Better Health: Smart Health Commentary Better Health (TM): smart health commentary



Latest Posts

How is Healthcare Like A Garden Fungus?

3 Comments »

Hot and humid weather has spurred on the growth of many of my outdoor plants, including bamboo, rosemary, and various peonies. However, I was unpleasantly surprised by the arrival of three fungal guests, only one of which I could identify: the dog stinkhorn. As its name suggests, it is one unpleasant-smelling organism. A certain mushroom website described it as looking like “a dog phallus dipped in excrement.” They are not too far off. But sadder still was the assertion that there is no known cure for this fungal invader.

As I considered my new mushroom issue, I suddenly realized that there are interesting parallels with the healthcare system. Let me explain.

First of all, what does the average person do when they experience a new medical symptom/problem? The person goes online to research the symptom for possible diagnoses and treatment options. Is s/he successful? Sometimes yes and sometimes no. In my case, I could only identify one of the three types of fungi in my garden, even after finding this very nice mushroom identifier tool. Why wasn’t I successful? I’m not a fungi expert, and really didn’t know how to navigate my way through the complex descriptors required to correctly identify the little beasts. The questions included the following:

Fungus Website (FW): Is the spore color olivacious?

Dr. Val: What part of the mushroom is the spore, and what kind of olive are you referring to? I don’t know how to answer that.

FW: Describe the stem type. Is it lateral, rudimentary, or absent? Does it have a volva?

Dr. Val: Um… If the stem is lateral, does that mean it’s sticking out of the side of the mushroom? What makes a stem rudimentary? Does that just mean it’s not fancy? And as for the last question… that sounds kind of pornographic and I don’t think I’d know a fungus volva if I saw one.

FW: Can the pore material be separated from the flesh of the cap?

Dr. Val: What’s pore material?

FW: Is the mushroom edible, hallucinogenic, or poisonous/suspect?

Dr. Val: Well, it definitely looks “suspect” but there’s no way I’m going to test it out for poisonous or hallucinogenic effects.

And so it went. I tried to answer some of the identifier questions to get me to the correct fungal I.D. and in the end I received this message, “we were unable to find a match for your search.”

When patients try to find a diagnosis for their symptoms online, they will inevitably have a similar experience. Medical speak is like a foreign language, subtle differences between signs and symptoms seem obvious to experts, but can be opaque to patients. And even a very bright and educated consumer is bound to get lost in figuring out appropriate next steps. I’m a savvy woman, but when it comes to mycology (the study of fungus), I’m completely lost. How much more complicated is it to navigate the subject of human disease for those who don’t have formal training in medicine?

My point is this – medicine is incredibly complex, and a knowlegeable heatlhcare provider is critical in helping patients successfully navigate the maze. With all the health information on the Internet, it’s tempting to self-diagnose. But that’s a dangerous proposition – one that might lead you to presume that (to use my analogy) a poisonous mushroom is edible, or that a life threatening symptom is innocuous.

The Internet can be a great educational tool, but use it in conjunction with a close relationship to a trusted expert. If you don’t have a primary care physician, you can find one here. If you’d like to have your question answered by a physician online, try the Revolution Health forums. Not every question is selected for a professional reply, but many are. For a guaranteed response, eDocAmerica is a great resource.

Good luck, and I hope that your garden remains fungus-free. I’m now going to try to find a mycologist to tell me if it’s really true that there’s “no cure” for the dog stinkhorn. Unless any of you know the answer?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The Flip Side of the Medical Malpractice Coin

4 Comments »

American physicians are appropriately frustrated about the high cost of medical malpractice insurance, and the frequency with which false and/or exaggerated claims are filed against them. In the Philadelphia region, a spine surgeon must pay upwards of $300,000.00 a year in malpractice insurance. The law allows Obstetricians to be sued for mishandling the birthing process until the “child” is 20 years old. In many states, there is no cap on the amount of money awarded in a true case of negligence, and juries set the pay out – which can exceed 20 million dollars per verdict.

Interestingly, Texas instituted a new policy in which firm caps were placed on malpractice claims. The cost of medical malpractice insurance dropped precipitously, and over 7000 physicians flooded into the state.

I recently interviewed Canadian Senator Michael Kirby about the medical malpractice process in Canada, and he laughed at how litigious the American system is. He said that keeping the malpractice system from being abused is quite simple: fine plaintiffs who bring forth frivolous suits, set caps on pay outs, and allow awards to be set by judges, not juries. You can listen to our discussion here.

However, there is a flip side to this coin – when providers are permitted to practice without any real legal recourse. I was astonished to learn (from my blogging colleague across the pond, Dr. John Crippen), that in New Zealand midwives are permitted to practice without any form of malpractice insurance. In fact, a recent case demonstrated obvious negligence resulting in the death of a newborn baby. What recourse did the mother have? Apparently, her legal actions resulted in a payout of $2,000.00 and a promise of closer oversight of the practices of midwives.

Wow.

On the spectrum of “reasonableness” for medical malpractice policy, I believe the Canadians win, followed perhaps by Texans. What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Drugs in the Water Supply

2 Comments »

When I eat out at a restaurant I’m inevitably asked whether or not I’d like bottled water with my meal. My answer usually depends upon the city I’m in – New York water tastes great, so I ask for tap water in Manhattan. The water in DC tastes like a swimming pool (at best), so I usually order bottled water at Washington restaurants.

But little did I realize that the water I’ve been drinking (whether from DC, NY or even from the bottle) has small traces of pharmaceutical chemicals in it. A new investigation conducted by the Associated Press suggests that most major urban water supplies are laced with tiny amounts of prescription drugs. How do the drugs get in the water supply?

Remember that water cycle you (or your kids) studied in grade school? Well, the “underground phase” is where the action happens. Drugs that we swallow pass through our bodies and some is released in our urine and stool. We flush that down the toilet and the fluid debris is treated in a sewage plant and then the water portion is released back into the water supply. Sewage plants and water filters are not designed to remove trace chemicals like heart medicines and anti-depressants, so they remain in the drinking water. Kind of disturbing, right?

Well, the good news (if there is any) is that the amounts of chemicals in the water are pretty small – we’re talking parts per trillion. Just to put that in perspective, that’s more than 1000 times smaller than the minimum amount needed for therapeutic effect from the fluoride added to the water system. And the concentration is far below the therapeutic threshold in the bloodstream for these drugs. But how do we know that tiny amounts of drug exposure isn’t harmful in some cumulative way?

Research into the potential long term effects of these chemicals in the water supply has focussed mostly upon the presence or absence of the drugs, and the concentrations at which they’re present. Animal studies (such as the “feminization” of fish exposed to environmental estrogens) and cell culture research suggest that exposure to larger concentrations of these drugs can cause negative outcomes, but to my knowledge there are no long term studies of the potential impact of very small concentrations on human health. But before we become outraged at this apparent lack of investigation, let’s think about why it’s so difficult to gather this kind of information.

First of all, concentration-wise, pharmaceuticals represent a small fraction of the thousands of man-made chemicals in the environment, including everything from pesticides to personal care products. So it’s very difficult to prove a cause and effect for any one drug’s influence – we are each exposed to a very dilute cocktail of chemicals in our daily lives, whether through the water we drink, the food we eat, or the air we breathe. How can we tease out the potential damage of one chemical over another?

Secondly, it’s pretty likely that any potential harm (from chemicals at such small doses) would take many years of exposure before a clinically measurable threshold is reached. It’s very difficult and expensive to study large groups of people over time – and it’s hard to know what their lifestyle choices may contribute to their overall chemical exposure. Over time people change jobs, change what they eat or drink, change where they live… the complex interplay of environmental factors make it hard to interpret exposures and effects.

And finally, how do we know what outcomes to look at? It’s possible that these small doses of pharmaceutical products could affect our bodies in fairly subtle ways – which again makes it difficult to measure. It’s hard enough to study cancer rates in populations, but how would we study differences in physical or mental performance? Or slight changes in mood or heart function?

Since there’s no easy way to prove a connection between drugs in our water system and our general health and wellbeing, we are likely to be left with far more questions than answers. I think we all agree that we’d rather not be exposed to trace amounts of any chemicals in our water supply, but unfortunately the cost of filtering all potential contaminants from the water is exceedingly high. Reverse osmosis (a process currently used to reclaim fresh water from the sea) can cost as much as $1-18/gallon depending on the system in place and the country using it. While reverse osmosis could guarantee a chemical-free drinking water supply, we couldn’t afford to supply it to all Americans. And in the end, it’s still unclear if solving that part of the puzzle would improve our overall health.

I hope that we’ll find ways to reduce the chemical load on our environment, and that advanced water purification technology will become more affordable in the future. Unfortunately, trace amounts of chemicals, drugs, and pesticides are more ubiquitous than we’d like to believe. The impact they may have on our health is difficult to measure, and largely unknown at this point. Perhaps the bottom line is that we’re all connected to one another through our environment – so that granny’s heart medicines may yet live on (albeit in trace amounts) in your bottled water. All the more reason for Americans to pull together to live healthy lifestyles, control our weight, and try to prevent the diseases that are requiring all these drugs in the first place.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

When is Weight Loss Surgery an Appropriate Option?

4 Comments »

I’ve wrestled with this question for many years: “When is weight loss surgery an appropriate option?” I used to do weight loss research prior to working at Revolution Health. My studies focused on using “natural” methods to reverse type 2 diabetes – in other words, weight loss via diet and exercise. My study subjects were all obese, and most had struggled with weight for decades.

At some point during the trial, people would often ask: “Can’t I just have surgery for this and not have to struggle so much?” And I would gently remind them that surgery was no picnic, and to try diet and exercise first. “But it’s so hard!” they would say. I would acknowledge their difficulties and offer lots of empathy, and firmly encourage them to stick with their diet. In the end I found that only half of my study subjects could manage to stay on the diet for months at a time. So what should the other half do? Give up and let their diabetes ravage their bodies?

My friend and colleague Dr. Charlie Smith rightly points out that weight loss surgery can dramatically improve the health of people who have been unsuccessful at losing weight through diet and exercise. Heart disease, diabetes, and cancer rates were dramatically improved for morbidly obese people after weight loss surgery. So there is a clear benefit for some people to have the procedure.

However, the caveats should not be overlooked. First of all, weight loss surgery does not guarantee long term weight loss. It’s possible to gain back all the weight lost if eating behaviors are not changed. The human stomach is amazingly stretchy, and even if it’s surgically reduced in size, with repeated overeating it can eventually stretch to accommodate large meals again. Secondly, some types of weight loss surgery (like gastric bypass) can affect the body’s ability to absorb critical vitamins. Without enough of these nutrients, one can end up severely anemic, and osteoporotic just to name a few serious side-effects. And finally, the surgery itself is quite dangerous, carrying with it a potential risk of death as high as 1 in 200!

So weight loss surgery can be life-threatening, and is not a quick fix for a long term problem. However, morbid obesity itself is so dangerous (with the increased risk of heart disease, diabetes, and cancer) that it may require this extreme intervention to actually save lives. For people who have more than 100 pounds to lose, and have sincerely tried diet and exercise without success for a prolonged period, then weight loss surgery may be an appropriate option. For those whose lives are not at risk because of severe obesity, it doesn’t make sense to undergo such a risky procedure.

Are some people successful at losing a large amount of weight and keeping it off without surgery? Yes! The National Weight Control Registry keeps a list of thousands of Americans who have lost at least 30 pounds and kept them off for at least 6 years. What’s their secret? You guessed it – regular exercise and a calorie controlled diet. Some other things that these “successful losers” have in common: 1) they eat breakfast 2) they have a cardio machine at home 3) they weigh themselves regularly.

If you’d like to meet a group of people who are working towards long-term weight loss success, feel free to join my weight loss support group. We have weekly challenges, tools and trackers, a vibrant discussion group, and free medical insights to help you along your way. Weight loss is really hard to achieve by yourself. It takes encouragement, support, and a community of like-minded folks who are determined to make a difference. You can do it!… and I’d be honored to support you along the way.

P.S. There’s a special group forming at Revolution Health for folks who need to lose 100 or more pounds. It’s called “Overweight But Not Giving Up.”  Check it out.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Doctors: Whom Can You Trust?

No Comments »

I must have a really trustworthy face. No matter where I go, absolute strangers ask me for directions, they request that I watch their belongings, hold their place in line, they even ask me to help with their kids. I am continually astonished by the uninvited inquiries that I receive walking down the street, on the train, or even in foreign countries. I guess people think I’m both harmless and likely to know how to help them. They are right about the first part, and not quite as right about the second.

Just a couple of days ago I was settling into a train seat when the woman in front of me peaked over the head rest and asked if I’d mind watching her bags while she left to go to the restroom. I happily agreed to do so, wondering what I’d actually do if someone tried to take her bag. And as I mused about how on earth I’d won her absolute confidence without even making eye contact, I began to think about the idea of trust. How do patients decide whom they trust with their medical care?

I’d like to think that trust is earned – and many times it is – but there’s also something more primitive about it than that. Without knowing a person for long enough to judge his or her character, we often draw conclusions nonetheless. How successful are we at these snap decisions? Well, we might be quite good at it. I was amused to find an online test where you may judge the sincerity of a person’s smile just by looking at a 4 second video clip. Some of the models were asked to smile convincingly, and others were told a joke or were caused to laugh by some genuine means. Most people figure out which smile is contrived and which is natural most of the time. See how you do.

And so, when it comes to finding a primary care physician, or a doctor that you trust with your medical care, should you rely on your gut instincts or is there a better way to assess their competency?

I’ve wrestled with the idea of online physician ratings for a couple of years. Part of me thinks that it’s impossible to capture all the qualities of a good physician in some simplified form filled out by non-medical professionals. But another part of me wonders if a large collection of different experiences might add up to an opinion trend that’s on the mark. Whether or not you’re a fan of physician ratings, they are here to stay. Perhaps the best we can do is offer as many ratings as possible so that the average might provide high level, helpful information. Revolution Health has a free physician rating tool. Check it out.

How do you know whom to trust? Do you rely on your instincts or the referral of someone you know? Would online physician ratings be helpful, harmful, or simply limited in their utility?

Let me know… and if you see me on the street, yes, I’d be happy to watch your bags.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

How Do Hospital Executives Feel About Locum Tenens Agencies And Traveling Physicians?

I recently wrote about my experiences as a traveling physician and how to navigate locum tenens work. Today I want to talk about the client in this case hospital side of the equation. I ve had the chance to speak with several executives some were physicians themselves about the overall…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »