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Thursday, April 21, 2011

Doctors' Work: The Advantages of Growing Old

The View from the Office

What I’ve Learned in 30 Years of Family Medicine

            You can’t prevent 100% of anything. You’re not responsible for guaranteeing anything. Most of the power lies on the patient’s side of the partnership, and a healthy lifestyle is the primary tool. Your job is to help them unleash their power to be healthy.

            Health is not freedom from disease. Health is a matter of being aware, content, and eagerly looking forward to the future with whatever physical or emotional limitations you might have and being firmly rooted in your community and your family and committed to their general welfare.

            What you really owe your patients is to think for yourself. The experts don’t know your patient, and most of them are paid by a drug company. Your loyalty to your patient is uncompromised. No one knows their details like you do.

            Every visit should be treated as a new patient visit. Going over the family situation, lifestyle score, job, and problem list and medication list should be routine.  Just as when you join any practice, every patient is new to you and deserves the same basic intake and assessment from you. These assessments need to be global and represent your best effort to get to know their place in your community. There shouldn’t be any visits where you just treat a cold and let them go. Every visit is an opportunity to get to know them better. Colds don’t matter. Not being thorough just because you’re rushed is a lack of discipline. Discipline is what makes you efficient and keeps you from getting behind in your schedule.

            Every visit should start with a conversation about lifestyle. This is, after all, the key to health. Using the formula 0-5-10-30-150 (for 0 cigarettes, 5 servings of fruits and vegetables a day, 10 minutes spent relaxing in some way every day, maintaining a  BMI < 30, and getting at least 150 minutes of exercise a week) makes this a simple conversation. Try it. Your patients will respond positively to it.

            You can’t beat the 80/20 rule. The 80/20 rule states that 80% of your best results come from just 20% of your best efforts. Medical school curricula were designed by a bunch of obsessive-compulsives who didn’t know a thing about time management. You can’t do everything for every patient. It is pretty easy to identify 80% of traditional practice standards that can just be tossed out. A simple example is the physical exam. What’s a complete physical. Here is my version:

“Vitals reviewed. Constitutional: She is oriented and well-developed, well-nourished, and in no distress. She appears not diaphoretic. No distress. HENT: Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, react to light and accommodate. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm and normal heart sounds.  Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal. No stridor. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness. Abdominal: She exhibits no distension and no mass. Soft. No tenderness. She has no rebound and no guarding. Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness. Lymphadenopathy:   She has no significant adenopathy. Neurological: She is alert and oriented. Gait normal. Skin: Skin is warm and dry. No rash noted. She is not diaphoretic. No erythema. No pallor. Psychiatric: Mood, memory, affect and judgment normal.”

This is not a list of the most relevant findings, rather it is evidence of a brief survey of the body that is systematic, easy to perform, and keeps all the Medicare auditors happy. This has the advantage of focusing on the most readily apparent and easy to observe abnormalities; most of the time no abnormalities are recorded for most of the parts of the exam that are done. With repetition this becomes very quick and effortless. My complete physical takes only 2 minutes; problem focused exams take only half that.

            The physical exam is only one example. There are many more. Just to take another simple one. Don’t focus on every preventive measure that could possibly be done. This would cost too much in time and money, and since the USPSTF has recommendations for 169 interventions, you would find it just overwhelming. Besides we can’t prevent 100% of anything anyway. The simple rule is to pick up to 7 of your top priorities, and use every visit to make sure they are very well taken care of.

            In order to be efficient you have to work in your own way. Any physician who is using a progress note form (whether paper or electronic) that is designed by someone else has been dealt a major blow to efficiency, productivity, and creativity. There is no single common denominator to medical care. The methods of effective practice are as rich and varied as the people who are practicing medicine and the patients who see them. As a craftsman, you are simply negligent if you don’t design your own tools for the way you work. Your efficiency, accuracy, and creativity all depend critically on getting in your groove and just humming along in a way that comes natural to you. Your progress note form should be a brief map for the interaction you want to have with patients. Below is my basic progress note template for both new and established patients, acute or chronic care issues.

            It starts with the chief complaint from the patient’s perspective since, if you don’t address this right up front, you have lost their attention and you have missed an opportunity to map your use of time together. Then the very next thing I want to get to is social history where I learn as much about the patient’s milestones through life and role in the community as I can. I spend 2 minutes on completing a lifestyle score using my formula for health (0-5-10-30-150) and remind them how central these 5 behaviors are both to health and the care of any disease. My review of systems includes a search for any and all problems (my note uses a list of the top 16 to prompt me to think of common problems that need not be obvious; you would be amazed at how easy it is to take care of a cold for a patient and not realize that they have cancer) for which the patient has been treated in the past. The added advantage of this is that it expedites your review of chronic diseases giving Medicare the 3 pieces of information they want about at least two each visit (current disease status: whether progressing, improving, or stable; whether it is well-controlled or not; and whether there are any side-effects of treatment); this process also creates a nice mini-report card of the effectiveness of your care.
I also review some basic housekeeping details like whether they need glasses, use hearing aid, have dentures, or need a dental checkup too.
 I review what laboratory testing has been done recently and make sure I have values for my top 5—lipid panel, renal function, A1c (if BMI > 30 or have HTN), TSH, and a CBC.
Finally I do my review of my top 5 preventive medicine tasks (lifestyle score [already done], lipid testing, immunizations, Pap and mammogram review for women (particularly noting any past history of abnormals) and offering a PSA test to men, if they want it, and a general discussion (not necessarily any testing) of the pros and cons of colon cancer screening (not essential in my opinion), prostate cancer screening (not recommended), and skin cancer screening. It is worth remembering that a healthy lifestyle avoids more cancer than all of the traditional cancer screening programs put together at a mere fraction of the cost. After that I am just jotting a few notes to myself about abnormalities on exam and the “to do’s” I take away from the visit, and we’re done.
            All in all, this is a rich, 15 minute experience that gets the job done. And, of course, I’m not done yet. I hope to get better.

Figure 1: My Basic Progress Note
Visit #:                   Age:    Gender:          Name:                                     DOV:  4/21/11

Social:   Lives with:                                Occupation:                           
Lifestyle score:  0   5   10   30   150
Smoking:         Etoh:               Known drug issues:
ROS:  glasses?              Hearing?          Last dental check?                Other assistive device?

Chronic Problem List:                                               
Status                 Control                    Side Effects:
Major 16:
HTN    Lipids       CAD         DM      BMI > 30         Smoker        CHF
Hx of cancer                      Depression               Hep C         Thyroid           
BPH     Asthma/COPD Afib   Warfarin                  CVA/TIA      Chr Pain
GERD   Sleep apnea
Surgeries: ________________________________________________________________________

Diabetes:        A         B         C         D         E                      F: _______________________________

Major Labs:   LDL: (cholesterol)    Cr/GFR: (kidney)          A1c: (diabetes)          TSH: (thyroid)               LFTs (liver)      PSA (prostate)


Last Pap:            Last Mammo:         Last colonoscopy:              Last PSA:                   Flu:                    Last DT                 Pneumovax                         Shingles:

Exam: BP:                   BMI                                                    



Creating this global yet intensely targeted health assessment process has been the work of the last 30 years. It takes some experience to get both an adequate perspective (i.e., you can’t worry about every detail) and a confident ability to select what to focus on (that works for you). It takes 30 years to be both relaxed and confident (they don’t naturally go together). Residents starting out in practice are at such a disadvantage in trying to practice good medicine. They are still stuck trying to do it all (impossible), trying to know everything (impossible), trying to keep the experts happy (impossible), and trying to have a life (not quite impossible). Thirty years down the road, one is able to accept that one can neither knows everything nor attends to every detail and one doesn’t give a damn about the alleged experts any more. Moreover, we have a life, for better or worse, the one we made. It is no longer subject to the doubt or speculation that is so distracting to younger physicians. Finally, we are by now firmly entrenched in our communities, and they are taking care of us every bit as much as we take care of them, and the beautiful cycle of nurture completes once again.

Friday, April 8, 2011

Getting to Know Your Heart Risks

The View from the Office

 Does a Healthy Lifestyle Mean That You Never Have to Take Pills?

       If you have a healthy lifestyle, does that mean you shouldn't have to take pills?  Of course, I believe that everyone should have a healthy lifestyle. And increasingly more and more of us are achieving this goal. I've noticed that one of the things that happen to people who have healthy lifestyles is that they think they shouldn't have to take pills. The belief is this: If I keep working on my healthy lifestyle that should bring my blood pressure down, lower my cholesterol, and prevent me from ever getting diabetes. This principle is sound and applies most of the time, but there are many, many exceptions. The logic is especially true if you've had a healthy lifestyle all your life since childhood. But even then there is the matter of your genes. A healthy lifestyle does not change your DNA. The purpose of this week's article is to show you a way to know if taking some extra pills for your blood pressure, cholesterol, or general vascular disease prevention (like aspirin) is a good idea. 
     The problem that I am addressing is the fact that so often in my office I am trying to urge patients to start taking a blood pressure medicine so that their blood pressure doesn't linger around 148/94 mm Hg, but actually gets down to 120/80, where your heart and blood vessels will function optimally. Similarly, when it comes to cholesterol, I have no problem convincing the patient whose total cholesterol is over 300 mg/dL that they should take a medication called a "statin", but when I try to convince a patient whose blood pressure is just a little high, like 148/94 mm Hg, or whose "bad" cholesterol (LDL) is only 10-20 points above normal, which is 100 mg/dL, that they would really benefit (i.e., add years to their life) if they got that cholesterol way down into the good range like around 70 mg/dL, they just don't want to do it. They don't want to add a new medication, possibly for life, for just a minor abnormality. The problem, however, is that even a minor abnormality over a long, long period of time does significant harm. When you add several minor abnormalities together over a long time, they do a great deal of harm. This is the whole rationale of analyzing cardiac disease risk over multiple risk factors. Treatment is not just for those with severe abnormalities; it is for anyone who wants to enjoy the benefit of health for a much longer period of time.
     Think of it this way: Would you have ask your auto mechanic to do just "half" of a tune-up? Would you want to put used motor oil into your engine? Remember that your body has pipes and pumps that need engine cleaning agents regularly titrated to your biological parameters (e.g., blood pressure, lipid levels, glucose, etc.). Just think of your blood pressure medications, cholesterol lowering medications, aspirin, etc., as engine-cleaning detergent gasoline. 
      Of course, not all medications will make a big difference. How do you know which ones will give you the biggest bang for the buck. Until recently this has been a very difficult calculation to do and the scientific evidence has been hard to interpret. But now we have some wonderful tools from the American Diabetes Association that gives you a simple graphical visual illustration of just how much benefit you will get from lowering your blood pressure just 5 points, or 10 points, or 20 points. You can do a similar calculation for your weight and dramatically see how much difference losing 5 lbs, 10 lbs, or 20 lbs will make for you. In this article I am going to demonstrate how the ADA's program, "My Health Advisor" (My Health Advisor (  or search for "my health advisor" in Google), can help you pick exactly what medication, or what level of blood pressure or cholesterol will do you the most good.

     To start with you have to enter some basic data about your self. Here is a summary of the data the program collects.

   Then based on this profile, the program (which takes some 10-15 minutes to run your numbers through the extensive Archimedes database) produces a report to show you the your probability of a heart attack, stroke, diabetes, etc., if you just keep tooling along just as you are. One of the nice things about the program is that it lets you save a copy of your data and your report so you can revisit it in the future and play out a variety of "what if" scenarios based on where your biological parameters are and where you would like them to be.

      You see in the graphic above that there are slider bars next to your weight, cholesterol, and blood pressure, and there are check-mark boxes for other interventions such as stopping smoking, taking a baby aspirin daily, or taking a prophylactic heart medication like an ACE-inhibitor or a beta-blocker.

    In the graph above the pink bars shows the reduction in my risks if I just get my blood pressure down to 120/80 mm Hg.

     In this graph you see the effect if I go all out and lower my weight from 210 to 185, if I lower my LDL cholesterol from 94 to 70, and lower my blood pressure from 130/80 to 120/80 mg Hg, and start taking a heart-protective medication (an ACE-inhibitor). The combination of interventions would lead to a very impressive reduction in overall risk. 
     Major reductions in risk like this are a very good thing, and the way to get there is by taking a medication. Thus my advice is to try to move away from the hostility towards taking medications. Stop telling yourself that it is all a plot just to make money for the drug companies, or that it will cause you lots of problems from side-effects. What these medications give you, if you lower your cardiac risk, is extra years of life--very high quality life, in fact, if you have a healthy lifestyle. When you evaluate the trade-off--a good number of extra years of life against a few annoying side-effects, the balance of benefits to risk is very positive. On the other hand, if you chose not to avail yourself of the wonderful benefits of these medications, that too has a side effect--dying early is a rather nasty one.
      We are blessed to live in an era in which we have truly effective medications, now all blissfully available as low-cost generics. Unfortunately, we have come to take for granted this embarrassment of riches. We forget that 30 years ago the medications to achieve these goals were not available or were so expensive that they were out of reach of many. I think we are all well aware of many, many people who died back then from diseases that are now easily treatable. That simply doesn't need to happen any more. 

     To maximize your life opportunity you should build your health on two firm pillars:  (1) you should create and sustain a healthy lifestyle for you and your children based on the formula for health (0-5-10-30-150); and (2) You should use the "My Health Advisor" program to really understand your risks and to make your own decisions about blood pressure, cholesterol, and heart-protective medications. These are all very inexpensive and very effective. No corporation needs profit from your decision if you use a generic, and the generics are every bit as good as the fancy brand names (which are all destined to become generics anyway). If you really value health, you will get aggressive about asking for these medications because they can do for your health such an amazing thing--keep you on this earth so you can be with your friends and family a good bit longer. All your friends and family would want you to.

COMMENT: In my separate publication in April, FP Revolution (FP Revoluation recent issues) I will describe in detail how to use the other ADA program for risk assessment in diabetic patients (Diabetes PHD,   Diabetes PHD or enter the search term "diabetes phd" into Google). This program allows diabetic patients to change their risk not only for heart attacks and strokes, but also for kidney failure, blindness, and foot amputation. All of this represents high-tech medicine at its best. And best of all--you are in control all the way!