids?

I think it's time to put the swine flu epidemic in perspective. According to a recent WebMD article: In a typical U.S. flu season, an average of 36,000 people die of flu or flu complications, and about 200,000 people are hospitalized.

Swine flu hasn't come anywhere close to that. Swine flu has sickened at least 141 people in the U.S. and 365 people worldwide, according to the CDC and World Health Organization's tally of lab-confirmed swine flu cases as of Friday, May 1.

Here in Arkansas at UAMS there has been such a run on Tamiflu prescriptions, an anti-viral medication, that all physicians have been requested to think very carefully before giving in to patient hysteria when prescribing this medication. Predictions are that much of the Tamiflu prescribed will never be taken, but it is removing significant numbers from pharmacy shelves which may be detrimental in the future should we need it. So far, there are no reported cases in Arkansas.

So how do you stay informed without letting the hysteria take over your life?

Adopt Rational Measures

· Hand washing. Mom always said, “Wash your hands” because she knew it prevents more illness than any other single proactive thing you can do to keep yourself healthy. But we don’t want to tip the scales into obsessive compulsive behavior. Wash your hands as needed relative to your situation and exposure. If you have minimal contact with others at work, you are not at as great a risk as someone in the health, school, nursing home or daycare industry.

· Cover your mouth. Another gem from Mom. It is common courtesy to cover your mouth when coughing or sneezing, then go back to the first example given here and wash your hands.

· Avoid sick people when you can. You can’t avoid your sick husband or two year old, but if someone is hacking up a lung in isle three, use isle seven to get to the milk.

· Go home if you’re sick. Don’t expose everyone else in the office just because you have to update your spreadsheet. It is much more cost effective for you to miss a day than the entire office.

Restrict Media Exposure

· A little bit can go a long way. The best way to scare yourself about anything is to become an expert on the subject. Too much information can generate its own anxiety. Only read what you need and leave the technical stuff to the experts who get paid to worry.

· Be a good role model for your children and grandchildren. Your role is to take care of them and make their world a safe and secure place. So if they see you watching CNN all day long willing to drop everything when they announce an update, children will take that fear you are demonstrating and multiply it out of orbit. Do not transfer your fear into your child’s anxiety. Unless you like staying up with a four year old too afraid to go to sleep because the swine flu might get them.

The bottom line is stay informed, but stay sane in how you go about it. Keep your update watching in moderation and take normal precautions with the health of yourself and your family. Yes, moderation works for swine flu fear too.

And since we are in Arkansas and our favorite football team is the Razorbacks, I’d like to add that the only swine you should fear is on the football field, “GO HOGS!”

Sunday, May 3, 2009

Vitamin D May Be Our Most Important Vitamin Supplement

Vitamins are those special chemicals that help our bodies function properly. Most studies support getting our vitamins in food rather than in supplements. Food products naturally balance the content of nutrients including vitamins, and it is possible to take too much of some vitamins if we take supplements. Besides Vitamin D, discussed here, the other most important vitamin supplement is folic acid (a B vitamin) if you are a woman and might get pregnant, and during pregnancy.

Recent studies show that Vitamin D is beneficial for many things, from preventing diabetes and heart disease to preventing cancer and having healthy bones. Vitamin D is not really a vitamin but a hormone substance that is vital to the body. Hormones are chemicals produced in one part of the body and travel to other parts to help the body function. The thyroid gland, the ovary and the testicle are examples of organs that make vital hormones. Turns out, Vitamin D is made in the skin from sun exposure and travels throughout the body doing good work.

To avoid skin cancer, and because of living indoors much of the time, we are not getting as much Vitamin D as our ancestors. Sunscreen blocks the sun absorption that produces Vitamin D. There is a lot of discussion today about getting enough "healthy" sun exposure to both produce Vitamin D and yet not raise the risk of skin cancer. About 20-30 minutes a day of direct sunlight to our skin seems to be more beneficial than harmful. Natural sun is preferred rather than "tanning booths" that only give certain UV radiation.

Vitamin D can be taken as oral supplements. In the past, 200 - 400 IU was considered an adequate daily dose, and many calcium supplements have this amount of Vitamin D. The Institute of Medicine Food and Nutrition Board now feels that we should be getting 1000 - 2000 IU daily. Stay tuned to this as the discussions are ongoing. The good news is that Vitamin D is readily available and inexpensive to take. It may be the most important of all vitamin supplements for children and adults of all ages. People with limited sun exposure, dark skin, over age 50 and overweight or obese have an increased need for the supplement. It is safe in doses up to 2000 mg for adults. Supplement doses for children are still being worked out.

So, put Vitamin D down on your list of important health habits and consider both your regular "healthy" sun exposure and taking a supplement.