Where Do you get your health information, part II

In an earlier post I asked where people get their health information. In this post I’m just listing some more websites people can get some unbiased health information:

Medline Plus

Talking to Your Doctor

Talking with your doctor

NIAID Community Immunity

Centers for Disease Control and Prevention

If you’d like to look up some medical terminology and abbreviations: Understanding Medical Words Some Common Abbreviations

If a couple of the links sound familiar, it’s because I used the phrase ” Talking with your doctor” as a title of a much earlier blog post. Of note, I wasn’t aware of the above links when I wrote my original blog post.

Don’t believe the hype – 10 persistent cancer myths debunked – Cancer Research UK – Science blog

Don’t believe the hype – 10 persistent cancer myths debunked – Cancer Research UK – Science blog.

This site is a reminder to take a lot of “advice”, or at least some headlines, with a grain of salt. In earlier posts I’ve gone over a bit as to where to get health information and things  to think about when evaluating claims (Here are the posts: Where do you get your health information? and Evaluating Health Care Claims ). This link talks about some of the more common myths that still make rounds a lot on the internet.

healthcare disparities

A few months ago there was an article in a prominent medical journal about an association with one’s income and place of death (it was looking at hospice patients only). The higher one’s income the more likely someone was to die at home with hospice rather than in a nursing home or hospital.

As a practicing physician,  that there are healthcare disparities bothers me. There are multiple factors that go into this. Some are patient related (limited english skills, little/no social support in cases of people with little mobility), some are patient and societal (I would put literacy here, not just health literacy). As of 2013 I would hope that being a member of a minority would not have an effect on one’s healthcare. There is evidence  – and i don’t recall which journal I saw this in – that minorities that go to hospitals that have good healthcare results do as well as non minorities, and those that go to hospitals with less good results have corrispondingly poorer outcomes. In this case I guess we could argue for putting systems in place for all health care institutions to give health care with good results.

One thing physicians get measured on are things like checking cholesterol levels, glycosylated hemoglobin A1c’s twice a year, etc. However  to just focus on measures like that take time and energy away from measuring and doing other things that ‘count’. Sending someone for a test and usually takes less time than spending 1/2 an hour educating patients as to why those measures count and how to take care of their health. There have been articles that have brought this issue up. There are easy answers. However, I have a feeling that at least as of 2014, having processes in place to be sure that patients are educated about disease prevention and self management would go a lot farther in preventing complications than would checking a glycosylated hemoglobin twice a a year.

Related articles

Evaluating health care claims

In some ways this post is a continuation of my previous one titled “…because it’s natural”. In a lot of diseases such as DM-2, Alzheimer’s, and heart disease, there are multiple mechanisms that contribute to either the disease itself or to it’s complications. Two mechanisms of disease that seem to get a lot of space on TV, print and on the internet is that of inflammation and oxidation. Whether it is someone promoting a “super food” that has a lot of antioxidants in it (or a lot of anti-inflammatory activity), or a pill that has plant extracts in it that reduce oxidation or inflammation, the claims should be  taken with a grain of salt. For example in some cases, there may be multiple good studies that show taking said supplement does act as good antioxidant. However this doesn’t mean that the supplement will improve one’s health or lengthen lives. This is a problem with using what’s called a surrogate endpoint. Don’t get me wrong, using surrogate endpoints can be useful when the more significant and relevant endpoints are things to be avoided (death or disability for example) or might not happen for years  – I don’t think a study that would take 30 years to start showing something works would get funding – or finding enough people to study would be practical. It helps if a change in the surrogate endpoint has already been shown to be related to reduction in a particular disease’s morbidity or mortality.There are also observational studies that show certain things (high vitamin A levels, higher beta-carotene intake) are associated with lower levels of a particular disease state. Sometimes using a surrogate endpoint  (or  noticing an association between two things such as high levels of vitamin A and lower rates of a particular disease) ends up leading to people doing negative studies. For example, many deaths after a heart attack are related to arrhythmias. A study called the CAST (short for Cardiac Arrhythmia Suppression Trial) showed  higher mortality in people who were on anti arrhythmia drugs. It doesn’t mean that the drugs didn’t have a role in other disorders. I have a feeling it means that we were just asking the wrong question (even though it needed to be asked and answered) about treating arrhythmias after heart attacks. I use the example of the CAST study to make the point that showing something changes the level of something (either up or down) that is thought to be involved in causing disease – be it inflammation, oxidation, arrhythmia or otherwise – doesn’t mean it affects the disease it is said to. It may be that to treat a disease with anti-inflammatory medications (or substances), one also needs to block other pathways of that disease as a well for any to be effective. This is why most cancers are treated with more than one drug. This is why people are often on more than one blood pressure medication. As I mentioned in my last post, any claims should have data supporting that they work. The results should be reproducible, hopefully other by other researchers. Getting back to my original assertion from the start of this particular blog post, if someone is touting a “superfood” for health, It is appropriate to ask if it actually improves health, decreases complications, etc. In my opinion, just to say something is a “super food”  because it is a ‘super anti oxidant’ is blowing smoke.  That isn’t to say that anti-oxidant rich foods don’t promote good health. There are too many studies that are negative that to look at one thing and say “this is the holy grail of food”. This also undersimplifies things too greatly. It’s better, in my opinion, to say “these are the types of foods/eating (or habits if one is talking about other aspects of lifestyle) that are associated with good health. For examples, many of the studies that show that olive oil intake is inversely related to cognitive decline are more agnostic about what role each component in olive oil plays, despite showing benefits. Is it the kinds of fatty acids in olive oil? Is it the polyphenols that act as antioxidants?  Is it the anti-inflammatory chemicals in olive oil? I suspect the answer is yes, it is all three. Is it the answer to everything: just have olive oil and you’ll live to 100? I doubt it. My bottom line on health care claims:

Be critical but open minded: ask the following questions: “Does it actually affect or prevent disease? Does it decrease complications of the disease and not just something thought to be associated with disease or complications thereof?”. If the answer is “yes, it does reduce _fill in the blank_ and there is a proportional reduction in the amount of deaths/strokes/people going on dialysis/etc then you have a winner. IF the answer is “it does reduce _fill in the blank_” but there is no reduction in _fill in this blank as well_” it may mean that the answer is more complicated than we think. It may mean that the wrong question(s) were asked, or the right ones hadn’t been asked.

Also be wary of claims that make a product or procedure seem that it’s THE ANSWER for a particular disease. It may be a piece in the puzzle, but in order to be considered as such, the answer to the question ‘where’s the proof’ should be along the lines of “here are the studies…”

If the person makes statements like “doctors are in the pockets of ‘big pharma’ and aren’t interested in curing disease”, then be wary. I think most doctors get into this business to make people better. If there was a pill that taken once or twice cured someone of his or her type 2 diabetes (and did not cause some other severe life threatening disease), I think most doctors would use that pill.

Also ask if this the first study of something? Often a treatment is found in a study to be helpful. The numbers of people may be small. Due to the nature of studies, the participants are typically more homogenous than the population as a whole. Once larger studies are done, the benefits of a medication/procedure, etc may not be as large as initially thought.

Another question ot ask is this better than what we have now? Though it could be asked of a new medication, I’m primarily thinking here of new surgical procedures (eg, robotic surgery for certain things). If offered ask: is the rate of complications less with the new procedure? Is mortality less? Is the recovery time quicker with the new procedure?

Tough conversations and Paperwork.

Two kinds of conversations with patients are particularly tough, and sometimes related. One conversation is delivering bad news, such as the diagnosis of cancer or of a diagnosis such as HIV/AIDS. Sometimes the conversation can be tempered by a positive such as having caught the disease in an early stage, or that enough treatments are available so instead of being a virtual death sentence, it becomes a chronic disease.

The other conversation that can be difficult is talking to patients about end of life issues. Part of it is resistance as facing one’s mortality is difficult. Unfortunately people often wait until it’s too late to have conversations with family and their physician. This can put a person’s physician and family into difficult positions. By this I mean, if a disease such as Alzheimer’s has advanced enough, a patient may not be able to voice an opinion on whether he or she would want CPR, Intubation etc in the case of a heart attack. Anyone who has practiced long enough has seen patients who are unable to live independently due to dementia and have no family or other person to act as a proxy to make decisions on his or her behalf. It can take weeks or months to go through the court system to have a healthcare proxy, guardion or some similar decision maker legally assigned. In other circumstances, someone may be incapacitated by the effects of a disease, stroke, etc and unable to speak for him or herself and end up getting far more treatment at end of life than they would have wanted when they come in unconscious, unable to breath for themselves, etc and end up on a ventilator (breathing machine).

There are several ways around this. All start with conversations with family and/or friends in deciding who will be a health care proxy. There are health care proxy forms that can be filled out. Also a form known as “five wishes” is also a good place to start. The site it can be found at is aging with dignity. The first two pages act as a health care proxy form as well. The pages on the five wishes allow for more narrative as to what one’s wishes are for end of life care. Once either a healthcare proxy form or the five wishes form are filled out, they do no good if left in a drawer where no one can find them. A copy should be given to your primary care physician. Another copy should be kept in a place where you or your proxy can easily access it (preferably he or she should have his own copy as well). As circumstances arise (for example, if your healthcare proxy dies or decides they can’t/wont potentially act as a health care proxy and you appoint a new one), a new form can replace the old. However your doctor should have the updated forms for your chart.

At some point someone might decide that based on whatever set of disorders they have, that should their heart stop or that they require CPR for whatever reason that they want to be “DNR” this stands for “Do Not Resuscitate”. This often is a point of confusion when talked about in a hospital setting. This does not mean stopping treatment for cancer, heart disease, lung disease, etc. It simply means that if some’s heart stops or they stop breathing, that CPR or advanced life support measures won’t be started. There is a form such as the which is used to inform EMTs and other responders about your choice should they be called. Hospitals have their own forms that are used for inpatients.

For people with a disorder or set of disorders where one’s life expectancy is a year or less, a MOLST form can be considered. It delineates what life sustaining interventions (eg, feeding tubes, dialysis, etc) will accept.

Lastly a “File of Life form” can be filled out. I referred to this, perhaps a bit indirectly, in my last post. This is a form that can be filled out indicating whether one has a health care proxy, who that person is, where the form can be found. It also lists medical problems, medication lists, doctors’s names and phone numbers. Often they are put on the the refrigerator door so if one is unable to speak, EMTs and other responders can have important, and perhaps even life saving, information without having to search for it. Some forms are also small enough to be placed in a wallet.

Not all of these forms need to be discussed at one visit with your physician. To find them online you can search for the terms of “health care proxy”, MOLST, DNR, “file of life” and add the state you reside in for forms specific for your state.