http://northbrook.suntimes.com/news/8983983-418/our-neighbor-dr-unger-counts-his-blessings-thanks-patients.html

I hope everyone is having a grand holiday season.

I am working on a blog on WEIGHT LOSS – this always seems to be on the minds of people around this time of year, but it is requiring more research than I anticipated!

Good Health!

Dr Mike

If you haven’t gotten the opportunity to read the story, it’s very short:

http://seussmd.wordpress.com/2010/07/05/the-dawn-must-come/

Dr, Mike

The following is a list of things that doctors wish patients knew.  It is not a wicked diatribe against patients.  Far from it.  The vast majority of patients are lovely people.  I am actually blessed with a patient population that I feel must be the envy of doctors everywhere.  They are bright, inquisitive and well-informed.  They take part in their own healthcare, and put effort into their well-being.  My “problem patients” are such a small minority that I have no reason to complain.  I’m a truly blessed and lucky physician in this context.

So what do doctors wish patients knew?  I’m glad I asked!!  

Doctors think long-term – Patients want the quick cure!

When a primary care doctor sees you for the first time (i.e.  Your Internist or Family Practitioner), they see you as someone they will be taking care of for the rest of your life, and they begin the process of identifying who you are as a patient, so they can best manage you for the years to come.  They are all about “The Big Picture”.  For this reason, the current over-use of Acute Care Facilities, Emergency Rooms and Minute-Clinics are a terrible and dramatic step down in care for almost all people.  These places don’t know you, your health problems for the last decade or more, or all of the sundry other issues that your primary care doctor is intimate with.  Patients see them as quick ways to get care, especially at odd hours when the doctors office is not open.  The Quick Fix! For about 90% of medical problems, the nurse practitioner or physician assistant you are likely to see at one of these places can handle the issue without any problem.  Unfortunately, you never know when your problem is going to be one of the 10%.  The scary thing is, most of the time the person taking care of you doesn’t either!  They just get it wrong, about 10% of the time.  I know, I see the back-end of this system every day…when the patient is no better, was misdiagnosed or mistreated, and I am left to pick up the pieces a week or two later.  They always tell you to follow up with your doctor.  Very few ever do.

Furthermore, your doctor, in his long-term thinking, would like to offer you appropriate preventive care, but it is very hard to get some patients in for their yearly physicals and preventive maintenance care.  Again, patients often want The Quick Fix and doctors want to prevent you from having medical problems in the future. Forming a long-term relationship with a primary care doctor is one of the best things you can do for your long-term health.  Do not underestimate the power of having a doctor that has been with you through the years!  The push towards corporate medicine is also partly to blame for the degradation of the Doctor-Patient relationship.

Day #1 Medical School:  Telephone Medicine is Bad Medicine

Even my best “trained” patients often call and ask me to “call in a prescription for my cold”, or ask to to diagnose them over the phone.  Some doctors will do this, and these doctors have fallen prey to the worst trap in all of medicine.  They are doing the patient a giant disservice, most of the time, by trying to identify their problem over the phone and treat it sight-unseen.  Any medical issue which is significant enough to require a prescription medication ought to be diagnosed properly before it is treated.  Yet, many patients actually like their doctor because he will do this for them.  Maybe that’s why so many doctors do it; to try to make their patients happy.  Certainly, there are exceptions to this rule.  If a patient of mine has had 12 ear infections in the last 24 months, and now has all of the usual symptoms of another one, it’s very unlikely that it is something else the 13th time.  In these specific kinds of cases, it may be prudent to treat them over the phone.  Mostly though, don’t be angry with your doctor when he demands to see you for your ailment, he is treating you properly…like he was trained.  I’m quite sure that when I try to diagnose things over the phone, I get it wrong as often as I get it right.  We often get the “I’m going out of town in 30 minutes” phone call, or the “I’m in Anchorage, Alaska and I have a sinus infection” phone call; leaving us either providing inadequate (and possibly dangerous) care, or being the bad guy and asking them to be seen by a doctor.  The other half of this issue is that when doctors treat you over the phone, they have used their skills, spent their time, accepted liability…and do not get reimbursed.  Insurance companies don’t pay doctors for a telephone consultation.  Your attorney will bill you for a minimum of 15 minutes of his time for a phone call, at an hourly rate of $300 or higher…yet you expect medical care over the phone, gratis.  Hmmmm!

Antibiotics do not cure the Common Cold

I wrote a blog about Antibiotics (http://seussmd.wordpress.com/2010/03/22/antibiotics-in-the-garden-of-good-and-evil/), and you can read the whole kit-and-kaboodle there, but the take home message is that most upper respiratory infections are caused by viruses.  Viruses do not respond to antibiotics, which can only kill bacteria.  Prescribing antibiotics for a simple cold does you much more harm than good, as we incur antibiotic resistance and expose you to the possible side effects or allergic reactions that all antibiotics can cause.  Patients feel “cheated” when they don’t leave their doctor with a prescription, and only receive advice on how to feel better.  Frustrating, I’m certain, but we still do not have a cure for the common cold!  Doctors who prescribe antibiotics for every sniffle are just too lazy to discuss the downside of prescribing them, and would prefer to make their patients happy and get them out the door.  It takes much more “effort” and time for us to explain why an antibiotic is not appropriate than to just write out a prescription.  If you doctor ever tells you an antibiotic is not appropriate for your infection, be happy that you have one that still practices medicine properly!  Good doctor!  Nice Doctor!

Most supplements are a waste of money, or possibly even dangerous

I wrote a very exhaustive blog about herbal remedies (http://seussmd.wordpress.com/2010/07/18/the-herbal-minefield/).  Most are merely a waste of money, and will neither help you or harm you.  Some offer some minimal benefit.  Some are very beneficial.  Many are outright harmful.  Many have a multitude of interactions with each other or with prescription medications (this is the danger when a supplement contains dozens or possibly hundreds of chemicals, since it is not purified in any way).  All are harmful if they are used instead of seeing a doctor.  Do not self treat yourself with herbal products.  You are probably neither qualified to diagnose the problem, nor qualified to use the proper herbal remedy.  Honestly, most of the “doctor replacements” out there who prescribe with herbal remedies are not qualified to diagnose you either, though they may have an extensive knowledge of the herbal products they use.  There is no problem seeing them as a supplement to normal medical care from a licensed Medical Doctor or Osteopathic Physician, but do not use them as replacements!  I have had 2 patients in the last several months who caused themselves liver damage with herbal supplements (Valerian and Kava Kava); thankfully they recovered after stopping the supplements.  I had one patient who fell prey to a “Holistic Health Center” who sold her $1200 worth of supplements, based on suspect blood tests that no doctor would condone.  As PT Barnum once said, “There is a sucker born every minute”.

Please take your medicine

Medical non-compliance is one of the toughest things doctors deal with in practice.  It is especially frustrating when the patient expects to be cured, but does not follow directions.  This happens more often than I care to admit.

“Mr. Smith, I see you are back today with diarrhea and abdominal pain.  I saw you in December and again in March for this same problem.  It’s now May and you have it again?  Did you see the gastroenterologist like I asked you to?”

“No Doc, I just haven’t had time.”

“Are you taking the medication I prescribed back in December?”

“Well I took a few doses and it seemed to help, but once it ran out, I didn’t fill it again.”

*Face Slap*

Unfortunately, sometimes the repercussions of non-compliance are much more serious than some diarrhea.  A very dear person, very close to me, recently had a stroke because they did not take their medication for very high blood pressure.  Their doctor did not make it clear to them what the repercussions of non-treatment might be, but the doctor did prescribe the medication and it is the responsibility of the patient to follow the directions of their physician or be prepared to deal with the consequences, and be responsible for them.  In her case, she had side effects from the medications which she didn’t care for, and stopped the medication.  She ought to have returned to her doctor to discuss other options, but this is a common tale!  If you cannot comply with the directions of your doctor, do not just stop treatment!  Please make an appointment with your doctor to find another treatment option.

We cannot cure all things

It is the 21st century, and many patients believe that we can cure nearly all that ails them with a simple pill, and diagnosis is as easy as passing a magic wand (or Tri-Corder) over their body.  Unfortunately, medical science is not perfect.  We cannot diagnose or treat everything.  Of the things we can treat, we may not be able to completely cure every problem.  Realistic expectations are something that were lost sometime in the last century.  If someone has used and abused their back for the last 50 years, and they come into my office with back pain and degenerative arthritis, they may have to accept that a certain amount of pain and disability will be present for the rest of their lives due to this wear-and-tear on their body.  We cannot turn the hands of time backwards!  Most patients come to realize this, but often not before much frustration and ire is directed towards his physician(s), either to their face or behind their back.  Trust me, we’re not holding back on you!  If there was a magic pill to fix what ails you, we would use it!

Research online, but do so carefully and only at respected web sites

Someone’s medical blog (including mine!) is not a “reputable” source of medical information!  I wrote a blog on critical thinking (http://seussmd.wordpress.com/2011/02/15/critical-thinking-a-lost-art-form/) as a lost art form, and it applies here.  Just because you read something on the internet, does not make it true.  Do not blindly Google the term “cancer cure” or “hypertension” and expect to get useful/reputable/reviewed information.  There are good web sites for medical information (which I will list in a moment).  If you do find something online which you think is applicable to you, print it out and bring it to your doctor!  If I had a dime for every time someone came in with internet-born medical misinformation….well….I’d have a lot of dimes!

www.cdc.gov (information on travel health, infectious diseases and preventive care)

www.fda.gov (for drug information)

www.medlineplus.gov (Diseases and conditions)

www.webmd.com (Diseases and conditions and medications)

www.cancer.gov (National Cancer Institute information about cancer)

Generic Medications almost always work as well as the higher priced brand name medications

There are rare exceptions to this rule, but almost all generic medications (made in the United States and filled through licensed pharmacies) have a very high quality control, and work identically to the much higher priced, brand-name medications.  Medications made overseas are beginning to become problematic, although ones which are proven to come from Canada are probably still ok.  There are counterfeit medications flooding the market, usually through internet drug providers, and these medications may contain little or none of the active ingredients.  The TV program 60 Minutes did an program on this very recently.  There are also a few drugs, which are prescribed in tiny little doses (micrograms instead of milligrams, or very few milligrams) where even a small difference in the dose can lead to dramatic overdose or underdose!  It hardly matters if your allergy pill contains 180mg of Allegra or 184mg, but it can be very bad if your blood thinner contains 2mg of warfarin or 2.5mg!  So, for drugs where accuracy is important, or the doses are very small, your doctor may elect to only allow the brand name medication to be used.

Fevers are not ordinarily harmful

This is a common problem, especially in pediatrics.  Mothers see that their child has a fever and rush for the bottle of Children’s Tylenol or Motrin.  I don’t blame them!  We love our kids and we are very protective of them, especially when they are sick.  The fact is, that fevers are part of the natural immune response against infection.  Unless the fever is very high (i.e. 104+) there is little harm being done, and possibly the fever is helping to kill the infection!  Certainly, fever can make people feel pretty crappy, especially kids.  It is not harmful in these cases, to treat the fever to make them feel better.  However, if the person feels ok with the fever, it is probably ok to just let it be!  The exception to this rule is a fever in a child less than 3 months of age or anyone who is taking medications which suppress the immune system.  For these two sets of people, fever can be a sign of very serious disease and that patient should see a doctor quickly.  Fevers that do not go away within a few days should also probably be evaluated by your physician.

Our work does not end when we walk out of the exam room, nor did it begin when we walked in

Most good doctors will review the chart for a few minutes before they come into the room to see you, to re-familiarize themselves with your case.  If consults were obtained with sub-specialists, we read those carefully, which can often take 5-10 minutes.  Once we leave the room, we must carefully document the entire encounter.  For me, it usually takes between 3 and 10 minutes to complete the chart after we see you.  If tests were ordered, we have to evaluate them when they come back.  If they are normal, this may only take 3-4 minutes.  If they are abnormal, it can take 5-15 minutes, especially if we have to look something up to properly evaluate the results.  If we must communicate the results to you, we either write a note on the results and mail them off to you (all patients in my office get a hard copy of every test we order sent to them in the mail with my comments on each test) or if the results are complicated we call you.  This runs between 3 minutes (easy notes) to 15+ minutes for a complex phone call.  If you see another doctor and they call to discuss your case, this can take another 5-20 minutes of our time.  Now add up all that time for every patient we see every day.  Your 15 minute time slot seems a lot bigger now, doesn’t it?  Much like an iceberg, most of our time on your case can’t be seen!

“My doctor never calls me back”

A busy doctor may easily receive 20 or 30 phone calls each day, sometimes more, especially if they have a busy practice in nursing homes or if they have several patients in the hospital at the time.  If your doctor spent even 5 minutes returning each phone call, he would have to add 100-150 minutes to his day.  And, truthfully, we all know that not even one of those phone calls is actually likely to take him less than 5 minutes from beginning to end (including documenting the phone call in the chart afterwards).  Doctors must come up with ways to ensure that your issues are dealt with, without spending 3+ hours on the phone every day.  Allowing the front office and nurses to deal with some of the issues is one answer.  Having them ask the doctor about the phone call between patients, then calling the patient back with an answer is another.  If the problem is too complex, they will either ask you to make an appointment if that is appropriate, or the doctor will call you back himself.  Now, if you are calling your doctor’s office and no one is calling you back at all….then you have a good reason to complain!  Don’t put up with that!

Respect is a Two-Way Street

It is assumed that your doctor will be professional and courteous with you.  If he/she isn’t, find a new one.  But that street goes both ways.  The following is a short list of things that happen every day, but ought not, if patients were likewise courteous:

• If you have an appointment, please show up.  ”No Shows” are not only discourteous, they are financially ruinous.  The empty time in our schedule cannot be replaced, ever, when you just don’t show up.  Many offices, mine included, will charge you a fee if you do not show up.  Our office gives you “Three Strikes”, then you are charged for every No-Show without 24 hours notice.
• Please show up to your appointment on time.  The #1 reason (by far) that doctors run behind on their schedules is because patients show up late and expect to be seen.  If someone shows up 10 minutes late, and the doctor sees them anyway and spends the usual and customary time with them, he is now 10 minutes behind for the rest of the day.  Every single patient behind them will be seen 10 minutes late.  If two people show up 10 minutes late, the doctor is now 20 minutes behind for everyone else…including the ones that were kind enough to show up on time!  If a patient is given the 2:00 – 2:15 appointment slot, and they show up at 2:15, ought the person scheduled at 2:15 have to wait for them, and every patient after that?  At my office, we don’t think it is appropriate for a single patient to decimate the schedule for everyone who was courteous enough to show up on time.  If you show up more than 15 minutes late to your appointment, we will not see you.  You are welcome to wait until I might have an opening in my schedule, or you are free to reschedule (later in the same day if available), but we do not allow the tardy patient to delay the on-time ones!  Funny, once this happens to a patient once or twice, they show up on-time after that!
• Do not call after hours for anything other than emergencies.  Doctors have lives as well.  Doctors like to eat dinner with their families, go to movies or plays, go golfing, and all the other things “normal people” do.  If they are being paged in the middle of the movie, it pretty much ruins the movie while they get up, leave, answer the page and come back.  So, if it can wait until the next business day…then it ought to.  Actually, almost all of my patients are very good about this, but there are always a few that will call you at 10pm to refill their prescriptions over the phone.
• Pay your physician promptly.  We are amongst the few professions that bills for our services after the fact.  Your plumber would demand payment immediately and you wouldn’t think twice about paying him, yet my office always has folks who take months to pay their bills.  Doctors are not in the business of offering lines of credit, and if you don’t pay promptly, they are essentially giving you a 0% interest loan.  This backlog of collections can actually make it impossible for a small office to function.

The “Oh, by the way…” or The Long List

When patients make an appointment, they are always asked what the appointment is about.  This is done for a couple reasons.  The first reason is so that the doctor can prepare for your visit by reading your chart with an eye for things that might be causing the problem.   The other is so that the receptionist can estimate how much time will be required to take care of your problems.  If you state that you want to talk about your allergies, and nothing else, they will probably put you into the schedule for a standard 15 minute appointment (even shorter in some offices!  I have seen appointment slots as short as 5 minutes in some offices).  Many patients then think, “As long as I’m here, I might as well ask him about these other things”.  Doh!  You have been given a 15 minute appointment slot, which is not enough time to take care of more than 1 or 2 issues.  Some patients actually walk into the office with a list of 10 or 12 things, even though they only mentioned one when they made the appointment.  Be prepared for the doctor to only be able to handle 2 or 3, then ask you to make a follow-up appointment to deal with the other issues in a longer time frame.  Remember that problem with doctors running late?  Late patients were the #1 cause?  This is the 2nd most common cause of doctors running late.

Anecdotal Information

I wrote a blog on Critical Thinking (http://seussmd.wordpress.com/2011/02/15/critical-thinking-a-lost-art-form/) which explains this more completely.  Doctors make decisions based on large amounts of data from well constructed studies that are designed to provide overwhelming evidence that the treatment provides benefit which outweighs the risks.  This is called Evidence Based Medicine.  Often, patients will not follow the advice of their doctor based on a single circumstance they happened to witness; an exception to the rule.  My adage is “There are exceptions to all rules, but do not make your rules by the exceptions”.  Perhaps your doctor has prescribed a medication for you to lower your cholesterol, which is very high.  This medication has been shown, in very large and well-designed trials, to lower your risk of heart attack or stroke by 50%.  When you get home, you call your best friend and tell her about your new medicine.  She tells you that she took the same medication but it inflamed her liver and she had to stop it.  This frightens you, even though your doctor warned you that it was a rare side effect of the medicine.  You decide not to take it.  Does this thinking process sound familiar?  This kind of thinking process is the bane of physicians everywhere.  It is sometimes very hard to convince patients that the experience of thousands of patients is more important than the experience of one patient that they happen to know.

Doctors are not insurance experts

There are thousands of insurance plans in the state of Illinois alone.  Thousands.  There is no way we can know what plan covers what.  It would take 1 or 2 full time employees to keep abreast of every plan, especially when they will often change without much warning.  It is the responsibility of the patient to know (or find out) what is covered by their plan.  If your doctor orders a test, medication or therapy and you are not certain if it is covered, then find out before you undergo the test, take the medication or get the therapy!  All insurance plans have toll-free numbers you can call and ask if the proposed service will be a covered benefit.  Piece of cake, really, but patients still become angry when they find out that their insurance plan didn’t cover the therapy which they undertook and they end up with a bill!  A little bit of due diligence, before or after the visit, can go a long way!

Primary Care doctors are working on very tight margins

It used to be that being a doctor meant you would work very hard in medical school, give up a decade or more of your life in hospitals for training, but at the end you would make a good living.  This is still true for sub-specialists.  Primary Care doctors are now so poorly reimbursed by insurance companies that our hourly wage is decidedly lower than most plumbers and many other skilled laborers.  How can this be?  The reimbursement for office visits is very low; the non-physicians who made up the reimbursement scales felt that procedures required more skill than brain-work.  Thus, I can spend an hour with a patient, sorting through dozens of medical problems, complex medical histories and a long list of medications; to finally come up with a complex treatment plan for 6 or more complicated medical issues.  The reimbursement for this work is less than the money a dermatologist receives for removing a two moles off your back; a 10 minute procedure requiring very little thought.  That is half the problem.  The other half is that the reimbursement rates are based on the Medicare Guidelines for reimbursement (which are very low).  Usually, private insurance will pay us 10-20% more than these very low rates and adjust whenever the Medicare rates adjust.  Since 1995, the reimbursement rates for primary care have remained flat and unchanged while inflation (at 3% yearly) has raised the cost of overhead and cost of living by 48%.  This represents, essentially, a 48% pay cut since 1995 for all specialties.  While sub-specialists operate at a profit far above their overhead, primary care doctors now have such narrow margins that their take-home pay has dropped to the point that trying to convince new doctors to choose primary care as a specialty is nearly impossible apart from doctors from foreign medical schools that may not have any other option.  When you toss in the gargantuan costs of medical school….well…you see the picture!  I still drive my 11 year old Toyota Camry.

By Apollo the Physician…

I have the privilege of being a doctor.  It is an occupation which represents a time-honored trust between physician and patient.  In no other occupation does someone tell a stranger their innermost secrets and trust them with their very lives, on a daily basis.  It is a responsibility that doctors take very seriously.  The reputation of physicians has been tarnished somewhat in this age of the corporate takeover of medical care.  The almighty dollar has taken precedence over the doctor-patient relationship.  For this, I am sorry beyond my ability to express.  This is not the medical system I entered into when I started medical school in 1988, and I hope it is not the one I am practicing in when 2018 rolls around.  I am honored to practice medicine.  I am honored to work amongst some of the brightest and most caring people I will ever meet, anywhere.  While the medical establishment may have critical flaws in it, the doctors who participate in the care of patients are largely a group of caring and skilled human beings.  Please remember…they are human beings.  Just like you.

Good Health!

Dr Mike

So, when is it showing?  I’m glad I asked!!

The schedule for when the show will be televised is below.  You will have to figure out which region you are in.  After that, you can watch…laugh…cry…as long as you are entertained!

SKOKIE(Channel 35)*

March 17, Thursday, @7:30pm

March 24, Thursday, @7:30pm

*SKOKIE includes Arlington Heights, Bartlett, Des Plaines,Glenview, Golf, Hanover Park, Mt. Prospect, Northbrook,Park Ridge, Prospect Heights, Schaumburg, Streamwood,Wheeling.

SKOKIE(Channel 19)*

March 17, Thursday, @7:30pm

March 24, Thursday, @7:30pm

*SKOKIE includes Buffalo Grove, Elk Grove Village, Hoffman Estates,Inverness, Lincolnwood, Maine Township, Morton Grove, New Trier Township,Niles,  Northfield, Northfield Township, Palatine, Rolling Meadows, Wilmette.

EVANSTON(CHANNEL 6)

March 7, Monday, @5pm

March 10, Thursday, @5pm

March 14, Monday, @5pm

March 17, Thursday, @5pm

HIGHLAND PARK*(Channel 19)*

March 7, Monday, @6:30pm

March 9, Wednesday, @11am

March 14, Monday, @6:30pm

March 16, Wednesday, @11am

*HIGHLAND PARK includes Deerfield, Glencoe, Winnetka.

ELMHURST(Channel 19)*

March 8, Tuesday, @7pm

March 15, Tuesday, @7pm

*ELMHURST includes Bedford Park, Bellwood, Bensenville, Berkeley,Berwyn, Bloomingdale, Bridgeview, Broadview, Brookfield, Burbank,Burr Ridge, Carol Stream, Cicero, Clarendon Hills, Countryside, Darien,Downers Grove, Elmwood Park, Forest Park, Forest View, Franklin Park,Glendale Heights, Harwood Heights, Hillside, Hinsdale, Hodgkins,Indian Head Park, Itasca, Justice, La Grange, La Grange Park, Leyden Township,Lombard, Lyons, Lyons Township, Maywood, McCook, Melrose Park, Norridge,North Riverside, Northlake, Oak Brook,  Oak Park, Oakbrook Terrace, Proviso Township, River Forest, River Grove, Riverside, Roselle, Rosemont, Schiller Park,Stickney, Stickney Township, Stone Park, Summit, Villa Park, Westchester,Western Springs, Westmont, Willow Springs, Willowbrook, Wood Dale,Woodridge.

- Dr Michael Unger

What is critical thinking?  I’m glad I asked!

Critical Thinking, in its broadest sense, is purposeful reflective judgment concerning what to believe or what to do.  Critical thinking clarifies goals, examines assumptions, discerns hidden values, evaluates evidence, accomplishes actions, and assesses conclusions.

There is very little critical thinking that occurs amongst most people in the United States.  It is a skill which is no longer being taught, except in advanced science curricula, and this inability to assess information in a valid way is undermining huge swaths of the American World.  We lack the ability to make “sense” out of information, or even to assess if the information we are reading makes “sense” in the first place.  The result is that when someone reads something in print, or hears it on the television, most Americans take it as fact.  They accept it on face value.  They assume that someone ELSE did the critical thinking for them, and would not allow such things to be printed or said if they were not true.  Sadly, this is not the case.

Some examples might be helpful?  How about a simple one…

Some months ago, a smoke plume was seen across the ocean off the coast of Los Angeles.  Glen Beck got on the air and declared that a Chinese submarine had test fired a missile in American airspace.  True?  Of course not, but millions of Glen Beck followers believed it without a second thought.  Individuals with even a hint of common sense in them would have thought, critically, “that just doesn’t seem likely”.  After all, test firing a ballistic missile in our airspace would be an act of war.  The diplomatic repercussions alone would have been devastating to China, across the planet.  Doing so would have served no useful purpose but to anger the entire planet.  This simple step of critical thinking was not performed by millions of people who believed, en mass, that the Chinese had indeed fired a missile in our air space.  This created fear, unnecessarily, which was Glen Beck’s chief motivation in the first place.  I think most people can see where critical thinking should have applied here.

How about a more complicated one?

Your doctor has prescribed a medication for you to lower your cholesterol, which is very high.  This medication has been shown, in very large and well-designed trials, to lower your risk of heart attack or stroke by 50%.  When you get home, you call your best friend and tell her about your new medicine.  She tells you that she took the same medication but it inflamed her liver and she had to stop it.  This frightens you, even though your doctor warned you that it was a rare side effect of the medicine.  You decide not to take it.  Does this thinking process sound familiar?  Perhaps this one is even more familiar:  Your doctor recommends that you take a baby aspirin every day, to prevent heart attacks.  You don’t tell your doctor, but your dad had a heart attack and he took aspirin every day of his life!  You don’t think it works, so you don’t take it.  After all, your mom never took aspirin and she never had a heart attack!  Or, how about this one?  Your doctor tells you to get a colonoscopy to screen for colon cancer.  You decide not to do it, because your uncle got one and had a lot of bleeding afterwards, and after all, no one in your family has ever had colon cancer.  You also know your neighbor got colon cancer even when he had his colonoscopy.  It must not work.

All of these examples are called “Anecdotal Data” and they are the scourge of physicians/scientists everywhere.  It harkens back to the quote I placed at the beginning of this article.  There are, of course, exceptions to all rules.  It is a catastrophic mistake to allow those exceptions to become your guiding influence.  After all, they are called “exceptions” for a reason!  Personal experience and anecdotes ought never be the guiding influence when it comes to critical decision making.  The experiences of 10,000+ people (or millions of people…) over many years are much more likely to predict your experience than the experience of a single random individual.  This type of non-critical decision making is actually so common in the real world, that it is a constant uphill battle for physicians to oppose such influences.  It is also a constant uphill battle in other arenas such as politics, where candidates can sling lies and partial truths at voters, in an effort to sway their opinion.  Even though I am a very moderate, middle-of-the-road individual when it comes to politics, I have become angered beyond indignation at the recent ploys of the Republican Party, as they use lies, partial truths and a manipulation of true facts as their chief weapons since the 2008 elections.  It offends me, as a seeker of truth, that such things can occur without the righteous indignation of the people.  But, sadly, the people don’t even know they are being served up lies, as truth; for they do not think critically.  They do not think to even doubt what is being told to them, either in print, in commercials or in speeches.

Thomas Jefferson once said that the purpose of education was to create an informed electorate.  I believe that the American Educational System has failed us on a mammoth scale, in this regard.  I believe the most important tool that education can give a child before he graduates high school, is the ability to think critically.  The ability to collate through information, asses the truth of that information, and formulate an informed opinion.  Everyone has opinions these days.  Very few of them are informed opinions.  I do not mind if someone has a difference of opinion.  In fact, I welcome it.  I mind, very much, if someone has a difference of opinion which is based on something other than the fact and truth of the matter.  If someone tells me they don’t like Barack Obama because he raised their taxes, I fume.  This is a common thing I hear, because the republican party has said it so many times.  However, it’s not true.  98% of americans (that is a real number) got a tax BREAK under Obama, yet most americans believe what they have heard from the republicans because it’s an easy way to generate ill will towards a standing democratic president.

When lies, deceit and partial truths are the best way to make progress in this country, we have already lost the most important battle.  Honest and impartial debate, based on the objective facts, lead towards decisions which are validated in reality and are much more likely to lead to good results.  This may sound obvious, but it is not the way the world is spinning at the moment.

I encourage everyone to screen all information with a critical eye.  Do not accept information, from any source, without evaluating it for yourself.  Does it make sense?  Is the source reliable?  Does the source have a vested interest in making you believe what they are presenting as fact?

I encourage everyone to get their information online from reputable sources.  Do not read someone’s random blog to find out if some new herb will cure your cancer.  Go to WebMD, or the National Institute of Health or the medical site of the Mayo Clinic or Johns Hopkins.  Don’t even believe me, if you think what I am writing doesn’t make sense.  Find out for yourself.  Get the facts.  Always the facts.  Base your opinions on facts.  Just the facts, Ma’am.

Remember this…people will usually believe what validates their own view of the world (remember how hard it was for Galileo to convince the Christian World that the Earth was not the center of the universe?).  It is very hard work to make them believe the facts of a matter, if they do not correlate with their internal world view.  True objectivity is very rare, but make it a worthy goal for you and your children.

Good Health!

Dr Mike

The original article in the medical journal Lancet has been exposed as an intentional fraud.  The lead investigator was paid nearly 1 million dollars to “find” a connection between autism and the MMR vaccine, so that lawsuits could be brought to bear on the drug companies.

It was bad science from the outset.  Little did we know it was fraudulent science.  Intentional fraud.  A fraud against civilization and against the children of the world.  Irreparable harm has come of this, as hundreds of thousands (and possibly millions) of children have gone un-vaccinated, specifically because of this study.  A whole movement against vaccines derived from the evil of a single man.  The deaths of multitudes of children on the shoulders of this one greedy individual.  I hardly know how to react.  I am infuriated.  I am shocked.  I am relieved?

Relieved yes.  Because the vaccine naysayers do not have a single leg to stand on.  Not a single piece of scientific evidence now exists to connect vaccines to autism.  Perhaps we can put this dark era behind us, and continue down the road of an enlightened civilization.

It has always bothered me that ungrounded opinion, without a scrap of evidence, can exist in the same argument as solid scientific principle.  It has always bothered me that some people view scientific theory as mere opinion or hypothesis.  Perhaps they do not understand the process?  I think mostly that when these “theories” do not coincide with their internal framework of belief, their only options are to dismantle their framework or to not believe the theory.  It is easier to do the latter, especially if you don’t understand the mammoth undertaking required to bring a theory to fruition.  Decades of work by hundreds or thousands of brilliant individuals.  Tested.  Retested. From every point of view.  Such immense efforts finally brought to fruition; the efforts of our best minds, which can be cast aside by a couple famous naysayers. (cue:  Jenny McCarthy).

Unfortunately, when naysayers are given fuel (from dishonest scientists) or airtime (from whatever talk show Jenny might be on this week), it grants credence to their arguments.  What are people to believe?  They want to protect their children, and they are not equipped to make the decision themselves.  Who has the time to go to med school, just to decide whether or not to vaccine your kids?  I can see where the parent might be confused.

I beg you.  Plead with you. Please remember this one rational thought.  Recommendations made by large medical organizations such as the CDC (Center for Disease Control), the AAP (American Academy of Pediatrics) or the FDA (Food and Drug Administration) are made based on a rational and complete evaluation of all the available information.  Decisions made by brilliant people, based on brilliant work by other brilliant people.  Are they always right?  No.  Are they usually right?  Absolutely.  If you are going to base a decision based on the opinion of any organization, please follow the advice of these institutions and not Jenny McCarthy.  You can bet that when they are wrong, the CDC/AAP and FDA will immediately correct themselves.  The same cannot and will not be done by the groups that speak against these rational scientists and physicians.

Vaccine your kids.  Follow the advice of your doctor.  We will remain vigilant, hoping to ensure that our recommendations are always the best ones, and we will change those recommendations should evidence come to light that disproves us.  We are good that way.

A famous quote…

“Science – It works, Bitches”

Good Health!

Dr Mike

In my blog on Influenza (http://seussmd.wordpress.com/2010/10/04/influenza-the-flu/), I made some final “non-scientific” remarks, mentioning that I thought it was possible that the influenza vaccine might grant cross-protection with other strains of the flu virus.  As it turns out, I was right!  It’s always fun to be right, especially when people’s health is concerned!

Here is a link to the article (http://news.yahoo.com/s/nm/20110110/hl_nm/us_flu_vaccine), showing that some people who were infected with the H1N1 Swine flu now have “Super Antibodies” to many forms of influenza, including all of the forms from the last decade and the Super Flu Epidemic of the 1918 Flu and even one form of the H5N1 Avian flu!

This has led scientists to start working on a “Super Flu Vaccine” that might grant protection from all possible strains of the flu!

So, what is the take home message?  I’m glad I asked!

Get your Flu Shots.  They might just be the secret weapon against the big super flu epidemic of the future!

Good Health!

Dr Mike

So what preventive care should people get and when should they get it?

I’m glad I asked!

The list below is based on the most up-to-date recommendations from the U.S. Preventive Services Task Force.  For any particular preventive screening, they have established its usefulness and graded each on the following scale, which I will be referencing.  The web site (link at the bottom of the blog) has graded out preventive care procedures for, literally, hundreds, of possible interventions.  I am going to talk about the most important ones for the general person.  For people who are at high risk for certain other medical problems, it may well be that it behooves you to get preventive screening for that problem, while the general population would not benefit from it.

So why don’t we screen for everything?  I mean, if we can, shouldn’t we?  What is the harm of testing everyone for every conceivable medical problem?

Well, my friends, there are many many reasons why this is not done.

1.  Cost – We would bankrupt the system if we screened every single person for every disease, including diseases they are highly unlikely to ever even hear about!  Sure, there are people who absolutely need to be screened for Sickle Cell Anemia, but if we screened every person regardless of their risk, it would cost us hundreds of millions of dollars.

2. Outright harm – yes indeed.  Screening can hurt you!  How, you ask, incredulously?  If you screen a low risk population, then most of the positive test results will be false positives.  if you get a false positive, you will probably need follow-up testing to see if the screening test was real or not.  This can lead to dangerous outcomes.  I will give you 2 examples.  In the past, we used to give “The Executive Physical” which was titled after high-power male executives at large corporations.  This overly-complete exam usually included a stress test looking for heart disease.  When you do stress tests on people who are neither having symptoms of heart disease, nor have many risk factors, the majority of your positive stress tests end up being false positives.  Unfortunately, you cannot ignore a positive stress test (or only ignore it if you want to be sued to the moon when they have their heart attack!), so these people end up being referred for angiograms to see if they have real cardiac blockages.  Unfortunately, about 1 in every 200 people who get angiograms have some kind of substantial complication during the exam (i.e.  heart rhythm problems, puncture of the arteries or even death).  So….we were taking young and healthy executives and we were killing them!  Not so good, eh?  Another fine example is when the state of Illinois demanded that all people asking for a marriage license get tested for HIV.  You can tell that an illinois bureaucrat made that decision, and not a doctor!  Again, when you take a low risk population and screen them for a fairly rare disease, most of the positive results are false positives.  So what we had was thousands of people coming up with false positive HIV tests; all which required expensive follow-up testing to determine if the original test was accurate.  The costs alone were catastrophic, but worse still were the thousands of people who were literally freaking out, waiting for the results of their follow up testing, right before they were supposed to get married.  A few suicides later, the state of Illinois stopped the program!  As you can see, screening for everything in everyone can end badly!

3. Failure to help – in most cases, screening programs for rare or unusual diseases does not improve the mortality rate from the disease.  If it doesn’t grant some sort of survival benefit, there is rarely a reason to screen!  This argument is the one that makes the general population angry and upset, since it is hard to understand.  It makes “sense” to screen all smokers with a Chest X-ray, looking for early lung cancer, but every study ever done on this program has shown that once we find a cancer on Chest X-ray, it is usually too far advanced to save them, or even help them to live longer.

4.  Low Yield – this is another common problem with screening tests that infuriates the public.  For example, recently, they determined that Mammographic Screening for women between the ages of 40 and 49 did not make sense.  The reason is that Breast Cancer is rare enough in women this age, that you have to do mammograms on tens of thousands of women in order to find enough early cancers to save the life of one woman.  The cost was $56,000 per year of life saved, in this age group.  For a 5-year survival (i.e. “cured”), this is $255,000 per life saved.  Despite the high costs, the public wants mammographic screening to be available to all women of these age groups; partly because Breast Cancer is very exposed in the press and it is the 2nd most common cancer killer in women.

Ok, so let’s talk about the screening that makes most sense, with some basic discussion!

Blood Pressure Screening

I wrote an entire blog on Hypertension, and I welcome you to go back into the archives and read it.  The short and snappy answer from the USPSTF (United States Preventive Services Task Force) is that all adults should be screened for high blood pressure at least every other year (if your blood pressure is “normal” on the first screening) or every year if it is borderline.  It grants blood pressure screening a GRADE A on the scale noted above.  It’s cheap, has no known complications and is saves lives in bucketloads.  The screening and treatment of hypertension is amongst the most cost effective preventive measures you can take!  Do it.  Do it now.

Pap Smears

Men, you can skip this one!

Pap Smears are done in order to screen women for Cervical Cancer.  It is amongst the best screening programs we have.  By this, we mean that it is cheap, saves lives and is relatively safe!  The recommendation is that all women have their first Pap Smear done within 3 years of becoming sexually active, or age 21, whichever one comes first.  Continued testing should be at least every 3 years as long as the results are negative, until age 65 (Grade A recommendation).  Continuing Pap Smears in low risk individuals after age 65 is a GRADE D recommendation.  Understand, that the recommendations of the USPSTF are not the same ones as your gynecologist will probably recommend.  They are absolute minimum recommendations based on cost/benefit analysis.  Most women, especially those who are not in continuing monogamous relationships, should probably get them yearly.  There will also always be a change as soon as you have a borderline or positive test; then you are no longer under the auspices of these guidelines!

Prostate Cancer Screening

This is much more controversial.  We do screening with the PSA (Prostate Specific Antigen) blood test every year beginning at age 40, and the rectal examination of the Prostate Gland yearly after age 50.  However, the data regarding the PSA test is murky at best (Class I) and the Rectal Examination has actually never been proven to save lives at all (Grade C).  The problem with the PSA test is that the false positive AND false negative rates are pretty high.  Thus, you can have a positive test and probably not have the disease, or you can have a negative test and still have prostate cancer!  Positive tests usually end up with prostate biopsies…a very unpleasant test with a small complication rate.  The rectal examination is still offered, as there were some studies showing that a combination of PSA testing plus rectal examination seemed to slightly increase the chance of survival.  It has also been a part of the exam of all men over the age of 50 for a long time, such that most men expect it and feel that doctors who do not do the test are shirking their duty!  I personally suggest getting the PSA test, with the full knowledge that it is imperfect, and allowing the doctor-patient relationship to do the rest when discussing what to do with the results.  The Task Force specifically states that patients over the age of 75, or men with a likely lifespan of less than 10 years, should not be screened.  In these populations, it is far more likely that they will die of something other than prostate cancer, even if it was discovered, since it is usually a slow growing cancer and many never spread.

Screening for Colon Cancer

This is the one I have a hard time selling to patients, even though it is a slam-dunk!  Colon Cancer screening can be done in several ways, but the highest grade is for Colonoscopy (a procedure where a fiber-optic camera is inserted through the rectum and pictures are taken of the entire colon.  Yes, you are sedated for the procedure!).  The best thing about colonoscopy is that if they find a pre-cancerous “polyp”, they can remove it right there on the spot!  It’s both screening and cure, in one fell swoop!  Screening colonoscopy for people age 50-75 is Grade A, ages 76-85 is Grade C and older than 85 is Grade D.  The first test should be at age 50, and the interval determined by what they find (usually anywhere from 2-10 years depending on the kinds of polyps they might find, or if they find nothing at all!).  Colonoscopy is an invasive procedure, so complications occur in 25 people out of every 10,000 (less than 1/3rd of 1%).  In the 15 years I have been a practicing, I have seen 1 complication from a screening colonoscopy.  Screening should occur at a younger age for people with colon cancer in their family.  There are alternatives to colonoscopy, but they are not as good.  Hemoccult Testing of the stool (looking for microscopic blood in the stool) has not been shown to improve mortality (i.e.  once a cancer is bleeding into your colon, it is usually too late) and is Class I.  CT Colonography has fewer risks (6 complications per 10,000 procedures) but you have to have follow up colonoscopy anyway if they find something!  And, they find “something” in 16% of all tests!  There is also radiation exposure from CT scans; enough to cause an one additional cancer of some type per 1000 people tested.  People can also screen themselves with a Barium Enema combined with a Flexible Sigmoidoscopy (a scope passed into the first 60cm of the colon from the rectum).  Doesn’t work as well, has a 3.4 in 10,000 complication rate…and you have to proceed to a full colonoscopy if they see something!  All in all, you are best off with the colonoscopy.  They are working on “Capsule Endoscopy” where you swallow the camera and they take pictures, but the data is not yet sufficient to make a recommendation.  However, again, if they see something you will need a colonoscopy anyway!

Screening for Osteoporosis

Screening for low bone density, or “osteoporosis” is done by performing a very low radiation test called a Dexascan.  There are ultrasound methods which look at your feet or fingers, but they do not work very well and are probably only good for screening high risk patients.  Current guidelines suggest that screening women over the age of 65 is a Grade B recommendation, as finding and treating asymptomatic osteoporosis does save lives (the average lifespan of a woman after her first hip fracture from a fall declines dramatically and is less than 1 year if they can’t fix it due to high surgical risk).  The real controversy is whether or not we should scan post-menopausal woman (age 50-ish to 60).  Screening in this age group is a Class C recommendation.  I recommend screening this lower age group in women who are at high risk (i.e. family history of osteoporosis or if they fit the “profile” for a woman who will get it:  Small, Caucasean/Asian, female.) or if they have other risk factors (steroid use, chemotherapy, malnutrition, vitamin D deficiency, alcoholism, drug abusers).  When to do follow-up screening is based on the findings at the first test.  Men over the age of 75 also can be considered for screening.

Breast Cancer Screening

Screening women, ages 50-74, for breast cancer is a Class B recommendation.  Screening before the age of 50 is a Class C recommendation.  Over the age of 75 is Class I.  The controversy about screening women age < 50 has been discussed earlier.  Interestingly, the Task Force recommends against (Grade D) teaching Breast Self Examination.  The data show that women who examine their own breasts are much more likely to find benign findings which require follow up testing (i.e.  mammograms, ultrasounds or biopsies) than findings of a malignancy.  Thus, the cost and suffering for these women is much higher, as well as exposure to interventions which might have complications.  Although I think it would be a hard sell to encourage doctors not to teach breast self-exam because of all the publicity it has been given, it may well be that it does more harm than good for most women.

Screening for High Cholesterol

Another slam dunk!

Testing people over the age of 35 is a Grade A recommendation.  No risk and tons of benefit.  We can prevent strokes and heart attacks and save lives by finding high cholesterol early and treating it.  I did an entire blog on high cholesterol, so please feel free to go back into the Archives and read more about it.  Testing people age 20-35 is a Grade B recommendation (Grade A if they have any other risk factors, such as a family history of high cholesterol or heart disease).  The task force actually did break down their recommendations into many sub-groups, dependent on risk, but it is far more complex than most people need to know.  That’s why you pay your doctor!

Vaccines

I did a huge blog about the benefit of vaccines so please read it (and there are several follow ups, but the original blog was one of my first ones), and the Task Force bows to the superior data and knowledge of the CDC when it comes to determining the benefit of vaccines (and even provide a link to the CDC page).

Summary:  Get your vaccines.  Get them all.  They extend lives and save lives more than every intervention listed in this blog, put together! Vaccinate yourself.  Vaccinate your family.  Vaccinate your children.  Listening to any other advice about this is a critical misrepresentation of the facts and medical knowledge.

The Yearly Physical

A lot of people do not get their yearly physical.  Again, they feel well, so they think it’s pointless!  The fact is that if you get your yearly physical, your doctor will do all of the preventive care we talked about in the paragraphs above!  There was a study that showed that people who got yearly physical exams from an Internist lived 7 years longer than people who did not.  There was some problem with this study, in that you could argue that people who get yearly physicals are more worried and involved with their healthcare in general!  All the same, the study did show a remarkable difference between people who saw their doctor yearly and those who did not.  Apart from cost, there can be no argument against it, so I certainly recommend a yearly physical for all patients 40 and older, and at least every other year for patients under the age of 40 who have no significant medical problems and take no medications on a regular basis.

Website for the United States Preventive Services Task Force:

http://www.uspreventiveservicestaskforce.org/recommendations.htm

Good Health!

Dr Mike

Don’t I sound proud?

I talked about Influenza!  I’m on a quest!  A Mission!  I will make sure that people are educated about the true nature of  ”The Flu” and will do my knightly best to get people vaccinated!  All I am missing is a Guinevere or a Dulcinea! 

If you read the blog about my experience with the taping of my first appearance, you may recall that while the interview eventually went well…there were some technical snafus at the onset which made the process much more time consuming.  Thankfully, this most recent experience was bereft of such obstacles and we managed to get the whole process done in less than 50 minutes.  Joy!  Rapture!

For those of you in deep need of comedic relief in your life, or if you would merely like to see your host LIVE on television, you can catch me on the show Contempo. It is a local cable show on the Comcast Cable Network, so much of northern Illinois will be able to see it.

When is it showing?  I’m glad I asked!  You can find the program channels and times, for each of the regions, in the list below!  (the formatting is not pretty, but I’m definitely too lazy to type the whole list, so i’ve  cut and pasted it, and the results were less than miraculous!).

Highland Park (Channel19)

*November 1, Monday, @6:30pmNovember 3 , Wednesday, @llamNovember 8, Monday, @6:30pmNovember 10, Wednesday, @llam  *Highland Park includes Deerfield, Highwood, and Winnetka.

Elmhurst(Channel 19)

*November 2, Tuesday, @7pmNovember 9, Tuesday, @7pm   * Elmhurst includes Bedford Park, Bellwood, Bensenville, Berkeley, Berwyn, Bloomingdale, Bridgeview, Broadview, Brookfield, Burbank, Burr Ridge, Carol Stream, Cicero, Clarendon Hills, Countryside, Darien, Downers Grove, Elmhurst, Elmwood Park, Forest Park, Forest View, Franklin Park, Glendale Heights, Harwood Heights, Hillside, Hinsdale, Hodgkins, Indian Head Park, Itasca, Justice, La Grange, La Grange Park, Leyden Township, Lombard, Lyons, Lyons Township, Maywood, McCook, Melrose Park, Norridge, North Riverside, Northlake, Oak Brook, Oakbrook Terrace, Oak Park, Proviso Township, River Forest, River Grove, Riverside, Roselle, Rosemont, Schiller Park, Stickney, Stickney Township, Stone Park, Summit, Villa Park, Westchester, Western Springs, Westmont, Willow Springs, Willowbrook, Wood Dale, and Woodridge.

Skokie(Channel35)

*November 4, Thursday, @7:30pmNovember 11, Thursday, @7:30pm  *Skokie includes Arlington Heights, Bartlett, Des Plaines, Glenview, Golf,Hanover Park, Mt. Prospect, Northbrook, Park Ridge, Prospect Heights,Schaumburg, Streamwood, and Wheeling.

Skokie(Channel 19)

*November 4, Thursday, @7:30pmNovember 11, Thursday, @7:30pm  *Skokie includes Buffalo Grove, Elk Grove Village,Hoffinan Estates,Inverness(parts), Lincolnwood, Maine Township, Morton Grove, New TrierTownship, Niles, Northfield, Northfield Township, Palatine, RollingMeadows, and Wilmette.

Evanston(Channel 6)

November 1, Monday, @5pm. November 4, Thursday, @5pm November 8, Monday, @5pm November 11, Thursday, @5pm

If I had a nickel for every time a patient walked into my office and said “I’ve got the flu”,….well…..err….well, I’d have a lot of nickels, that’s for sure!

So what is Influenza, really?  I’m glad I asked!

Well, let’s start with what it isn’t, shall we?

It’s not a diarrheal illness (i.e.  ”The Stomach Flu”).  Your flu shot is not going to prevent you from getting these gastrointestinal illnesses, which are correctly called “Gastroenteritis”.  When you get “The Runs”, it has nothing to do with any flu of any kind.  It’s a colloquial term which has misrepresented the illness on a goliath scale.

It’s not a bad cold, which is caused by a multitude of viruses.  Your flu shot is not going to stop you from getting the typical upper respiratory illnesses.  A lot of people think their flu shot “doesn’t work” because they still get sick over the winter.  The influenza vaccine only prevents influenza and nothing else.

So what is Influenza?

Influenza is a potentially life threatening acute respiratory illness, mainly caused by Influenza A or B viruses that occurs in outbreaks and epidemics worldwide, in the winter season.

You will notice that I put that sentence in bold font and italicized the words “respiratory illness”.  If you have an illness and there are no respiratory symptoms of any kind, you probably don’t have Influenza (although it is still possible).  You will also note that it says that Influenza is caused by 2 different viruses.  Remember that viruses are not affected in ANY way by antibiotics, so if you have Influenza, antibiotics are not going to help you.  We do have some anti-viral medications which are FDA approved to treat influenza but they don’t work very well (more on this later).

Symptoms

Influenza is dominated by respiratory symptoms, of the upper or lower respiratory tract, along with systemic signs of illness such as fever, headache, body aches (often severe) and weakness.  In my experience, fever, body aches and cough are present in nearly 100% of true influenza.

Risks

Influenza, although acutely debilitating, is almost always a self-limited illness (i.e.  it goes away on its own).  We call this “uncomplicated influenza” and is the typical influenza we see in most people.  However, in certain “at risk” populations (and sometimes even in healthy people), Influenza can be deadly.  The very young, the very old, people with chronic illnesses and people with underlying heart or lung problems (i.e.  heart disease, asthma, emphysema) can be killed by Influenza.

Between 25,000 and 35,000 people die every winter in the United States from Influenza.

That’s right.  People get all up in arms and talk about vaccinating the whole country from Anthrax, when 6 cases pop up in Washington D.C., but those same people won’t get a Flu Shot to prevent a real true killer.

Transmission

This is what makes Influenza deadly.  It is easily passed from one person to another, leading to wide outbreaks and epidemics.  Large amounts of Influenza Virus are present in respiratory secretions.  As a result, infection is easily transmitted through coughing, sneezing and talking.

The incubation period is about 1-2 days after exposure, then symptoms appear, sometimes abruptly.  Most people are sick for 2-5 days, although some people can be sick for a week or more.  Some people have persistent symptoms of weakness, or easily becoming tired, which is called “Post-Influenza Asthenia” and can last for several weeks.

Complications of Influenza

When the illness doesn’t proceed as noted in the paragraph above, it may be that the illness is “Complicated Influenza”.  The  major complication of Influenza is pneumonia, which occurs most frequently in certain groups with underlying chronic illnesses, or people in chronic care facilities (like nursing homes).  This pneumonia can be from the Influenza Virus itself, or a secondary bacterial invader (often a streptococcal or staphylococcal infection).  It is this pneumonia that is responsible for most Influenza deaths.

Sometimes, instead of the typical “muscle aches” associated with Influenza, a person will get a more severe invasion of the muscle tissue which actually begins to break down.  This is called Myositis or Rhabdomyolysis, and can be very dangerous.  When the muscle tissue breaks down, it releases certain substances into the bloodstream which can cause kidney failure.  Remember that the heart is a muscle and invasion of the heart muscle can be deadly in this regard.

Rarely, the virus can invade the brain and cause encephalitis, which can cause much debilitation or even death.

Diagnosis

So how do we diagnose influenza?

In most cases, we diagnose the illness based on the season, symptoms and an exam of the patient.  We call this a “Clinical Diagnosis” and does not require any special testing.  This is especially easy in the midst of an outbreak.  In some cases, where the diagnosis is less clear (or if the patient is hospitalized and severely ill), we can use a lab test to make the diagnoses.  Doctors have access to a rapid test which takes about 15 minutes, but these tests are often negative very early in the illness or late in the illness, when less of the virus is present.  There are more accurate tests available, but they take 1-2 days to get a result, which makes their usefulness minimal in an office situation (we use them in the hospital a lot).  When it is important to our treatment decisions, we order one of these tests.

Treatment

There are 2 drugs available which are active against both Influenza A and B.  They are called Zanamivir and Oseltamivir.  It should be understood that anti-viral medications are in their infancy, in the world of medicine, and do not obliterate the virus like anti-biotics do when we treat bacterial illness.

When initiated promptly, antiviral therapy can shorten the duration of symptoms by 1-3 days; the benefit is greatest when given within the first 24-30 hours and in patients with fever at initial presentation.  Little or no benefit has been demonstrated when treatment is initiated 2 days or more after the onset of illness. However, a patient survey found that only 13% of patients called their doctor within 48 hours of the onset of influenza-like symptoms!

Some studies have suggested that antiviral therapy reduces the severity and incidence of the complications of Influenza (noted above), the duration of hospitalization in patients with severe influenza and influenza-associated mortality.  However, there are currently insufficient data to reach firm conclusions about the ability of antiviral therapy to prevent influenza-associated complications, either in healthy adults or those at high risk.  One large analysis of the data did not detect a reduction in influenza-related respiratory complications in healthy adults.  Obviously, more studies are needed.  Also obviously, these antiviral medications do not work particularly well!!

Of course, these medications have their own litany of possible side effects, and they happen to be a little more prevalent than those we see with more typical antibiotics, so we tend to not overuse these medications unless we really think they are going to help!

Flu Shots

Since Influenza is a potentially lethal illness, it behooves us to vaccinate against it!

Thus, the CDC develops a Flu Vaccine each year.  Based on immunological and epidemiological data, they attempt to “guess” what strain of flu will dominate each season.  They then create a vaccine against the 2 or 3 most likely viruses.  Since they are more accurate in their guessing when they can observe the world for illness, and accumulate more data, they wait until the last minute to reach their conclusions, then the drug companies are forced to try to start growing the necessary cultures to make the flu shots.  Given this time pressure, and the complicated procedures required to manufacture safe vaccines in such short order, we are sometimes in short supply of flu shots!  The CDC is not always right in their guessing, to be sure, but given the difficult science involved, they are pretty damn good!

Flu shots are ordinarily distributed starting in October, to ensure that the body has a chance to respond to the vaccine and have antibodies available to fight the flu when flu-season strikes us (ordinarily December until April).  It takes a couple weeks for the body to develop a strong immune response, so try to get your shot before the end of the year if possible!!

Do they work?

Absolutely.  In most years, the vaccine is 80% or better to prevent influenza.  Also, those individuals who do happen to get their flu shot, and still get influenza, usually get a much more mild and short-lived version of the illness.

So who should get vaccinated?

Well, we used to advise vaccination only for individuals at risk for the serious complications of Influenza. As of 2010, the CDC now recommends universal vaccination of all individuals older than 6 months of age.

There are two vaccines.

The Nasal Spray Vaccine is approved for healthy people age 2-49 who are not pregnant.  Since the nasal spray vaccine uses a weakened but live influenza virus, it is possible to get a very weak case of the flu from the vaccine itself.  For people who are averse to needles, it may be a good option.  It is not an option for people with compromised immune systems, since the vaccine has a live virus in it.  Individuals who are getting chemotherapy (or in contact with such individuals) should not receive live virus vaccines.  The same goes for people with HIV or other immune-system disorders.

The regular flu “shot” is an inactivated virus so it cannot give you the flu under any circumstances.  Read that again because it’s a terrible piece of urban folklore that the flu shot will give you the flu.  It can’t.  It can give you a mild shot reaction which can include soreness at the injection site with a low grade fever, but it can’t give you influenza.  If you happen to get sick after you get your flu shot, it is likely just bad luck and a coincidence.  Flu shots CAN give you vaccine-related side effects, but they do not include the flu!  I will include a link to the CDC website on influenza for those who want more information!

Ok, so everyone should get vaccinated.  There will always be people who are thinking they would rather skip the vaccine.  Usually I hear, “I never get the flu, doc!” or they just don’t like needles!  Firstly, I want to encourage you to get vaccinated anyway.  Even if you don’t save your own life, maybe you will save someone else’s life!  Its possible, even likely, that if you get the flu, you might give it to someone else who may not have your killer immune system!  I’m sure you would feel terrible if you gave flu to someone who died from it!  If that little guilt trip wasn’t sufficient to convince you (shame on you!), then remember that the following is a list of people who really absolutely positively have to be vaccinated:

1. Pregnant women
2. Children younger than 5, but especially children younger than 2 years old
3. People 50 years of age and older
4. People of any age with certain chronic medical conditions
5. People who live in nursing homes and other long-term care facilities
6. People who live with or care for those at high risk for complications from flu, including:
   1. Health care workers
   2. Household contacts of persons at high risk for complications from the flu
   3. Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

This list includes the people who are at high risk of flu complications.  They are at high risk of becoming one of the 25,000-35,000 people who die every winter in this country from influenza.

As I mentioned at the beginning of this article, the flu vaccine is not going to prevent you from getting sick this winter.  You will still get all the usual colds and runny noses you would get ordinarily.  It will not prevent “The Stomach Flu” which really isn’t a flu at all.  It only prevents true Influenza.  That’s enough though since real influenza is a real killer.

For those who wonder, the H1N1 virus is one of the three in the seasonal flu vaccine being given this year.  I wrote an entire article about H1N1 earlier this year, so feel free to head back into the archives and read that as well if you wish!

Some Non-Scientific Reasons to get Vaccinated

I am straying from the tried, true and scientifically proven road of medicine, just for a moment.

In the world we live in today, the threat of a true influenza pandemic (an epidemic that is on all the major continents of the planet) is very high.  We see true pandemics every so often and we are well overdue for a good one.  The H1N1 Pandemic ended up being overblown; not because it wasn’t a wide spread illness but because it wasn’t as lethal as most flu viruses.

It makes some sense that if one gets a flu vaccine very year, which protects you from 3 flu strains, you will build up immunity against a wide variety of influenza over time.  I have been vaccinated for flu every year for about 25 years, so i have antibodies against at least 75 strains of influenza.  When the big pandemic hits, my immune system may have some antibodies that have some defensive activity against the killer strain that will hit us (not if….but when…).  While this is not as scientific as my brain would ordinarily like, it seems to be that getting regular vaccines may provide some protection against closely related strains as well…perhaps granting me partial protection against hundreds of other related influenza strains.  When the killer pandemic hits, it may be that people who were regularly vaccinated against flu will have some immunity, and be spared the more severe illness.

It’s worth thinking about!

Good Health!

Dr Mike

The CDC Website link on Influenza:  http://www.cdc.gov/flu/protect/keyfacts.htm