Asthma & Stress
We have always known that stress can aggravate asthma. Stress can aggravate a lot of illnesses, from coronary heart disease to peptic ulcer disease. But can stress cause disease where none previously exists?
From 1994 to 1996, researchers at the Channing Laboratory at the Brigham and Womenís Hospital in Boston, studied 496 children recruited from a Boston hospital within 48 hours of birth. They wanted to determine if the level of caregiver stress could cause an increased risk of asthma in children who had a genetic predisposition to asthma.
Of the 496 children, 287 (58%) never wheezed during the 14 months of the study, 116 (23%) had one episode, 47 (9) had two, 28 (6%) had three and 18 (4%) had four asthma attacks. After correcting for maternal smoking, breast feeding frequency, number of respiratory infections, birth weight, parental asthma, ethnicity and socioeconomic status, they found that higher levels of caregiver stress predicted an increase risk of wheeze. White caregivers had a lower level of stress than Hispanics. Divorced and single caregivers showed a higher level of stress than those that were married. As household income increased, stress levels decreased.
In a related study, allergic reactions to a potent German cockroach allergen can cause severe asthmatic attacks which may result in emergency room visits for sensitive asthmatic children. This allergen elicits immunoglobulin E (IgE) response in 60-80 % of allergic patients. Cockroach allergen (Bla g 2) is not linked to enzymatic activity as dust mite allergens have shown. The "enzyme hypothesis" for allergic reaction was originally developed to explain why dust mite allergens are so strongly associated with the development of allergic responses. This hypothesis is based on the fact that dust mites are enzymes.
For more complete information, please visit the American Thoracic Society Online Web Site: www.atsjournals.org
Coughing & Asthma
On my semiannual trip to the dentistís office, the hygienist casually mentioned that her husband has had intractable coughing for the past ten years. It was worse after exercise and during the night. Heíd been to a doctor who felt allergy skin tests were in order. At another doctor, he was given an inhaler to use prior to running or vigorous exercise. My hygienist said her husband didnít go back because he didnít like taking medications.
Coughing is frequently the first symptom of asthma. The bronchi are trying to go into paroxysms of constriction which is bronchospasm or coughing. If they stay constricted, then the air passes through a smaller tube, wheezing becomes apparent, and we call it asthma.
A specific form of asthma is exercised induced or cold induced. The rapid movement of air in and out of the airway causes constriction and wheezing. This is generally treated by taking an inhaled bronchodilator 15 minutes prior to working out or exercising. Some people, on walking into a frigid environment such as a wintry outdoors or a freezer, will experience constriction of the bronchi causing coughing or wheezing. This can usually be eliminated by taking one or two puffs of a bronchodilator 15 minutes prior to entering the walk-in freezer or stepping out into sub-zero weather.
Allergic hay fever and asthma are generally caused by inhaling pollens. This is referred to as seasonal hay fever or asthma and is usually due to trees blooming in the spring, the grasses in the late spring and early summer, and the flowers and weeds during the summer and fall.
Allergic perennial rhinitis and asthma may also be caused by the above three types of pollen, as well as house dust, molds and animal danders. These symptoms are year round.
The first evaluation of hay fever and asthma, like any other disease, is a thorough medical history and physical examination. The medical history should make the proper correlations so that the allergen can be removed, in the same way that penicillin is eliminated if you are allergic to penicillin. One does not need a skin test to penicillin. It can be dangerous, if not fatal. Similarly, other agents are removed from the environment, such as feather pillows and bedding, foam pillows which collect molds, and kapok pillows generally found in overstuffed furniture. If one has symptoms from pets, whether cats, dogs or birds, these should be removed from oneís indoor environment.
The doctor who treated this man obviously made the correct diagnosis of exercise-induced asthma, which has a straight forward treatment of the inhalation of bronchodilators prior to exercise. However, his doctor did not make the correlation of his intractable coughing at night. My first question was, "Does he sleep on a feather pillow, a feather mattress or under a feather comforter?" She answered that they slept on a feather bed. For most asthmatics, sleeping on a feather mattress or under a feather comforter or on a feather pillow is almost like dying. I recommended that she stop at Penneyís or Gottschalksís on her way home, purchase Dacron-Polyester pillows and comforters, and remove all the feathered contents from her house. If they have emotional value, seal them tightly in plastic. Donít place them in another room of the house if you have central heat or air. Surely youíve noticed people sneezing on their back porch because of the trees blooming a hundred yards away. Having the feathers inside the house would not be healthy.
Here we see a common problem played over many times a day in thousands of offices. Bureaucratic medicine pushes doctor to spend such a short time with their patients, that it is easier to spend hundreds if not thousands of dollars on unnecessary testing, rather than spend 10 extra minutes to determine the diagnosis. It would be less costly to actually pay the doctor directly for a $100 office call, than the 20% copay of a thousand dollar lab evaluation which would still not give the answer or suggest the right treatment in the case outlined above. We need health insurance for the expensive operations or hospitalizations for which we canít planĖnot the office call. When the government takes over healthcare, the number of people without appropriate healthcare will far exceed the 40 million without insurance today. Just look at whatís happening in Canada where 80% of the people wanted government medicine and now only 20% are still for it. Or the case in Britain, where the waiting lists are years long as in a third world healthcare system.
Weíre hearing a lot about practice guidelines these days. It is touted as making a medical practice more cost effective. The primary goal is to improve the bottom line. Otherwise, how can the shareholders and CEOís command their millions.
Phil Alper, MD, reports that in France, the "Order of Physicians" (initially created by the Vichy Government during the Nazi occupation) was instructed to create a cookbook listing "appropriate" guidelines for ordering tests and medication. It leans heavily on office-based physicians and spares the more politically powerful hospital sector, even though the latter consumes nearly 60% of the health money.
French doctors are terrified! Computers have made mathematical criminals of doctors without any awareness of wrongdoing. In the first two months of the program, dozens of doctors have been fined thousands of dollars.
If this sounds familiar, it should. The same distinction is happening in this country without "The Vicious Government" even being involved. Managed care companies and doctors working for hospital foundations or HMO foundations are increasingly separating the doctors who work entirely in their offices and those who take care of hospital patients. The data touted is that this is more efficient and more cost-effective care.
This theory doesnít hold water...as most physicians are aware. The government has singled out doctors they can control, and those doctors are office-based practitioners rather than the entrenched hospital doctors. Hospital-based doctors may know that they will be the next group under scrutiny. But in their desperation, they hope they can be out of medicine before that occurs. The tragedy continues.
Electronic Medical Records
Most Americans assume that the facts they tell their doctor are confidential and protected. In fact, medical records enjoy less legal protection than video rentals. And Congress has not acted to safeguard the confidential communications between doctors and patients. Instead, it has already laid the groundwork for the national database that would make our medical histories accessible to millions of unidentified users without our knowledge or consent.
The popular Kennedy-Kassebaum Health Insurance Portability and Accountability Act (HIPAA) added an eleventh hour provision that every American be assigned a national "health identification number." This alarming measure received no public debate, no hearings and little scrutiny. This section of the law is a ticking time bomb.
Our patientís medical records deposited in a national database without our consent nor our patientís consent would make it available to anyone with access. Although just a few hundred thousand initially, the secondary access is well into the millions. Suppose you have discussed mental illness, impotence, incontinence, cancer or even genetic testing, you may never obtain insurance again or even get a job.
In fact, a University of Illinois study of Fortune 500 companies disclosed that one-half already admitted to using medical records in employment decisions. A Maryland banker who had access to the state health commission computer, pulled up a list of every person who had cancer in his area and checked it against the names of customers at his bank. He then called in the mortgages of all the cancer patients. He was not even punished. A women with a genetic predisposition to breast cancer was denied insurance coverage for treatment because it was labeled a "pre-existing condition."
Our profession must resist every effort at making our patientsí records an open book. While we should facilitate their use for medical treatment decisions, they should not be used for financial, employment or political gain.
CAT Scans Here & Abroad
The cost of medical care in the United States is frequently compared with the cost of medical care in other western nations. But does the higher cost of US medicine reflect a higher level of care? Let me give you a comparison.
Mr Atkins developed left-sided weakness while at the grocery store. His wife called for medical advice and I directed her to take him to the emergency room for prompt evaluation.
Several hours later I received a call from the ER physician reporting on Mr. Atkinsí neurologic status. The doctor had already checked the carotid circulation in his neck with a Doppler ultrasound and performed a CAT scan of his brain. This allowed prompt institution of treatment.
The reason for the prompt evaluation of a stroke is that early treatment may prevent permanent brain damage. For example, if the cause of the weakness is partial obstruction of the carotid artery that supplies the brain with blood and oxygen, prompt surgical removal of the obstructing plaque can restore circulation and prevent damage to the brain. Some of the newer medical drugs can dissolve a fresh clot in the vessels.
MEDLINE reports that there are 19 new drugs in development for the treatment of strokes. Many have to be used during the early evolving stages of a stroke. But what good will all this medical research do if the benefits can't be used?
This type of medical technology is not available to 95% of the world's people. Friends of ours from London, who come to Sacramento every year for our Jazz festival, explained the absence of their drummer last year. They said that he'd had a stroke. He was hospitalized in a London suburb. He had not improved after a week and his doctor requested a CAT scan of his brain. The hospital did not have a CAT scanner and none were available except in the larger hospitals of London. This patient had to be transferred to such a hospital so that a CAT scan of his brain could be accomplished. However, so much time had elapsed since the initial episode, that the treatment was no longer beneficial.
The next time someone suggests we adopt a government plan from some other country, just remember that the level of care in a small suburban hospital in this country is frequently better than in the largest hospitals in many parts of the world, including those we think are advance or developed countries like the UK.
Dr Jones, a physician in a California community, received a notice from the medical board that a consumer had complained that he had taken liberties with a patient. A Mrs Francis complained that Dr Jones had raised her left bra slightly while listening to her heart in order to see her mammoplasty scar.
As Dr Jones was preparing his response, he called to inform his attorney concerning this allegation and was immediately told not to send his response to the medical board because he could lose his license. He was told to come in and bring the record. The attorney, Charlotte Brown, prepared a letter to the medical board concerning the allegation stating it was totally unfounded because that was the normal procedure for listening to the mitral valve. She told Dr Jones that she could not let him make any contact with the medical board. She feared that almost anything a doctor would or could say would in some way incriminate him--possibly even send him to jail. So she handled the entire allegation until it was dismissed. The fee was about 20 hours of attorney time or about $6,000. Another expensive month in the life of a California physicianís practice.
In retrospect, Dr Jones remembered that this patient was very pleasant but detached. She would wait 15 minutes, and then reschedule if the doctor was late. She had no significant medical problem. It then dawned on the doctor that Mrs Francis obviously was a paid medical board spy to entrap doctors.
About six months later, Dr Jones met the chairman of the Medical Board at the society office. He started up a conversation and asked for his business card. The Medical Board chairman became so nervous that he dropped his billfold and his card file. This confirmed his suspicions.
So always be cautious when you feel that there is something unusual about your rapport with a patient or when the patient is pleasant, matter of fact and a stoolie. And never, ever, deal with your own medical board. They are not there as your friend. They are there to justify their position with the public by showing how many licenses they have removed. If necessary, they will remove licenses from good doctors rather than lose their jobs.
Peer Review has become a system of doctors eliminating other doctors from competing against those in power.
It was meant to be a confidential means of improving care through objective evaluation and was implemented with the cooperation of the medical societies.
But in California, a large medical group that had members on the medicine committees of the six hospitals in the greater metropolitan area used the Peer Review system to eliminate competition. As they did Peer Review of the records, they would make an issue of a minor variance in patient care to put the targeted doctor under review. Once under review, it prevented the doctor from doing Peer Review on the group reporting the adverse reviews. With each chart reviewed, another member of the group would give an "objective review" of the same record. Frequently another variation was found.
One of the targeted doctors obtained legal counsel concerning this obviously hostile process. He was told never to respond to the letters (since the medicine committee was not operating with logic) until he had obtained at least three outside opinions in each case. So this doctor made a copy of the medical record, went by the "photocopy place" to make six copies of the record, and sent them out to six professors or senior members in their group by express mail. In each case, by the time he had to appear before the medicine committee, he would have at least three outside consultants supporting his care. He would be granted a temporary reprieve. This doctor was summarily suspended on three occasions. In each case, after calling in the outside opinions, he was reinstated.
This Peer Review harassment cost the doctor over $50,000 in attorney fees. We will tell you about the doctors in the competing group in a later installment. Stay tuned. It may save your professional life.
Medicare Medical MUD
The anger of the federal government against doctors is played out with a vengeance in the latest Medicare regulations. Since January 1, 1998, the government has decreed the nature, extent, and completeness of every evaluation physicians perform on their patients--whether they need it or not. The examination will also have to be recorded so that the lowest bureaucrat can read it, or the physician will be fined exorbitantly.
Before it will pay for a complete evaluation, Medicare decrees that the patient must have several fully developed medical problems in the medical history. There must be at least nine of the organ systems recorded. To charge for a complete evaluation, a doctor must also have examined every portion of the body, including the breasts, phallus, prostate or pelvis. If the patient has a gynecologist and her pelvic exam is up to date, Medicare requires a redundant examination, whether or not the patient wants it. A doctor can either do the exam against the patientís wishes or charge for an intermediate or brief exam even if the doctor spent an hour performing a medically indicated thorough examination.
Should the physician charge for a complete exam and the government bureaucrat feel that one item is missing, the doctor may be accused of fraud, committing a felony and be fined up to $10,000 per line in error and even go to jail. If the doctor performed all of the exams but the bureaucrat could not read the doctorís writing, the doctor can still be fined or sent to jail.
Government hostility against doctors runs deep. More and more rules and regulations harass good physicians rather than allow them to practice their profession.
Doctors Owning an Insurance Company
With all the difficulties that doctors experienced with HMOs, the California Medical Association decided to start their own insurance company. The initial capital was an infusion of $1000 from any doctor who signed up. Thousands of doctors joined for fear of losing patient referrals, and so Cal Advantage was born.
After a year, many of these doctors were still waiting for their first patient under the auspices of Cal Advantage. Instead, they received notice that the newborn insurance company needed an infusion of more capital to grow.
Now, after two years, weíre finding that the baby never left the hospital and is currently in the intensive care unit being resuscitated. Investing doctors never saw any patients and were told that they lost their investment. The doctor-owned insurance company didnít make it.
But should it ever have been begun in the first place?
The problem with such a venture should have been obvious from the beginning. Managed care is the process of managing patientís health to conserve costs as efficiently as possible. Financial reality requires that many services not needed or of borderline necessity be denied. How can doctors deny their own requests for sophisticated and expensive tests? The conflict of interest between good medicine and restrictive policy should have been apparent and the entire proposition should have been cancelled.
Doctors need to again assume the role of being the patientís medical advisor, managing the patientís health in the most efficient manner and not be party to any financial gain based on the extent of the evaluation. But physicians should not have to limit their patient care by being involved with the insurance business.
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.