UAMS Steps Up its Support of Primary Care by Creating a Service Line (and I have a new Job)

UAMS has initiated a Primary Care Service Line and I have accepted their offer to lead it. It is an exciting time for us and for me personally, after over 25 years in my current job as Executive Associate Dean for Clinical Affairs. Here is a copy of the announcement that went out yesterday: Dear Colleagues: We are pleased to announce that Charles W. Smith, M.D., has accepted our offer to be the Director of the Primary Care Service Line. In addition, he will also serve as the Medical Director of the Service Line. Due to the opening of our new distributed clinics, we are accelerating the startup of the Primary Care Service Line in order to adequately support these clinics. Eventually, all primary care services sponsored and supported by UAMS will be a part of the service line. As founder of the UAMS Center for Primary Care, Dr. Smith has been focusing increasingly on this vital component of our clinical enterprise in the past few years. In his new post, he will oversee planning, development, and implementation of the service line, which includes working with the Chairs of the various primary care oriented departments, recruiting and appointing the administrator of the service line as well as the clinic directors, serving as a member of the Council of Service Line Directors, and numerous other service line duties. In his new role, he will report through the Chief Service Line Officer to Dr. Townsend, the Vice Chancellor for Clinical Programs. Dr. Smith is ideally suited for this new role. He has worked in various roles to promote clinical programs and clinical teaching in the College of Medicine and UAMS for the past 25 years. He joined the faculty as a Professor in the Department of Family and Preventive Medicine and Associate Dean for Clinical Affairs in 1989 and was promoted to Executive Dean in 2007. For a number of years, he served in both Associate Dean role and the UAMS Medical Center Medical Director roles. While he will begin service line duties immediately, he will gradually transition out of his current role as Executive Associate Dean by the end of this calendar year. Among many accomplishments, Dr. Smith established the Physician Relations Office to improve processes for referrals and communication with referring physicians. A key component of the office is the UAMS Associates Program, which coordinates annual visits by staff liaisons to 750 referring physicians in Arkansas to provide information and hear and relay their concerns to campus leadership. Dr. Smith also founded the Diagnostic Clinic for referrals. Dr. Smith’s dedication to providing more effective health care for Arkansans kindled his longtime interest in electronic medical record (EMR) implementation and facilitating the use of web technology. He chaired the implementation committee for the campus’ first EMR system and has remained an active leader in EMR adoption, including the comprehensive EPIC system. Dr. Smith has been a leader in the development of a patient portal, online physician consultation and online call schedules. In 1997 he founded an award-winning, web-based medical information company, eDocAmerica, a UAMS BioVentures-supported startup that provides patients with tools, information and input from medical professionals to help individuals make better decisions about their health and health care. Dr. Smith is a founding Co-Editor in Chief of the Journal of Participatory Medicine, an online, peer-reviewed journal of the Society of Participatory Medicine. He has served as President of the American Board of Family Medicine, Deputy Editor of American Family Physician, and Chair of the Association of American Medical Colleges Group on Faculty Practice. He has published many articles in his field and co-authored a book, the Handbook of Family Practice. Prior to his recruitment to UAMS, Dr. Smith was Dean of the School of Primary Medical Care at the University of Alabama School of Medicine in Huntsville. He received his medical degree from the University of North Carolina in Chapel Hill, where he completed his family practice residency. Please join us in welcoming Charlie to his new post. G. Richard Smith, M.D. Roxane A. Townsend, M.D. Dean, College of Medicine Vice Chancellor for Clinical Programs Executive Vice Chancellor, UAMS CEO, UAMS Medical Center

You Can't be Healthy if you don't Exercise

This morning, one of my colleagues admitted: "Charlie, you know I don't work out".  Even though she seems healthy, I immediately replied: "You know, you can't be healthy, if you aren't involved in a regular exercise program!" 

Do you agree with me that this is true?  Most of my patients and friends do, but many of them claim a variety of reasons for not doing it. 

Perhaps the most common reason I hear for a lack of regular exercise is not having sufficient time.  But my answer to you is that no one has time, they just have to make it.  How can you do this?  By just scheduling your exercise session and dropping everything else to do it.  After all, what is more important than improving and safeguarding your health?  I believe those that do not have enough time to exercise simply aren't putting this high enough on their priority list.  As for me, I found that if I don't get up early and get my workout in before I leave for work, I have a lot of trouble juggling personal and family needs when I get home in the afternoon.  If becoming and staying healthy is truly important to you, it is worth adjusting your daily schedule to ensure 30 min or more of aerobic exercise on at least 5 days of the week.

One of the other very common reasons I hear for not exercising is people telling me that they are too tired.  However, exercise is actually a good treatment for fatigue!  Researchers at the University of Georgia found that persons who exercised for at least 20 minutes at least three times a week for 6 weeks were much less likely to report fatigue than those who didn't exercise.

It's never too late to get started with this program.  If you are currently sedentary, you should start slow and work up to 150 or more minutes per week of aerobic exercise.  Increase your duration and intensity by about 10% per week until you reach your goals.

So, get on board and get healthy!

 

What is a Vacation Anyway?

What is your idea of a vacation? 

Most consider it to be a week or two (or more) of kicking back in the pool or on the beach.  My wife, Connie, and I returned today from a week in our house in Fayetteville, AR.  Our idea of a relaxing week away from the grind of everyday life may strike you a bit differently than the traditional vacation.  We enjoy our own version of a week of fitness "boot camp".  Well, it may not be THAT intense, but it certainly is active.  We wake up early, eat breakfast and walk for 2 1/2 hours, with our Golden Doodle "Dolly" in tow.  This usually includes a cinnamon roll break at the Little Bread Company, one of the coolest little places you have ever seen and, currently, rated the # 1 eating establishment in Fayetteville.  It is essentially a hippie joint where the employees all seem happy and the ambience of the place puts you in a great mood.  On our way back to our house, Dolly terrorizes 3 or 4 squirrels in the center of the U of A campus. 

Before lunch, we load a yoga video for 20 to 30 minutes before replenishing for the afternoon.  These are devoted to biking on our tandem.  Fayetteville, courtesy of the Waltons, is almost finished with a dedicated walking/biking path from Fayetteville to Bella Vista, AR, a distance of about 35 miles. It is called the Razorback Greenway. Since it not yet quite finished, we spent most days doing about a 25 mile loop from Lake Fayetteville to south of town but, one of the days, we drove to Spingdale to take in the northernmost aspect of the Greenway through Bentonville and the Crystal Bridges grounds to Bella Vista, AR and back.

As a side note, we were there during the annual Wal Mart associate/shareholder meetings and the scene is interesting, to say the least.  There are Wal Mart workers from all over the world there, hosted in student dorms and transported around campus by golf carts and buses.  While I was in Sam's buying a TV, one came up and asked me if I needed help (I did).  I asked him a question he couldn't answer and then I realized he was a Wal Mart associate visiting from South Africa.  The event was hosted by Hugh Jackman and featured concerts by Elton John and Jennifer Hudson.  Interesting company, Wal Mart!

About mid week, we decided it was time to take in Crystal Bridges in Bentonville, founded by Sam Walton's daughter, Alice, and regarded as one of the premier art collections in the world.  To say it is impressive would be a gross understatement.  We are not aficianados but it was very nice and well worth the afternoon we spent seeing it.

Evenings were time to dine out and Fayetteville has diverse, excellent cuisine from Taste of Thai (our favorite) to Celi's Mexican and, the last night Theo's with great salads, wine and Filet Mignon.  We had early dinners, so we would have time for wine and music (courtesy of Pandora) on our deck at home.  A little TV, then to bed and do it again tomorrow.

We came back a little tired and sore, but very relaxed, refreshed and ready to resume "normal life" tommorow. 

Does that sound like a vacation to you?  It certainly does to us!

The Scope of Participatory Medicine--Does it really include Everyone?

Several of my colleagues recently joined me in writing a new chapter to add the White Paper: "E-Patients.  Can they help us heal Health Care?.  This chapter was recently published in the on line Journal of Participatory Medicine, titled "A Model for the Future of Health Care".  The paper describes a health care system where patients and providers participate as partners, with patients largely in control of their own health.  The authors encourage you to open the link, read the paper and add your comments  at the end of the paper.  We would benefit from your feedback!

I asked several friends and colleagues to read and comment on the paper and the responses I got were interesting and a little unexpected.  To summarize, they said:  "This is all well and good, but some patients, even educated ones, just aren't interested in the "participatory" model".  Their point was that many patients trust their providers and don't have the energy or motivation to do on line research, prepare questions for the office visit, or even track their own lab results.  They just want to visit their doctor periodically and hear their recommendations and follow them!

The other feedback theme was that there are still many patients who don't have the health literacy or the technological wherewithal to function as participatory partners in their health.  These are the disabled, poor and disenfranchised.  They don't have smart phones, data plans, lap top computers, ipads or wireless internet access.  Many of them hardly know how to read, much less understand the often complex health discussions found online.

So, in spite of an engaged, activated, increasingly empowered cadre of e-patients out there, those of us in the Participatory Medicine movement have a big problem we need to address:  What do we do about the able but unmotivated, uninterested group and how do we addressthe poor and disenfranchised?

Your thoughts, comments, and expressed opinions are greatly appreciated!

Sometimes, the Best Care is to do Nothing

The dynamics, interactions, and expectations that are played out in the office between doctor and patient can lead to some uncomfortable moments.  Most of the time, as a provider, I feel the need to obtain some test or order new medication to address the patient's issues.   Often, the provider feels obliged to prescribe something, or to obtain a study, even when there is no a clear indication for doing so.  This may be an attempt to provide a satisfactory encounter or to avoid professional liability risk.  Often, appropriately, the provider may be simply giving the patient the benefit of the doubt.  However, it may be a disservice to the patient to prescribe a test or medication if the doctor believes it isn't necessary.  We should, as providers who are committed to high quality care, renew our commitment to carry out the most appropriate course of action, regardless of whether that may lead to an awkward moment with the patient.  Here are a few simple illustrative examples:

• Patient has respiratory illness, probably viral, but requests antibiotic treatment.
• Patient has headache, probably tension, but feels a CT scan should be ordered "for good measure".
• Patient has chest pain and chest wall tenderness, but gets admitted to "rule out" a myocardial infarction.
• Patient has fatigue and mild depression, with "low normal" testosterone level, and asks you to prescribe testosterone supplement.
• Patient has had trouble losing weight with dieting and requests amphetamines for weight loss to "jump start" the process.

These are representative examples, but there are many other scenarios in which the cost or risk of side effects from the treatment likely outweigh the potential beneficial effects.  It is often tempting, rather than taking the time and effort to explain the reason why "a" or "b" is not needed, to go ahead and provide the prescription or order the test, then move on to see the next patient.  When we do this, we not only do the patient a disservice, but we contribute to the unsustainable cost of health care.

I consult a variety of financial, legal, and other professionals expecting them to render their honest appraisal and recommendations.  If this is a recommenation not to do something, I would certainly accept, and appreciate their candor; as a doctor I should do no less!

Your comments and dissenting opinions are always welcome!

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.

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.

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.

What can patients expect after Health Reform?

Big changes are on the horizon for the health care system. Physicians are going to be paid increasingly on the basis of outcomes of care, as well as effectively managing their practice population as a group; for example for all of the patients in my practice with diabetes, what is the average blood sugar of the group and, thus, how good a job am I doing "controlling" the disease state "Diabetes" in our practice?  Less and less can physicians expect to be paid for doing more tests, ordering more x rays and CT scans, and seeing patients in the office more often.  Instead, we will have greater incentives to be available to our patients, to work more effectively as a health care team, to communicate with patients about their test results outside of office visits, and to encourage patients to contact us via e mails, text messages, or online video tools.

These changes will provide major challenges to all of us, and will pose requirements for changes not only for the health care team, but also for the patients.  Below are the 5 things that I believe will be significant changes from the patient's perspective, and will gradually assume a greater presence in physicians practices over the next two to five years:

1. Patients will not need to visit the doctor's office as often.
As primary care practices begin to function as Patient Centered Medical Homes, they will be paid through outcome incentives and on a "per patient per month" basis rather than fee-for-service, making it more desirable to do things in ways other than using the relatively inefficient doctor visit approach.  Followups will occur via e visits and online portals (see below) will allow transmittal and review of data such as glucose and blood pressure monitoring in order to make decisions about the management of chronic disease.

2. Prescriptions will be routinely refilled, and many new prescriptions provided, using e mail or text messaging.
For established patients, there will rarely be a need to come to the office for a prescription refill; rather, using e mail and electronic prescribing, this relatively mundane, administrative aspect of practice will become much more efficient for both doctor and patient.

3. Patients will be challenged to put increased emphasis on preventive practices.
Rewards will be provided to providers for practices that obtain high levels of immunizations, recommended exams, mammograms, cholesterol checks, etc.  This will result in much more focus on preventive practice by your physicians.

4. Interaction with physicians offices will increasingly be through online electronic portals that are connected to the electronic medical record.
One of the primary reasons this method has not taken hold sooner is the lack of payment for it, forcing providers to funnel their patients into office visits in order to make a living themselves.  With the reform methods in the works, these perverse incentives will begin to disappear and the doctor patient relationship will be freed up to be what it should be, with free flowing communication independent of financial constraints.

5. Patients will be increasingly recognized as the drivers of their own health care.
The Participatory Medicine movement challenges patients to recognize that they, not providers, are the drivers of their own health, and to take control of this through acquisition and monitoring of their own health data and by obtaining the information they need to become, and stay healthy.

These are major changes that will not come overnight, but in order for the health care system to avoid bankrupting the country, and to begin to eliminate the billions of dollars spent on medically unnecessary care, they are sorely needed.

Your comments, questions and dissenting opinions are always welcome.

Working Together to Create an Affordable Health System

As we approach the presidential election next week, health reform is front and center as a key issue for the US. Entitlement programs, liability concerns by professionals, broad insurance coverage plans, and patient requests for expensive care have put the country on an unsustainable course that threatens us financially.

Many of the ideas for health reform, including encouraging more comprehensive primary care through patient centered medical homes, bundling payments to providers, and reclaiming money paid to hospitals for unsatisfactory outcomes are nibbling at the edges of what needs to be done.

But I can envision a radically different system from the one we currently have, one that centers on effective partnerships between professionals and patients in which the focus is on the issues that are truly necessary and really make a difference.

Here listed is a few of these:

• A commitment to nutritional balance and appropriate calorie consumption
• Regular exercise
• Avoidance of smoking
• Moderation of alcohol consumption
• Regular preventive visits to the doctor, using published guidelines for testing
• Commitment to careful control of blood glucose for diabetics
• Patient commitment to blood pressure measurement and adjustments necessary to achieve control.

Finding a physician who will lower the barriers to care, communicate easily and effectively with you to help you answer your questions, and provide guidance as needed is another crucial step in the effective, efficient health care system of the future.  

There is currently a growing shortage of primary care physicians, especially those who are open, innovative, and willing to maintain these types of patient relationships.  An essential part of the effective health reform of the future will require addressing the need to train these additional primary care physicians.  

Far too much effort, attention, and money is currently being spent on unproven or ineffective strategies and far too little is directed towards the outcomes in the bulleted list noted above.  Hopefully, this discrepancy will begin to be increasingly noticed and will start to be addressed.  

The answers to our un-affordable health care lies not in personalized medicine and ever more expensive procedures but in focusing on the basics of health and building a system around keeping Americans adherent to those principles.

Your comments or dissenting opinions are always welcome.

Phone service expands eDoc's Reach

One of the limitations to eDoc's information services is that one has to have a computer linked to the internet. This, of course, is not always possible. So, if you're away from your computer, don't have a link to the internet, or may simply not have internet access at all or may not even own a computer, you can communicate with us by telephone.

Since our service is "asynchronous", meaning provider and client are not connected in real time, we do this by using a unique telephone interface that records your message and transmits it to the eDoc providers in a voice file that we can open and listen to at our computers. We then can type an answer to your question and our system calls you back and "reads" our answer over the phone. It has a little bit of a "robot" sound, since the text to voice technology is not actually a human talking.

I encourage you to put the phone number in your directory and, the next time you need to ask us a question, but aren't close to your computer, give this new technology and try. Then, let us know how you like it or how well it worked for you.

By using technology the folks at eDoc are trying to improve your health, and the health care system, by making it easy and convenient to get the answers you need, from reliable professionals, at the time you them them.

Thanks for using eDocAmerica.

eDoc Launches New Site for Individuals

If you are an individual, not associated with a corporation or group that already has eDoc benefits, log on to our new site http://www.edocamerica.com/individual and check us out. This new plan allows you to access to eDoc services free for the first month, then for the low price of $11.99 a month after that.

Give us a try. I believe you will find our services to be second to none in the category of reliable, on line health information.

On Patient Autonomy

Recently, I was involved in a discussion on an e mail list serve and decided to takes some of my comments on patient autonomy and blog about them. This arose following a debate about whether the term "patient" engendered a sense of passivity and, therefore, whether the term should be dropped in favor of something else, like "client" or something similar.

Having participated in the preparation and dissemination of the white paper on e patients, I don't see the need for 'factions' or disagreements in the service of advancing Participatory Medicine. As Alan Greene aptly stated, "This is a big tent, with room for all". I want all of my patients to be as autonomous as possible. In my view, their autonomy is independent of the doctor/patient relationship that I have with them. They make the choice to enter into, or to activate or deactivate the relationship with me. They may ignore my input, seek a second opinion, or fire me and seek the care of another physician at any time. They truly are in control, in that sense. The only thing I have control over and am responsible for is trying to provide the best advice or consultation that I can.

They use the internet for education about their health issues and, increasingly, to join patient communities for problem solving, support, information and research. Some even seek the input or advice of professionals they have never met through online services like eDocAmerica. Sometimes, they may find that information they get on the internet or from other patients demonstrates that what they received from me was in error. So much the better, if they can use networking to improve the quality of the information at their disposal, we will have a healthier, more efficient health system.

The less they "need me" the better I like it but I continue to hope, in their best interest, that they are exerting their autonomy by making good choices and achieving optimum outcomes. Just like I don't expect to achieve an optimum outcome with a complicated home repair without a consultant such as an electrician, or to be able to fix my car without a mechanic, or achieve a legal victory without a lawyer, most patients won't achieve optimum medical or health outcomes without a medical consultant. And, has also been pointed out, some outcomes absolutely require a physician (e.g. surgery, intensive care, chemotherapy, radiation, etc).

And, do these consultants ever make errors, be they of commission or omission, you bet! That is why the partnership is important. As good or as meticulous as a doctor might be, he is inevitably going to miss things that the patient and their caregivers are in the best position to recognize and correct. They may also be, by virtue of networking and patient communities such as ACOR and others, privy to information that is more current or more relevant than what they may receive by their own physicians. We, as physicians should not worry about, or be threatened by this, but should embrace it as the best chance for the patient to achieve optimum outcomes.

Fitness, Part 2

This is another "eDoc Academy" video on non aerobic fitness. I hope you enjoy it.

More on Fibromyalgia

I'm calling these Youtube videos "edoc Academy". This is the third in an ongoing series of topics from my practice. This one on Fibromyalgia.

Fitness

Take a look at this cam recording video that I did on getting started with a fitness program:

Introduction to Participatory Medicine

This is a video called "Introduction to Participatory Medicine" which I recorded today on You Tube. Take a look if you get a chance and feel free to share your ideas and reactions.

Thanks.

Sugar May Be Raising Your Blood Pressure

Most of us know that salt raises blood pressure in many people. When I learned that in medical school almost 40 years ago, I have not touched a salt shaker since. I enjoy having a low normal blood pressure. A new study published in the Journal of the American Society of Nephrology (July, 2010) suggests that sugar, especially the fructose that comes from corn syrup, may also raise blood pressure.

A study team from the University of Colorado in Denver looked at sugar intake among thousands of Americans in a major national nutrition survey between 2003 and 2006. Those who consumed more added sugars such as the fructose in soft drinks had significantly higher blood pressures than those who did not and ate more natural foods such as fresh fruit.

Fructose from corn syrup is a major cause of the obesity epidemic and may also be contributing to the most common chronic disease of adults, high blood pressure.

I have a bold suggestion to make that if followed will improve your health and that of our nation:

Eliminate all soft drinks and fruit drinks from your diet and the rest of your family. Whether with sugar or "sugar free", they adversely affect your health. Drink water instead. If you want caffeine or some other flavor, drink tea (not sweet tea) or a modest amount of coffee, both natural substances. Use a slice of lemon in your water or tea if you prefer to alter the flavor. Get your fruit natually from an orange, apple, bannana or berries, not from juice.

The elimination of soft drinks and fruit drinks would transform the American diet and help us be healthy again. And don't worry about the soda companies. A growing part of their business is bottled water today. We need to move them in the right direction too.

Food Rules to Live By

Michael Pollan has become one our most important writers about human nutrition. His book, The Omnivore's Dilemma (2006), spelled out why the almost 8 billion humans on this planet had better balance what we eat, for our own health and the health of the planet.

He published a small book in 2009 (Penguin Books) called Food Rules: An Eater's Manual. His rules are around 7 words in 3 brief statements: Eat Food, Not Too Much, Mostly Plants. How simple and wise is that!

These three statements make up the three parts of this small book, with lots of practical "rules". Here are some of the best:

Don't eat anything your great-grandmother would not recognize as food
Avoid food products containing ingredients that no ordinary human would keep in the pantry
Avoid foods that are pretending to be something they are not (like imitation butter)
Shop the peripheries of the supermarket and stay out of the middle
Treat meat as a flavoring or special occasion food
Eat animals that have themselves eaten well
Don't overlook the oily little fishes
The whiter the bread, the sooner you'll be dead
Be the kind of person who takes supplements - then skip the supplements
Eat more like the French, or the Japanese, or the Italians, or the Greeks
Have a glass of wine with dinner
Stop eating before you are full
Eat when you are hungry, not when you are bored
Eat slowly
Spend as much time enjoying the meal as it took to prepare it
Buy smaller plates and glasses
Serve a proper portion and don't go back for seconds
Breakfast like a king, lunch like a prince, dinner like a pauper

and the last one:
Break the rules once in awhile

So, enjoy a healthy diet and eat right!

Getting and Staying Healthy: Getting Enough Sleep

Our busy lifestyles often aren't conducive to getting the recommended amount of sleep at night. According to the National Sleep Foundation, adults need between seven and nine hours of sleep every night. Dr. Kenneth Berg from the Mayo clinic states that persons who get less than seven hours of sleep per night have a higher mortality than those who have adequate sleeping habits. Inadequate sleep has been linked to increased risk of motor vehicle accidents; an increase in body mass index – a greater likelihood of obesity due to an increased appetite caused by sleep deprivation; increased risk of diabetes and heart problems; increased risk for psychiatric conditions including depression and substance abuse; and decreased ability to pay attention, react to signals or remember new information.

So, if you are currently getting less than 7 good hours of sleep at night, consider making a change to try to increase that to a minimum of 7 or 8 hours. Here are some other suggestions for you to consider to improve your quality or quantity of sleep:

1. Establish regular sleep and wake schedules.
2. Have regular, relaxing bedtime routines such as taking a hot bath or playing quiet music.
3. Create a dark, quiet, comfortable and cool environment.
4. Make sure you have a comfortable mattress and pillow.
5. Avoid watching TV, using a computer or reading in bed.
6. Avoid eating 2-3 hours before your regular bedtime.
7. Exercise regularly during the day, but avoid exercise at least a few hours before bedtime.
8. Avoid caffeine and alcohol products close to bedtime.

Let me know if you have comments or additional suggestions...