Live Your Life: Don't Numb It

I'm writing this post from the San Francisco Bay Area (specifically the San Francisco International Airport (SFO) which I just found out is not open 24/7 but rather closed until 4AM) where I've been the last few days, celebrating the life of one of my best friend's wife who passed away earlier this month.  It's a sad commentary that it took this event to bring together so many friends & family, many who I have not seen for several decades.

Coincidentally, I read an article published yesterday in USA Today regarding the addictiveness of the pain medications that I prescribe.  This issue along with the concomitant increase in overdose deaths has become a major issue in politics & healthcare.  In fact, the Centers for Disease Prevention & Control published data earlier this summer on this issue.

Don't get me wrong.  I don't want my patients to hurt needlessly.  But we need to balance our desire for pain control against the risk for addiction & death.  Too often, we look to pills to numb us from our lives.  Instead, we should strive to live life, not numb it.  Something that death reminded me this weekend.

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Dietary Supplements: Is the Fox Guarding the Hen House? Part 7

Back towards the end of July, just over 2 months ago, I stumbled onto USA Today's investigative series, Supplement Shell Game.  Most of us believe that everything on supermarket & drug store shelves has been vetted by the appropriate authorities such that it's been proven safe & effective.  But if you look at the claims that these dietary supplement manufacturers make, that clearly can't be the case as they promise miracles w/o any risk or side effect just because they're natural, organic or herbal.  It's as if we've suspended belief such that wiping our a--es in the woods w/poison ivy and/or poison oak won't lead to their traditional rash.  In fact, there is no mandatory 3rd party oversight regarding these dietary supplements, something that you might ponder if you read the standard Food & Drug Administration disclaimer from behind which all the manufacturers hide.

Don't get me wrong.  All medications, whether prescription or over-the-counter, and all dietary supplements, regardless of how natural, organic and/or herbal, have side effects, some known, many not.  In other words, there's no free lunch, no matter what the ads claim.  And medications manufacturers are not immune from contamination & manufacture problems.  But at least these are discovered & publicized by the FDA, as opposed to dietary supplements which are only exposed & brought to light thanks to investigative journalism because their manufacturers aren't required by law to prove either safety nor effectiveness of their claims.

If you want to see something scary, watch the deposition given by one of the supplement designers who describes his lack of education, use of substances not previously tested on humans, and his own testing on himself & a few friends prior to marketing said substance.  Just 2 days ago, USA Today publicized the presence of methamphetamine-like substance in a popular dietary supplement.  Of course, the manufacturer said this was a contaminated counterfeit.  So I was a bit surprised to find that this same manufacturer caved in a day later (yesterday) and stopped production of this contaminated product.  The only problem is that the product hasn't been recalled and thus is still available for purchase.  Caveat emptor.  Buyer beware.

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James Gandolfini's Demise: Heart Attack or Cardiac Arrest

My wife had the pleasure of meeting James Gandolfini earlier this year at a fundraising function and told me that he was just delightful in person, nothing at all like his most famous role as Tony Soprano.  As I'm sure you're all aware by now, the 51yo actor passed away 2 days ago while in Italy.  What's not clear is exactly how/why this happened.  Initial reports stated that he died from a heart attack.  Now some are calling this cardiac arrest.  What's the difference?  And does it really matter?

USA Today put together a nice review of the differences between two conditions.  Most notably, a heart attack (also known as myocardial infarction) is due to blockage of blood flow to the heart, leading to death of cardiac tissue, thus causing chest pain.  Death of heart muscle can also impact the electrical conduction system of the heart, leading to a short circuit, thus stopping the normal beating of the heart, ergo cardiac arrest.  While one can survive a heart attack, if the heart's normal rhythm isn't restarted in time, cardiac arrest most often leads to death.

So what's your chances of a heart attack or cardiac arrest?  Work w/your family doc & review your risk after plugging in a few numbers & facts into the Framingham calculator that gives a 10 year estimate of heart attack risk.  Remember that a 10 year risk >20% is considered the equivalent of already having had a heart attack.  Also, know that this calculator isn't 100% accurate but just the basis for starting a conversation & discussing options for optimizing your health.  Depending upon your age, ethnicity and especially your family history, your risk score may come out higher or lower than it should.  Still, that doesn't mean that you can ignore your blood pressure, cholesterol, sugar & tobacco use.

Take care of yourself, if not for you, then for your family.  51 is an awfully young age at which to pass away. The only consolation I have is that we're a better world for having enjoyed his skills.

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Obesity: Is It A Disease Or Not?

Oh, what a difference 18 hours or so makes.  Like many of you, I subscribe to many electronic tables of contents & news headline/summary emails.  I woke up yesterday morning to the headline, "Obesity Not a Disease, AMA Council Says" sent at 3:45AM.  I came home yesterday evening to the USA Today headline, "Medical group recognizes obesity as a disease".  So which is it?  It turns out that both are correct!  Remember that we're talking about medicine here, where things are never as simple and black & white as we'd like them to be.

The American Medical Association's Council on Science & Public Health report declared that there is insufficient evidence to declare obesity a disease (see page 19 of 87), despite all the issues associated with excess weight & body fat.  Key among their concerns was the inexactness of body mass index which does not take into account lean vs fat body weight.  In other words, BMI prizes a "skinny fat" desk jockey or a fit athlete who is overweight by virtue of tremendous muscle.  

However, the AMA's House of Delegates ignored the CSAPH's report and voted by 60% to declare obesity a disease (see page 78 of 87).  Good triumphs over evil, right?  Well, not so fast.  While we, the general public, like to think of the AMA as representing all physicians (and certainly the AMA would like us to think so), it turns out that, in reality, the AMA represents just 25.6% of all American physicians, most of whom are not primary care providers.

But if you delve deeper into the numbers, medical students represent 22.2% of AMA membership while resident physicians (those still in training) represent 17% (in effect, only 60% of active members are licensed to practice w/o supervision, for whatever that's worth).  In essence, while 1 in 4 "physicians" is a member of the AMA, only 1 in 7 physicians (no quotation marks) is represented by the AMA, and of those, only 3 out of 5 voted to declare obesity a disease.  

So does this really matter?  Or is this just semantics?  By declaring obesity a disease, the idea is to destigmatize a condition that affects over one-third of the population (toss in those who are overweight but not yet obese and you've now included two-thirds of the population!) and increase funding for research as well as payment of both medical & surgical options.  Time will tell whether this declaration really makes a difference.  As for me, good nutrition, as evidenced by the Mediterranean diet, and regular physical activity, are still key to health (and weight).

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Prince Philip & Geriatric Medicine

If you've been following the international news, especially that coming out of the United Kingdom, you probably read that Prince Philip, Duke of Edinborough, was released from the hospital after spending 5 days to treat a bladder infection, just in time to celebrate his 91st birthday yesterday.  Now, you're probably asking yourself why someone would need to be hospitalized for a bladder infection?  I suppose one could blame this on his status as a member of the royal house.

However, I believe it's more a reflection of geriatric medicine, specifically care of our elderly.  While physicians on this side of the pond tend to have a higher threshold for hospitalization, we also tend to have a lower threshold for our frail elderly who can more easily turn bad at the drop of a hat.  I know what you're saying and I hear you.  It's only a simple localized bladder infection, not a systemic kidney infection prone to worsening into urosepsis (infection leaking into the bloodstream).

But the fact is the elderly don't always respond quite the same as you & me (assuming you're not 10 years older than me as the standing definition of elderly!).  They don't always develop a fever from infection.  Nor do they always complain of painful, frequent & urgent urination due to bladder infection.  Instead, a previously lucid individual might present with confusion.  Or s/he might complain of sudden fatigue & non-specific malaise.

It's our responsibility as physicians in general & geriatricians, specifically, to listen closely to our patients and be leery of any change in status.  More importantly, we also need to look for drug-drug & drug-disease interactions as well as make every attempt to simplify & reduce what is most likely an egregious case of polypharmacy.  In the end, we focus on function and quality of life as the goals, rather than on disease specific markers.

The sad news is that 15 minutes isn't nearly enough time to thoroughly care for our elderly in the manner in which they need & deserve.  Frailty & debility.  Falls & fractures.  Poor hearing & eyesight.  Depression, dementia & delirium.  Incontinence.  These are the basic syndromes that need to be addressed and  yet we haven't even begun to tackle the common organ specific issues such as coronary artery disease, heart failure, hypertension, diabetes, stroke, kidney failure, etc.  Let's fix the system before we find ourselves in need of geriatric care.

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RIP Nate Dogg 1969-2011

I don't claim to follow rap or hip-hop but Nathaniel D. Hale, better known as Nate Dogg, passed away yesterday at age 41.  No details were given regarding cause of death but USA Today did report that he had suffered strokes in 2007 & 2008.  In fact, he suffered his first stroke at 38 years old and his second at 39 years old, only to die 3 years later.  Now, I don't know about you, but despite being a geriatrician, I think of stroke as being a condition of the elderly.  Not that it's any less painful in our (grand)parents generation, but to lose a talent with so many more years to offer us is truly sad.  We can't prevent all strokes, but we can certainly minimize our risk if we adopt healthier lifestyles, at the risk of putting out a shameless self-plug.  Let's do our best to maintain our ability to complete our life goals.  And let's not leave this Earth prematurely.

Telemedicine, Schmelemedicine

As you know, I'm setting up a small private practice in Las Vegas.  However, I'm breaking trends with tradition by offering to "see" patients outside of my local area.  This will entail the use of phones & email once a formal doctor-patient relationship has been properly established.  But the question of the day is what constitutes a "proper" relationship?  In the good old days, you went to your doctor's office and waited several hours before being seen physically.  With modern technology, you could potentially see your doctor via videoconference, although most states frown against this unless the physician is also licensed in the state in which the patient resides.  Certainly, state & federal regulations currently require at least an initial, if not regular, physical visit.  Because this issue affects me (and you) directly, I am sensitive to any light shed upon the matter, whether on a local or national level, since I don't want to lose my license.  What are your thoughts?