September 21, 2013
Do Patients Need More than Six Minutes with the Doctor?

I recently came across some unsettling advice given to doctors by a practice management consultant.  In order to improve a practice’s income the expert suggests, “…[P]hysicians can easily move from seeing six patients per hour to 10 by socializing less.”

Something about this opinion was deeply disturbing to me.  Patients already feel like they wait too long and pay too much to see providers they don’t really know.  How can further reducing a patient’s time with the physician be considered an improvement?

Further choking off the already limited time available for doctors and patients to get to know each other, and thereby eroding the therapeutic relationship, is a threat to the very heart of medicine.  It is a grave mistake to suggest that private conversation between patient and provider is mere “small talk” and somehow a waste of time.

People, not mere organs or inanimate machines, have medical problems.  It is people who get diabetes, cancer, heart attacks, infections, and broken bones.  These people have families, jobs, responsibilities, and future plans, all of which affect the success or failure of treatment.  Decades of research show that clinics, hospitals, and providers who miss this point have worse outcomes.  Good medical care requires a therapeutic understanding of all the sources of strength and stress in a patient’s life.  Gaining this level of understanding requires time.

A doctor who sees 10 patients an hour must see a new patient every six minutes.  This is of course impossible to pull off without help.  Despite advances in medical technology, including machines that provide immediate results, the timeless medical acts of listening to a patient’s experience, performing an exam, developing a treatment plan, and writing prescriptions takes the same amount of time as it did a hundred years ago.  The stethoscopes today do not listen any faster and the blood pressure cuffs, even blood pressure machines, do not work any faster than they did for our grandparents’ doctor.

The modern answer has been to relegate the time-consuming acts in a medical encounter to support staff.  Medical assistants take vital signs, nurses take the history, and scribes record the doctor’s prescriptive plan in an electronic record.  The doctor only needs to be present for a focused exam (takes about 2 minutes) followed by a brief discussion of the diagnosis and treatment, adding up to about six minutes.

The primary reason for this phenomenon is economic, not medical.  Healthcare has become big business.  And in this business of medicine the primary commodity being exchanged is the patient.  More patients through the system means more revenue for the facility.

Money exchanges hands whenever you see the doctor.  Your very presence in the clinic generates income for a team of administrators, case-managers, coders, billers, and support staff.  This money is further siphoned off by insurance companies, government regulators, medical supply companies, and pharmaceutical companies.  Only about $0.28 of every dollar spent for your healthcare actually goes to pay for the care you receive from the doctor.  The rest goes to pay for the facility, staff, tests, and endless stream of other interested parties.

The doctor-patient relationship, which was once very private, is now better described as a medical home.  Every visit in this home requires contact with an extended family of caregivers, each generating an additional charge, and each replacing the time that used to be spent personally with the doctor.

Of course you, the patient, pay for these extra services.  First you pay higher premiums to your insurance company, or receive lower wages when your employer pays for your insurance, and then you pay higher co-pays for the limited time with your doctor.  Even when the money does not come out of your own pocket you end up paying more with your time by waiting longer to see a provider as medical facilities try to cover overhead costs by squeezing in more patients per hour.

The casualty of this trend has been an erosion of the time available to foster a doctor-patient relationship.

But society has an interest, if not a responsibility, to guard the integrity of the doctor-patient relationship.  Research over the last half-century shows that when patients are granted meaningful time with their doctor, health care outcomes improve, medical error rates fall, fewer unnecessary medications or tests are ordered, and doctor satisfaction rates improve. 

This last point is important for small communities that are struggling to recruit permanent doctors from an ever-dwindling pool of primary care providers.  Over 30 years ago, researchers found that a primary source of physician satisfaction was the positive relationships with patients, not income.  And the primary source of dissatisfaction was “time pressure.”

One of my favorite Norman Rockwell paintings is the 1929 “Doctor and Doll.”  It depicts a caring physician taking time to listen to the heart of a treasured doll held by a concerned little girl.  I strategically hung a copy of this painting in my clinic.  To me it is more significant than my medical school diploma.  My diploma shows what I should know.  The Rockwell painting shows who I should be.  For in that painting Rockwell shows that a doctor is closest the heart of medicine when he or she has time to listen to what matters most to the patient.  In my experience, listening to what is most important to patients often takes more than six minutes.

image

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

January 22, 2012
FDA Advisors Warn Birth Control Pill Increases Risk for Blood Clots

Hormonal contraceptives, commonly called birth control pills, made news recently when an FDA advisory board released a report on whether several forms of the medication should be labeled as safe for general use.

The FDA advisory committee recommendations are important, not only for women hoping to avoid pregnancy, but for the many young women who are prescribed hormonal therapy for reasons other than contraception.  

Doctors may prescribe hormones to treat severe acne, dysfunctional uterine bleeding, or premenstrual dysphoric disorder (monthly physical or emotional problems preceding a menstrual period).

The FDA advisors are concerned about the risk of blood clots in people using hormonal birth control. 

Hormonal contraceptives are known to increase a person’s risk of life-threatening blood clots, called venous thromboembolism (VTE).   The risk is even higher for people taking a newer hormone called drospirenone found in birth control pills like Yaz or Yasmine.   While a blood clot forming in a non-pregnant, overall healthy young woman is a rare event, when clots do occur, studies show that 90% of all events are associated with hormone contraceptive use.

Furthermore, smoking, obesity, and diabetes increase a person’s risk of an adverse cardiovascular event while taking hormonal contraceptives.  

Smoking is especially risky when taking hormone therapy.   Eighty to ninety-seven percent of fatal heart attacks and strokes in women under age 44 are associated with a combination of hormone therapy and tobacco use.  For this reason, many doctors will not prescribe hormonal contraceptives to women who smoke.

Venous thromboemolisms (VTE) associated with hormonal contraceptives tend to form in the deep veins of the legs often causing pain and swelling of the affected limb.   Clots in the leg can break free and become lodged again in the lung.  A sudden clot in the lung, called a pulmonary embolism, causes chest pain and shortness of breath, or a life-threatening inability to get oxygen to the bloodstream.  

After reviewing available studies, the FDA’s Advisory Committee for Reproductive Health Drugs and Drug Safety and Risk Management recognized the increased risk of VTE, but the committee voted to recommend that the FDA allow hormonal medications, like drospirenone-containing pills or the hormonal patch, to be prescribed stating that the benefits of the medication outweigh the risks.

The advisory panel also recommended that these hormonal contraceptives should include a stern warning regarding the increased risk of a life-threatening venous thromboembolism. 

Women prescribed hormonal contraceptives, including the hormones contained in a birth control pill, a patch, an injection, an intrauterine device, or vaginal ring, should speak with their physicians regarding the risks and benefits of hormone therapy.  

Patients with known cardiovascular disease or conditions that increase the risk of a blood clot, or venous thromboemolism (VTE), should not use any form of hormonal contraceptive.  Conditions that increase a person’s risk of VTE include smoking, cancer, recent major surgery, extensive airline travel, poorly controlled diabetes mellitus, clotting disorders, or a personal or family history of blood clots in the past.

  

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

August 5, 2011
Do You Have Barometric Bones? The Effects of Weather on Joint Pain

People with arthritis or other pain syndromes often complain that their pain is worsened with certain types of weather. Some people even claim to have barometric bones, the ability to predict an approaching weather change by a worsening of joint pain and stiffness.

Is there any scientific evidence to support this common phenomenon? There is plenty of anecdotal evidence.

As early as 400 B.C., ancient Greek and Roman doctors noted that many illnesses were related to changes in the seasons. This led to common phrases like “feeling under the weather.”

By 1930, the Journal of the American Medical Association (JAMA) reported that there was strong evidence that warm weather was beneficial while low barometric pressure was detrimental to patients with arthritis.

Doctors continue to recognize the effects of weather changes, but they have a hard time experimentally testing these effects because it is next to impossible to replicate a weather system in the laboratory. In 1961, an arthritis specialist named Hollander tried. Dr. Hollander designed a pressure chamber to manipulate the barometric pressure and humidity in an attempt to test how these weather factors affect a person with arthritis. His study found that arthritis patients reported more pain with both increased humidity and a falling barometric pressure only when these factors occur simultaneously.

Since then, many studies have found that patients with osteoarthritis, rheumatoid arthritis, and fibromyalgia experience increased pain with weather changes.

Temperature, barometric pressure, humidity, and precipitation all prove to have some effect on the perception of painful or stiff joints. However, the type of weather that causes the exacerbation of pain is not the same for every patient. One person may find that wet, rainy weather associated with low barometric pressure makes the joints ache while another person hurts worse when the weather becomes hot and dry under the influence of a high pressure system.

Changes in weather, not a specific type of weather, seem to be the consistent trigger for most people with arthritis.

Research shows that people with back pain have the greatest sensitivity to weather changes followed by people with pain the in arms and wrists. Weather has the weakest effect on people with fibromyalgia or temporomandibular joint (TMJ) pain.

While it may not be scientifically possible to use arthritis pain to predict the weather, some meteorologists use the weather to make the reverse, and likely more helpful prediction regarding the risk of having a flare of pain due to weather changes.

Popular weather sources like Accuweather (accuweather.com) and the Weather Channel (weather.com) now provide an “aches and pains” forecast. According to these sites, the weather outlook can be used to predict a flare of arthritis. I suspect readers with barometric bones could have predicted as much.

  

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

June 23, 2011
Decline in Salmon Runs Linked to Decline in Health

The North Pacific Fishery Management Council met in Nome recently.  Much of their work focused on the economic tension between the deep-sea pollock fishing industry, which has been shown to interfere with salmon migrating patterns, and local communities who depend on good salmon returns for food. 

Many of the topics discussed would seem foreign, if not irrelevant to the average person.  As I sat through a few of the sessions, however, it struck me that the decisions being made by this body would have a tremendous impact, not merely on the economics of the region, but on the very health of every person living in the Norton Sound region.

Here is why.  The people of the United States are in the midst of a cardiovascular disease epidemic.  Unlike infectious disease epidemics that come and are quickly controlled, the current epidemic of cardiovascular disease is occurring in three destructive waves that so far do not recede, nor do they show any signs of doing so.  The first wave is obesity, followed by a rise in Diabetes Mellitus, followed subsequently by an exponential rise in cardiovascular disease. 

In the U.S., this tsunami was once a forecast; it is now a reality.  Unless positive changes are made, within ten years, 52% of the U.S. population will have diabetes or pre-diabetes (which is just diabetes in its earliest and most treatable form) at an estimated cost of over $13,000 per year per person afflicted.   Once diagnosed, people will spend most of their spare time and money trying to prevent the dreaded complications of heart disease, stroke, kidney failure, and blindness.

In rural Alaska the statistics are even more alarming.  Where as the U.S. as a whole saw a 93% rise in the prevalence of diabetes mellitus between 1990 and 2006, the Norton Sound Region experienced a 233% increase in diabetes during the same time period.  This is one of the highest rates in the world.   A researcher from the National Institute of Health recently visited Nome and exclaimed, “In other places we study the effects of a problem after it has occurred.  Here you are riding a wave that is about to crest.”

The socioeconomic causes of this epidemic are complex.  But there are solutions.  Two ongoing national research projects that include people from the Norton Sound Region have clearly demonstrated that obesity, diabetes, and the resulting cardiovascular disease can be prevented by two simple actions:  first, maintain a healthy diet, rich in omega-3 fatty acids; and second, remain physically active.  This is why your doctor tells you to eat more fish, like salmon, and exercise for at least 30 minutes each day. 

In rural Alaska, healthy foods such as salmon and seal oil, and the energy expended to gather them, once resulted in low rates of diabetes and cardiovascular disease.  The rise in these chronic diseases appears to parallel the decline in access to traditional sources of nutrition.

This trend was first seen in the lower-48.  Consider the Karuk tribes of Northern California. diabetes and heart disease was once rare among the Karuk.  Prior to World War II, the Karuk consumed an average of 450 pounds of salmon per person per year.   Today salmon consumption in this group is less than five pounds per person per year and the rates of diabetes and heart disease is rising at twice the U.S. average. 

According Dr. Kari Norgaard, a sociologist from the University of California, the dramatic reversal is directly linked to the destruction of a fisheries resource base. 

The decline of salmon in California rivers resulted from dams built without fish ladders and water mismanagement beginning in the 1960’s.   Based on a study of the Karuk experience, there appears to be a clear link between a decline in access to salmon, and a decline in the health of a people.

Regarding the Karuk tribes, Dr. Norgaard states, “The loss of traditional food sources is now recognized as being directly responsible for a host of diet-related illnesses among Native Americans including diabetes, obesity, heart disease, tuberculosis, hypertension, kidney troubles and strokes.”

The people of northwest Alaska face a similar threat.  If mismanaged, or worse unmanaged, salmon runs in the Norton Sound region could decline and perhaps disappear.  

It must be recognized that the loss of salmon is not a mere threat to the economics of a region; it is a threat to the very health of rural Americans.  Nothing can replace a healthy lifestyle with access to bountiful runs of nutritious salmon.  An unlimited supply of federal aid and the best medications will do nothing to prevent the destructive wave of diabetes compared to the physical effort exerted and nutrition gained from casting a net, preparing the catch, and eating the salmon, a vital source of cardiovascular health.    

If we find a way to perpetuate healthy salmon runs in Alaska, we will have contributed an important piece to the solution of one of the most pressing health concerns of our time. 

  

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

April 24, 2011
Why Doctors Volunteer

Last month I had the opportunity to travel to Haiti with a medical relief team facilitated by the Haiti Christian Development Program (HCDP), a non-profit development foundation based in Little Rock, Arkansas.

During this trip I had the privilege of working alongside an amazing group of medical providers and medical students who regularly donate a portion of their skill and time to work in underdeveloped countries like Haiti. I spoke with many of these providers about why they take time away from their personal practices to come to Haiti. Their answers give insight into the hearts and minds of many doctors in America today.

“One of the things I’ve seen over the last several years is that more and more doctors are doing this type of trip,” says Hank Farrar, a physician who serves as director of the pediatric residency program at Arkansas Children’s Hospital, “Years ago when I was in medical school people thought you were a little bit crazy if they found out you were going to do something like this. Now a lot of people do it. I think it’s because people have started to realize there’s more to life than just their day-to-day work.”

Mike Justus, a family practice physician from Searcy, Arkansas agrees, “You know, if I don’t come, my world gets very small. Life becomes six in the morning to ten at night going down the same street back and forth working in the same exam rooms. I forget that the world is much bigger than that.”

There is a sense in which this type of service is a part of the Hippocratic oath says David Smith, a cardiologist with Heart Clinic Arkansas. “It’s giving back to the profession what you have been given. It’s a professional mandate since you have been blessed with this education. You are not a product of yourself. You are a product of your community, a larger community.”

Dr. Smith is in many ways the brains and heart behind HCDP, which has established an impressive array of relief programs. In addition to medical relief work, HCDP supports an educational farm, a microloan program, a feeding program, and a community development program currently constructing new homes for people displaced by the 2010 earthquake.

Smith describes a spiritual basis for the development of HCDP.  A practicing Christian, Smith believes his work among the poor is a part of what he describes as “a mandate for Christians.” Smith says, “We want to follow the example of the master. Certainly he went about healing and restoring people throughout his life. So if we want to be like him and we’ve been given the opportunity to be a healer, then we want to give that back.”

Many of the doctors commented on how their volunteer work is driven by a spiritual commitment. “I like reaching across cultures and finding things I have in common with the whole brotherhood of man,” says Brian Alexander, an anesthesiologist at the Arkansas Heart Hospital. “I like seeing people’s needs and meeting those needs one-on-one. It’s easy to send money, and I do that some. But sometimes it’s good to get dirty and rub shoulders with the people—to observe their needs and love them and reach across cultures with Christ’s love.”

“Here there is an opportunity to touch on the whole spiritual aspect of life that gets lost in the background noise of work at home,” says Justus. “The need is not always in the prescription. The need is in the heart.”

For many doctors, volunteer work among the poor is extremely rewarding. “I really enjoy my work at home, but I can honestly say this type of work is the most satisfying medicine that I practice,” says Alexander. “It makes me more compassionate. It changes me. There are reasons I come that have nothing to do with medicine. It makes me a better husband and father. I get away from the materialistic side of society. It makes me more compassionate. And it translates into my work back home.”

“As a specialist you begin to get more sensitive to smaller issues,” says Smith who describes how work in Haiti affects his work as a cardiologist in the United States. “You become very aware of poverty again and more tuned into the fact that you need to try to provide affordable health care because you too have an indigent population at home. It’s not just in Haiti.”

“I think it helps makes me a better doctor,” says Farrar, “because I become much more reliant on my clinical skills. I can’t just read numbers off a report from the laboratory because there is no laboratory. We become much more reliant on our physical exam skills and thinking through problems rather than reflexively relying on tests.”

Smith often takes medical students on trips to Haiti. “These medical students and residents, most of them, have never been in a third world country. For them to even think about medical missions they need to have an introduction.”

Megan Lyerly, a medical student from the University of Arkansas, who joined the team this year, describes how the trip to Haiti affected her perspective of health care. “I feel like we are our brother’s keeper. A lot of times in America we get bogged down with the health care system. You know medicine is not as easy as it should be and here in Haiti it’s all about treating the people and making their life better. It’s a more simplistic view of medicine and the way it should be.”

Lyerly’s husband, Shane Lyerly, also a medical student adds, “It’s a reminder that even back home we really don’t understand what people may be going through.”

“This is my first experience as a medical student having some autonomy,” says Madison Orsburn, a medical student also from the University of Arkansas, “Throughout medical school there is always someone looking over my shoulder. This is the first time that I had a chance to think things through myself.”

Orsburn says he is motivated by what he calls “the positive smile sign,” a phrase he coined after treating an elderly woman with severe arthritis of the knees, “After doing a knee injection I saw her smile and the light in her eyes. That’s the relief she came looking for and when I leave here she’s still going to have that relief and that smile.”

When asked if the work in Haiti validates his choice to become a pediatrician, Orsburn described a long day of seeing children with various mild problems, “then you get that kid just covered in scabies and you know they’re miserable and you think ‘I can do something for this.’ That’s a good feeling, when you feel you can actually help someone.”

For doctors who have practiced medicine for a long time, working among the poorest people in the western hemisphere is a reminder of days when the practice of medicine came with a sense of mission. “There is a language change and a semantic difference between the way we talked about medicine 30 years ago and today,” says Justus, “If you sat down with a group and talked about it now the discussion is performance-based and productivity-based instead of asking are we better people and are our patients better people because of the work we do today.”

In one week, this small band of medical providers treated over 2000 people in hot, dusty, remote clinics in and around Gonaives, Haiti. The work was hard. But every one of those providers says they will return. As Smith says, “Once you come down and establish friendships, those friendships get deeper and deeper every year. And you want to see these friends again. In a small way you want to bring your cool cup of water that nobody else throughout the year is providing for them.”

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

January 24, 2011
How to Treat Dehydration Caused by Vomiting or Diarrhea

Viruses that cause vomiting and diarrhea are more prevalent this time of year. Doctors call this problem gastroenteritis or the stomach flu. While a brief bout of diarrhea or vomiting may be inconvenient or a little embarrassing, the dehydration that occurs from a severe case of the stomach flu can be life-threatening, especially in children.

One of the most significant causes of preventable death and illness worldwide is dehydration. The most common cause of dehydration is a gastrointestinal illness that results in a life-threatening loss of water from the body. The current cholera outbreak in Haiti, which has killed over a thousand people, is a good example.

Cholera is rare in the far north, but many similar causes of diarrhea and vomiting are very common. These bacteria, viruses, and parasites are just as serious in causing dehydration in rural Alaska. The World Health Organization estimates that 1.7 million children under age five die every year from dehydration worldwide. Even in the United States diarrheal disease leads to 220,000 hospitalizations (10% of all pediatric hospitalizations) and 400 pediatric deaths annually.

Fortunately, life-threatening dehydration can be easily prevented if the problem is identified early and treated using a safe, inexpensive, easy-to-prepare oral rehydration solution (special drink given by mouth). In fact, 93%-96% of children who receive oral rehydration early in the course of an illness never require hospitalization or I.V. fluid replacement.

Commercially available oral rehydration solutions, like Pedialyte, are available at most grocery stores.

A standard rehydrating sports drink, like Gatorade, can be turned into a rehydration solution by mixing 8 ounces of the sports drink with 8 ounces of water and adding a ¼ teaspoon of salt. This gives the solution roughly the same electrolyte concentration as Pedialyte.

In remote regions like rural Alaska, the need for rehydration often occurs at times when pre-made solutions are not available. In these cases, a simple recipe may be used to make an oral rehydration solution (ORS) out of ingredients commonly found at home.

Here is the recipe:

  1. Start with a 16-ounce cup of clean drinking water.
  2. Add ½ teaspoon of salt (mix and taste the solution to ensure it is no saltier than tears).
  3. Add one tablespoon of sugar and mix.
  4. Squeeze in and mix the juice and pulp from a citrus fruit like an orange, lemon, or lime. Banana puree, mango juice, or even blueberry juice may be used in a pinch.

Rehydration should begin at the first sign of increased fluid loss from diarrhea, vomiting, or sweating with fever.

In general, the best dose of any one of the oral rehydration solutions is ½ cup for children under 20 pounds and one cup for children over 20 pounds given after each loose stool or episode of vomiting. Adults may tolerate higher doses.

The trick is to give the solution slowly. One to two teaspoons given every five minutes is a tolerable rate for most ill children because it allows for rehydration without causing vomiting from expansion of the stomach. Even when a child vomits during oral fluid replacement, if given in small sips, much of the oral rehydration solution makes it past the stomach.

Children under age 6 months or any child with diarrhea or vomiting associated with fever over 102˚ F should seek medical help. Other signs of more serious illness associated with dehydration include: blood in the stool, frequent diarrhea or vomiting, mental status changes, severe lethargy, or failure to tolerate oral rehydration. A child having these symptoms should see a medical provider as soon as possible.

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

December 4, 2010
Vitamin D: Are You Getting Enough?

The National Academy of Sciences Institute of Medicine’s (IOM) released a report earlier this week slightly raising the Dietary Reference Intake (DRI) levels for vitamin D considered adequate for most Americans.   The report states that most people are currently getting the required amount of vitamin D.  However, questions remain for special populations, including those living in the far north, regarding how much vitamin D is needed to protect against chronic disease.

Long known to be an important nutrient in bone health and calcium metabolism, vitamin D, also known as 25-hydroxy vitamin D, has become a focus of research in recent years.  This research has shown that a deficiency in vitamin D is associated with over 50 diseases affecting every system in the human body. 

In 2007, Michael Holick, M.D., Ph.D. published an article in the New England Journal of Medicine (NEJM) in which he described how a deficiency in vitamin D is associated with a growing list of medical problems including bone disease, certain cancers, diabetes, and heart disease.  Since then, other researchers have shown that a healthy vitamin D level may prevent or reduce the risk for influenza, autoimmune arthritis, obesity, multiple sclerosis, and asthma. 

There is even evidence that vitamin D supplementation may help ward off the common cold.  In 2004, researchers demonstrated that vitamin D given daily as cod liver oil reduced the average number of wintertime pediatric visits for respiratory infections in a group of New York City children.

Vitamin D is naturally produced in the skin after sun exposure.   It is not actually a vitamin but a pro-hormone, a molecule that the body converts to a hormone in order to regulate important functions at the cellular level.  Receptors for vitamin D are found in every organ of the body.

Sunlight is the primary catalyst for the body to produce vitamin D.   People who live in the far north are at risk of vitamin D deficiency because dark winters and poor UVB radiation penetration of sunlight at northern latitudes inhibits the synthesis of vitamin D in the skin.  

Unless supplemented in the diet, vitamin D levels in the blood drop significantly in the winter months due to reduced exposure to solar radiation.  This effect is seen year-round in those who remain exclusively indoors, like some nursing home patients, or in those who persistently use sunscreen.

When sunlight exposure is limited, vitamin D must be acquired through diet or supplementation.  Regular consumption of salmon, seal oil, or marine foods can prevent vitamin D deficiency.  One 3.5 oz serving of salmon contains between 600-1000 units of vitamin D3.   Supplementation with vitamin D3 can also prevent vitamin D deficiency.  The IOM committee recommends 600 units of vitamin D3 daily for anyone over age 1, and 800 units of vitamin D3 daily from all sources for adults over age 71. 

A number of physicians now believe these recommendations are overly conservative and recommend at least 2000 units daily from all sources for otherwise healthy adults.   Patients with chronic diseases are often prescribed even higher doses.

For comparison, a short time in direct summer sunlight can cause the body to produce around 10,000 units of vitamin D.  Toxicity does not occur because the body quickly degrades any unneeded vitamin in the skin. 

Vitamin D has become one of the most common screening labs drawn at health fairs or during primary care preventive health visits.   The results are used to define a person’s risk of deficiency.  Vitamin D deficiency is defined as a level less than 20 ng per milliliter.  Between 20 and 29 ng milliliter, a person is said to have vitamin D insufficiency.  Results of 30 ng per milliliter or higher are considered normal; although it should be noted that people who live in more equatorial regions with plenty of direct sunlight maintain a level between 50 and 60 ng per milliliter.

Patients should discuss proper dosing of vitamin D with their provider.   There are wide variations in the amount of vitamin D people need to supplement to attain healthy blood levels.   People who consume salmon or who travel to lower latitudes during the winter will not require the same dose as someone who eats little marine food and spends most of the year indoors.   Blood tests may need to be repeated every 6-8 weeks until an optimum dose is determined.

Supplementing vitamin D can cause problems for the relatively few number of patients with diseases that affect calcium in the body.  Patients with hyperparathyroidism, sarcoidosis, and certain cancers must cautiously monitor their Vitamin D and calcium levels during supplementation.

Vitamin D deficiency causes damage slowly.  Levels may remain low for years before any symptoms develop, and even when present, symptoms are vague and non-specific.  Some patients with vitamin D deficiency describe a diffuse bone or muscle pain, general fatigue, or feelings of depression.  Often patients do not recognize any symptoms until the low levels have caused irreversible damage as in osteoporosis, diabetes mellitus type I, or multiple sclerosis.

As a part of good preventive health care, patients should consider having their vitamin D levels checked at least annually followed by a discussion with a medical provider regarding the need for supplementation.

  

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

June 28, 2010
SALMON: Superfood of the Sea

Salmon are arriving back into the region.  Soon fish racks and smoke houses will add their scents to the welcome aromas of summer, and our freezers will be restocked with many varieties of salmon, arguably the world’s healthiest meat.

Though it is easy for people in Northwestern Alaska to take the presence of wild salmon in the summer for granted, the American Heart Association (AHA) and the American Diabetes Association (ADA) would say we are fortunate to have access to such healthy food.   These organizations recommend fatty fish like salmon for the prevention of serious disease and the promotion of overall health. 

Wild salmon provides an excellent source of protein.   Salmon contains nearly the same amount of protein per serving as red meats with only half the amount of total fat and only a quarter of the amount of heart clogging saturated fats. 

Salmon provides a natural source of healthy polyunsaturated fats called omega-3 fatty acids.   Two forms of omega-3 fatty acids are found in salmon: docosashexaenoic acid (DHA) and eicosapentaenoic acid (EPA).   Research shows that consumption of DHA and EPA reduces the risk of heart attack, heart arrhythmias, and stroke.  In Northwestern Alaska, the Genetics of Coronary Artery Disease in Alaska Natives (GOCODAN) has shown that a diet rich in foods like salmon, which are high in omega-3 fatty acids, are associated with lower triglycerides and LDL (bad cholesterol) and a higher HDL (good cholesterol). 

Salmon may also help people with autoimmune diseases.  The omega-3 fatty acids found in salmon are known to have anti-inflammatory effects that reduce symptoms and need for extra medication in people with rheumatoid arthritis, ulcerative colitis, psoriasis, Crohn’s disease, and lupus erythematosus. 

In recent years, salmon has been highlighted as an important source of vitamin D3.  People who live in the far north are at risk of vitamin D deficiency because dark winters and poor UVB radiation penetration of sunlight at northern latitudes inhibits the synthesis of vitamin D in the skin.   Vitamin D deficiency has been associated with an increased risk for heart disease, osteoporosis, type I diabetes mellitus, certain cancers, multiple sclerosis, rheumatoid arthritis, and susceptibility to infectious disease.

Regular consumption of salmon can prevent vitamin D deficiency.  One 3.5 oz serving of salmon contains between 600-1000 units of vitamin D3.   Experts recommend 400-1000 units of vitamin D3 daily for children over age 1, and 800-1000 units of vitamin D3 daily from all sources for otherwise healthy adults. 

Wild salmon also provides essential minerals like selenium and vitamin E, antioxidants that help detoxify the body of waste products and improve the immune system, and may also protect against prostate cancer.

Some people are wary of possible toxins found in salmon.  Various studies show that salmon meat contains low levels of mercury and polychlorinated biphenyls (PCBs) that once ingested can remain in the body for years.  This concerns some nutritionists who discourage the consumption of fatty fish, especially in pregnant women and young children.  However, the extent to which these toxins cause disease in people who eat salmon regularly is unknown, and all experts agree that population subgroups, like rural Alaskans, who once relied exclusively on a salmon-rich diet suffer negative consequences in overall nutrition if they decrease their intake of marine foods.

Therefore, the American Heart Association states that the risk of not eating salmon far outweighs any risk from accumulating toxins from eating fish.   The Food and Drug Administration (FDA) currently recommends limiting salmon consumption to 12 ounces (3-4 servings) of fish weekly for pregnant women and children.   Generally, adults may safely consume 14 ounces or more of salmon weekly.

Salmon is one of the healthiest meats in the world.  This readily available superfood from the sea provides excellent health benefits to the people of Northwestern Alaska.  So let’s go fishing.

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

May 17, 2010
E-HEALTH: Internet Based Medical Guidance

You may have already heard this great sports medicine story. Tim Stauffer, pitcher for the San Diego Padres, woke up in the early morning hours feeling very ill.  He used his iPhone to browse the Internet site WebMD.  After reviewing his symptoms online, he called his trainer who arranged an urgent taxi ride to the hospital where the suspected appendicitis was confirmed, and Stauffer underwent emergency surgery. 

According to the Pew Research Center, Stauffer’s story is not unique.  The use of Internet technology for access to medical information has become commonplace.  In 2005, the Pew Internet & American Life Project found that seventy-nine percent of Internet users have used the Internet to search for information on health topics.  Following up on this data earlier this month, Suzannah Fox, associate director for digital strategy for the Pew Research Center, said, “When it comes to online health searches, specific diseases and treatments continue to be the most popular topics. But the greatest growth is in seeking information about doctors and hospitals, experimental treatments, health insurance, medicines, fitness, and nutrition.”

Jay Parkinson, MD, a pediatrician and preventive medicine specialist from Brooklyn, New York, who is a strong advocate of Internet-based medicine says, “Doctors need to start getting used to this.”  He points out that Google has become a primary source of medical guidance, “Google returns what you’re looking for 70% of the time on the first page and 95% of the time on the second page.”

The Internet has also become a forum for people to gather and share information in a system that Fox and others call “participatory medicine.”  Participatory medicine means that patients connect with others who have similar symptoms through social media, blogs, or podcasts.  Patients may also participate in their own healthcare by researching their illnesses or medications online using trusted web sources like WebMD or MedlinePlus. 

Furthermore, there has been a virtual explosion of health-related apps (short for applications) for smart phones, which provide tools to help patients with everything from weight loss to management of diabetes.   Marketing experts recognize that people, even doctors, are using web-based technology to stay up-to-date on relevant medical information.

The Internet has become more than a mere source of raw medical data.  Health care providers also recognize the power of the Internet to decrease the distance between patients and their providers.  Across the United States, many medical practices and large hospitals, like the Mayo Clinic and Cleveland Clinic are updating their services to allow online access for patients to communicate with their physicians, obtain prescriptions, make appointments, review their personal medical record, and even obtain remote second opinions from physicians thousands of miles away through privacy-protected websites.

Patients should remain cautious about posting private health information online unless communicating with a health professional through a secure website.  In general, standard e-mail and social media should be viewed the same way as having a conversation in a clinic lobby or other public forum where there is little expectation of privacy.  Secure websites, on the other hand, provide an increased level of security and privacy, such as you would expect in an exam room with your healthcare provider.  

The Internet does not replace the healthcare professional and cannot substitute for the importance of having a trusted primary care provider.  In the end, good medicine occurs much as it did in the time of Hippocrates where a patient receives treatment from a trusted person trained in the medical arts.  The Internet, however, enhances this relationship in a way Hippocrates never could have foreseen.  Now patients with web access can hold the world’s most up to-date-medical knowledge in the palm of their hands, making the patient and provider partners in healthcare. 

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com

February 10, 2010
SHINGLES: Can a Vaccine Help?

Shingles is a painful rash primarily striking adults.  It is caused by the same virus that causes chicken pox in children.   A few years ago, the FDA approved a vaccine for the prevention of shingles in older adults.  Many people have asked if this “shingles” vaccine is right for them, and if so, at what age they should receive the immunization.  Only you and your medical provider can answer these questions, but a little background information may help guide the discussion.

Shingles is caused by the varicella zoster virus (VZV).  Prior to 1995, when a vaccine against VZV became available in the United States, most people were exposed to the chicken pox virus in childhood, thereby developing a life-long immunity.   Now, most children receive the chicken pox vaccine series starting at age one.   After a childhood chicken pox infection or immunization series, most people never suffer from the virus again.   However, in some people, for unknown reasons, the varicella virus can remain dormant within the long nerves of the body until some trigger allows for a localized outbreak of the virus, called shingles.

These outbreaks are usually isolated to the skin served by the nerve in which the virus has remained dormant.  The outbreak starts as a focal area of severe pain or burning followed by a characteristic blistering rash over the affected strip of skin.  In most cases the pain subsides in 2-10 days, but in a small percentage of patients, the outbreak can lead to a long-term pain syndrome called post-herpetic neuralgia.

Outbreaks usually occur in persons over age 60 with at least fifty percent of people who reach age 85 experiencing at least one attack.  Younger people with a weakened immune system caused by illness or immunosuppressive medical therapy may also experience attacks of shingles. 

Shingles is treated with antiviral medication and pain medication to reduce the duration and severity of the outbreak.

A person with an active shingles rash is contagious and must avoid contact with others who could be harmed by a VZV infection particularly infants, pregnant women, and anyone with a compromised immune system.  

In theory, the shingles vaccine helps boost the immunity of a person who has had prior VZV exposure.  It is approved by the FDA for administration to adults age 60 and over.  Early studies on the vaccine show that it reduces the incidence of shingles by 51.3% and the feared complication of post-herpetic neuralgia by 66.5%.   Like many other vaccines, large numbers of people must be vaccinated to realize a benefit in the whole population.  According to research, 58 people have to receive the shingles vaccine to prevent one outbreak of shingles, and 364 people have to receive the vaccine to prevent one case of post-herpetic neuralgia. 

Given that the risks associated with receiving the vaccine are minimal, there is likely little harm in giving the vaccine to large numbers of people; however, because so many have to be immunized to prevent one outbreak, experts debate on whether the vaccine is cost effective.

The effectiveness of the vaccine on persons under age 60 is unknown and is therefore not recommended by the FDA.  Whether or not the shingles vaccine prevents future outbreaks in a person who has already suffered an attack of shingles is also unknown; however, the Center for Disease Control and Prevention recommends vaccination even if a prior attack has occurred.

The varicella zoster vaccine is available to patients in the Norton Sound region only by prescription.  If you are over age 60, you may consider speaking with your provider at your next visit about the risks and potential benefits of receiving the shingles vaccine.

Robert Lawrence, MD

Alaska Family Doctor

www.alaskafamilydoc.com