Should Email Communication Between Doctor and Patient be Promoted?

A recent article in the Wall Street Journal reviewed the emerging role of email in healthcare, arguing that doctors should more aggressively offer their patients the option to communicate with each other through email. Unlike other professionals in the United States, doctors have generally resisted the adoption of email into their practices. But according to the WSJ article, email can result in many benefits to both the doctor and patient. With email capability, patients have more immediate access to the office staff and can potentially get their problems and concerns addressed more quickly. They can also maximize their cost savings by minimizing office visits and reducing lost time from work. The author further elaborates that although doctors are not permitted to submit a charge to Medicare for email communication, they can benefit by delivering better medical care which results from the ability to monitor their patients’ conditions more closely through email.

Although these points are all valid, some areas of concern remain. In my own medical practice, I formerly used email with patients for about two years. But I eventually abandoned email and don’t ever envision going back. For sure, most patients loved using email. The option to report any symptom or concern at any time of the day without having to bother with telephone menu prompts or dealing with the hassles of making appointments proved to be tremendously convenient. And for those questions that were straightforward and consisted of hardly two sentences at most, email at times was a definite time saver.

Not infrequently, however, email could create a fair amount of inefficiency and confusion. Mostly everyone has either sent or received an email in which the content somehow did not fully convey the point intended. Despite reading, and rereading the message, the intent of the email was never fully apparent. I often felt that my responses were clear and concise, only later to learn that further clarification was required. On several occasions, I recall dispensing advice under the assumption that a patient was already taking a certain medication when in fact, they were not – all leading to confusion and the inevitable thread of emails that seemed endless. In the end, the potential back and forth that can occur with email often resulted in the need for an office visit in order to clarify the mess that was created from the original email.

Most worrisome to me, however, was the very real possibility that a diagnosis could be missed whenever an office visit was replaced by an email communication. There is an aspect of the doctor-patient interaction that that cannot be duplicated through the email process. Since the beginning of modern medicine, the face-to-face doctor-patient interaction has always been regarded as paramount to all successful medical decision making. It is only through the office visit that one can observe body language and identify other physical cues that assist in making the right diagnosis. Simply put, without this interaction you potentially miss the boat on what the patient needs.

Those on the side of more email use would counter-argue that it would only be medical issues of a “minor” degree that would be relegated to email status. That is fine, but in everyday life it pretty much impossible for most patients to know what is a “minor” issue that is email appropriate and what is more serious and in need of a visit. Seemingly trivial medical symptoms can often represent a serious condition. For patients to rely on an immediate email response or for the physician to sift through the nuances of an email to determine whether something is emergent or not becomes are gargantuan task.

I have concluded that email communication can work in a safe and efficient manner only if certain restrictions and systems are in place:

1. Security: email should require logging into a secure system, which often requires several steps, such as entering in a medical record number and password. This would prevent any aspect of your conversation with the doctor from getting stolen. Many would prefer that their hemorrhoids remain a private matter and not circulating freely in cyberspace.

2. Receipt Confirmation: email sent to the Doctor should have a receipt confirmation in the form of an autoreply. In this way, the patient will know right away if their message arrived safely.

3. Word Limitation: email messages should be limited to 140 characters, similar to Twitter. Word limiations prevent patients from posing questions that are too complicated to answer by way of email. Likewise, doctor responses should be limited to the same extent. If it can’t be done in 140 characters, then the issue requires a call

4. Word Scanning: medical email software should have a built in review process in place that scans each email created by the patient and clears it before allowing it to be sent. It would screen for “alarm” words in the email, such as “chest pain”, “stroke”, “gun-shot wound” or “suicidal”. If such words are in any way contained within the email message, then the message does not get sent and the patient gets a reply – “based on the content of your email please call the office immediately”.

5. Email Delivery: it should be understood that email is read only once per day and each email sent will have only one reply. This prevents the back and forth that can happen with email use.

OK. So patients can do all of that, and maybe get an accurate answer from the doctor. Or dare they pick up the phone and punch in 7 keys to speak with a live person, make an appointment, and have their best chance of getting the right treatment? You make the call.

Statins and the Risk for Future Diabetes

Statin drugs, prescribed by doctors for lowering cholesterol, have arguably been the most successful drugs ever, at least in terms of sales.  To some extent, statins have been worthy of such elevated status.  After all, statins do follow through on their claim to both reduce cholesterol, and more importantly, to reduce the risk of heart attacks and strokes.  By lowering cholesterol, statin drugs also reduce the amount of plaque within the heart arteries, allowing for smoother and more uninterrupted blood flow.

Over the past decade, many doctors have privately asked themselves whether the entire world’s population should be prescribed a statin.  Better yet, some enthusiasts have joked that statins should be placed in the drinking water given their proven heart benefits.  As sales of statins have climbed, it seems that most adults, whether they be Octagenarians or Generation Xers have been advised to take a daily statin.  And finally, not to miss the bandwagon alltogether, the American Academy of Pediatrics recently recommended checking cholesterol values in all children and to prescribe statins for those who cannot improve cholesterol values with lifestyle changes.

It is with this degree of enthusiasm (or insanity), that something had to finally give.  Recently, researchers from the University of Massachusetts examined the long-term affects of statin therapy in 150,000 women aged 50 to 70.  It turns out that those who had been taking statin drugs were 50 percent more likely to develop diabetes, a very unexpected finding.  Why this is the case is entirely unknown as statins are not understood to have any direct effect on the pancreas, the leading organ involved in blood sugar control.  The irony it presents, nonetheless, is that statins reduce one risk for heart disease by lowering cholesterol to only later in life create another risk factor for heart disease, or Diabetes.

So what to make of this? Should everyone throw away their statin? Like everything in life, it all depends.  For those patients with a known heart condition or those with a very high risk for heart disease, it is probably best for them to continue using statins.  Although Diabetes can fill up heart arteries with plaque, statins likely work faster to clean them up, the net effect being cleaner arteries.  However, for the casual patient who doesn’t have a particularly high risk for heart disease and never knew why they were prescribed statins to begin with, one might want to have a sit down with their doctor and talk about this one.  Let us not forget that heart disease isn’t the only illness made worse with Diabetes.

Nature Versus Appetite Suppression

Lately it seems impossible to surf the internet or to listen to the news without being warned, yet again, about the adverse consequences of excessive weight gain. Many conditions such as Arthritis, Diabetes, and even Sleep Disorders are now found to be caused in part by obesity. Fortunately, a successful weight loss program can eliminate these problems and return us back to good health. Although that may sound like good news, the problem is that most people fail miserably in achieving long term, sustainable weight loss.

Aside from surgical procedures such as the Lap Band and the Gastric Bypass, there really haven’t been any new, effective medical interventions that can assist us in achieving successful weight loss. And just when it appears that a new medicine promises to act as a potent appetite suppressant, the FDA inevitably withdraws the drug, citing lack of evidence for long term clinical efficacy and/or the presence of worrisome adverse side effects. This has been most frustratingly true of medications that work as appetite suppressants, that is, drugs that try to trick our brains into thinking that we aren’t hungry so we don’t eat as much. There are at least ten drugs that ultimately failed in real life and are no longer prescribed.

Why has it been so difficult to develop a drug that can reduce our appetite and make us eat less? After all, scientists have been fairly successful in manipulating human biology in so many other areas of medicine. We have cancer drugs that annihilate tumor cells while preserving healthy tissue.  We also have other drugs that can drive down cholesterol levels to that of a healthy 12 year old. Nonetheless, we still can’t do anything to control the human appetite for food?

One explanation relates to the basic evolutionary role of appetite. Lets imagine that you were asked to design the most efficient living organism that could survive famine, infection, physical hardship and every other possible onslaught that a successful creature must confront. Its most important feature would probably rest in its ability to continually acquire energy in the form of calories. Why? Because in order to breath, think, and exist in this world you need energy every day, all day long. And in order to acquire energy, you need to have a very powerful and reliable system for reminding you to go out and get food. Without this system which we call our appetite, we would not seek food as regularly and aggressively as we do. Since nature recognizes the central importance of appetite for survival, it has devised hundreds of back up mechanisms to make sure that our appetite instinct remains powerfully intact. In essence, nature has created an elaborate system of  back ups for the back ups, just in case all other back ups fail. So if one pathway for sustaining appetite is broken, the brain moves to plan B, then C, and if those fail, it has many more trump cards in its arsenal. Like sending an astronaut to the moon, multiple back up plans for communication failures and other worse case scenarios are created in order to ensure a successful return to earth.

In the end, you cannot win the game of appetite suppression. Nature simply will not allow it. This is not to say that nature has committed us to a species of junk food seeking glutens who have no control over what we eat and how often we eat. Certainly the human brain will accommodate a reduction in calorie intake both temporarily and in the long term. However, the idea that we can reduce our intake of calories by trying to play games with our appetite mechanism is doomed for failure. You might find more success trying to dunk on Shaquille O’Neill.

All of this reminds me of my time in Africa as a medical resident. I can honestly say that I did not see even ONE overweight person during my stay. They regularly ate breakfast, lunch, and dinner. The food was basic and lower in total calories and was consumed in quantities just enough to satisfy the appetite. Absent were liter sized sodas, 3000 calorie hamburgers, and night-time snack foods processed in some far away factory. I am not sure why they eat so differently than we do. Perhaps their eating methods are the result of limited access to high calorie food. In any event, I am pretty sure that appetite suppressing pills are not part of their secret. I hope that some conclusions can be drawn from here.

The New Flu Shot for 2010

After the mayhem caused last year by the emergence of H1N1, a.k.a “Swine Flu”, this year’s Flu season seems to be shaping up to be much more calm and far less unpredictable.  To begin with, H1N1 has clearly been on the wane and thus far, seems to be a relative non-factor in every day office medicine.  Of course, now that we have a better handle on H1N1, the vaccine for Swine Flu is now widely available without any need for restricting use for certain patients.  However, a major change this season is that the basic Flu Shot will contain both H1N1 and the garden variety seasonal Influenza vaccine, all in one injection.  So we basically got our act together just in time for H1N1 to be on the run.  Talk about too little too late.

In any event, the Flu shot that is available in the pharmacy or doctor’s office will cover it all – no need to ask for the regular influenza but not H1N1, or vice versa.  In addition, this season’s Flu Shot covers a third virus, or H3N2.  H3N2 is understood to be a variant of Influenza B, which is suspected to come our way this fall.  Unlike H1N1, H3N2 is believed to cause a potentially severe illness primarily in elderly patients.  How researchers arrived to this conclusion is not known to me, but given last year’s snail-like response to H1N1, I would imagine that the CDC does not want to be caught with its pants down yet again. 

It also used to be the case that not all patients were advised to receive Flu Shots.  As early as last year, only adult patients over the age of 50 (or younger patients with specific medical problems) were offered Flu Shots.  This year, essentially all patients except those less than six months of age are advised to receive Flu shots.  The broader approach to include younger patients is based upon the idea that if you are young enough not be harmed by seasonal Flu, then you are also young enough to be at risk for fatal H1N1.  Similarly, if you are old enough not to have to worry about H1N1, then you are old enough to be at risk for medical complications of seasonal Influenza.  So the CDC simplified things by recommending the Flu shot to everyone. 

Since there have only been about 400 fatalities worldwide this spring and summer from H1N1, why even bother with a vaccine that covers H1N1? Why not just get the vaccine for the basic seasonal influenza virus? The CDC answers that H1N1 could make a big come back this fall and therefore mass vaccination against it is necessary. Probably a more honest response would be that they have already made the vaccine as a combined H1N1/Influenza unit and there’s no turning back now. So we’re basically stuck getting vaccinated for both.

As with any Flu season, the take home point should be to try to get the shot early in the fall, to wash your hands often, and to steer clear of anyone who even mentions the word “flu”.

Vitamin D2 or D3?

It has been about 3 years now that Vitamin D level testing and supplementation has arrived to the scene. Surprisingly, it has caught on quite well. I pretty much know that the whole world is on to this when my father in law, an ex-Marine Vietnam Veteran who has seen the doctor maybe 4 times in his life asks me about Vitamin D.

So the question has evolved, and is not whether one should take Vitamin D, but which one, Vitamin D2 or D3? The quick answer is take either. Scientists have been debating this one back and forth, much like the old “taste great, less filling” commercials of years past. Nonetheless, what can be said with a good deal of certainty is that regardless of Vitamin D2 or D3, it should be taken with food, as the presence of fat allows for its absorption through the intestine.

That said, there is some difference between Vitamin D2 and D3 with regard to half-life, or the time that it remains active and circulating throughout your body before it is eliminated. Since D3 has a modestly longer half life, it is arguably better to take D3 instead of D2 if you are dosing it less often than once per week (as would be the case if taking it once or twice per month). Therefore, for those taking it daily, which usually ranges between 400 to 2500 units per day, either D2 or D3 is fine.

In the end, just buy it and take it. You have bigger concerns, like what you are going to watch on TV tonight or how you might need to rearrange the sock drawer.

Livalo, the latest (Johnny Come Lately) Statin

The FDA has approved the marketing of Livalo, a statin, indicated for the treatment of high cholesterol. In addition to treating the usual, garden variety high cholesterol in patients both with and without heart disease, Kowa, the company that makes the new drug, proudly touts the additional benefit in treating elevated triglycerides. Very good.  But in case Kowa hasn’t noticed, there are now 8 statins on the market, three of which are generic. And yes, they all treat the full range of different cholesterol abnormalities, including high triglycerides.

As with many new drugs that acquire FDA approval, perhaps Livalo reduces cholesterol more efficiently than other statins. Or perhaps Livalo is superior in limiting side effects commonly seen with cholesterol medications. Unfortunately, neither claim seems to be the case. Livalo is essentially no different in its effectiveness in reducing LDL. And as far as side effects go, the incidence of muscle pains and liver enzymes abnormalities have been comparable to other statins.

Like many, I ask myself why a company would bother going through the painstaking process of FDA approval when there apparently is nothing novel about Livalo? At this point who knows. For the patient, I would be very cautious about being offered free samples of Livalo by a doctor’s office. There are plenty of cheaper statins out there that are at least as effective as Livalo. It would be wise to let this Johnny Come Lately impress us with a little more data before considering its regular use.

Reflux Treatments and Bone Loss Concerns

For decades, Gastroesophogeal Reflux Disease (GERD) has been treated rather easily and efficiently without any controversy or sophistication.  Patients were encouraged to first try lifestyle changes.  After a couple of lame attempts at cutting out spices and reducing things like chocolate and alcohol, doctors would quickly call it quits on non-drug treatments and wind up prescribing acid-reducing drugs such as Prilosec, Prontonix, Nexium, and Aciphex.  Together, these drugs, commonly known as PPIs (Proton Pump Inhibitors), quickly formed the cornerstone of reflux treatment, carving out a $25 billion per year portion of healthcare dollars.  To the delight of doctors and patients, PPIs seemed to be capable of wiping out reflux symptoms with virtually no apparent side effects or drug interactions.

The safety of long-term PPI use started to come into question about one year ago.  Researchers began to raise questions about possible risks that long-term users may develop, particularly with regards to osteoporosis.  By suppressing acid build-up, the mechanism by which PPIs are thought to control reflux, patients may wind up absorbing much less calcium from their food.  With less calcium absorbed, patients might have less available minerals for building high quality bone.  So down the road, the concern is that patients who take PPIs may have a higher risk for hip fractures.  

Before even thinking about stopping your PPI, you need to consider several issues.  Firstly, if your risk for osteoporosis is low to begin with, then the chances of developing  future bone problems on account of PPI use will likely remain low, period.  So no need to change a thing.  On the other hand, if you already have osteoporosis or are considered to be at high risk, then it might make sense to minimize PPI use by trying other alternatives.  For example, the previous generation of acid controlling medications, such as Zantac or Pepcid may perform just as well in controlling reflux symptoms.  What’s more, no evidence has implicated Zantac to future osteoporosis or hip fractures.   The catch here is that Zantac, for a considerable number of people, is generally not as effective as PPIs. 

Secondly, you ought to make a legitimate, wholehearted attempt at anti-GERD lifestyle measures.   These measures include sleeping with the head of the bed at 45 degrees, losing weight, and avoiding consumption of alcohol, chocolate, and spicy foods.  Yes, we doctors are all about eliminating all forms of fun.

If all of the above fails and PPIs turn out to be the only method to achieve effective control of GERD symptoms, then so be it.  If you continue taking PPIs then you simply need to do your best to prevent and/or treat osteoporosis, i.e, making the most of excercise and consuming adequate amounts of calcium and Vitamin D. 

In the end, the issue of PPIs and osteoporosis is relatively minor.  Unlike other more immediate health related concerns, the question of PPIs and its relationship to osteoporosis can be dealt with calmly and in the context of an office visit.  So please don’t toss your Nexium pills out into the garbage quite yet.

New Blood Pressure Goals for Diabetics?

“Thanks Doc for putting me on that fourth blood pressure pill.  I am feeling much better now that it is 130/80.” 

I have heard that statement uttered exactly ZERO times in my career.  Without exaggeration, I really think that I have a better chance of winning the Heisman Trophy in College Football than I do hearing those words from a patient.  The fact is, as blood pressure targets for certain populations of patients seem to get more and more aggressive, medicines get piled and piled on.  And as more drugs get prescribed, people just feel worse and worse despite “better” blood pressure control.  No wonder some people prefer to get a wisdom tooth pulled than to visit their primary care doctor.

For years, blood pressure guidelines for patients with Diabetes was 130/80.  For the fortunate patients, 130/80 is easily achieved by way of weight loss, salt reduction, exercise, and by taking one or two blood pressure pills.  For many patients, however, achieving the target of 130/80 requires many medications with all of the associated side effects and an early entry into the donut hole.

Recent studies seem to suggest a change in attitude about target blood pressures for patients with Diabetes.  Roughly 4,700 patients were enrolled in the ACCORD study (Action to Control Cardiovascular Risk in Diabetes).  Half were treated to a target blood pressure of 120/80, the other half to 140/90.  After five years, there was no statistically significant difference in heart attacks, stroke, or other major cardiovascular complications among the two groups.  So no long-term benefit was achieved by adding almost two extra pills in order to lower blood pressures by ten points.  Quite sobering indeed especially when one considers how much time and energy can be spent chasing a potentially useless target.

Based upon these results, official guidelines have not changed, yet.  Researchers are still trying to figure out why “better” blood pressure control didn’t translate into improved cardiovascular outcomes.  Perhaps patients with Diabetes whose blood pressures are resisting “optimal” control are trying to tell us something – “I want it higher and I need it higher”.  Attempts to fight this could be proving to be fruitless.

I think that it is fair to conclude the following:  for patients with Diabetes who have been able to achieve 130/80 with minimal interventions and medications, then good for you.  You should not change anything.  For those who have found themselves adding more and more pills to just barely reach 130/80, I do believe that there might be some changes down the road for you in the form of fewer medications prescribed.  The experts on both sides of the debate will fight this one out in a no-holds barred spirited debate.  I have a hunch as to who the winner will be, which will allow some of you to spend less, defer the donut hole and perhaps feel better.

The Safety of Generic Medications

With the cost of healthcare on the minds of most Americans, generic medications have been playing an increasing role in everyday patient care.  With that, questions about the efficacy of generic medications have been raised more frequently.  Generics are, by definition, a chemical copy of the original brand, and by FDA backing, should have the same efficacy.  In most cases, generic medications are substantially cheaper in price, resulting in a cost savings to patients of $10 billion per year.

That is all good, if weren’t for the fact that many patients and doctors swear that the quality of generics is not always the same.  Frequently, patients report differences in efficacy when medications are changed from brand to generic.   Unfortunately, there can be truth to that claim.  The FDA allows for some degree of variability among generic drugs.  By law, a generic drug must maintain no more than +/- 10% variability in absorption of the drug when compared to the original brand name.  When generics are tested, healthy volunteers are given a dose of a generic drug and blood levels are measured 72 hours later.  Generics are allowed to have 10 percent less or 10 percent more of the drug in the body compared to the brand name.  The important point is “compared to the brand name”, not compared to other generics, which is where there can be a problem.  Since many drugs have multiple generic manufacturers, the actual range of variability between two generic drugs (made by two different companies) can theoretically be 20%, since one drug might be absorbed 10 percent better than the brand name while a different generic might be absorbed 10 percent less.  The possibilty of  a twenty percent swing in blood medication levels could be significant for some patients.

In the majority of circumstances, however, the potential 20 percent variability in drug levels among generics does not result in any meaningful change in treatment outcomes, as blood pressures remain controlled, pain medications continue to control pain, and blood sugars and cholesterol values remain below expected levels.  That said, a word of caution is certainly in order for specific medications and conditions, among the most important,  blood thinners, epilepsy drugs, and thyroid medications.  For these conditions, a possible 20 percent difference in blood levels can be too much.  A change to generics, such as Coumadin to Warfarin or Dilantin to Phenytoin would need to be approached with caution.

In the end, for the vast majority of conditions,  generics are effective enough and make sense both medically and economically.

Coffee Consumption – Good for You?

Coffee consumption shares all of the hallmarks of behavior that you would expect to be harmful to your health.  After all, coffee apparently tastes good, elevates the mood, provides much-needed additional energy, can make socializing easier, and is famously addictive.  How could something with those characteristics NOT be bad for you?

So for both the lay person and the trained medical professional, coffee has always been thought of in the same way as other addictive behaviors, such smoking or alcohol consumption.  And like smoking and drinking alcohol, coffee must, in some way, be harmful to one’s health.   As such, decades of research by the coffee Gestapo has tirelessly attempted to prove a negative impact of coffee consumption on general health.  The determination with which researchers have pursued evidence for a negative relationship would impress even the most persistent college kid looking for a date.   However, time and time again, all efforts to demonstrate a negative relationship has consistently failed. 

Recent work, on the contrary has suggested instead that coffee may actually prevent some illnesses.  A recent study by the National Heart, Lung, and Blood Institute, involving 1140 patients aged 45 to 74 at high risk for Diabetes were followed for a period of 7 years.  Among multiple behaviors evaluated, coffee intake was closely monitored.  After correcting for differences in smoking, blood pressure, and other cardiovascular risk factors, the coffee drinkers had a far lower rate of Diabetes, specifically 67 percent less.  What’s more, it seems that the more coffee consumed, the greater the protection against Diabetes.  Those who consumed greater than 12 cups per day derived the greatest protection.  (In case you were wondering, if you assume 8 hours of sleep time, that would come out to 3/4 of a cup every hour.  Perhaps with that kind of single-minded focus, who could have the time or energy for eating bad food, smoking, drinking alcohol or engaging in any other bad habits?)

As in any observational study, confounding factors could explain the results described.  For example, coffee drinkers may share other behaviors aside from drinking coffee that may be responsible for the observed benefits.  What that might be would be another topic of research. 

To be sure, there are definitely certain conditions in which coffee consumption is not advised – chronic insomnia, heart rhythm abnormalities, rebound headaches, and pregnancy.  That aside, it looks like the coffee addicts out there can continue drinking up, since no research to date has shown a negative impact, but instead potential positive benefits.  But let’s be honest, as if any research for or against coffee consumption would have stopped us from drinking anyway!

For the curious, I do not know if the coffee drinkers in the study added sugar, milk, cream, Splenda, etc.  I will try to find out though.