Being a physician isn't easy.

Here's an article from the NYtimes.

While this doesn't have much to do with geriatrics, I thought I'd weigh in. The premise of this article is that since medical school and residency are subsidized by the states and the federal gov't through Medicare, there is a social obligation for physicians to serve the greater good and put the good of society above individual goals such as family and lifestyle. This is especially true in primary care specialties. And since women are the dominant subgroup of physicians who work part time, women ought to be ashamed of themselves for being so selfish. So says the anesthesiologist who clearly didn't care to meet the primary care needs in the country herself despite her subsidized education. For the sake of brevity, I'll make my points in a list:

1. It is not the job of women medical students to shoulder the burden of the primary care shortage in the US. Physicians should not have to (and I would argue can not) make up for major shifts in specialty choice driven by economics, public policy, the health insurance landscape and specialists like anesthesiologists.

2. Medical school is no more subsidized than any other public school education. Going to a public school is a benefit by working people paying taxes (of which doctors will pay a lot). No one expects those who go to public universities to enter public service in other fields and expecting that in medicine makes no sense. Why not ask it of lawyers? Or MBA types?

3. While residency is subsidized by the government through medicare, I would argue that the residents themselves subsidize their own education by taking a low salary while working long hours and sacrificing much in their personal lives. While the government does subsidize graduate medical education, they also set the rules that resident physicians (who are licensed physicians) can not bill for their services. So the subsidy is really just another way of paying a salary that is justly earned. If the subsidy goes away, then resident physicians ought to be able to bill for their services.

4. Part time women physicians bring incredible balance, perspective, talents to the physician work force that would not be there otherwise. If it was mandated that all physicians had to serve full time for 10 years after residency, I would think that the percent of women physicians would drop and medicine would be far worse off because of that.

5. It is too easy to look at physicians who work less than you and criticize their lack of dedication. As someone who worked as a solo doc, on call 24/7, seeing my patients 7 days a week in the hospital, I could be critical of a shift working anesthesiologist who hands off patients to other docs. How dare she think that transitioning patients between docs is good care? Where is her dedication? Doctors have to quit trying to guess each other's motives and just judge the quality of medicine that is practiced.

6. I would argue that having a healthy private family life is good for professional life.

7. Notice that there is no critique of the quality of part time physicians. If patients want a full time physician then they can select one. If they are satisfied with a part time physician, then where is the harm?

8. Students already graduate with $150,000 debt (average) which grows during residency. This is the reason that out of 20-25,000 medical students, only 90 choose geriatrics. Saying that medicals students are not appreciative of their subsidized education is incredibly insensitive to students who choose not to be anesthesiologist who make 3-4 times what a geriatrician makes ($100,000 to 150,000).

9. The shortage of doctors in this country is a problem of public policy, medical education, not women physician who choose to work part time. Why are women to be blamed for this instead of the men?

10. How is working full time her only metric of what it means to be a good doctor? She has defined it so that she meets the definition and other women don't. But what is she doing to correct the primary care shortage, health care discrepancies, deal with the underserved? No offense to my anesthesiology colleagues, but when I used to round in the hospital seven days a week, go to my office afterwards for a full day of clinic five days a week, go to football games on Friday nights, work in the ER one shift a week, do 200-300 physicals at the elementary and high school once a semester, teach about smoking to 4th graders, do home visits during lunch, attend deliveries at night, see my nursing home patients once a month, work as a medical director of a nursing home and hospice, teach PA students in my office, I felt more like a doctor than the anesthesiologist who worked half my hours but was still "full time." Yet somehow this anesthesiologist sees herself as enough of an ideal doctor to look down on others. Sigh...... I won't even mention some of my doctor friends who are working in rural third world countries. My work pales in comparison to their dedication.

At the end of the day, being a doctor isn't easy. The training asks for enough sacrifices on its own. It's too easy for a doc to criticize anyone working less than them as being lazy and anyone working harder than them as being a workaholic. I knew a doc who said his patients came before his wife. She would get hospitalized for overdoses a couple times a year but he felt if you didn't put your patients first, you weren't a real doctor. I knew another doc who felt if your office wasn't your house (i.e. work downstairs, live upstairs), you weren't a real doctor. This crazy machismo competition has got to end. At the end, if we practice good quality medicine, we should be proud whether it is a little bit or a lot. Just doing that is hard enough.

so much for brevity

Should I start dialysis? Should I stop dialysis?

Over the last week, this issue has come up three times. One of my office patients who's chronic kidney disease (CKD) is at stage 4-5 (1 being least severe, 5 being the worst) decided not to proceed with dialysis. One patient in the NH decided to stop dialysis and another in the NH (nursing home) had not been on dialysis ever. All had stage 5 CKD. In all three situations, after a very careful family discussion, the decision was made against pursuing dialysis. Obviously, this is a big decision.

So what does dialysis do and why do people need it? The short version is that dialysis takes over the functions of failing kidneys: getting rid of excess potassium, excess fluid and general toxins.

What is involved in starting dialysis? First you need access because it is a blood filter machine. So either a port placed in the chest that sticks out, an artificial graft placed in the arm or a modification to the bodies own vessels called a fistula in the arm. Then usually, three times a week one would go to a dialysis center for 3-4 hours to get the blood filtered. More is involved than this, but this is the short version.

What happens if you are on dialysis? Well it can be very tiring, there can be complications such as nausea, bleeding, infection, clotting of the graft/fistula/port. It is almost always lifetime unless someone gets a kidney transplant.

What happens if you don't do dialysis? Well this is what is interesting. Many people do just fine. Even with the most severe cases of CKD. It depends, if someone is initiating dialysis because they have had recurrent episodes of being fluid overloaded, having a high potassium or being confused then they will not do so well without dialysis. But if a patient is stable and is just being told to do dialysis to be safe, we're learning that older patients may do okay without dialysis for years.

Discussion:
Without any question, dialysis is a life saving measure. It can extend life in most people. In some who have complications, it can shorten life just like any other medical procedure that goes wrong. It has been studied that older adults who initiate dialysis tend to decline in function over time. Not necessarily more rapidly or less rapidly than those who do not do dialysis, but needing dialysis is a sign of frailty that starting dialysis will not reverse. In other words, dialysis will not help somebody gain function that they have lost. It will not get someone back to how they were before even if that is 3 months before. (Generally speaking). There is more and more discussion among physicians and older adults about not starting dialysis and using watchful waiting in the meantime. For those who do not need dialysis, it is certainly an option to just watch it, knowing that there is some risk involved in doing so.

Here's a good article to read.

A guide to making health decisons

For the average patient, navigating the health care system can be daunting, intimidating, and frustrating. For those who are caregivers of older patients, you add feelings of intense guilt, burden and regret sometimes. And for those who are unexpected decision makes, it can be overwhelming. Full code or no code? Which nursing home? How to manage finances? Which medications? What would my loved one want? etc.

I plan on writing a guide for health care decision-makers/caregivers to help navigate a variety of contexts: the office visit, hospital, nursing home, hospice as well as specific decisions such as: is this the right diagnosis; should I start/stop a medication; is a surgery necessary, feeding tubes, code status.

I will tell a story of a patient of mine. I have a young 50+ year old female who went into the hospital for a wound. She has no dementia, lives independently with a caregiver. She makes her own decisions. Other than being mostly a quadriplegic, she is healthy. Somehow, while in the hospital, her surgeon told her that her albumin was low, she was malnourished and unless she got a PEG tube, her wound would never heal. She eats normally, has no swallowing problems and is a very compliant/adherent patient who has great understanding of her health issues. Against her gut feeling, she let them put it in and came to my nursing home for rehab. I was very surprised to see her with a PEG tube because she definitely does not need it. As she told me the story I had a sinking feeling that I should have intervened. Unfortunately I did not know that she was asked to make this decision. Two problems with story, 1 medical, 1 relational-

The medical objection is to the surgeon's assumption that a low albumin reflects malnutrition causing a wound which can be corrected by PEG tube feeds better than oral feeds. First, the patient is not malnourished. Albumin has nothing to do with nutrition. There is no reason to think that a can of Boost via PEG three times a day is any better than a can of boost ingested orally.

The relational objection is that the surgeon did not take the time to explain to the patient to her level of satisfaction why the PEG was necessary. The truth is that he would not have been able to do so because it wasn't necessary but no attempt was made.

So what is the patient supposed to do? Gut feeling was that this was an unnecessary procedure, but how is she going to disagree with her surgeon? First, she could have involved her primary care doctor (me) and asked the surgeon to call me. She could have insisted on a consult with a GI doctor. She could have picked a doctor who cared about answering questions and making sure that decisions were made collaboratively.

When it is a caregiver making decisions, I think the dynamics can be even more complicated. Does the physician involve both the caregiver and the patient in a collaborative relationship? How does the caregiver balance risk vs benefit? What happens if the patient gave unclear instructions?

I hope to give somewhat of a guide with questions caregivers should ask in different settings, answers to listen for and statements to make that will communicate wishes clearly to physicians. I'll give it a go!

I really dislike medical billing

I have to confess, I have been sent to collections once. It happened after my wife was in a motor vehicle accident. She went to the hospital by ambulance to get checked out because she had some back and neck pain. Afterwards, we got bills from the ambulance, ER physician, hospital, radiologist and lab (all separate). Somehow I lost track of one and a year later, I got a notice from a collections agency. Out of the 5 entities, 4 got the insurance info I had presented at registration in the ER but one did not. sigh.....

So recently, my son was born. Of course he has no existing insurance until he gets added. The pediatrician and obstetrician who did the circumcision accidentally billed it under me and my insurance ID which promptly got rejected by the insurance company. In order to correct it, I called the insurance company and the biller for each physician. Not my mistake but my mess to clean up. I hate that.

The problem is that billing is a pain for physicians to. I have to keep track of medicare guidelines that care about how many review of systems I ask patients about. So instead of saying to a patient, is there anything that is bothering you? Anything else? (like a normal person may), I have to say, do you have any fevers, loss of appetite, diarrhea, burning when you pee, chest pain, shortness of breath (ideally 2 points from 10 organ systems). The person is obligated to say, no, no, no, no, no, I would have said something, no, no, no. All this to be compliant and not be accused of medicare fraud.

Somehow the billing system works for neither patients nor physicians. Nothing in health care reform every addresses that.

Red Yeast Rice

I was asked recently about red yeast rice. This is what I wrote:
I do recommend Red Yeast Rice. It does lower cholesterol in small trials. Here's an example of one:

BACKGROUND: We examined the cholesterol-lowering effects of a proprietary Chinese red-yeast-rice supplement in an American population consuming a diet similar to the American Heart Association Step I diet using a double-blind, placebo-controlled, prospectively randomized 12-wk controlled trial at a university research center.

OBJECTIVE: We evaluated the lipid-lowering effects of this red-yeast-rice dietary supplement in US adults separate from effects of diet alone.DESIGN: Eighty-three healthy subjects (46 men and 37 women aged 34-78 y) with hyperlipidemia [total cholesterol, 5.28-8.74 mmol/L (204-338 mg/dL); LDL cholesterol, 3.31-7.16 mmol/L (128-277 mg/dL); triacylglycerol, 0.62-2.78 mmol/L (55-246 mg/dL); and HDL cholesterol 0.78-2.46 mmol/L (30-95 mg/dL)]who were not being treated with lipid-lowering drugs participated. Subjects were treated with red yeast rice (2.4 g/d) or placebo and instructed to consume a diet providing 30% of energy from fat,<10% from saturated fat, and<300 mg cholesterol daily. Main outcome measures were total cholesterol, total triacylglycerol, and HDL and LDL cholesterol measured at weeks 8, 9, 11, and 12.

RESULTS: Total cholesterol concentrations decreased significantly between baseline and 8 wk in the red-yeast-rice-treated group compared with the placebo-treated group [(x+/-SD) 6.57+/-0.93 mmol/L (254+/-36 mg/dL) to 5.38+/-0.80 mmol/L (208+/-31 mg/dL); P<0.001]. LDL cholesterol and total triacylglycerol were also reduced with the supplement. HDL cholesterol did not change significantly.

CONCLUSIONS: Red yeast rice significantly reduces total cholesterol, LDL cholesterol, and total triacylglycerol concentrations compared with placebo and provides a new, novel, food-based approach to lowering cholesterol in the general population.
(PMID 9989685)

So it works in populations. There are three questions
1. Does the lowering of cholesterol lead to lower heart attacks and strokes like statins? Zetia for example may possibly lower cholesterol without preventing heart attacks and strokes. So while it does lower cholesterol, in reality that isn't the goal.
2. How does one know that the red yeast rice obtained is of equal quality to that found in studies?
3. What are long term safety issues?

These are the same questions of any herbal/alternative/complementary supplement.

It's worth considering using Red Yeast Rice because not everyone tolerate statins. And it can be used with statins possibly (it does possibly work by blocking the same enzyme in the liver however).

Does Aricept work? yes/no/maybe so

So this is my favorite picture from any study I've ever read on the treatment of dementia. This study is from Mass General's NIH funded Dementia/Memory center. Published in 2008 in the Alzheimer's Disease Associations journal, it is a publication of their longitudinal data. In academic terms, this is a retrospective historical cohort control study looking at three groups: Placebo, Aricept only and Aricept plus Namenda. (cohort=group of people) All prospective, placebo controlled trials that are of decent quality are less than 2 years in length, and all but about 4-5 are a year or less in length. So for this chronic disease, we have very little data about the benefits/harms of using the 4 FDA approved dementia meds long term. This study attempts to answer this question using the best data available.

So on to this study. This picture is from Mass General's decades long database of patient info. The top picture is the placebo group, the middle one is Aricept only and the last one is Aricept plus Namenda. What is being measured is cognition (Blessed Dementia Scale) where the higher the number the greater the impairment. The dark line going across each graph is the line of best fit or approximately the average of each group. The flatter the line, the more preserved the cognitive ability. Each little line with dots is an individual person.

The punch line from the study is that this is the longest cohort controlled data published to date (2008) and not only does it confirm a benefit to medications, but an increasing benefit over time. Let's look at this....

So does Aricept and Namenda work?

1. Yes: In this study you can see that the dark line in the bottom picture (Aricept+Namenda) is flatter than the dark line in the top picture (Placebo). This is consistent with almost every placebo controlled study. By the time you get to the end of the study, the group on treatment has an overall/average score that is better than the placebo group.

2. No (You'd never know part 1): If every patient achieved that average score for the population, you would likely never know the difference. If one person worsened by 6 points (out of 36) on placebo but another person worsened by 4 points, you'd be hard pressed to figure out who kept two of their points. While these results are statistically significant, clinically, very difficult to tell. This picture is also seen when looking at function (Activities of daily living) or any other measure of Alzheimer's. Average benefit is incredibly difficult to tell without looking through the magnifying glass of a researcher.

2. No (You'd never know part 2): But every patient does not achieve the average benefit. That should be clear from the chaos of the light lines connected by dots. There is an incredible variation of the course of dementia whether on treatment or off treatment. Patients improve, stabilize and decline whether they are on treatment or not. Trying to compare how a patient is doing compared on treatment to guessing how they would have done off off treatment to measure effectiveness for an individual patient is futile because you just never know. Regardless of group, you can see in this picture that for any specific individual patient, you can see a matching patient in another group. In other words, a stabilization of MMSE, a decline of only 1 point per year, an improvement of 1 point per year, an improvement in ADL's can all come out of any group.

3. Maybe so: So does it work? The answer is maybe. But you'd never know. It is clear these drugs have an effect in populations, that the response is incredibly variable. They may really work. For a very small proportion, they may work really really well and those improvements may be masked in groups of people. But it should be clear that the average person benefits little or not at all. So why do most people feel that these drugs do nothing? An incredibly variable response which is very very small leaves a lot of us thinking that these medications don't seem to be doing anything most of the time. It's just so hard to tell.

Conclusion
Would I take it if I started with mild dementia? Yes, if I were healthy, were on minimal medications, did not have to sacrifice anything to afford it and most importantly had zero side effects from the meds. Also, I'd want to have a decent quality of life (personally meaning that I could communicate and not be in a lot of pain)

Second conclusion: Be very wary of any treatment of dementia that says it works and publishes their average data between two groups of people. The skeptic in me would want to ask: 1. how would I know if it is working so I can stop it if it is not working? 2. What is the exact benefit and what proportion of people achieve that benefit.

What is the purpose of hospice?

Whether or not to be on hospice can be an incredibly emotional, gut wrenching, contentious decision. This is something I'll discuss with patients on a weekly basis whether in my office, nursing home, or hospital. In surveys of some populations, the vast majority of people with a hypothetical terminal illness would want palliative (or comfort) oriented care but in the same survey would reject hospice services which aims to provide that type of care. Why? Somehow, hospice services are seen as something negative. People fear that hospice means that everyone has given up, they will be left to die alone, they are being told they have less than 6 months to live, that they are being abandoned.

Having been a hospice director (but no longer at my current job) and working with dozens of hospice agencies (both for profit and not for profit), I know there is a lot of confusion as to what hospice is supposed to be.

There are several types of patients that sign on to hospice and you will note very different goals.
1. The patient who is actively dying. This patient has less than a week to live. Has already started the dying process of multi-organ failure, low blood pressure, low heart rate, coma, kidney failure, cessation of eating/drinking etc. Hospice is used to help make the dying process comfortable. Possibly at home.
2. The patient who is sick and tired of doctors/therapeutic interventions such as ICU's, intubation, ER visits and wants to be left alone. This patient wants to have quality of life maximized without invasive procedures.
3. The patient who has a very short life expectancy (i.e. < 6 months) who still wants to live as long as possible but has some patient preferred limits (i.e. no intubation) and/or doctor limits (chemotherapy/dialysis is no longer effective as an option). The difference between the last two is that the last patient may still want options that the doctors are no longer offering. The limits on care options are due to the severity of the illness, not the patient's preferences. One contentious issue is ED visits/hospitalizations/Codes. Some patients may still want this even when it is ineffective. One very real example is that a true code in nursing home (where the patient is found without a pulse and not breathing) is 100% fatal situation. Yet it is not uncommon to find half of nursing home patients as full code. Hospice is an easy answer to patients #1 and #2, but can be very upsetting to those who are patient #3. Patients in the last category feel that options are being taken away that they still want (everything from blood draws to xrays, to ER visits, ICU care etc). Ideally, hospice could be flexible for patients in this last category, continuing to provide patient centered education while allowing the patient the dignity of directing their own care. However I find this is often not the case and why hospice has such a bad name. Often hospice nurses, in the name of improving quality of life, will dictate goals of care TO the patient, set limits on what options are considered available regardless of patient wishes and fail to let patients direct their own care. As the proportion of patients being referred to hospice reflects an increasing diversity of goals, this type of management will fail and offend many. (i.e. Palin's death panels). Hospice agencies used to dealing with patient #1 and #2 will need to increase flexibility to help those in category #3. So far many haven't. In this case, ideally the primary care physician will be able to medicate mediate between hospice and the patient, advocating for the patient and ensuring the patient gets the care that they want.