Reflections on the State of Online Health

As 2009 draws to a close, the US health care system is ailing and quasi-reform proposals are frantically being debated and voted on. Although some type of reform is likely in 2010, we will have only scratched the surface of what still needs to be changed. One particular aspect relates to the ease with which patients can use the internet to improve their health care. At eDoc, we've been using the internet to improve the health of our users for over a decade. Ten years ago, I predicted that patients would routinely use internet messaging to interact with the health care industry by now, but I was wrong. Although, increasingly, web 2.0 approaches are providing innovative communication and health management tools for patients, the growth of interaction between patients and doctors has been much slower than I predicted it would be. And the future still remains cloudy. The issues are nothing new and include:

1. Many patients still lack ready, reliable internet access. This is especially true for those who need it most: sick, elderly, and financially disabled persons.
2. Most insurance companies do not recognize e visits as reimbursible under health insurance plans. This provides a powerful disincentive for physicians to spend significant amounts of time answering e mail questions from their patients, since they are reluctant to bill patients directly for this type of service.
3. Professional liability issues have not been well worked out, leaving physicians and malpractice insurers feeling squeamish about supporting this approach.
4. Licensure issues remain the domain of individual states, are not consistent from state to state, and maintain unachievable standards in their definition of "doctor patient relationships". This requires a physician who wants to provide "on line care" to have a license in every state for which they provide this care (edoc provides medical information, not on line practice). Moreover, they define the minimum requirements for establishing a doctor patient relationship as an "in office" history and physical examination performed by that individual.
5. Physicians and health care providers who are interested in providing online care are dissuaded from getting involved lest they be tarred by the brush of thousands of online health care supplement companies, bogus care recommendations from quacks, and illegal drug distributions sites.

So, how will we deal with this, and in what direction will we go in the future? Hopefully, my predictions for the next few years will be more accurate than my last ones:

1. Online care will continue to grow, in spite of the obstacles mentioned above, because the internet an incredibly powerful and efficient resource for patients. The growing demand will eventually overwhelm the remaining barriers.
2. Patient and peer groups will become increasingly sophisticated, with or without the cooperation of health care providers, and will increasingly rely on each other, rather than sole reliance on trained professionals.
3. Grudgingly, more payers will begin to support online care as the patients/employee groups realize the benefit and demand it of their employers and insurers.
4. Access to online services will continue to grow, including adaptation on cell phone applications, which will lower the bar for patient groups that are currently left out of the action.

The ability to communicate with a physician via secure e mail has tremendous benefits, including saving unnecessary office visits, allowing patients to optimize the timing of their visits to physicians, and increasing patients' confidence to act on issues and questions. Moreover, it allows physicians and patients to emphasize and more efficiently monitor preventive practices such as healthy diet, exercise programs, weight loss programs, smoking cessation and others.

Health care reform may increase the number of patients who have some type of insurance, but thus far, has not included proposals to reform the online environment to encourage or stimulate more communication between doctors and patients.

As always, your comments or dissenting opinions are welcome.

Merry Christmas and Happy New Year to all, and thanks for being a part of eDocAmerica!

Do Diet Sodas Make You Fat?

You would expect that diet sodas would help you lose weight since they have no or minimal calories. Drinking a diet soda rather than a regular soda saves you all that sugar, right? Many people develop diet soda drinking habits due to several factors, the caffeine, the sweetness or just wanting to drink something without the calories.

The link between diet sodas and weight is not what you might expect. Reviewed recently in the medical journal JAMA (Dec. 9, 2009), a major heart study showed that people who drank more than 21 diet sodas per week had twice the risk of becoming overweight or obese compared with people who don't drink diet soda. In another major study, daily consumption of diet soda was associated with a 67% increased risk of developing type 2 diabetes (cause by excess weight). Drinking diet sodas gives you the same "sweet tooth" behavior as other sweets and actually results in people eating more calories than if they stayed away from sweets in general.

Other research is even more disturbing about the addictive nature of diet sodas. When rodents are fed artificial sweeteners, not only do they consume more calories and become obese, but they become very addicted to the sweeteners. When given the option of repeated use of cocaine or diet soda, they preferred the diet sodas!

There are so many options for healthy drinking than diet sodas. Water is the healthiest beverage to complement natural foods. If you want some caffeine, coffee or tea would be healthier than diet sodas. Be mindful of what you put in your body and I'm sure most of you have thought that diet sodas are not very good for you.

Is a Low Carb Diet a Bad Mood Diet?

An interesting study out of Australia suggests that long term use of a low carbohydrate diet may result in more common bad moods and hostility. 106 overweight and obese people were followed over a year with either a low carb diet without fat restriction (the Atkin's Diet) or a low fat diet. Both resulted in the same amount of weight loss, but those on very low carb diets were cranky more often. This makes sense since carbohydrates increase serotonin in the brain, an important neurotransmitter that affects mood. Common anti-depressant medications such as Prozac work by increasing serotonin. Fats and proteins reduce serotonin.

How you put these findings in perspective? It all leads back to a balanced diet. Whole grains, a natural source of carbohydrates, are good for you! The bottom line is that we all should eat a healthy diet and avoid excess calories that put on excess weight. Simple carbohydrates, such as sugars, cause more hunger and induce us to eat more. Complex carbohydrates, especially when mixed with protein, do not do this. Saturated fats also are not optimal foods in any large amounts.

Eating right means eating healthy foods most of the time, and not too much food. Grains, vegetables and fruits are the foundation of any healthy diet. Protein sources should be healthy, such as nuts, vegetables, fish, dairy and lean meats. Healthy fats such as vegetable oils should be eaten regularly and in moderation. Beware of any diet that seriously restricts any natural food type. You might lose weight, but having frequent bad moods is certainly not worth it!

New Journal for Health Professionals and Patients Launches with Ambitious Ideas

Last week at the Connected Health Symposium in Boston, a new journal was launched, The Journal of Participatory Medicine (http://www.jopm.org/). This journal's mission is to transform the culture of medicine to be more participatory. This special introductory issue is a collection of essays that will serve as the 'launch pad' from which the journal will grow. I would like to ask you to log on and read these essays and help us as we connect patients, caregivers, and health professionals.

I am one of the Journal's Co Editors. The other is Jessie Gruman, PhD, founder and president of the Center for Advancing Health, a Washington-based nonprofit organization funded by the Annenberg, Macarthur, Kellogg Foundations and others. The Center works to increase patient engagement. She holds BA from Vassar College and a PhD from Columbia University teaches at The George Washington University. Jessie authored The Experience of the American Patient: Risk, Trust and Choice (2009); Behavior Matters (2008) and AfterShock: What to Do When the Doctor Gives You -- or Someone You Love -- a Devastating Diagnosis (2007).

Please take a look and send us your ideas.

What is Your Daily Glycemic Load?

I've written before here about the glycemic index, that measure of how fast a food causes your blood sugar to rise. High glycemic foods, like simple sugars, cause our blood sugars to rise quickly resulting in a pouring out of insulin, a rapid fall in our blood sugar, and we become hungry again soon. Protein in our diet blunts this glycemic index effect, as does eating more complex carbohydrates such as in vegetables.

An new concept has emerged that complements the glycemic index, called the glycemic load. The glycemic load reflects how much total carbohydrate is released in your body from various foods. While carbohydrates, sugars and starches, are a core part of our nutrition, we know that eating a lot of them results in more hunger and we end up eating more calories and gaining weight. Low carbohydrate diet plans have shown some advantage over low fat diet plans for losing weight, although both work if the total calories eaten are reduced.

Dr. Mabel Blades has written a simple book that can be used as a guide to the glycemic load of common foods. I have used it to reduce my glycemic load, for example how much Cheerios I put into my morning cereal. I have increased the ratio of protein from yogurt to the amount of grains, keeping enough grains to give me the desired amount of fiber. I have also cut down on how much bread I eat, one of the first dietary interventions of low carbohydrate diet plans like the South Beach Diet. If you would like to order this simple handbook, you can find it from any online book source:

The Glycemic Load Counter. Mabel Blades. Ulysses Press, Berkeley, CA 2008. My doctor actually gave me a copy as part of my physical exam and health assessment. I'm five pounds lighter after just a couple of weeks.

More on Participatory Medicine: Patient Research

This post is adapted from one I wrote last week on e-Patients.net Blog: http://e-patients.net/archives/2009/09/participatory-medicine-and-patient-research-its-gonna-be-a-new-world-indeed.html.

Matthew Herper’s post about thalidomide treatment of Myeloma is a good example of how patients will contribute to medical knowledge in the future, and may form a cautionary tale for patients who get involved to this degree in formulating new treatment approaches.
I work with Bart Barlogie, MD, (quoted in the article as the physician who ran the first clinical trial of the use of thalidomide in treatment of Myeloma) who is an innovative clinician researcher who has extended the life of many patients with Myeloma with his treatment approaches. He is also treating my wife who was diagnosed three years ago with Waldenstrom's Macroglulinemia, a form of lymphoma that resembles Multiple Myeloma (she has responded very well to his treatment).

I was a good friend of Tom Ferguson, MD, who came to UAMS and was treated with thalidomide in 1999. Tom was also the founder of the “e-patient scholars” who started this web site and still meet annually. What he began has morphed to the budding Participatory Medicine movement, evidenced by the formation of the Society of Participatory Medicine and the soon-to-be-launched Journal of Participatory Medicine, which I will Co Edit along with Jessie Gruman. And that takes us back full circle to this story of a patient doing research about their condition as an example of Particpatory Medicine, which Tom strongly encouraged, facilitated and exemplified with his actions.

Whether Beth Jacobsen’s accusations about Celgene stealing her husband’s idea has merit or not is not something I am prepared to comment on. I’ll let the courts sort that out. But the fact that her husband pushed her physician to try a novel approach to try to save his life, and that it was tried (even though it didn’t work for him), is an example of what will happen increasingly in the “new world of Participatory Medicine”.

The article notes that, although Mr. Jacobsen didn’t respond to Thalidomide, the next patient had a dramatic response. Again, ironically, Tom Ferguson was one of the early patients who was treated at UAMS by Dr. Barlogie with Thalidomide. His Myeloma was rather advanced at the time, in 1999. Whether the Thalidomide was the reason or not, he did well for years after that. I didn’t meet Tom until much later, in 2005 and he died of complications of his disease in 2008.

So, he would undoubtedly be cheering with the knowledge that the treatment that helped him beat back his disease for over a decade was probably “discovered” by a patient who was practicing Participatory Medicine!

How many other clinical trials are out there waiting to be started by ideas engineered by patients who have the utmost to gain and the ultimate motivation–saving their own life.

Participatory Medicine: Patients doing research, usually online, and taking the ideas into the medical arena. Get ready, it’s going to be a brand new world!

When Dreams are NOT So Sweet

Have you ever been startled out of a deep sleep by a crying child? The first few times this happens, we parents levitate out of bed with our heart pumping and adrenaline surging, ready to do battle to protect our offspring. Parents are ever diligent during the day to make their children’s world as safe as possible. We hold their hands while crossing the street, we child proof our homes, we make sure their daytime care facilities – be it daycare, babysitter or school – are a safe environment. And at night, we tuck them in their warm and cozy beds with a full tummy and a gentle kiss on the forehead. Then we allow ourselves to relax, enjoy adult company and finally sleep before we have to do it all over again the next day.

Then the nightmares begin. For most children, nightmares are occasional incidents that can often be attributed to a specific event, or to an overtiring and difficult day. Sometimes we never know what triggered them. We are just glad they don’t happen very often.

Are nightmares normal? It certainly looks that way. Most children will have some experience with them. Nightmares may be the brain doing some extra work, below the level of full consciousness, to work through a stressful situation from their day. We all need time to process difficult issues and sometimes nightmares are a side effect of that healthy process. When the nightmares happen more often, this could be a sign that the child is not coping well with something stressful. The nightmares continue, increasing in frequency, as the child tries and fails to resolve the stressful issue.

How can we help our crying child in the middle of the night? Alan Siegel, Ph.D. from Cappella University suggests the four R’s for nightmare relief.

Reassurance that they are not alone, that they are safe and that it is OK to talk about their dream is the most important first step. Give your child a hug and let them know that you understand about nightmares and that everyone has them. Then discuss the dream.

Rescripting how the dream ends after you’ve gotten the details of the actual dream is like assertiveness training for the imagination, (according to Gordon Halliday, see reference below). Encourage your child to use their imagination in changing the scary parts and rewriting the ending where they are in control of the situation. Put that dinosaur in time out, tell that tiger, “bad kitty!” and make him turn into a kitten, or shout, “Boo!” to the ghost and scare him away. But be cautious about using so much imagination here that the nightmare’s message or warning of a possible coping problem goes unanswered. And certainly, don’t be so creative that you end up creating your own nightmare scenario!

Rehearsal goes a step beyond the new endings we imagined in rescripting. We go over the dream again with our new solution, and then we apply that tool to a similar situation.

Resolution involves getting to the root of the matter. Or what caused the nightmare in the first place. If the child had difficulty with a similar situation the previous day, ask them how they would now change that outcome? And remember that children will only talk about the scary stuff when they feel safe enough to relive it in the retelling. Writing, art work, or creating a play or story are good alternate ways your children can express their fears.

So what do we do when nightmares occur too frequently? When the nightmares are consistently violent or disturbing, when they just won’t go away no matter what you try, it may be time to turn to an expert. Your pediatrician can rule out any side effects from prescription drugs or any physical condition that may be triggering the nightmares. After the physical aspect has been ruled out, a behavioral health specialist should be consulted.

Now, as a practicing psychologist, I can tell you that I have also used some of these same procedures, very slightly amended, to help older children and adults as well. So, keep that in mind if you have your own issues with troubling dreams. Hopefully, this little ditty on nightmares will help you and help our little ones sleep like the proverbial baby.

Pleasant dreams.

Thanks for reading and please leave a comment on your own experience with childhood nightmares.

References for this blog:

Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares by Alan Siegel and Kelly Bulkeley. Published by Random House's Three Rivers Press. Copyright © 1998.

"Treating Nightmares in Children" by Gordon Halliday in Charles Schaeffer, (editor) Clinical Handbook of Sleep Disorders in Children (New York, Jason Aronson, 1995)