Friday, January 25, 2013

What to Do If You Have the Flu

Flu season is in full swing this year, with thousands of Americans suffering from its symptoms. The Centers for Disease Control (CDC) has estimated that an average of 36,000 people in the U.S. die from influenza or from its complications each year. Influenza is particularly hard on the elderly, people with a weakened immune system, children, and those with chronic illnesses, such as emphysema and diabetes.

Several weeks ago, a Health Tip went out encouraging everyone 6 months or older to receive the flu immunization. As expected, most of this year's flu cases have occurred in those who were not vaccinated. Unfortunately, getting a flu shot does not guarantee that you will not get the flu. While immunization remains the most effective way of preventing the flu, recent statistics from the CDC indicates that the effectiveness of the vaccine this year is 62%. This means that if you received the vaccine you are about 60 percent less likely to get the flu, but not completely immune.

How do you know if you have the flu? Mild cases of the flu can be similar to a common cold, but typically, the flu is much more severe. Muscle aches, severe fatigue, cough and headache predominate over common cold symptoms of runny nose and sore throat. Characteristic of the flu also is fever (100-102 degrees F) that can last for three to four days. Of particular concern in those who contract the flu are its complications, including bronchitis and pneumonia, which are responsible for the majority of flu-related hospitalizations and deaths.

What you can do for the flu? Most people with the flu end up being miserable for a few days, but recover on their own. A number of non-prescription medications, while not treatments for the virus itself, can help with flu symptoms. Over-the-counter medications and self-care measures include:
  1. Limiting activity and getting plenty of rest.
  2. Staying hydrated by drinking water, sports drinks or electrolyte replacement fluids.
  3. Gargling salt water (1 : 1 ratio) or using throat lozenges for sore throat.
  4. Taking acetaminophen (e.g. Tylenol®) or ibuprofen (e.g. Advil®, Motrin®, others) for fever or muscle aches.
  5. Taking decongestants (Claritin-D, Sudafed, others) can ease discomfort from stuffy nose, sinuses, ears, and chest.
  6. Using cough medicine or cough drops for temporary relief from coughing.
It is important that aspirin be avoided in anyone under the age of 18 with the flu because of its association with Reye syndrome, a condition affecting the nervous system and liver. In most people, medical attention or antiviral drugs are generally not required.

When should someone seek medical attention? People at increased risk of serious flu-related complications, including young children, elderly persons, pregnant women and people with chronic illnesses, such as diabetes, should contact their medical provider with the first signs of an influenza infection. Emergency warning signs in children include difficulty breathing, bluish skin color, extreme irritability, inability to keep food or liquids down, and high fever. Adults with shortness of breath, confusion, chest or abdominal pain, and persistent vomiting should receive urgent medical care. Someone in whom flu symptoms improve initially but later develop worsening cough and fever may have a bacterial infection and should receive medical attention.

What is the doctor able to do? Antiviral medications are modestly effective in shortening the duration of the flu and may help to avoid complications. For these to work effectively, however, it is important to start treatment within 48 hours of the development of symptoms. Below are antiviral medications approved for treating adults and children one year and older:
  1. oseltamivir (Tamiflu)
  2. zanamivir (Relenza)
  3. amantadine (Symmetrel)
  4. rimantadine (Flumadine)
In December 2012, the U.S. Food and Drug Administration expanded the approved use of oseltamivir for treating children between the ages of 2 weeks to one year. Antibiotics used for bacterial infections, such as Ampicillin, Keflex, Cipro, etc., are not used to treat uncomplicated cases of the flu. These may be required, however, with certain flu-related complications, such as pneumonia or ear infections.

When can I return to work or school? The Centers for Disease Control recommends that people recovering from the flu stay at home for at least 24 hours after their fever is gone. While at home, flu victims should avoid contact with others in the household to keep them from getting sick. Also, frequent hand washing will help to keep from infecting others.

Sunday, January 20, 2013

Is it Possible to Really Receive "Whole Person" Care?

This week, along with a psychologist colleague, Chris Rule, I began a Balint Group with senior Family Medicine residents at the University of Arkansas.  This approach was inspired by Michael Balint, a general practitioner in London who led groups of GP's along with his partner and wife Enid at the Tavistock Clinic in the late '40's and early '50's.

Balint explored concepts such as the "collusion of anonymity", in which he decried the tendency of specialists to pass patients around to each other with no one caring for the whole patient.  So, through the use of these groups, and the use of case presentations with discussion, he set out to deeply explore the nature of the doctor-patient relationship and to encourage his colleagues to "go deeper", to "listen to patients in a new way" and to recognize that much of the value of being a primary care doctor had nothing to do with ordering tests, writing prescriptions or assigning a physical diagnosis to every symptom.

He noted that, time after time, the groups' patients "offered" up a symptom and the doctor "accepted" it, in a sense allowing that process to thwart the opportunity to explore what was truly going on with the patient.  This process in no way means that the physician seeks to find a psychological cause to all symptoms but it does suggest that no one in the health care system is as well positioned to integrate psychosocial issues with biological issues to truly provide whole person care.  To do this, the physician must learn to truly listen to patients, without jumping to a diagnosis or treatment approach too soon to get to the real issues.

This is why I went into Family Medicine and why, after 39 years of training and practice, I am still inspired to go to work every day.   I'm still learning how to get better at talking to, and understanding, patients.  And, I thank mentors like Michael Balint for providing the model for integrating medicine and psychology for us.

Sunday, January 6, 2013

Is Your Doctor Reconciling your Medications?

The Institute of Medicine’s (IOM) seminal study of preventable medical errors estimated as many as 98,000 people die every year at a cost of $29 billion.  Everyone who is taking medications should be concerned about the adverse potential of medication side effects, as well as problems due to drug interactions.  The Joint Commision, recognizing the risks of medication use, has begun to place  major emphasis in its surveys of hospitals on a process called "medication reconciliation". 

Medication reconciliation involves a detailed review of current medications and doses, including assurances that the patient is taking the medications and doses as listed in the record.  This process is especially important during transitions of care such as at the beginning of a hospital admission, transfer of a patient from one unit to another, from surgery to the medical floor, or upon discharge from the hospital.  It is also important, during routine visits to the doctor and, whenever a new medication is listed, determination made that no adverse interactions are likely with the new combination.

I strive to reconcile medications at every patient's visit with me.  This may occur during annual preventive care visits or during follow up visits with patients who have chronic disease states such as diabetes or hypertension.  The process also needs to include over the counter medications and supplements, in addition to any prescriptions provided by another physician.  I am continually amazed that, in virtually every visit, a patient's medication list requires at least one or more modifications.  I am also amazed that, whenever I see someone else's patient, the list is frequently woefully inaccurate and, in many instances, appears to have never been reconciled.

What, then, is the point of this article?  It is to make patients more aware of the importance of medication reconciliation and challenge you to become an active partner in the process with your primary care physician.  How can you do this?  Many clinics print out a medication list for review when you check in to the clinic.  If this is not happening, I suggest requesting it from your team.  Additionally, it will be helpful for you to bring a list of the medications and doses that you are currently taking, as this will provide a helpful and accurate tool for the nurse or physician to use to "reconcile" your medication list. 

A brief list of the various actions that may result from this process will illustrate the importance of medication reconciliation:

1. Elimination of drugs that the medical teams think you are taking, but aren't.
2. Identification of, and deletion of, medications that could be causing a dangerous drug interaction.
3. Elimination of drugs to which you may be allergic.
4. Drug by drug review of potential side effects you may be experiencing.
5. Addition of drugs provided by another doctor that your primary physician did not know you were taking.

You can become a more active participant in your own health care by assisting, or initiating, the process of medication reconciliation and making sure it happens with every visit to your doctor. 

Your comments or opinions are always welcome.