Category Archives: Good Doctoring

Why We Need To Replace Hippocrates’ Oath And Apocryphal Trope

The skeptical cardiologist has never liked the Hippocratic Oath and so was quite pleased to read that it is gradually being replaced by more appropriate oaths with many medical graduates taking an excellent pledge created by the World Medical Association.

Here’s the first line of the Hippocratic Oath

Asclepius with his serpent-entwined staff, Archaeological Museum of Epidaurus

I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.

Much as I enjoy the ribald hi jinx of the gods and goddesses in Greek mythology and appreciate the back story behind words like panacea and hygiene* I just don’t feel it is appropriate to swear an oath to mythical super beings.

Let Food Be Thy Medicine-The Apocryphal Hippocratic Trope

Hippocrates is often cited these days in alternative medicine circles because he is alleged to have said “let food be thy medicine and medicine thy food.”

I’ve come across two articles that are well worth reading on the food=medicine trope which is often used by snake oil salesmen to justify their useless (presumably food-based) supplements.

The first , entitled “Hey, Hippocrates: Food isn’t medicine. It’s just food” comes from  Dylan Mckay, a nutritional biochemist at the Richardson Centre for Functional Foods and Nutraceuticals, He writes:

Food is so much more than medicine. Food is intrinsically related to human social interactions and community. Food is culture, love, and joy. Turning food into medicine robs it of these positive attributes.

A healthy relationship with food is essential to a person’s well-being, but not because it has medicinal properties. Food is not just fuel and it is more than nutrients — and we don’t consume it just to reduce our disease risk.

Seeing food as a medicine can contribute to obsessing about macronutrientintake, to unfairly canonizing or demonizing certain foods, and to turning eating into a joyless and stressful process.

People tend to overvalue the immediate impact of what they eat, thinking that a “super food” can have instant benefits while undervaluing the long-term effects of what they consume over their lifetime.

The Appeal to Antiquity

The second article is from the always excellent David Gorski at Science-based Medicine entitled let-food-be-thy-medicine-and-medicine-be-thy-food-the-fetishism-of-medicinal-foods.

Gorski notes that just because Hippocrates is considered by some to be the “father of medicine” and his ideas are ancient doesn’t make them correct:

one of the best examples out there of the logical fallacy known as the appeal to antiquity; in other words, the claim that if something is ancient and still around it must be correct (or at least there must be something to it worth considering).

Of course, just because an idea is old doesn’t mean it’s good, any more than just because Hippocrates said it means it must be true. Hippocrates was an important figure in the history of medicine because he was among the earliest to assert that diseases were caused by natural processes rather than the gods and because of his emphasis on the careful observation and documentation of patient history and physical findings, which led to the discovery of physical signs associated with diseases of specific organs. However, let’s not also forget that Hippocrates and his followers also believed in humoral theory, the idea that all disease results from an imbalance of the “four humors.” It’s also amusing to note that this quote by Hippocrates is thought to be a misquote, as it is nowhere to be found in the more than 60 texts known as The Hippocratic Corpus (Corpus Hippocraticum).

Gorski goes on to point out that:

this ancient idea that virtually all disease could be treated with diet, however much or little it was embraced by Hippocrates, has become an idée fixe in alternative medicine, so much so that it leads its proponents twist new science (like epigenetics) to try to fit it into a framework where diet rules all, often coupled with the idea that doctors don’t understand or care about nutrition and it’s big pharma that’s preventing the acceptance of dietary interventions. That thinking also permeates popular culture, fitting in very nicely with an equally ancient phenomenon, the moralization of food choices (discussed ably by Dr. Jones a month ago


We’ve learned a lot about medicine and nutrition in the last 3 thousand years. We can thank Hippocrates, perhaps, for the idea that diseases don’t come from the gods but little else.

It’s time to upgrade the physician pledge  and jettison the antiquated Hippocratic Oath.

We now have real, effective medicines that have nothing to do with food for many diseases. It’s important to eat a healthy diet.

But the food=medicine trope is just too often a  marker for pseudo and anti-science humbuggery and should also be left behind.

Hygienically Yours,

-ACP

*From Wikipedia, an explanation of the Gods and Goddesses mentioned in the Hippocratic oath

Asclepius represents the healing aspect of the medical arts; his daughters are Hygieia(“Hygiene”, the goddess/personification of health, cleanliness, and sanitation), Iaso (the goddess of recuperation from illness), Aceso(the goddess of the healing process), Aglæa/Ægle (the goddess of the glow of good health), and Panacea (the goddess of universal remedy).


The Physician’s Pledge

  • Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948
    and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968
    and the 35th World Medical Assembly, Venice, Italy, October 1983
    and the 46th WMA General Assembly, Stockholm, Sweden, September 1994
    and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005
    and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006
    and the WMA General Assembly, Chicago, United States, October 2017

  • AS A MEMBER OF THE MEDICAL PROFESSION:

  • I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;

  • THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

  • I WILL RESPECT the autonomy and dignity of my patient;

  • I WILL MAINTAIN the utmost respect for human life;

  • I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;

  • I WILL RESPECT the secrets that are confided in me, even after the patient has died;

  • I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;

  • I WILL FOSTER the honour and noble traditions of the medical profession;

  • I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;

  • I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;

  • I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;

  • I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;

  • I MAKE THESE PROMISES solemnly, freely, and upon my honour.

 

 

One Question On A Borderline Stress Test and One Comment About Me , Gundry And BIG PHARMA

A reader asks me the following question:

I’m 35 years old male and was positive for myocardial ischemia during stress test. The cardiologist said that my result was borderline. I’m not sure what does he meant by “borderline”. Also does it help if I do CAC score since my stress test already came out with positive MI?

Good questions.

First off, to understand what any stress test means we have to know the pre-test probability of disease. For example, in 35 year old males without chest pain the likelihood of any significantly blocked coronary artery is very low. This means that the vast majority of positive or borderline tests in this group are false positives, meaning the test is abnormal but there is no disease.

Even if we add exertional chest pain into the mix the probability of a tightly blocked coronary in a 35 year year old is incredibly low (but there are some congenital coronary anomalies that occur.)

The accuracy of stress tests varies depending on the type. The standard treadmill stress test with ECG monitoring is about 70% sensitive  and 70% specific. Adding on a nuclear imaging component improves the sensitivity (it makes it more likely we will pick up a blockage if it is present) to about 85% however, in the real world, the specificity (chance of a false positive) is still quite high. Accuracy varies a lot depending on how good the study is and how good the reader is.

Borderline for either the stress ECG the stress nuclear (or stress echo) means that the test wasn’t clearly abnormal but it wasn’t clearly normal. It is in a grey zone of uncertainty.

Given your low pre-test probability of disease it is highly likely your “borderline” test result is a false positive. Whether anything else needs to be done at this point depends on many factors (some from the stress test)  but most importantly, the nature of the symptoms that prompted the investigation in the first place.

If there are no symptoms and  you went for more than 9 minutes on the treadmill likely nothing needs to be done.

Would a coronary calcium scan add anything?

A very high score (>let’s say 100 for age 35) would raise substantial concerns that you have a coronary blockage.

A zero score would be expected in your age group and probably wouldn’t change recommendations .

A score of 1 up to let’s say 100  means you have a built up a lot more plaque than normal and should look at aggressive modification of risk factors but likely wouldn’t change other recommendations.

So the CAC might be helpful but most likely it would be a zero and not helpful.

A Nasty Comment.

The skeptical cardiologist gets lots of nasty comments about his post on the bad science behind Dr. Esselstyn’s diet and another post on the totally bogus Plant Paradox book/diet by Stephen Gundry. I don’t think Esselstyn is a quack but he pretends that there is scientific support for his wacky diet when all he has is anecdotes.

With Gundry, on the other hand, there is a strong smell of quackery.

With this new book he’s developed a line of ridiculous foods that he’s approved.

Gundry will sell you a 75$  piece of chocolate with resveratrol added to it. Despite the multiple health claims for this antioxidant (found in red wine) there are no proven health benefits.

 

Snake oil and supplements abound in all of his presentations and there is much promotion of useless expensive skincare products and  foods that only he sells.

I’m thinking of  adding promotion of special, super-charged olive oil to the red flags of quackery.

There’s no health  reason to get extra-virgin olive oil adulterated with anything. Just make sure you are actually getting EVOO.


Here’s one of Gundry’s supporters comments.

Thank you for your opinion and that’s exactly what it is YOUR OPINION. I suggest you try the Plant Paradox. You sound like someone from a pharmaceutical company. Why don’t you write about how BIG PHARMA is deceiving the public along with how they are keeping people sick.

People who leave nasty comments on my blog typically don’t identify themselves. I can’t tell if this is an authentic comment or someone paid by Gundry’s vast snake oil empire.

They really like using ALL CAPs.

And they like to accuse me of being from BIG PHARMA or in the pay of BIG PHARMA.

BIG PHARMA and I, apparently, have the goal of misleading the populace about the benefits of Gundry’s BS diet and useless supplements so that they will remain sick and require drugs that  gain us huge profits.

I’m still waiting for the checks from BIG PHARMA to roll in. In the meantime I am scrupulously avoiding lunch with pharmaceutical reps and drug/device sponsored boondoggles.

Pharmalargically Yours,

-ACP

N.B. If you’d like to see how much money BIG PHARMA is paying me (or any doctor) you can go to the Dollars for Docs website run by Pro Publica here.

Medical Emergencies On Airplanes: Should Doctors “Heed The Call”?

In a recent episode of Larry David’s hilarious HBO series,  Curb Your Enthusiasm, (“Accidental Text on Purpose”), Larry, (after giving up his aisle seat to a woman with a supposedly overactive bladder) finds himself sitting next to Dr. Nathan Winocour. When a call for medical assistance for a stricken airplane passenger is issued, Larry is perturbed that the doctor fails to “heed the call.”

Winocour justifies his inaction with two comments:

“Give it a minute. He’s gonna be fine.” and

“Have you ever been part of an emergency landing? Is that what you want, Larry? To spend the night in Lubbock, Texas, at a Days Inn with a $15 voucher from Cinnabon? Think about it.”

He’s correct that the vast majority of medical “emergencies” resolve without any specific intervention.

And if he had attended on a patient with a serious non-transient medical problem he would suddenly find himself having to make an incredibly difficult and life-deciding decision on whether or not to  divert the plane or make an emergency landing with insufficient diagnostic tools and inadequate information.

Dr. Winocour is not alone in this failure to heed the call. Many physicians are conflicted about identifying themselves as a physician in medical emergencies-on planes or elsewhere.

Last year, a British physician was described in an article as having assisted in 3 medical emergencies while on American Airlines flights in the previous year. This man is so eager to assist in in-flight emergencies that he “pre-identifies” himself as a physician as he boards the plane.

I wondered how many physicians enthusiastically pre-identify themselves as ready to heed the call, so I posted a poll in 2017 on the physician social media site, SERMO.

Most Physicians Don’t Want To Assist In Medical Emergencies In Flight

A majority of physicians indicated that they were not interested in assisting in medical emergencies in flight.

Screen Shot 2018-02-01 at 8.14.01 AM

Only 3% would pre-identify (with another 2% agreeing to pre-identify if they were upgraded to first class). Another 19% would not pre-identify but would respond it there was a call for a physician.

Medical Liability Issues

In 1998 Congress passed the Aviation Medical Assistance Act, which tries to protect medical Good Samaritans who heed an airplane call. The act protects physicians, nurses, physician assistants, state-qualified EMTs and paramedics:

“An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”

Despite this apparent protection, many physicians left comments like the one below on SERMO indicating they would not heed the call due to concerns about medical liability:

Yes, I am aware of good samaritan docs trying to come to the rescue but were sued anyway. The standard of care still applies to doctors rendering care, whether they are acting as a good samaritan or not- thus we are held to a much higher standard of care than any bystander would be rendering aid. Good samaritan laws in several states note that doctors remain bound to the physician standard of care whether charging the patient or not. Even if it is a life threatening situation involving a complete stranger, the doctors are held to a higher standard of care that permits the patient or their families to sue you. In Florida, there are no caps on malpractice, therefore you can be held personally liable for all your assets, with the exception of those held in “tenancy in entirety”. Therefore I never identify myself as a doctor when coming on a scene to help anyone outside my office, and never give my name if rendering aid.

Other Factors Limiting Heeding

Other physicians noted the lack of appropriate medical supplies on airplanes and the hassle factor.

I’ve responded several times. The last time was when the plane hit an air pocket and the drink cart came down on a flight attendant’s foot. I needed an Ace bandage. Opened the small kit–lots of stuff but no Ace. Opened the big kit to see the contents list. I could have run a code or taken out a GB–but nothing for a compression dressing. Finally wrapped her foot with her panty hose and put an ice pack on it. Then they insisted I fill out a raft of forms about opening the kits, although nothing had been touched. They had my name and address but didn’t bother to say thanks. I did hear from the flight attendant–her foot was fractured.
Never fill out those damn forms unless they agree to pay you for it. And take your own ace bandage.

One MD expressed concerns that failure to heed the call could lead to legal consequences:

I don’t think the risk is zero (in the US) if no other passenger identifies himself/herself as a physician in the event of a flight emergency. For example, if a passenger dies en route and it was later discovered you were on that flight and that had you intervened you might have saved a life, the family members could come after you.

Hm. Now I have another reason to wear ear plugs and close my eyes when flying; can’t be dinged when I did not hear/see the announcement for a physician.

This urologist’s comments are typical of those who have volunteered, but feel like they didn’t help too much and were inadequately thanked or compensated for their time and effort.

I assisted on a flight from Ireland back to the states. Woman had a vasovagal episode and passed out. Spent about 15 minutes and only thanks I got was asking me for my name and license number “just in case.” It was United Airlines. Will never offer my services again unless someone needs a foley.

Dr. Winocour’s failure to heed the call ended up costing him dearly. When he desperately needed a joke for a speech he was giving,  Larry refused to heed the comedian call.

How do you feel? Should physicians heed the call in the air?

Airobatically Yours,

-ACP

Are Physicians Influenced By Pharmaceutical Gifts?

The Skeptical Cardiologist stopped giving talks for pharmaceutical companies 5 years ago and stopped accepting lunches from pharmaceutical reps because he wanted to be certain that he was not being influenced by them in his writing or patient care.

I made an exception 6 months ago and consumed panang curry provided by a pharmaceutical representative who was promoting the blood thinner Pradaxa.

He enthusiastically extolled the virtues of Pradaxa throughout the lunch and made some excellent points supporting the use of the drug. Shortly thereafter, when I was considering which of the newer blood thinners to prescribe for a patient , Pradaxa was foremost in my mind.

The scientific data that Boehringer Ingelheim wanted me to be aware of entered the crowded marketplace of ideas in my head that day but I prefer the data that enters my consciousness come from unbiased sources.

A new study from Georgetown University, published in PLOS One provides support for physicians eschewing pharmaceutical gifts.

The authors point out in their introduction that gifts are important:

Gifts, no matter their size, have a powerful effect on human relationships. Reciprocity is a strong guiding principle of human interaction. Even gifts of small value, such as “modest” industry-sponsored lunches, may foster a subconscious obligation to reciprocate through changes in prescribing practices. DeJong et al has shown that a meal with a value of less than $20 can increase the prescribing of branded statins, beta-blockers, ACE inhibitors, and antidepressants.

The study found:

Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups. All differences were statistically significant (p<0.05).

The conclusions of the study:

Gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties. Gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors. Our study confirms and expands on previous work showing that industry gifts are associated with more expensive prescriptions and more branded prescriptions. Industry gifts influence prescribing behavior, may have adverse public health implications, and should be banned

Michael Joyce has written a detailed and insightful analysis of this paper at the excellent website, HealthNewsReview.org.

He points out the limitations of this and all observational studies:

Although the study cannot definitively establish cause-and-effect between a provider receiving such gifts and any subsequent upturn in their prescribing, it does make a significant contribution to a growing body of literature documenting how drug company largesse is clearly linked — either consciously or otherwise — to the way in which health care providers prescribe.

And the article quotes Daniel Goldberg, an expert on bioethics:

“First, in situations when the evidence is imperfect, and the decisions are subtle, as is so often true in medicine. In these ambiguous situations the evidence clearly suggests that gifts can sway doctors in one direction, even if there’s no evidence to support that as the best decision. Second, it frames decisions in pharmaceutical terms, even when there may be other options — proven to be better — that have nothing to do with drugs.

Drugs are just one tool. But we have ‘pharmaceuticalized’ health care to a point where many patients are conditioned to equate health with access to drugs.”

Since I consumed the panang curry, I’ve gone back to bringing in my own lunch. Thus, my lunch/breakfast typically consists of Trader’s Point full fat plain yogurt with lots of blueberries and raspberries, and perhaps some ground up flaxseed and/or almonds (although today I’ll be bringing in leftover-meatloaf and roasted root vegetables.)

It’s not as tantalizing as the curry, but it leaves my crowded brain free to ponder the multitude of unbiased data from scientific papers, rather than the talking points a pharmaceutical representative would prefer I ponder.

The end result, I hope, is unbiased blogging and prescribing-better information for readers and better care for patients.

-ACP

 

How Much Does or Should An Echocardiogram Cost?

One might assume the skeptical cardiologist has a quick and accurate answer to this question given that he has spent a very large amount of his career either researching, teaching or interpreting echocardiograms.

Surprisingly, however, it turns out to be extremely difficult to come up with a good response.

An echocardiogram is an ultrasound test that tells us very precisely what is going on with the heart muscle and valves. I’ve written previously here and here on how important they are in cardiology, and how they can be botched.

As in the  example of a severely leaking aortic valve  below, we get information on the structure of the heart (in grey scale) and   on  blood flow (color Doppler). This type of information is invaluable in assessing cardiac patients.

In the last week I’ve had 2 patients call the office indicating that even with insurance coverage, their out of pocket costs for an echocardiogram were unacceptably high – almost a thousand dollars.

Wide Variations In Equipment, Recording and Interpretation Expertise For Echocardiograms

A small, handheld ultrasound machine that performs the basics of echocardiography can now be purchased for 5 to 10K. More sophisticated systems with more elaborate capabilities cost up to 200K. In my echo lab the machines are typically replaced about every 5 years, but in smaller, more cost sensitive labs they can be used for decades.

An echo test typically takes up to an hour, and a sonographer performs up to 8-10 tests per day. At facilities trying to maximize profit, tests are shortened and sonographers might perform 20 per day.

In the U.S., echos are performed by sonographers who have trained for several years (specifically in the field of ultrasound evaluation of the heart) and earn on average around 30$ per hour, however, Medicare and third party payors usually don’t require any sonographer certification for echo reimbursement.

Physicians who read echocardiograms vary from having rudimentary training to having spent years of extra training in echocardiography, and gaining board certification documenting their expertise.

Interpretation of a normal echocardiogram takes less than 10 minutes, whereas a complicated valvular or congenital examination requiring comparison to previous studies, review of clinical records and other imaging modalities, could take more than an hour.

Given these wide parameters, estimating what one should charge for the technical or physician portions of the average echo is challenging.

Wildly Differing Charges For Echocardiograms

Elizabeth Rosental wrote an excellent piece for the NY Times in 2014 in which she described the striking discrepancy between 2 echos a man underwent at 2 different locations:

Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. “Why would that be?” Mr. Charlap asked. “It really bothered me.”

Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups”

This graph shows the marked variation across the US in price of an echo.  In all the examples, however, what the hospitals were paid was around 400$ which is the amount that CMS pays for the complete echo CPT code 93306.

Costs Outside the US

At the Primus Super Specialty Hospital in New Delhi, India, apparently you can get an echocardiogram for $50.

This site looks at prices for private echos across the UK. The cheapest is in Bridgend in Wales (where suicide is rampant) at 175 pounds. You can get an echo for 300 pounds at the Orwell clinic (where their motto is “War is peace. Freedom is slavery. Ignorance is strength.”)

At one private  UK clinic, you can have your echo read by Dr. Antoinette Kenny, who appears extremely well qualified  for the task.

“In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.”

Whereas I would not be interested in getting an echo done in India or Mexico, I would definitely have one done in Dr. Kenny’s center if I lived nearby.

Self Pay Cost

My hospital, like most, will write off the costs of an echo for indigent patients. I will read the tests on such patients pro bono (although doctors never use that term because we feel it makes us sound to lawyeresque).

The hospital also has a price it charges for those patients who are not indigent, but who have excessively high deductibles or co-pays with their insurance. In some cases this “self-pay” charge is significantly less than what the patient would pay with their insurance.

Paying out of the pocket for the echocardiogram may also make sense if the patient and/or physician really thinks the test is warranted, but the patient’s insurance deems it unncessary.

If you find yourself in a situation where a needed echocardiogram performed at your ordering doctor’s preferred facility is prohibitively high, it makes sense to look around for a more affordable option.

However, I must advise readers to be very cautious. In the NY Times example, the hospital charges for Mr. Charlap seemed inversely proportional to the quality of the echo he received.

This is not necessarily the case for a self pay echo. It is more likely that a cheap upfront out-of-pocket cost quote in a doctor’s office or a screening company reflects cheap equipment with minimal commitment to quality and brevity of exam and interpretation time.

I have encountered numerous examples of this in my own practice.

One of my patients who has undergone surgical repair of her mitral valve decided to get an echocardiogram as part of a LifeLine screening (see here and here for all the downsides of such screenings).

The report failed to note that my patient had a bicuspid aortic valve and an enlarged thoracic aorta.  These are extremely significant findings with potentially life threatening implications if missed.

If a high quality echo recording and interpretation is indicated for you make sure that the equipment, technician and physician reader involved in your case are up to the task.

Ultrasonically Yours,

-ACP

What Pain Medications Are Safe For My Heart?

The skeptical cardiologist is frequently asked by patients if it is OK to take certain pain medications.

Yesterday, I got a variation on this  when a patient called and indicated that he had been prescribed meloxicam and tramadol by his orthopedic surgeon for arthritic leg joint pain. The orthopedic surgeon said to check with me to see if it was OK to take either of these medications. (Patients, if you want to skip to my answer skip down to the last two sections of the post and avoid the background information.)

What Is The Risk Of Pain Medications?

Cardiologists have been concerned about the increased risk of heart attack and heart failure with non steroidal anti-inflammatory drugs (NSAIDs) since Vioxx was withdrawn from the market in 2004.

NSAIDS have long been known to increase risk of gastrointestinal (GI) bleeding  by up to 4-5 fold, Scientists developed Vioxx, a COX-2 inhibitor, hoping to reduce that risk but Vioxx  turned out to  increase the risk of heart attack.

Since this revelation it has become clear that NSAIDS in general increase the risk of heart problems as well as GI problems

This includes the two over the counter (OTC) NSAIDS:

-ibuprofen (in the US marked most commonly as Motrin or Advil, internationally known as Nurofen). For extensive list of brand names see here.

-naproxen (most commonly sold as Aleve. Per wikipedia “marketed under various brand names, including: Aleve, Accord, Anaprox, Antalgin, Apranax, Feminax Ultra, Flanax, Inza, Maxidol, Midol Extended Relief, Nalgesin, Naposin, Naprelan, Naprogesic, Naprosyn, Narocin, Pronaxen, Proxen, Soproxen, Synflex, MotriMax, and Xenobid. It is also available bundled with esomeprazole magnesium in delayed release tablets under the brand name Vimovo.)

In 2015  the FDA mandated  warning labels on all prescription NSAIDs including

1) a “black box” warning highlighting the potential for increased risk for cardiovascular  (CV) events and serious life-threatening gastrointestinal  bleeding, ulceration, and perforation;

(2) statements indicating patients with, or at risk for, CV disease and the elderly may be at greater risk, and that these reactions may increase with duration of use;

(3) a contraindication for use after coronary artery bypass graft surgery on the basis of reports with valdecoxib/parecoxib;

(4) language that the lowest dose should be used for the shortest duration possible

5) wording in the warning section that there is no evidence that the concomitant use of aspirin with NSAIDs mitigates the CV risk, but that it does increase the GI risk

Since then, hardly a day goes by without me having a discussion with a patient about what drugs they can safely take for their arthritis.

A reasonable approach to using NSAIDS, balancing GI and CV risks, that I have used in the past comes from a 2014 review
This table and many authorities recommend naproxen as the NSAID of choice for patients with high CV risk.

Indeed prior to the publication of the PRECISION study in 2016 I believed that naproxen was the safest NSAID for my cardiac patients. I told them it was OK to use from a CV standpoint but to use the least amount possible for the shortest time in order to minimize side effects.

The PRECISION study compared a COX-2 NSAID (celecoxicib or Celebrex) to ibuprofen and naproxen in patients who required NSAIDS for relief of their joint pain.

The findings:

cardiovascular death (including hemorrhagic death), nonfatal MI, or nonfatal stroke, occurred in 2.3% of celecoxib-treated patients, 2.5% of the naproxen-treated patients, and 2.7% of the ibuprofen group.

There was no placebo in this trial so we can only look at relative CV risk  of the three NSAIDS and it did not significantly differ.

GI bleeding was less with celecoxib than the other two NSAIDS.

Although this study has flaws it throws into question the greater CV safety of naproxen and suggests that all NSAIDS raise CV risk.

My Current Patient Advice on Cardiac Safety of Pain Meds

Here is an infographic I came across from the Arthritis Foundation (complete PDF….here)

It’s a reasonable approach for these OTC drugs and I will start handing this out to my patients.

We should consider that all NSAIDS have the potential for increasing the risk of heart attack and heart failure, raising blood pressure, worsening renal function and causing GI bleeding.

Therefore, if at all possible avoid NSAIDS.

Acetaminophen (Tylenol) is totally safe from a heart standpoint and overall if you don’t have liver disease it is your safest drug for arthritis. However, it provides no anti-inflammatory effects and often is inadequate at pain relief.

Treating The Whole Patient

Meloxicam is an NSAID so my patient should , if at all possible, avoid it.

The other drug he was prescribed, tramadol, is an opiod. Opiods have their own set of problems including, most importantly,  addiction and abuse.

A recent review concluded

 reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date. Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction; for some harms, the risk seems to be dose-dependent.

As his cardiologist I am concerned about his heart, of course, but a good cardiologist doesn’t just focus on one organ, he looks at what his recommendations are doing to the whole person.

I certainly don’t want to have him become addicted to narcotics in order to avoid a slightly increased risk of a heart attack. On the other hand, the risks of the NSAIDS involve multiple organs, most of which don’t fall in the domain of the cardiologist.

My patient’s risk of taking either the meloxicam or the tramadol is best assessed by his primary care physician, who has the best understanding of his overall medical condition and the overall risk of dangerous side effects from these drugs.

Ultimately, I think the decision of which pain pill to take for chronic arthritis has to be made by an informed patient in discussion with his  informed (and informative) primary care physician. Only the patient can decide how much pain he is having and how much risk he/she wants to assume in relieving that pain.

Analgesically Yours,

-ACP

The Three E’s Of Interrupting Patients

The skeptical cardiologist was trained to listen carefully to patients who are relating their “history” as we term it and to minimize interruptions. However, there are only a limited number of minutes in the day and some patients are capable of monologues that rival a Shakespeare soliloquy.

If a physician doesn’t learn methods for getting the patient back on point he will spend his days stressed and running behind schedule.

A recent JAMA editorial describes the three E’s that physicians should employ when interrupting a patient.

The first “E” element is to excuse yourself. The second is to empathize with the topic being interrupted and the third is to explain the reason for the interruption.

For the patient who is repetitive, disorganized or circumcloquacious:

(circumloquacious (adjective): Using excessive language to evade a question, obscure truth or change the subject [comb. of ‘circumlocution’ and ‘loquacious’]

Always circumloquacious, she evaded defining the word and instead started a discourse on etymology and metalinguistics.

the writer suggests this typical “topic tracking” interruption:

Forgive me. You are sharing a lot and I can see you are really bothered about… your headache, fatigue, allergy, stomach pain… and this is frustrating and scary for you. I would like to switch gears and ask several specific questions, then do an exam to make sure we develop a plan that works best for you.

Excessively circumloquacious patients can be their own worse enemies as the office visit is spent on issues peripheral to their major problems.

Hopefully your doctor has learned some variation on the three E’s to deal with circumloquacity (I just invented that word!), otherwise he/she will continually be late and stressed.

Empathetically Yours,

-ACP

 

Dear Kim, I Am Indifferent To My Online Reputation

The skeptical cardiologist keeps getting  emails from Kimberly of mypracticereputation.com who informs him how important his online reputation is. The last email has quite an urgent, almost threatening tone: Kim reminds me of the multiple previous attempts to contact me and asks me if there is someone else in my practice she could speak with.

According to Kimberly, my online reputation “has become the primary way that patients, colleagues, referring practitioners, and even your friends  will come to learn about you.”

Kimberly informs me that her assessment “includes your online reputation score (A-F) scoring), the total number of reviews found about your practice online (some of which you may not be aware of) and your calculated current Reputation Danger Level™ (In Danger, At Risk or Protected).”

She has a really slick website:

Screen Shot 2016-01-31 at 12.41.36 PM.

However, I have no interest in checking my online reviews nor do I care what my Reputation Danger Level is.

If I were just starting a practice or fighting for new patients I might view this differently and consider engaging in such folderol.

However, at this point in my career, I am really only concerned with having positive interactions with the patients I have and helping them achieve optimal health as best I can. I get more than enough new patients by word of mouth from my current patients, their relatives, and from referring physicians who respect my patient care skills.

Also, I have a feeling that the majority of patients who take the time to write online assessments are disgruntled about something and want to tell the world. I’m not really interested in coming across a review of me that is totally unfair. It would only give me unnecessary stress.

I’m sure there are ways to expunge the negative reviews, likewise there are bound to be effective ways to ramp up the positive reviews. For positive reviews, for example, I could just ask the patients I know who really like my care and style to post something online. I don’t do that: it makes me uncomfortable.

But this just doesn’t seem right. If my online reputation can be manipulated by me or by myonlinereputation or their ilk, it would seem to further delegitimize the whole process.

Kimberly, if you happen to read this, please accept my apologies for not accepting your complementary (normally $249)  analysis.

And please stop sending me emails.

Disreputably Yours,

-ACP

 

My MOC Status Has Changed!

I am Board Certified by the American Board of Internal Medicine (ABIM) in both Cardiovascular Disease and Internal Medicine.

Recently the ABIM has changed the rules and started a Maintenance of Certification (MOC) Program which is chock-full of useless forms, fees and tests.

I, and thousands of other doctors have rebelled against this program, recognizing that there is no evidence it will improve doctors care, patient outcomes or overall quality of medical care but that it will fill the coffers of bureaucrats and bureaucratic institutions and fritter away valuable time we could be spending on patients.

I did not pay my several hundred dollar fee the ABIM demanded for 2015.

MOCAs a result, I received this morning an email from ABIM telling me that “your MOC status has changed”. I logged in and found that I was listed as “Certified, Not Participating in MOC.”

I’m still the clinical cardiologist I was yesterday and I still spend hours weekly reading about the latest developments in cardiology that impact clinical care, teaching residents, and giving conferences but I wonder what the ramifications of this will be.

Dr. Wes, a cardiologist who has been a vociferous opponent of MOC is alerting physicians that one ramification is that the SGR bill the Senate is considering would tie doctor evaluations to MOC status.

You can read his comments here. He includes sample letters to send to Congress.

If the federal government puts their weight behind sanctifying MOC, then all physicians will be forced to participate.

I strongly all urge all physicians to consider weighing  in on this with your local congresspeople.

-ACP

The Tie, The White Coat And The Fist Bump

My role models and mentors during my medical training taught me what I considered to be the proper appearance and demeanor of the professional  physician.

The male doctor wore a dress shirt and a tie. The doctor wore a white coat over his/her regular clothes. The more senior the doctor was in the medical hierarchy the longer the white coat and the more impressive the words written on the coat.

Presumably, this professional appearance of the doctor increased the confidence that the patient had in the professionalism of the doctor.

Upon encountering a patient in the hospital room or office exam room, the doctor extends his right hand, greets the patient and smiles and shakes hands.

I wore a tie and a white coat and shook hands consistently during the first 20 years of my practice but gradually these markers of a good doctor have fallen under scrutiny.

The Physician Necktie as Disease Vector

Beginning about 15 years ago studies were published suggesting the physician necktie could become colonized with bacteria and serve as a vector for transmitting bacteria. Some authors, as a result, have called for an end to doctors wearing neckties (bow ties may be an exception).

In the UK, the tie has been banned for those involved in patient care because

“Ties are rarely laundered but worn daily. They perform no beneficial function in patient care and have been shown to be colonised by pathogens.”
After reading about ties as vectors I gradually stopped wearing them at work. Initially, I felt uncomfortable, as if I were not being professional. Somehow, I felt my patients would respect me less. Over time, however, I have reached a point where I only wear a necktie on Wednesdays.
A logical reader might ask why I still wear them at all. I don’t have a good answer for that. Perhaps, I feel a need to wear the dress shirts and ties I have accumulated over the years. Perhaps I don’t really feel the tie is a big contributor to nosocomial infections. Perhaps I want my patients to see that Dr. Pearson can dress professionally on occasion but he chooses not to the majority of the time.
The White Coat As Disease Vector
 
I’ve been wearing a white coat to make hospital rounds since I was a medical student starting on the wards 37 years ago (Yikes! Has it been that long?). The coat gave me an immediate power and respect and identified me as a caregiver.
My two oldest daughters have both undergone a  “white coat ceremony,” recognizing the important and exciting transition from pre clinical studies to actual patient interactions in the health care field.
The white coat serves other purposes for doctors. I keep my billing cards in one pocket and in another I have a case with my business cards. The lapel serves as a convenient  spot to clip my hospital ID badge. I used to carry around EKG calipers or rulers in my breast pocket but as EKGs have increasingly gone electronic I no longer do this.
Presumably the white coat helps keep dirt and vomit and phlegm from patients from  sullying  the “street” clothes of the physician.
However, the down side of all that stuff landing on the white coat and not on the street clothes may be that the white coat is accumulating bacteria that can then be transmitted to other patients.
In a 2009 study, the white coats of 23% (34 of 149) of medical and surgical Grand Round attendees at a teaching hospital were contaminated with S. aureus, 18% (6 coats) of which were resistant to methicillin.
 As a result of studies demonstrating bacterial contamination of white coats, the Society for Health Care Epidemiology of America SHEA recently recommended
White Coats: Facilities that mandate or strongly recommend use of a white coat for professional appearance should institute one or more of the following measures:
  1. HCP should have two or more white coats available and have access to a convenient and economical means to launder white coats (e.g. on site institution provided laundering at no cost or low cost).
  2. Institutions should provide coat hooks that would allow HCP to remove their white coat prior to contact with patients or a patient’s immediate environment.

Laundering:

  1. Frequency: Optimally, any apparel worn at the bedside that comes in contact with the patient or patient environment should be laundered after daily use.
  2. Home laundering: If HCPs launder apparel at home, a hot water wash cycle (ideally with bleach) followed by a cycle in the dryer or ironing has been shown to eliminate bacteria.
Basically, they are strongly suggesting you don’t wear a white coat but if you do, wash it every day and take it off before you interact with the patient.
I must admit it will be difficult for me to stop wearing the white coat. Sometimes I find myself having to pop into the hospital without my white coat (stethoscope around my neck (yes stethoscopes can serve as vectors for bacterial transmission but they can be cleaned between patients)) and I feel like an impostor.
The Handshake As Disease Vector
It has long been my practice to start patient encounter with a hearty greeting and a (somewhat) hearty handshake.
The handshake has a profound cultural role and serves as the international symbol of greeting and departure with connotations of  respect, friendship, congratulations and formal agreement.
In the health care setting, the handshake has been shown to have the power to the improve the perception of the physician’s empathy and compassion. The handshake provides comfort and calms patients.
We’ve known for a long time that shaking hands is an excellent way to transmit diseases. Many of my patients, when they know they have a cold,  will state this up front and decline my handshake. This is something that most people intrinsically understand. Studies have shown that health care workers hands are a common cause of disease transmission in the hospital and this is why hand washing or gelling is mandated in the hospital between patient visits.
Sklansky, et al wrote an editorial in JAMA in 2014 advocating that the hand shake be banned from the health care setting because despite our best efforts at hand hygiene we often fail, either due to poor compliance or limited activity of alcohol based hand rubs against some pathogens (including C. dif).

They suggested some alternative greeting including the hand wave, the bow, placing the right palm over the heart or the namaste gesture from yoga.

Since then, a study has shown that the fist bump (mysteriously termed a dap greeting) does reduce bacterial transmission.

Researchers at Aberystwyth University in Wales (the home country of the skeptical cardiologist!) immersed a donor participants’ sterile-gloved hand into a dense culture of E-coli (a non-pathogenic strain), and after it was dry, exchanged greetings with recipient participants, who also wore sterile gloves.

fistbumpThey tested the handshake, the high five, and the fist bump in a crossover design so that each “donor” and each “recipient” tested all greetings, eliminating potential for bias among the volunteers.

The results (graph to left) showed  twice as many bacteria were transferred during the handshake compared with the high-five, but the fist-bump transmitted only about 10% of the bacteria a handshake did.

Is It Time To Lose the Tie, the White Coat and the Handshake?

It’s hard to teach this old dog new tricks but more and more I will be eschewing the handshake in my patient encounters.

I’m going to experiment with the fist bump (especially for my younger patients) and the bow and perhaps I’ll have signs put up in my exam rooms declaring them “No Handshake Zones.”

DrP
The Non-Disease Transmitting Dr.P. No necktie. White coat washed daily. Stethoscope cleaned obsessively. Hand not extended for handshake but prepared to fist bump. Non-diseases-transmitting ID badge attached.

I don’t think I can abandon the white coat yet. It’s like a security blanket for me. I will experiment more and more with not wearing it and monitor my patient’s reactions.

I will definitely try to wear the white coat for only one day and then send it off to be laundered (I wonder what the environmental consequences of that are?)