Friday, October 25, 2013

What should I ask my doctor?

How to handle a medical handoff...advocate for yourself or a family member when heading home from the hospital or off  to a consult for specialty care.

This morning I completed an online continuing medical education course on medical handoffs.  I wasn't even sure of what this meant when I registered and embarked on the course.  Turns out that it's just what it says, namely the handoff of a patient's medical care from one professional to another, say, for example, from me as primary care provider to a specialist consultant, or from a hospitalist to me as one of my patients is discharged from an inpatient admission back into my care.  These handoffs are risky business (and so this course is sponsored by my medical malpractice company) if information is incompletely or inaccurately transferred. 

I can't tell you how many times I've been in this situation--a patient comes to my office for follow-up to hospital care, and the discharge summary is not available.  Sometimes, I've heard the history via phone from the doc in charge at the hospital.  Too often, I did not even know that the admission occurred. More than once, the patient does not know the names of the physicians that were in charge of their inpatient care, and, worse yet, may not even know their final diagnosis! You may be nodding in recognition because this has happened to you or a family member.

This course gave a nice summary of that which a patient should know on leaving the hospital.  With just slight adjustments, many of these items could apply to any handoff situation where more than one professional is in charge of any aspect of your medical care. 
  • What are warning signs of a relapse? (I would add that any change that alarms you is worrisome enough to inquire about).
  • What are side effects to look out for from new medications?
  • Whom should I contact in case of difficulty? (I feel like your primary care doctor should be available to advocate for you in this matter even if they are not fully apprised on the matters at hand)
  • Does my primary care doc know that I was in the hospital and that I am leaving?
  • Do I understand why I was hospitalized, what was the diagnosis, and what is the treatment plan?
  • What results are pending?  Whom do I contact to find out these results? (this is extremely important, and applies as well to outpatient tests ordered by a specialist; find out if the specialist or your PCP will be the one to get the results, and call them if you don't hear from them within a reasonable amount of time).
  • Have any new medications been reconciled with my usual medications?  How long must I be on these meds, and who will order refills?
  • Where, when, and with whom do I follow-up? 
On average, PCPs only hear back from hospitalists 10% of the time after their patients are discharged from inpatient care.  An estimated 60% of discharges are made before all the in-hospital test results are in.  The hospitalist may assume that the PCP will follow-up; the PCP may not even know that the test has been done. 

Be your own best advocate on behalf of yourself or a loved one; ask these questions and make sure you get answers!

Friday, August 09, 2013

Why don't we do it in our sleeves?

I’ve just completed my annual flu review in preparation for the upcoming season.  As I consider the relative merits of preventive strategies, I’m reminded of all the various ways in which people, rather less than more, cover their mouths while coughing or sneezing.   One patient coughed weakly but wetly in the general direction of his hand located more than a foot away from his mouth.  My sweet 8 year old granddaughter coughed into her hand with fingers spread wide, droplets spraying through the gaps.  Another patient simply gave up hygiene altogether as she demoed her cough for me by doing just that, coughing directly into the space in front of her in which I happened to be standing (yes, I did get sick from that one).  

So here we go again, sharing air with our colleagues while trying to neither inhale their airborne sputum nor send our own into space.  For an amusing tutorial on sneeze/cough technique, check out "Why Don't We Do It In Our Sleeves?"

Saturday, March 09, 2013

Pu-erh tea and cancer prevention

I need to drink less coffee, but I’m sick and tired of tea.  So when a risk-free (as in no-cost free!) opportunity to try Numi Organic Pu-erh tea came my way, I’m thinking what’s to lose?  I was pleased by its rich and earthy flavor courtesy of a fermentation process during production--no weak sister green tea this stuff.  The bottom of my mug could not be seen when full of Cardamom Pu-erh. 
But what of these purported health benefits?  A visit to the NIH library at PubMed Central only strengthened the love; many Chinese researchers in multiple scholarly articles provided a slew scientific reasons to make mine Pu-erh in the a.m. 

The evidence was a regular alphabet soup of enzymes and genes and proteins favorably enhanced or suppressed by this brew and its metabolic byproducts of fermentation.  I’ll leave the anti-obesity praise to Dr. Oz who, incidentally, is looking downright anorectic to me.  Rather, consider some of the anti-tumor aspects of Pu-erh enumerated in an article(1) supported by grants from the“Scientific Puer Action” program.

If you remember the cell cycle from your intro to biology course, you know that actively dividing cells go through a three-step process wherein they grow, replicate their DNA and package it into chromosomes prior to splitting into two (hopefully) identical new cells.  If these orchestrated steps—G1, S, and G2—could be arrested in cancer cells but preserved in normal cells by a non-toxic, side-effect free substance, we would have the quintessence of cancer chemoprevention. 
Dr. Zhao and colleagues examined the effects of Pu-erh tea extracts on mouse tumor cell lines and control mouse embryo cells, and that is exactly what they demonstrated.  Essence of Pu-erh stopped the tumor cell cycle but did not affect the normal cells.  This effect was quite different than the anti-oxidant effects of unfermented green and black tea, suggesting that the molecular byproducts of its microorganism-based fermentation may be the origin of Pu-erh’s anti-cancer effect.

Well make mine Pu-erh!  Great flavor, way more nuanced and full-bodied than green, and stops tumor cell cycles dead in their tracks!

(1)    Zhao,L, et al.  Pu-erh Tea Inhibits Tumor Cell Growth by Down-Regulating Mutant p-53. Int J Mol Sci. 2011; 12(11): 7581–7593.

Saturday, February 02, 2013

“Body By You: The You Are Your Own Gym Guide to Total Women’s Fitness” by Mark Lauren

“[Mark] Lauren broke, and still holds, the Department of Defense’s long standing “underwater record” by swimming 133 meters, on one breath, subsurface, for 2 minutes and 23 seconds, until losing consciousness.”

You can’t beat those creds for an exercise guru.  Seriously though, not only can Mr. Lauren successfully train Special Ops forces, he’s developed a home-based, no equipment purchase required, fitness program first outlined in “You Are Your Own Gym” now tailored to meet the time constraints and physical requirements of women.  Based on “bodyweight” exercises, this program requires only that you pit your own weight against readily available surfaces such as doors and their handles, floors, tables, counters, stools, and chairs.

While I admit that I have issues with doors as props, picturing my husband saying “Now tell me again how this door ripped off its hinges,” I found this little program quite the heart-pounding challenge all accomplished within eighteen minutes in the privacy of my own kitchen.  Basically, you pull, squat, push, and bend your way through a routine that is clearly explained in prose and in pictures. So four categories with 25 graded exercises within each one for a total of 125 bodyweight maneuvers, many of which I will never perform in this lifetime (e.g. one-arm push-ups with hand elevated hip height and 2-second pauses).

That said, Mr. Lauren expects that you will progress only as far as you are able and at your own pace, and he fully explains how to advance without injury.  His patter through the book is encouraging, complete with enthusiastic sidebars titled “Hooya” which must be military talk for “you can do this” and “don’t give up soldier-girl.”  As with all habit changes—weight loss, diet change, smoking cessation, or exercise plans—this program will only work when you’re really ready to do it. But if the expenditure of time or money is your stumbling block, this could be the plan that changes your life and your body. 

The author has created an iPhone/iPad app for this bodyweight/your own gym thing for ( gasp) $2.99.  But it gets super reviews, especially from “mobile road warriors” (one reviewer’s term for those of us away from home for work or play). And shoot, I have no qualms about hanging off of hotel door handles and how amusing to have my iPad timing my moves and cheering me on.  I do think that “geriatric warriors” such as myself dealing with joint issues would also do well to spring for a trainer for an hour or two to modify moves such as “Sumo squats” and “Bulgarian Split Squats” to avoid injury.   Well, truth be told, trainer or no, I’m leaving Bulgarian Split Squats along with One-legged Squats and Assisted Pistols to women far younger than me.
I like Lauren’s plan, I appreciate his enthusiasm, I could live without his dietary advice.  Ready to take on an exercise program?  I recommend this book to you.  Hooya!          

Thursday, January 10, 2013

Is extra weight good for your health?

Researchers and statisticians have long sought a simple association between weight and good health.  This evaluation became easier when ideal body weight tables were abandoned in favor of a classification system based on body mass index (BMI), a single number found by dividing weight in kilograms by height in meters squared (made easier yet with the use of a smartphone app!).  Allowing for proportionately greater weights in individuals with large muscle mass, rising BMIs correlate with increasing fat mass.  On average, per conventional wisdom, as BMIs climb through normal to overweight and beyond, so does the risk of future disease.

So how many of us are normal in a BMI sort of way? According to recent US data, roughly one-third of adults have bypassed normal into overweight (BMI 25-30) and an additional one- third weigh in at obese (BMI 30 and above).  Epidemiologists warn that the obesity epidemic is increasing the incidence of chronic disease. 

Statisticians from the CDC conducted a meta-analysis (combining data from many studies) of  nearly 3 million subjects from 97 separate studies that looked at all-cause mortality over time as related to BMI(1). Relative to normal BMI, the researchers compared the risk of dying in those overweight (BMI 25 to 30) and obese (BMI 30 and above). The researchers used hazard ratios (HR) to express their findings, a measure of how often a particular event happens in one group compared to how often it happens in another group during the course of a study.  They found that the overweight and the grade 1 obese were slightly less likely to die than those in the normal BMI range (HR=.95).  On the other hand, those with BMIs at or above 35 had a calculated HR of 1.29, nearly a third again more likely to check out early than those weighing less.

Clearly, there’s a lot more at work here than whether or not one hauls extra weight through life’s journey.  An editorial that accompanies this article cites a host of confounding factors including sex, age, race, fat distribution, and cardiorespiratory fitness to name a few.  The article itself has a 138 item bibliography, most echoing the same conclusion, namely that overweight or slightly obese is not necessarily a long-term health risk but big-time obesity is big-time trouble over time.
Did we really need another study for this?

1.       Flegal, KM et al. Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories:. JAMA. 2013;309(1):71-82. doi:10.1001/jama.2012.113905.

2.       Heymsfield, SB and Cefalu, WT. Does Body Mass Index Adequately Convey a Patient's Mortality Risk? JAMA. 2013;309(1):87-88. doi:10.1001/jama.2012.185445.