Del Meyer, MD, Pulmonary Medicine

MedInfo Health Line

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2000

Your Fifteen Minutes Are Up

Last week I saw a new patient who changed physicians because of the impersonal treatment from her previous in-house For Profit HMO. This was one of those HMOs that owns the doctor group that work for it. The doctors were allotted 15 minutes per patient, and patients were expected to be seen on time. So the doctors parcel out their time evenly. Most of us average the time we spend with patients so some get a few minutes more and others maybe a few minutes less. Usually everyone gets more and thatís why we see our 5 oíclock appt as late as 6.

This patient told me she was just getting into her medical story with the previous doctor, when he closed her chart and informed her that her 15 minutes were up and she was welcomed to make another appointment to continue the discussion of her medical problem.

This reminded me of a few years ago when I had a clinic at the state prison. I was told that each inmate was allowed to see a doctor once a month for a medical problem. Most of the doctors would hear one problem, treat it and then call, "Next!"

I would never have dreamed that American medicine could ever become as impersonal as prison medicine. And I would never have dreamed that doctors and their patients would not rise up in arms and straighten things out in a hurry. But unfortunately, neither doctors nor their patients fully understood what and how the HMO movement really occurred and how a few administrators could make such a financial killing off the health care system. Unfortunately patient lives have been put in jeopardy and a few have died unnecessarily.

If this happens to you, be sure you keep records of all you misadventures for future reference. They may just come in handy some day for your surviving children.


Front Passenger Dash Board Bombs

Driverís side steering wheel airbags have saved many lives. However the governmentís requirement of extending airbags to the front passengerís side by 1999 in the cause of safety, has proven quite hazardous to children. Of the 23 people killed by passenger side airbags, 22 were children. The lone adult was a frail woman. For years, federal regulators and safety advocates ignored industry warnings, first predicted by General Motors in 1969, that passenger side air bags could kill kids. Now the government is in the awkward position of fumbling for ways to minimize the danger of a government required safety device that has been called a "lethal dashboard bomb." The whole idea was to have passive restraints because the government thinks we canít think. They want to protect us from ourselves.

However, one solution the government proposed, and is now implementing, is to keep the requirement but allow the airbag to be disconnected by the passenger. Now does that really make sense? Having the car manufactures install airbags for which they must charge us up to $700 and then allow us to deactivate them, at an additional cost of $150, is a waste of our hard earned money. But this is typical government logic. Rather than back off and say they made a mistake, they forget the original purpose was to eliminate our choice and now give us the choice to have or deactivate but not to spend the money unnecessarily.

The driver, a mature adult, needs the protection of the steering wheel airbag. But the passenger in front does not need this risk. An easy step would be to require the passenger dash to be "cushioned" to prevent hard blows to the head from impact on a metallic dash or window. That, combined with the seat belt law already in place, would not cost us hundreds of dollars unnecessarily or the lives of our women and children.


Home Care Costs

Hospital costs have gone off the radar screen. Major efforts have gone into reducing these costs. This has included doing more outpatient surgery and sending the patients home early for post hospital home care. The home care companies, many of which have been bought out by the hospitals, may not have reduced costs.

ABC's 20/20 reported on a child sent home on IV treatment. Critical Care America who was charging the childís insurance company over $3,000 a day did this. That's right $3,000, which is more than most hospitals charge for a day and adds up to about $100,000 a month. The family only became aware of it when CCA told them that their insurance was running out and the family asked for their statement of charges.

When patients are discharged, the hospitals frequently ask the physician for an order for home care. They then come up with a treatment plan which may include a RN visit once or twice a week, a physical therapy visit twice a week, a dietician visit, and others as the case may be. One of these visitors told me that they received about $112 per visit.

This was surprising to me since the same insurance carrier only paid me about half that for a visit I make every month to manage a patient on life support at which time I change his trach tube. In this era of cost constraints why are technical support visits paid at twice a doctor's visit?

When we make a purchase on a credit card, for instance, we have to sign the statement. When we have our car fixed on an insurance claim, we have to sign off on it to make sure the service was provided. If patients had to sign off on a charge ticket every service provided, they would immediately know what was happening.

In the case of the child reported by 20/20, mentioned above, if the Home Care Company required that the family sign off on a $3,000 daily home care bill, the family would have been quite concerned in a matter of days, rather than in a few months. If a hundred million Americans had to sign off on their health care charge every time a service was rendered, it is conceivable that we would have a hundred million citizens going after health care administrators. They would find a way to get their costs down overnight. The major health cost problems would then be solved.


Swan Ganz Catheter

Dr Eugene Robin has been informing doctors and trying to protect the public about the dangers of the Swan Ganz catheter that intensive care specialists frequently insert into your right heart to obtain rather sophisticated information. Dr Robin, a world premier medical scientist, points out that this procedure has never been subjected to standard scientific controlled studies we expect in this country to determine if the benefits are appropriate for the risks of use. An article in a recent issue of the Journal of the American Medical Assn again indicates that the risks for harm exceed the benefits of an improved outcome.

If you or your friends are admitted to the intensive care unit of a hospital and your doctor states he wants a cardiologist or pulmonologist to insert a catheter into your heart and lungs, be sure to ask specifically what benefits he hopes to gain. If the answer seems somewhat nebulous, such as "Iím unable to treat you without this information," then you have an important decision to make. You may ask him to treat you the best he can without the catheter, you can allow him to insert the catheter, or you can ask him to find you a doctor who can treat you appropriately without this specialized information.

Dr Robin and his colleagues feel that anyone undergoing a right heart catheterization, should be asked to sign a truly inform consent just as with any other procedure outlining the risks vs the benefits of the procedure and that in this case risks exceeds the benefits.

At the present time the patients dying after this catheter has been in place show significant damage to the lining of the heart from the catheter being whipped about with each heart beat. This shows up in the pathology journals, not in the clinical medical journals that the doctors that take care of you read. Hence, Dr Robinís attempt to distribute this information widely.

He has a weekly column in the Saturday SF Examiner.


Patients as Widgets

Patients have not comprehended their position in the managed care system as industrial products with no specialized problems. Dr Caroline Poplin, an internist and graduate of the Yale Law School points out that managed care is the industrialization of medicine. In her article "Transaction Social Science and Modern Society" she develops the premise that managed care is pushing medicine toward a more conventional industrial organization. Most manufacturers prosper by breaking down production into standardized tasks requiring little judgment, tasks that could be performed quickly and reliably by workers with relatively low skills. Managed care is such an organization with owners, administrators, and laborers. But who are the laborers? The answer is doctors. Then who are the patients? They are the products. Many patients still remember going to doctors who were the owners, administrators, and laborers in their individual practices. This was good for the patient since he was treated as an individual with this highest of skills tailored for him.

Retail medicine organized as a mechanized industry necessarily means that the product, which are sick human beings, can be treated on an assembly line basis as inanimate widgets.

However, in industry, any product that varies from the norm is discarded. As human beings we all vary from the norm. We can not be discarded. Is this variability that will eventually destroy managed care--unless it comes to a boil so slowly that we humans donít realize we are dying.


Why Worry?

After death and taxes, worry may be the most unavoidable fact of life according to the Menninger Letter. We worry about our personal concerns, our family, all the way to world crises. Worry has always been considered a negative experience. People who worry also tend to make decisions more slowly.

In light of these negative features, Mark Freeston and his colleagues form Laval University in Quebec conducted research to find out why people worry. They got 370 university students to participate.

The researchers identified two general beliefs about worrying. One is that worry is seen as a way to avoid a negative outcome. By worrying, we believe we can reduce the likelihood that something bad will actually happen.

On the other hand, worriers believe that worrying also has positive effects. If we worry enough, it may motivate us to discover a better way to do something, increase our control over a bad situation, or find a solution to seemingly insoluble problem. This explains why people continue to worry even when the experience seems unpleasant.

However, much of worry is irrational fear over which we have no control. For example, a mother who worries all day expecting a phone call to tell her that her childís school bus had an accident, something that is both rare and over which she has not control. When this becomes disabling, this is a symptom of a generalized anxiety disorder. They may experience social and occupational difficulties.

Worry is an undeniable fact of life. In most situations it is best to do all we can to live with lifeís uncertainties and resist the urge to give in to worry.


Work & Mental Illness

It is commonly accepted that satisfaction of a job well done adds to our sense of well being. But just maintaining a job--any kind of job--can be difficult for a patient with mental illness.

People that are mentally ill, e.g. Schizophrenia, have confused thinking and impaired social functioning. This obvious impairs insight in most jobs. Even treatment with drugs has shown minimal help. These people have great difficulty in taking any medical regimen and therefore, the treatment generally fails.

One study of patients at a Veterans Hospital shows that even part-time work may help enhance the self-esteem of such persons, leading them to develop better insight about how to cope with their illness. These researchers found that insight could be improved in high-functioning people with schizophrenia in a variety of jobs. These jobs were more effective than standard psychiatric treatments.

These studies point out that in addition to what most of us have known, Work defines us. Work is beneficial for us. It is also therapeutic.


Vitamins--The Unknown Frontier

An estimated 100 million Americans spend $6.5 billion a year on vitamin and mineral supplements. But these consumers are buying mostly unregulated substances that may help, may harm or may simply have no effect at all.

In the average grocery store, the vitamin-buying consumer faces a wall of possibilities. To add to the confusion, the labels on these bottles provide few clues that the products can be harmful as well as helpful. They do not mention this possibility because the Food and Drug Administration considers vitamins and minerals as "dietary supplements". As a result, no testing for safety or efficiency--or even for whether the supplements contain what the bottle says they contain--is required before vitamins are put on the shelves.

Even the experts in nutrition have trouble giving consistent information about vitamins and minerals because there is a lack of good long-term studies on them. The government can provide a bewildering volume of standards which it is in the process of revising. "No rational person can understand this stuff," says Dr. Marion Nestle, chairman of the department of nutrition and food studies at New York University. "All the different numbers are almost guaranteed to make the situation more confusing rather than less."

The current boom in the vitamin business began in October, 1994, when Congress passed the Dietary Supplement Health and Education Act, which basically keeps the FDAís hands off vitamins and mineral supplements unless something goes wrong. Stocks that had dropped in 1994 surged 70 percent in 1995, 57 percent in 1995 and 42 percent in the first half of 1997, wildly outperforming the overall market.

Vitamin suppliers fought hard for this profit margin. The FDA had been planning to apply existing regulations for items like drugs to vitamins, minerals, herbal preparations and other supplements. Those rules would have prevented manufacturers from making health claims of any sort for any supplements without agency approval. The vitamin industry responded with fierce lobbying, aided by a letter-writing campaign by consumers who feared that government rules would limit their access to all kinds of supplements. The 1994 law was a compromise--labels on vitamin and mineral products cannot make claims that a product cures a disease or gives a specific health effect without special FDA approval. However, the law does allow general statements on the label about a vitamin or mineralís function in the body.

The lack of specific claims has not stopped people from assuming vitamins offer extraordinary healing benefits. Based on meager evidence and word-of-mouth, consumers buy the supplements and hope that a nutrientís normal role is magnified and the vitamin can work as a miracle cure for terminal diseases such as cancer, or a magic wand tonic to a poor diet. The vitamin industry has profited handsomely by such unproven wishful thinking.

Faced with the growing need for more research, the National Institutes of Health established, at the request of Congress, an Office of Dietary Supplements in November 1995. Their research will take some time. Meanwhile, caveat emptor! (Buyer beware)


Vitamins & Minerals

Experts agree that more research on vitamin supplementation is necessary. But what is known--the finding that comes up again and again--is that when vitamins and minerals are consumed in food, they are just about always good for you. In pill form, however, particularly with high doses, vitamins should be used with caution.

One of the difficulties of pill supplementation is in calculating dosage. How much of any vitamin a person needs varies--age, sex, stage of life, and specific individual needs all factor into correct dosage. There is no single level of any vitamin or mineral that can be considered the optimum intake for everyone.

In addition, despite the possible healing properties of supplemental vitamins (unproven at this point), there are risks when nutrients are taken separately from foods containing them and in doses much greater than the body is designed to process.

Specific vitamin overdoses can cause known problems:

Too much vitamin A can cause headaches from increased brain pressure, liver and bone damage, hair loss, skin disorders, psychiatric symptoms and, when taken in early pregnancy, birth defects. Too much B6 can damage nerves. Too much vitamin C can interfere with tests for blood in the stool. Large amounts of calcium can limit the absorption of iron. Iron supplements can be deadly to small children, and the most common cause of poisoning deaths among children is not from caustics or aspirin--but from iron supplements intended for adult use.

Again, for the average healthy person who consumes a variety of foods, there is scant evidence that vitamin and mineral supplements are beneficial. Even for segments of the population who may need more vitamins--smokers, people who are ill or poorly nourished, the elderly and pregnant women--the long-term benefits are unclear at best. According to a 13-year study of 10,758 Americans, people who took vitamins did not live longer or suffer fewer cancer deaths than those who did not take vitamins.

Americans are heavier than ever, but not necessarily well nourished. However, nutrition experts, even those who believe in vitamin supplements, donít believe vitamin pills can compensate for dietary deficiencies. They emphasize that there are many health-promoting substances in foods other than vitamins and minerals. Their best advice: eat a balanced and varied diet that is low in fat and high in fruits and vegetables and complex carbohydrates.


Eating Healthy

Americans eat well. As a country, weíre well fed. We eat a lot, and we tend to weigh a lot. But that doesnít mean weíre healthy. With contemporary eating habits, itís becoming more and more difficult to follow a good nutritional diet. Americans eat out more, and fast food has become an everyday meal for many. This routine means more saturated fat and less nutritional balance.

Convenience is one of the reasons the vitamin industry has done so well in the last few years--We eat on the run, and we want our health on the run. We dine on hamburgers, french fries and pizza, and only 15% of us eat the recommended five servings of fruits and vegetables a day. But we pop a few vitamin pills and hope this takes up the slack. The problem is, research shows this doesnít work. Even scientists who believe in vitamin supplementation to aid with specific disorders donít believe vitamin pills can compensate for careless eating habits.

In January, 1996, The American Dietetic Association, the nationís largest organization of nutrition professionals, gave this advice: "The best nutritional strategy for promoting optimal health and reducing the risk of chronic disease is to obtain adequate nutrients from a wide variety of foods."

Good advice! Of course, it takes awareness to find out what foods provide you with the nutrients you need--but if your health is at stake, isnít it worth it?

Here are a few natural vitamin sources:

For Vitamin A, eat liver, egg yolks, fortified milk and dairy products and fish oil.

For beta carotene, eat carrots, sweet potatoes, spinach and other dark green leafy vegetables, cantaloupes and apricots.

Vitamin C of course is in citrus fruits, but also in melons, berries, peppers, potatoes, cabbage, broccoli and tomatoes.

You can get Vitamin D from egg yolks, fortified milk, eel, herring, salmon and liver.

Vitamin E sources are vegetable oil, nuts, wheat germ, whole grains and green leafy vegetables.

B6 is in bananas, beans and peas, avocados, poultry, fish and pork.

For B12, go to meats, diary products, eggs, liver and fish.

Calcium is in diary foods, but also in such vegetables as broccoli and collards, as well as in tofu.

Magnesium is in all unprocessed foods, highest in nuts, vegetables and grains.

Zinc can be found in meat, liver, eggs and seafood.

For iron eat meat, poultry, fish, eggs, vegetables and tofu.

Eating healthy may take a little work at first, but it has one other great advantage over fast food--itís cheaper, short-term and long-term.


Why Are We Losing the Battle with Hypertension?

For the past 25 years, the medical profession has battled hypertension and its related illnesses with great success. Significant declines in deaths from stroke and coronary artery disease are the result of effective treatments. So it was a surprise to hear the latest statistics about hypertension-related conditions: They show a rise in severe kidney disease and heart failure, a slight rise in the rate of stroke, and a leveling off of the death rate for Americans with coronary heart disease. Why the reversal?

The reasons for the turn around are not completely clear yet. However, the culprits include increased obesity, complacency among doctors and patients about high blood pressure, patients who stop drug therapy because of unwanted side effects (such as decreased sex drive and increased fatigue), and ineffective communication about hypertension to the public. Awareness about this disease and compliance with treatment are falling and the effect is deadly.

Hypertension affects 50 million Americans. And therapy generally has to be life long, so itís a matter of making long-term lifestyle changes in diet and taking continuous drug therapy if hypertension is to be controlled. Health officials have issued new treatment guidelines this year. And for the first time, they suggest a specific diet, one rich in fruits, vegetables and low-fat dairy foods and reduced saturated and total fats. Such a diet could significantly lower blood pressure for all Americans.

So eat, drink and be healthy, and donít forget the aim of healthy blood pressure, about 140/90 or less.


Plastic Surgery

I had a 50-year-old patient who had smoke several packs of cigarettes a day for more than 30 years. This had caused her skin to age and she looked more like 70. She would not pay for any pulmonary function tests for her COPD because she was saving all of her money for a face job.

Because of her aged and atrophic skin, we warned her that the skin would never look new or fresh and may not heal well because cigarettes remove all the collagen from beneath the skin which normally fills it out for a more youthful look.

However, she decided to proceed and came back about a month after the surgery. She sported a wound dehiscence (a separation of the scar) in front of her left ear with a scar forming that was about a quarter inch wide. As we had warned her, the skin she had was not very healthy and healing would be a problem.

Not spending a hundred dollars to get the usually required health care for her lungs, she spent $3500 on her face, which was not helpful.

When health insurance is touted as being unaffordable, it should be noted that the medical specialties that work outside of health insurance, such as plastic surgeons, are doing extremely well.

Thus when the government takes over health care, one thing that will happen. People will have more money to purchase unnecessary care.


It's a Relief to Know the Truth after All Those Conflicting Medical Studies

On two tables of stone, DIETS & DYING found on Mt Ararat, a short distance from Sinai, the final word on nutrition and health were found. (Weíre researching the validity of the finding.)

The Japanese eat very little fat or red wine and suffer fewer heart attacks than the British or Americans. The French eat a lot of fat, drink a lot of red wine, and also suffer fewer heart attacks than the British or Americans. The Italians drink excessive amounts of red wine and a lot of cheese and also suffer fewer heart attacks than the British or Americans.

CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you.


Disclaimer: These messages were written in the years as noted and may be somewhat dated at this time. Please consult your physician or other health care provider.