The Healthy Uninsurable Patient

On the heels of the Supreme Court ruling regarding the Healthcare bill my oldest daughter turned 26. (If you aren't aware, this is the age after which your child can no longer be listed on their parent's health insurance plan). After this, a saga began. She applied for a high deductible personal insurance with Anthem right before her birthday. At that time the extent of her medical problems included a twisted ankle about a week before she applied, for which she took a couple of days of naprosyn. Other than that she's been perfectly healthy. They declined her. Unbelievable! Exactly who do these people give insurance to?

She contacted an independent insurance agent, who was equally mystified, to try to help her. Anthem has yet to provide her with the promised explanation of their denial.

So here is the amazing thing--immediately after her denial, she developed epigastric and chest pain. She had recently been on an airplane and her chest pain was worrisome for a pulmonary embolis. So of course she got a CT scan which she will have to pay for out of the money she has saved for medical school. My question is--are the insurance companies now omnipotent, able to see into the future? If so, how do I, as a Family Physician, obtain the same powers. It would really come in handy in my line of work!

(Of course now she'll NEVER be able to get personal health insurance.)

Musings on a Night in Paradise (or How to Create your Own Misery)

My father-in-law likes to repeat a Zig Ziglar saying, "It's your attitude, not your aptitude, that determines your altitude." Last week, in the middle of paradise, I came to agree with him (something he'd likely be amazed about). Our family traveled to Guna Yala and stayed in rustic thatched huts on a tropical island for three days while visiting my daughter who is studying albinism in Panama.

You have to understand that my idea of camping is staying in the park lodge so sleeping in a hammock and taking "bucket showers" was not high on my list of things to do before I die. On top of that I am one of those odd people who hate the beach. That's really not correct. I hate SAND! It is pervasive. Really, if I want to exfoliate there are much more reasonable ways to do it.

We arrived on Isla Tigre in a hand-carved boat without benefit of life-preservers after a 40 minute ride in a ten-passenger airplane. (The gentleman sitting behind us from Amsterdam seemed relieved when I offered him a Dramamine at the beginning of our taxi down the runway). Our afternoon was spent mostly in a hammock. Probably my constant nodding off to sleep while trying to read Emperor of all Maladies: A Biography of Cancer was due to the medication because the book is excellent. The food was tasty, though I would get tired of rice before the three days were over.

That first afternoon and most of the night I was melancholy. Here I was on a beautiful tropical island with a breeze and my family but all I could think of were the discomforts. I was too hot to sleep in the hut so I slathered on DEET and slept outside in a hammock. The toilet was located in a concrete hut with no running water--you threw in water from the bucket for the "bucket shower" in order to flush. The plumbing could not handle toilet paper so that went into a garbage can. Don't think about the smell.

Somewhere in the middle of the night, as I was coming back to my hammock from the privy with the waves breaking on the beach ten feet away from me, I looked up at a beautiful sky full of stars and saw the Milky Way with my own eyes for the first time ever. It occurred to me that my melancholy was wholly generated from within. The thought made me laugh out loud. It was as if something burst inside and from that moment forward I knew this trip was going to be a blast and that whatever happened, I could handle it.

There are many times I see patients who create some or most of their own misery. I don't know how to give them that kind of "ah ha" moment. Repeating my father-in-law's expression to them would be patronizing and suggesting a trip to Guna Yala unhelpful (although seeing how happy the Guna are despite their lack of the things we consider necessary might help). Maybe the most I can do is have a little more understanding for them.

I Thought I Just Explained That...

Helping patients to understand the effects of lifestyle on risk-factors, explaining lab results and discussing disease processes, that's all part of my job, right? Patients go through their lists and we discuss strategies for improving their health. When they have a disease process we discuss alternative therapies, causes and second opinions. I use a white board which the patients seem to like, for writing down important points or drawing anatomy or sometimes just suggesting a book I think they'll like. I love the idea of participatory medicine and have "taken the pledge" to make this a priority in my practice. I'm blogging and tweeting and watching other blogs. I think I'm pretty good at making sure the patient understands his or her medication, disease, and followup before they walk out the door. Then a patient comes in and knocks me for a loop.

After a long discussion with a young woman regarding what I thought was an allergic reaction she walked back to the waiting room where my office staff overheard her say to her mother, "Dr. Nieder has no idea what this is and doesn't know what to do for it?" WHAT?!?!???!?!?!? Honestly I spent a long time discussing what I thought had caused her reaction and how to treat it over the next couple of days. It was not severe enough for a prescription so did she think that without a medication she wasn't "really" being treated? Was the fact that her presentation was puzzling and I was unsure to start make her think that I never put the puzzle pieces in place? Thank goodness her mom asked to speak with me!

Makes me wonder how many times I think I've been communicating just fine, when in reality what I'm saying sounds like all the adults in the Peanuts videos.

Sigh.

Due Diligence in Community Health Screening

In our "more is better" culture it is hard for people to understand that more tests do not equal better health. Physicians feel it necessary to order tests for multiple reasons; defensive medicine, patient requests, belief that it will find early, more treatable disease. Good examples of the latter is the controversy over the PSA test and yearly mammograms. In our community it is common for people of all ages to get "Life Line Screening"(the most well-known) or screenings done by other companies. It is offered at health fairs, as a perk for employees and their spouses, and at many churches. In my experience, most of the individuals undergoing these tests have almost no risk factors for the tests being run and many are too young for them.

Recently a middle-aged patient of mine came in with the results of her community screening in hand, done by a company called Stroke Prevention Plus. The first thing that I noticed was extremely high systolic blood pressure readings done by a technician looking for peripheral artery disease. This patient is a normal-sized woman who works out regularly. She's never had a systolic blood pressure over 120 in my office much less 160. On the day I saw her it was up a little--125.

The oddest thing about the results was a black and white "photo" stuck with a piece of scotch tape in the middle of the page. It was from an ultrasound. In the middle of the photo was an arrow pointing to the edge of a black shadow and in the upper left-hand corner were the letters "L thyroid". There was no identification on the photo whatsoever. Among the sheets that were mailed to her was a non-specific "Jane Doe" letter about "incidental findings" that could occur with the testing she had undergone. Nothing was addressed specifically to her. 

My interpretation, looking at the little photo and the arrow, is that the radiologist noticed a cyst on her left thyroid while interpreting the carotid ultrasound. I am speechless that she would be notified of a possible abnormality in such an impersonal and unprofessional manner. What if it is a cancer and she ignored it or wasn't smart enough to understand the significance of that photo? What if she thought everyone got a photo like that attached to their result sheets?

Does the company, Stroke Prevention Plus, think that they did their "due diligence" and are absolved from further followup of these abnormalities by this notification? Since they've performed over seven million health screenings, and no doubt monetarily flourished in the process, do they feel it unnecessary to inform a patient in a CLEAR manner what they "incidentally" found? Do they feel that they have done the patient a favor because they could have ignored the results? What an odd decision on the company's part! I'm thankful this patient is well-educated and understood that she should talk to me. I worry about other people who are not so capable.

 This post was modified 6-12-2012 to reflect the fact that this patient was screened by another company whose forms directly resemble Life Line's. Life Line has better protocols in place for followup. This does not negate the fact that there is no scientific support for screening such as Life Line in the general population, aging or otherwise, quite the opposite. http://www.minnpost.com/second-opinion/2012/03/buyer-beware-direct-consumer-health-screenings, http://www.sciencebasedmedicine.org/index.php/ultrasound-screening-misleading-the-public/, http://www.kevinmd.com/blog/2011/06/examining-evidence-community-health-screening.html.

The Magic Pill

When patients come in to one of my two exam rooms to wait for me, they see written on the white board THE MAGIC PILL "Walking five times weekly, 30 minutes (minimum)" Originally I had written the exercise recommendation for a specific patient but did not erase it. It generated so many conversations from patients coming in for other reasons that afternoon that now it resides permanently on the board (except when a helpful cleaning person erases it).

What has been surprising to me is that most patients WANT to talk about it. They frequently reference that they are walking, they want to walk or they hope to walk. It has been a great conversation generator. In addition to that it has given me the opportunity to talk about studies that illustrate how good walking is, or more generally, how important exercise is to well-being and longer living.

There are numerous studies linking improvement in depression with physical activity and a list of several of them can be found here. Thanks to direct-to-consumer ads, especially on TV, patients often have a magical idea of how anti-depressants work. When we talk about the number of side effects associated with these drugs, especially weight gain, medications become much less appealing.

Another important discussion often begins with how many patients have been told to stop moving because their back/knees/hips hurt. This is bad advice and it often comes from medical professionals. Of course it is USUALLY necessary to quit activity with an acute injury but if you stop too long muscle atrophy sets in and joint stiffness occur. More and more studies point to how important it is to keep moving. Denise Mann writes about this in a great article on WebMD entitled "Dealing With Osteoarthritis? Try WebMD's Joint-Friendly Walking Program".

Brisk walking (defined as a 15-20 minute mile) can reduce heart disease (NEJM), improve function in osteoarthritis of the knee (Annals of Int Med), and prevent the development of diabetes (J of Epid), among other health benefits.

To sum up I want to introduce a video I first saw in Dr. Mandrola's blog because it is entertaining and educational:

Patient Information Retention and the Internet

A patient with hypertension asked me about the nutritional value of sea salt versus table salt. He had heard advertisements suggesting that sea salt was less dangerous to hypertensive patients like him and wanted to know if that was accurate. I whipped out my iPhone and quickly looked it up on the MayoClinic.com website. Within seconds I could confidently tell him that there is little nutritional difference between the two types of salt--sea salt is processed differently using an evaporative process  whereas table salt is mined, processed and has additives to keep it from clumping. Table sauce usually has iodine added to it as well. As a consequence sea salt retains minerals that vary depending on its source and thus has distinctive taste. So the difference is a cooking distinction but there is no medical benefit to its use. Individuals with hypertension need to be careful of their salt intake regardless of the source. Patient (and I) were suitably impressed.

MayoClinic.com

Thirty minutes later I diagnosed a patient with a rare problem called Complex Regional Pain Syndrome (more commonly called RSD for Reflex Sympathetic Dystrophy). She developed her symptoms immediately after a minor surgical procedure and they were classic for the diagnosis. I spent a long time discussing what this meant; the poor understanding of its cause, possible treatments, prognosis and other possible diagnoses. I suggested that she look up information on MayoClinic.com and to see me back in two weeks after beginning steroids and sending her for PT. In the past I would have had misgivings about patients seeking information on the internet. As better resources have appeared on the web I am thrilled to be able to give patients a trusted information site. They are relieved to have access to another source of information and one that their physician is comfortable with. This reassures them that the information will be accurate. 

Studies suggest that patients retain somewhere between 14-50% of what they are told by their providers (see references below). Giving patients an authoritative site that they either write down or take a picture of on the white board I use makes it easier for them to recall what I said and further research information later. On their followup appointment they can ask further clarification with complicated issues or if it's something easy, they can email me with their question. Since 80% of internet users are searching for healthcare information I am happy to supply them with accurate sources.

References:

     Kessels RPC (2003). Patients’ memory for medical information. J Roy Soc Med 96:219-222.http://www.webcitation.org/query?url=http%3A%2F%2Fjrsm.rsmjournals.com%2Fcontent%2F96%2F5%2F219.full.pdf%2Bhtml&date=2012-06-03

     Jansen, et al (2008). Does Age Really Matter? Recall of Information Presented to Newly Referred Patients With Cancer. J Clin Onc http://www.webcitation.org/query?url=http%3A%2F%2Fjco.ascopubs.org%2Fcontent%2F26%2F33%2F5450.full&date=2012-06-03 

     J R Soc Med. 2003 May; 96(5): 219-222.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539473/