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Wednesday, April 22, 2015

Preventive Medicine: on being a "bad patient" (Readers beware: this is the rant of a curmudgeon. Take with at least one grain of salt.)

I am, or will be, a "bad patient." The "good patient" accepts advice gracefully. The "bad patient" may not be a bad person, but does not play the part of the patient well. The word patient comes from the Latin word root pati, to suffer. The "good patient" suffers well, and accepts help from a physician,who Merriam Webster defines as someone skilled in the art of healing. This relationship is one in which the roles are well defined. When the patient is not actually suffering and is even more confusingly "skilled in the art of healing" the roles get really wonky. I will be this kind of "bad patient."

One way in which I do not play the part of the patient well regards preventive medicine. I am getting to an age at which various things are recommended in order to reduce my risk of developing some dread disease. When it comes to these recommendations, I find that I have become quite the picky consumer. I would dearly love not to get a preventable disease, but after more than 2 decades of practicing primary care medicine, I have seen too many undesirable consequences of perfectly benign sounding medical tests.

Breast Cancer Screening:
I don't avail myself of mammograms. I did once, and that was fine. Starting age 50 I was supposed to get mammogams every other year, according to the US Preventive Services Task Force (USPSTF). Maybe I'll get another one sometime if the data gets better. A Canadian study showed no significant effect of regular mammography on breast cancer mortality in average risk patients, though women who get regular screening do get more treatment for breast cancers, including mastectomies and radiation therapy.

Colon Cancer Screening:
I haven't had a colonoscopy. In this test, a fiberoptic scope would be introduced into my lower intestine by way of the rectum and the whole colon would be visualized with the expectation of finding and removing polyps before they become cancers, or seeing cancers before they become incurable. USPSTF said I should have started those at age 50, but the data for women without suggestive family histories of colon cancer is not convincing and the potential for something to go wrong definitely exists. An inadequately sterilized colonoscope could introduce some unfriendly bacterium into my gut. I think I like my flora as it is, thank you. The procedure to clean out my gut, drinking a half gallon of polyethylene glycol solution until my bowels run clear, which is required before the procedure, may be fine, but I'm not entirely sure that a day of rapid intestinal transit is good for me. Intravenous sedation, which is usually given in order to make this procedure tolerable, has a small risk of killing me and will make me goofy, though possibly in a pleasant way. I will watch for updates, but I'm thinking I may have this procedure when I'm 60. Maybe. I prefer to reduce my risk of colon cancer by maintaining a healthy weight and eating a diet rich in fruits and vegetables.

Cervical Cancer Screening:
Pap smears. The recommendations have changed and the schedule is less onerous, but since I had regular yearly pap smears until several years after becoming monogamous, my chance of having a new human papillomavirus infection is vanishingly small, and it is that infection that leads to cervical cancer, which is the only cancer that a pap smear reliably detects. I think I may be done with pap smears.

Blood pressure screening is another story. Detection of hypertension and treatment of high blood pressure saves lives, prevents strokes, heart attacks and kidney failure. I can do it myself, and if my blood pressure is persistently high, I will actually see a doctor and start medications. Let that not happen, because I will not submit gracefully to someone else's opinion on which medication I should take. Unless, of course, they are right. Often I see patients started on some medication which just came out and is available in the doctors free sample cabinet. That one I don't want. It will be expensive to refill and we will know very little about how well it works in the long run. Don't I sound annoying?

Bone density testing. There are machines that will shoot photons at my bones and tell me if I am developing osteoporosis. I should get this done at age 65. Mostly I should avoid breaking bones, though, since that is the real problem. It matters not a bit if my bones are as fragile as dry corn stalks so long as they never break. Staying strong and agile is the best way to avoid falls and fractures. If I find out that my bones are thinning, the main option for bone strenthening are the bisphosphonates, such as alendronate (Fosamax). These are medications which, if they don't get caught in the esophagus and cause a terrible ulcer, which they are known to do, and they don't get entirely eliminated, unabsorbed, due to having taken food with them to avoid getting the esophageal ulcer, will enter my bones to reduce the natural breakdown of bone by my osteoclasts, thus messing up the delicate balance of osteoblasts and osteoclasts that creates normal bone architecture. This will reduce my risk of breaking a hip or vertebra if I fall, but will put me at risk for a rare but horrific breakdown of bone in the jaw called osteonecrosis. So I will work hard on my strength and balance, eat a good diet and encourage the effects of gravity on my bones via weight bearing exercise. Luckily I am not yet 65, so I can decide on this test later. I'm leaning toward not.

But what about taking estrogen for my bones? It is primarily the loss of natural estrogen at menopause that will lead to osteoporosis. Will I take estrogen, then, since I am in menopause? The drawbacks are a slight increase in breast cancer, but without a convincing increase in breast cancer deaths, so this is a wash as far as I'm concerned. There is a slight increased risk of developing blood clots to the legs and lungs, but I didn't get those when I made estrogen with my natural ovaries so I doubt I'll get them with a small dose of exogenous estrogen. There is a slight risk of developing endometrial cancer when taking estrogen if progesterone is not taken as well to maintain a thin endometrium. Birth control pills, which are about 6 times the estrogen dose of a standard estrogen replacement pill, have a progesterone agent in them, and that may well be adequate to maintain a thin and healthy endometrium. I can also check my endometrium regularly with a quick transabdominal bedside ultrasound and make sure everything is looking hunky dory. Will I get a stroke or heart attack with estrogen? The results from the Women's Health Initiative suggested that this might be a risk, but further study has suggested that it may have been the relatively high dose of medroxyprogesterone that caused that problem, and there was no actual survival disadvantage in long term estrogen users. Will estrogen help me avoid hot flashes and vaginal dryness? Yes, it will. Perhaps I shall take one sixth of a birth control pill daily, since that is cheap and generic and will avoid wallet toxicity.

What about vaccinations? Yes, with no hesitation. Yearly flu shots, though I recognize my potential benefit from these is low, pneumonia shots when the time comes, tetanus and acellular pertussis, yes, and appropriate travel vaccinations with the possible exception of yellow fever. (There is a longer discussion of that here.)

How about obsessing about my cholesterol? The present recommendations about cholesterol lowering are to treat patients with a 10 year risk of cardiovascular events of 7.5% or higher. The calculator for this has recently been shown to overestimate this risk, but I have always been in the vanishingly unlikely range, which means that I need not know my numbers. I have checked them occasionally and they are not pristine, but it is not clear to me what intervention would be most likely to lower my already low risk of cardiovascular disease. Certainly there is no indication for medications. I might become primarily vegetarian and eat fish when I can get it, embracing the Mediterranean diet. There is no good data to tell me which fats I should eat, but it seems wise to be moderate and avoid trans-fats which don't naturally occur in the foods I love anyway. 

Moving my body:
How about exercise? Exercise seems to play an important part in preventing all kinds of things I don't want, from diabetes to dementia. It will control my weight, which will help me avoid hypertension and cancer. It will improve my balance so I will avoid falling and breaking bones. I will be more likely to be nimble enough to jump out of the way of an oncoming bus or bicycle. Yes to exercise. Long walks in the woods, cross country skiing, visits to the gym, bicycling, swimming, canoeing. 

The yearly physical:
How about a regular physical exam? Not sure. So far it's been no for me, but yes for my patients. A physical exam is no longer really recommended, though there are many pieces of the physical exam that are part of what we recommend to patients as prevention. I think a physical exam is actually a good idea, but more as a prolonged discussion of preventive testing recommendations and to develop shared goals. Examining the body is not a bad idea, either. As we age, our bodies do weird things. A toe will point in the wrong direction, there will be a lump or a pain or a vague dysfunction, none of them severe enough to warrant a visit to the doctor, but each one deserving attention and maybe explanation. In total, these little irritations may paint a picture of a whole organism which needs some kind of intervention in order to be as healthy and vital as possible. If this kind of an evaluation and discussion is a physical, then yes, definitely, and I might even want one. 

So am I actually a bad patient? Since I am not a patient, it is still a moot point. They say doctors make terrible patients. We will just have to see, when the time comes.

Tuesday, April 7, 2015

Crazy idea: take blood pressure like the pros, and teach patients to meditate.

I recently read a discussion by 3 hypertension specialists, Drs. Jan Basile, Dominic Sica and David Kountz, on how to treat "resistant hypertension." Resistant hypertension is blood pressure that remains above goal despite treatment with 3 drugs, from different classes, one of which must be a diuretic. 10-15% of patients with high blood pressure will have resistant hypertension. These are the people who always seem to have blood pressure at levels that are concerning despite using medications that should be working. We wonder if they are actually taking the medications, but they assure us they are. It's almost like they are just taking sugar pills.

Often patients such as these have extensive testing to see why their blood pressures are so high. They get put on even more medications which then have side effects, and eventually we may just give up and decide that they are as good as they are going to get. Giving up helps to avoid still more medication side effects, but patients with resistant hypertension continue to have significantly increased risk of strokes, heart attacks and kidney failure, which presumably could be reduced by controlling their blood pressure.

So what do the experts do first? They take the blood pressure right. Their scrupulous method of checking the blood pressure is to have the patient abstain from caffeine or excitement for 30 minutes prior to having the blood pressure measured. They then sit in the exam room quietly for 5 minutes and the blood pressure is taken automatically 3 times, at 1 minute intervals, and the results are averaged. Adequately measuring blood pressure in the clinic setting requires that the patient be sitting, back supported, feet on the ground, not talking.

This is almost NEVER the way we do it. Five minutes sitting quietly? When does that ever happen? This would mean just sitting, not messing around with a phone watching cute animal videos, not reading about which movie stars are splitting up, not yelling at one's kids who are wandering around the examining room trying to stick forks in the electric sockets.

As far as I can picture this, the only way to actually get a person to sit quietly for 5 minutes, unless they already know how to meditate, is to teach them to meditate. The easiest instruction is to count each breath up to 10 and repeat. When thoughts happen, which they inevitably do, the patient is instructed to notice them and go on with counting. Mindfulness based stress reduction, which was just demonstrated in an article in this week's JAMA to be effective in treating insomnia in the elderly, also includes muscle relaxation and instruction on acceptance of emotions and sensations. But breath counting is a very basic meditation technique and can be taught in about 30 seconds. The nurse could do it, then go away for 5 minutes, come back and take the blood pressure. In silence. And then the patient has meditated, possibly for the first time ever.

So then you have taken the blood pressure correctly, and it is probably lower than it would have been with our standard techniques. This will likely reduce the number and dose level of medications patients have to take, and they have learned to meditate. They can do it again. It will help them sleep. Perhaps they will learn to like it, do it regularly, and it will reduce their levels of inflammatory cytokines. Then they will have fewer heart attacks.

I can hear the grumpy voices already saying that patients will never do this. I kind of think they will, though, if we advertise it properly. It is the ONLY way to get an accurate blood pressure, which will undoubtedly be lower than if we take the blood pressure the standard way. It will require a little bit of work flow rearrangement, but it is a great idea. I think I will try it first with patients who have resistant hypertension or those who I am thinking about putting on blood pressure medications for the first time. These are the situations in which both the patient and staff will be most motivated to try something new. I will also not necessarily tell them that they are meditating.

Wednesday, April 1, 2015

American Board of Internal Medicine Maintenance of Certification firestorm: what more to say?

About 2 years ago I finished the process of recertifying for the American Board of Internal Medicine. I had last done this in 1990 and had a time unlimited certification, but had heard that recertification, which included doing a certain amount of studying and then taking a long test, was a good idea. Specifically, one internal medicine physician had written an article about the process, which sounded a little like a medieval quest, complete with hardship and mortification. That sounded perversely attractive.

The process was expensive, about $1500 (now $1940) to sign up for the whole deal, which involved keeping track of the educational modules on the ABIM site, access to some educational material and completion of a Practice Improvement Module which was more disruptive than the rest of the process. I had several options, but chose to evaluate how well I was doing on preventive medicine, things like getting my patients to do mammograms and colonoscopies and screening blood tests and that sort of thing. There were before and after questionnaires for my patients to fill out which were tallied and available for me to see on the website. These told me how I was doing before and after instituting certain changes. I've always disliked being evaluated with a numerical scale in a disconnected manner, but it wasn't too awful and I did learn quite a bit about the current recommendations for preventive practice and the evidence behind them. I then took the long test, which was another fee, about half of the original fee, and waited maybe a month before being notified that I passed. In order to feel confident in my ability to pass the test, I attended a several day long preparatory set of lectures at a major medical school, which cost a few thousand dollars and took a couple of weeks off from work to prepare. I didn't resent it, because it felt like the process had fully updated my operating systems, but the cost ended up being somewhere between $10,000 and $20,000.

About a year later I learned that, in order to maintain my certification, the ABIM was asking that I complete ongoing approved Maintenance of Certification (MOC) activities, including the practice assessment modules which would be due every 2 years. This was a change, since the prior requirements were assessed every 10 years, culminating in the exam. I thought that I would go ahead and do this, since I had learned a good deal the previous go round. In my present practice as an itinerant hospitalist and sometime rural primary care physician, the practice assessment piece is really tricky, so I haven't gotten around to that yet. The requirement to do this is presently on hold by the ABIM.

Since the change in requirements for MOC, internists have been rebelling. Many of them have practice responsibilities that are more demanding than mine, so they really don't have time to do all of this. The scope of practice for internists is very diverse and many find that what they learn in the process is not that useful. The price is painfully high. Newsweek picked up the smell of blood in the water and wrote a nice inflammatory article that simplified the issues and opened them up to general scrutiny. The ABIM responded testily. Fur is flying everywhere. Much has been said by knowledgeable people on the many sides of the argument, and I will not attempt to cover their points. I have a few thoughts, though, that don't stand out in what I've read and have some bearing.

1. There is at least one other way to get certification as an internist. The American Board of Physician Specialties offers certification in Internal Medicine and various other specialties. It was initially started as a certifying agency for Osteopathic Physicians, but now includes MD's. The cost of certification is about the same as for the American Board of Medical Specialties, the parent organization for ABIM, and their recertification occurs at 8 year intervals. They do not require ongoing maintenance of certification activities, other than demonstrating involvement in continuing medical education for 50 hours a year. This might be a viable way to opt out of ABIM's requirements.

2. The concept of "Maintenance of Certification" didn't come from ABIM, but was adopted by the parent organization, the American Board of Medical Specialties in the year 2000. This board includes doctors of pretty much all varieties, including surgeons, anesthesiologists, radiologists and everyone I can think of. There are 24 member boards. I checked the boards of Family Medicine, Pediatrics and Emergency Medicine and all of them have MOC requirements that are ongoing in order to continue to have a board certification. There are at least a few of these doctors who write about their specific requirements, and it looks like they also find them onerous and of dubious value. The physicians who find the process to be just fine probably don't write about it. Most of those who are unhappy about the process are likely too busy to write about it and probably just growl quietly to anybody who asks.

3. It is very hard after finishing medical school and residency to keep up with the huge body of internal medicine, with its very active ongoing research on the pathogenesis of diseases and what therapies work and don't work. Having a process such as board certification and recertification that can provide a framework for relearning that body of knowledge as it changes is very important. Just achieving 50 hours of continuing medical education in the fields that most interest us is not enough to maintain competency. The process of learning what I needed to know to pass the ABIM test was valuable and I am a better physician for having done it.

4. Doctors don't want to be attached at the hip to their certifying boards. That goes for pediatricians, family practitioners, emergency physicians (and so on times 24) as well as internists. We already have to prove competency for maintenance of privileges at hospitals, state licensing agencies and even with insurance companies. Something about this recent MOC change was the last straw.