Category Archives: Good Doctoring

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increased risk of heart attack and heart failure with non steroidal anti-inflammatory drugs (NSAIDs) since Vioxx was withdrawn from the market in 2004.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

Saving Lives and Improving the Quality of Life by Deprescribing

Every time I see a patient in my office I review in detail the medications the patient is taking. My office staff and I obsessively work on making sure the list I have in my electronic medical record  matches exactly what the patient is taking.

As I review the medications I am asking  myself the following questions:

Does the patient need this medication?

Is he/she having side effects from the medications?

Is this the right dosage?

Are there any interactions between the medications that are important?

Is there a cheaper or safer alternative?

For many patients, I will reduce or stop what I consider to be unnecessary medications. Often this results in the patient feeling better, sometimes this is live-saving.

Dr. John Mandrola (electrophysiologist and former colleague of mine in my former cardiology practice in Louisville, KY) writes an excellent blog  at DrJohnM.org and has recently encouraged us all to ponder deprescribing, a verb that describes the process of stopping potentially inappropriate medications.

I encourage you to read his post (here) on deprescribing and his other informative posts on topics related to reducing inflammation in our lives, atrial fibrillation and cycling .

Since putting this post together, I saw a patient in my office whose mother would greatly benefit from deprescribing. My patient and I had in previous visits mutually decided that he did not need to be on a statin drug as he had had myalgia side effects from Lipitor and when we looked at his carotid artery it was not abnormally thickened and had no plaque. He asked me if his 95 year old mother (who is not my patient) should be taking Welchol and Zetia.

Zetia is a very expensive, brand name cholesterol lowering drug that has never been shown to improve cardiovascular outcomes despite effectively lowering the LDL or bad cholesterol. I never prescribe it.

Welchol is an expensive, brand name cholesterol lowering drug which has I only use in patients who have markedly elevated LDL cholesterol levels and evidence of marked atherosclerosis. It commonly causes constipation. I rarely prescribe it.

The data for treating cholesterol in patients over age 75 is lacking and by the time patients reach age 95 the risks of these drugs likely outweigh any benefits.

I think my patient’s 95 year old mother would  greatly benefit from a healthy dose of deprescribing!