Genetic Clues Are Ignored By Too Many Doctors










Genetic Clues Ignored

With the availability of home genetic testing kits from companies such as “23andMe” and “Ancestry DNA,” more people will be getting information about their genetic lineage and what races and ethnicities of the world are included in their DNA.
Geneticists, meanwhile, are also getting more tailored information about disease risk and prevalence as genetic testing in medical research centers continues.
Physicians accept that cystic fibrosis, for example, is much more common in people with Northern European ancestry and that sickle cell disease occurs dramatically more often in people with African origins. These commonly accepted racial and ethnic differences in disease prevalence are just the tip of the iceberg when looking at clinical differences that vary based on genetics.
But there’s a problem, a recent study from the National Institutes of Health found. Many physicians and other providers are uncomfortable discussing race with their patients, and also reticent to connect race or ethnicity to genetics and clinical decision-making, the study suggested.
Overall, physician focus groups “asserted that genetics has a limited role in explaining racial differences in health,” the authors added.
As a primary care physician who teaches urban health to medical students and as a state minority health commissioner who advocates for health equity, I see this as a problem that health care systems, and their providers, need to address.

The state of the science

Commercial DNA tests, such as those provided by 23andMe, not only give people their racial and ethnic lineage but also can provide a weighted risk for diabetes, stomach ulcers, cancer and many other diseases. In April, the FDA granted approval to 23andMe to sell reports to consumers that tell them whether they may be at heightened risk.
These companies already have the data that describe the risks for health problems based on the percentage of their ancestry composition. Those differences have been published and known in academic circles for many years. With the widespread availability of DNA tests, patients will now know their increased individual risks.
For example, Ashkenazi Jews, a specific Jewish ethnic population originating from Central and Eastern Europe, are known for having a disproportionate occurrence of a number of diseases, including Tay-Sachs disease, amyloidosis, breast cancer, colon cancer and many more.
The BRCA1/2 gene mutation greatly increases the propensity for breast and colon cancer and occurs in 1 in 40 people of Ashkenazi Jewish heritage, whereas 1 in 800 Americans in general carry that mutation. This 20-fold increased risk should prompt more aggressive screening for the gene, and more frequent and earlier mammography and colonoscopies in Ashkenazi Jews compared to the general population.
Relatively higher rates of these cancers occur in certain populations, such as Ashkenazi Jews, and demonstrates the need for more nuanced care based on data that is already available. But this information is too infrequently accessed by providers.

Genetics knowledge growing fast

African-Americans are another group with higher rates of certain genetically driven diseases. African-American men have an increased occurrence of prostate cancer, kidney failure, stroke and other health problems. Prostate cancer in African-American men, for example, grows faster and metastasizes four times as often than in European-Americans.

African-American men are at higher risk for prostate cancer.
pixelmedia/From www.shutterstock.com

But despite this increased risk for prostate cancer, doctors’ use of the PSA (prostate specific antigen), a test that works well with identifying prostate cancer in African-Americans, has steadily decreased due to recommendations aimed at majority patients who come from European-related heritage. In European-Americans, prostate cancer can be more indolent and occurs at a lower rate than African-Americans.
Also, certain types of blood pressure medications – ACE inhibitors, for example – lead to worse outcomes in African-Americans when used singularly as first-line therapy for high blood pressure, yet these medications work very well in Americans of European decent, a large study of hypertension therapy found.
A follow-up study that looked at subsequent clinical practices – which was done in response to changed recommendations based on race – showed nearly a third of African-American hypertensive patients continued to be prescribed medications that cause worse outcomes.
African-Americans also have a four-fold increased risk for renal disease leading to dialysis. Geneticists suspect that they have identified the gene that drives this difference yet most clinicians do not have the resources to test for this gene and identify the 30 percent of African-Americans that carry it.
And a gene that greatly increases the risk for Alzheimer’s disease, APOE-4, has also been identified and occurs disproportionately higher in European-Americans yet is almost nonexistent in African-Americans and is inconsistent in Hispanic-Americans. Great controversy exists surrounding the testing for this gene, given the devastating impact it could have on a patient or family. (Hispanic and African-Americans still have a very significant risk for Alzheimer’s disease, but it is not driven by this gene).

Genetically different responses to medications

Patient response to medications vary according to the presence or absence of genetic variants, which can impact the dose and the effect of many pharmaceuticals. Some of these differences can be anticipated based on race or ethnicity. For example, Warfarin is a commonly used medication in the treatment of a number of cardiovascular disorders including atrial fibrillation, deep vein thrombosis and heart valve replacement. It shows wide variations in dosing, with Americans of Asian descent requiring less medication and African-Americans requiring more to achieve equal effects. European-Americans have a variant gene that make having a major bleed on Warfarin much higher.

Some types of medications affect different groups of people in different ways.
Maoyunping/From www.shutterstock.com

A popular cholesterol-lowering medication, Rosuvastatin, better known as trade name Crestor, is twice as powerful in patients of Asian descent, and their manufacturing label indicates starting at a much lower dose in this population. In fact, the highest manufactured pill dose of Crestor is “contraindicated in Asian patients.”

Patient-centered care is the key

Because of the “patient-centered” movement in hospitals, clinics and insurance plans, providers are now feeling increased pressure to improve the quality of care provided to individual patients. Many outcomes and patient cost of care are now tracked by providers. And countless well-designed studies have validated verified differences in the clinical care of a number of pervasive diseases based on ancestry.
Providers need to educate themselves about the important differences that exist in their patient populations. Health disparities, while driven by a number of social factors, are also the result of some clinicians not applying known nuances in the care of special populations.
The ConversationAs home genetic testing grows, patients will be bringing their results to physicians for reaction and response. Physicians will need to be proactively prepared.
Greg Hall, Assistant Clinical Professor, Case Western Reserve University
This article was originally published on The Conversation. Read the original article.
 

Do You Trust Your Doctor
Blood Pressure Medication
Average African American Diet


Smoking is an Addiction

Smoking isn’t a habit, Smoking is an addiction.

As I encounter tobacco smokers in my practice, my family,  and in the community, one supreme issue comes through: smoking for these “hold-outs” despite smoke-free practices, taxes, and in-your-face campaigns is smoking is an addiction, and we need to start fully appreciating this problem more effectively in order to have an even greater impact. 

National campaigns have made great strides in decreasing the smoking rate over the last 50 years . . . from almost half of all Americans in 1965 to a new low of 15% in our most recent report. Unfortunately, that 15% still represents 47 million people, who still need help to stop.
Smoking is an addictionThink about it . . . if someone said “let’s take a leaf from a plant, dry it, wrap it up, set fire to it, and then inhale its smoke repeatedly” many would think the idea is crazy.  People who have never smoked struggle to understand because many still believe smoking is a ‘habit’ like spitting in public or chewing gun.  Many believe we can effect change by repeatedly saying “just say no” or by making logical associations between smoking and premature death.   While these approaches will (and have) worked with some, the many others who have continued to smoke in the face of these campaigns need better, more effective information that truly addresses why they don’t stop.

Smoking Statistics

Unfortunately, a disproportional number of smokers come from underprivileged minorities. Consider these smoking numbers from the CDC’s most recent data (2014):
·       More than 29 of every 100 American Indians/Alaska Natives (29.2%)
·       Nearly 28 of every 100 multiple race individuals (27.9%)
·       More than 18 of every 100 Whites (18.2%)
·       More than 17 of every 100 Blacks (17.5%)
·       About 11 of every 100 Hispanics (11.2%)
·       More than 9 of every 100 Asians (9.5%)
And these numbers are after many heroic and largely successful campaigns.

What remains are still 70% of smokers who actively want to stop, and 40% who have actually tried in the last year. If smoking was truly a ‘habit’, most if not all of these people would have stopped already. 

What percentage of people who actually want to stop spitting in public, or stop chewing gum, are successful? I bet the number is in the high 90’s. True ‘habits’ while aggravating to handle, aren’t that hard to break. The body’s addiction to nicotine is rapid and strong.

Smoking is an addictionFalse Beliefs

Unfortunately, many of the 47 million people who still smoke also believe smoking is a habit.  They actually believe they are ‘choosing’ to smoke.  Many think they ‘want’ to smoke.  But the evidence to the contrary is overwhelming. With economic strains, unemployment, low pay, and decreasing wages, why would someone choose to pay $8 for a pack of cigarettes (here in Cleveland, Ohio) which totals 40 cents per cigarette!  Based on the time to smoke a cigarette . . . 6 minutes, they pay 40 cents for 6 minutes of satisfaction.  People with financial hardships are not willingly choosing to spend that kind of money for a ‘habit.’
Add the overwhelming horrible health data associated with smoking which essentially says that whatever time a smoker spends smoking is lost on the back end. To put it differently, every minute spent smoking takes a minute off of your life. These are hard truths that almost everyone knows, but remains ignored by many. 
To then call smoking a ‘habit’ in the face of all of these truths, is missing an overly obvious point.

The Cost of Tobacco Keeps Rising . . .

Many believed that raising the cost of cigarettes would simply ‘price-out’ its wide-spread use, and to a limited extend, it has, but unfortunately the hardened addicts will simply ‘find’ the money to buy ‘what they need’ at almost any cost.  Former Surgeon General C. Everett Koop, the first to assert that smoking was an addiction, initially faced strong opposition from the general public.  His mandate to place warning labels on the cigarette packs was revolutionary and one warning simply states: ” Smoking causes a strong addiction, do not start it”.

My overriding point to the smokers reading this article is to recognize the evidence staring you in the face.  Recognize that a “nicotine fit” is evidence  of withdrawal from an addictive substance.  Recognize that planning your day around smoking breaks, deciding your travel options based on smoking availability, and spending an outlandish amount of money on tobacco . . . are ALL signs of severe addiction.  

Smokers cannot take steps to address an addiction unless they first recognize its presence. The non-smokers (including many of my doctor colleagues) also need to stop having the smug “I’m not that stupid to smoke” and “why don’t you just stop” attitude about the smokers in their practice.  Physicians should understand pure difficulty involved in stopping smoking.  Addictions are not stupid, they are real, strong, difficult to overcome, and need to be addressed in a sensitive and effective way. Patients need a physician they trust to work with them to overcome this huge health problem.

Smoking is an addiction

Addiction is merely a diagnosis to be addressed.  It is not a sign of personality weakness or inferiority. Like high blood pressure, strokes, lactose intolerance, and the flu, addictions need to be treated with the proper approach. Let’s start recognizing and treating nicotine addiction with proven and multi-pronged approaches. And let’s take the taxes we collect from current tobacco users and help them stop.

Do You Trust Your Doctor
Average African American Diet
Blood Pressure Medication
A Fib in African Americans Carusel



DNR Code Status Explained

One of the more difficult tasks in your life is deciding a “DNR code status” for yourself or, worse yet, a loved one.  DNR is short for Do Not Resuscitate which basically means ‘do not attempt to bring me back to life’.  Some people feel very strongly about having peace at the end of life . . . that you pass this life without disturbance.  Others want to live at all cost and even if their heart is “bad”, give them every chance to live. These two philosophical differences represent the two ends of a spectrum.  If you’ve lived a long life, get ill, and decline in health, your passing is expected . . . and to perform CPR (chest compressions or shocks) seems cruel to some as your last moments could be painful. 

In Ohio, the code status is limited to three: Full Code, DNR Comfort Care Arrest, and DNR Comfort Care.

The naming of these three advanced directives is helpful in some ways and confusing in others. DNR Code Status designations vary from state to state or even from county to county so find out what applies specifically in your area.

In Ohio (where my patients are located), what follows below is what applies to you.

We’ll review these code status’ individually and then go over some examples so you can be perfectly clear on the implications.

FULL CODE

Full code is easy to describe. It means you want “everything” that is medically possible done to keep you (or your loved one) alive. . . no matter what. This essentially means that no matter how much suffering is involved while getting care, it is worth it to get better when all is said and done.

When patients are diagnosed with cancer, many undergo chemotherapy that may cause nausea, vomiting, weight loss, hair loss, diarrhea, and more. . . all in order to get rid of the cancer, and recover and lead a happy normal life after the dust settles. If your heart stopped during this time, it would be appropriate to shock (with the paddles and the doctor yells “CLEAR” and then ZAP) the patient in an attempt to re-start the heart and get them past this sick time. 

You get everything that is clinically indicated.

Not everything that is medically possible. Your doctor still has the last say what is medically reasonable. 

DNR Comfort Care Arrest

This DNR code status is the confusing one! DNR Comfort Care Arrest essentially means that the patient is a FULL CODE until they “arrest” (heart stops or they stop breathing) at which point they would be made “comfortable” without shocking the heart or being put on a ventilator. This DNR code status is appropriate for most ‘older people’ or patients with heart or lung disease.

If you are 85 years old and your heart stops, it is because your heart has run its course. No amount of shocking and chest compressions will convince your heart to start again.  Attempts to start your heart will be futile, and your last moments will be painful as electric shocks and other interventions hurt (again, we tolerate the pain of these options with a FULL CODE so that we can live in case the heart stops and its not because it has run its course).

DNR Comfort Care Arrest is appropriate for most older patients because they will get everything clinically available to them, but when their last moment comes (if they “arrest”), they will be be “kept comfortable”.

With a DNR Comfort Care Arrest, you will get:

  • Surgery if needed
  • Antibiotics for all infections indicated
  • Intensive care treatment (ICU, etc.)
  • Chemotherapy for cancers
  • Anything else medically indicated

DNR Comfort Care

This DNR code status designation means that comfort will be the primary concern at all times. Comfort will drive all medical decisions.

DNR Comfort Care does NOT mean you get NO CARE. 

DNR Comfort Care means that the care you receive will be tailored with your comfort and happiness in mind.  It stresses the quality of your life, not the quantity. Three happy pain free days would be better than ten painful stressful days when both result in death in the end.

Hospice patients typically have a DNR Comfort Care code status. 

DNR Comfort Care CardBecause this can be confusing, here are some examples:

  • Urinary tract infection: could be treated because it is uncomfortable to have one
  • Chemotherapy for cancer treatment would not be offered unless there were specifically causing pain (that was best treated in this way).
  • A patient would not be sent to the hospital unless they would be more comfortable there.  Being packed up in an ambulance, put in the cold, sat in an emergency room, then transported to a hospital bed, then IV’s placed in arms, etc. is NOT comfortable. This situation is to be avoided if comfort is a prime directive.
  • Surgery will usually NOT be done.

Sometimes people carry a identification card for caregivers to see. HERE is one provided by the state.

This summary was difficult to put together (I admit), therefore there may be different angles, approaches to discussion, philosophical views, etc. that I left out. The important point is to have a honest conversation with a doctor you trust. Everything else will flow from there . . .

 

Please add your take on this in the comment section below, and I am sure this explanation will improve with more input!!!

 

Cleveland Black Doctor

Cleveland Black Doctor Cleveland Black Doctor

If you are looking for a Cleveland Black doctor or physician, look no further . . . Dr. Gregory L. Hall is the premier choice in Northeast Ohio. As a specialist in Internal Medicine, he sees patients age 18 and up. While many practices make you wait weeks to see the doctor, we’ll see you quickly, most of the time within the week.

African Americans have particularly severe problems with hypertension, strokes, obesity, and heart disease . . . and also have slightly different needs in the clinical care of these disorders.  Having the expertise and cultural competence in the care of African Americans is Dr. Hall’s specialty, and he is currently writing a book on the special needs of this population.

Louis Stokes Jeff Johnson
From Left to right, Jeff Johnson, Louis Stokes, & Greg Hall, MD

Born and raised in Cleveland’s Glenville neighborhood, Dr. Hall is very familiar with the medical resources available in Northeast Ohio and refers to specialists in their field from across the region.

He also understands the issues specific to the African American Community and makes an extra effort to diagnose and treat these conditions before they can cause harm.

Cleveland Black Doctor Dr. Hall’s office is conveniently located at 464 Richmond Road at the corner of Richmond and Highland in Richmond Hts, Ohio.

Trained at the world famous Cleveland Clinic, Dr. Hall provides up-to-date medical care in a family-like environment. Caring and comical, you will feel immediately at home with Dr. Hall and his staff. If you want a Cleveland-born Black doctor who make you feel at ease and takes time with you, look no further.

Most insurances are excepted, and we provide a sliding scale for uninsured patients who qualify.

Call the office of Gregory L. Hall, MD for an appointment, and you can be seen as soon as the next few days.

216 881-5055

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Cleveland African American Physician

Cleveland African American PhysicianIf you are looking for a Cleveland African American Physician, look no further . . . Dr. Gregory L. Hall is the premier choice in Northeast Ohio. As a specialist in Internal Medicine, he sees patients age 18 and up.  We’ll see you quickly, most of the time within the week.

Internal Medicine is a primary care specialty for adults and Dr. Hall sees patients with diabetes, high blood pressure, arthritis, headaches, dementia, and much more. He will be on your side . . . and has a special ability to explain complicated diseases and conditions.

African Americans have particularly severe problems with hypertension, strokes, obesity, and heart disease . . . and also have slightly different needs in the clinical care of these disorders.  Having the expertise and cultural competence in the care of African Americans is Dr. Hall’s specialty, and he is currently writing a book on the special needs of this population.

Born and raised in Cleveland’s Glenville neighborhood, Dr. Hall is very familiar with the medical resources available in Northeast Ohio and refers to specialists in their field from across the region.

Cleveland African American PhysicianHe also understands the issues specific to the African American Community and makes an extra effort to establish trust, and diagnose and treat these conditions before they can cause harm.

Dr. Hall’s sees patients at his office at 464 Richmond Road at the corner of Richmond and Highland Road in Richmond Heights, Ohio.

Trained at the world famous Cleveland Clinic, Dr. Hall provides up-to-date medical care in a family-like environment. Caring and comical, you will feel immediately at home with Dr. Hall and his staff.

Most insurances are excepted, and we provide a sliding scale for uninsured patients who qualify.

Call the office of Gregory L. Hall, MD for an appointment, and we will see you real soon.

216 881-5055

 

 

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Medicare Annual Preventive Health Exam

If you are 65 years or older, you are entitled to a Medicare annual preventive health exam that is covered at no additional cost.  During this visit, we will review your social and medical history including family risks, tobacco and drug use, your diet and physical activities, current medications and nutritional supplements, as well as any hospital stays or surgeries.

Annual Preventative ExamWe will also review if you have any risk factors for depression or other mood problems.

The overall purpose of a routine preventive exam is to identify potential health problems in the early stages when they may be easier to treat.

This exam is prevention focused, not problem focused. If you have a new health problem or other diagnoses that need to be addressed during your preventive office visit (high blood pressure, diabetes, skin rash, or headaches) we may bill part of the exam at 100 percent for your annual preventive exam, and part of your office visit for treatment of your diagnosis. The portion of your visit related to the treatment of your diagnosis would apply toward your deductible and coinsurance. If we feel that the majority of the time was spent with medical concerns, the entire visit may be considered a medical treatment visit and would not be billed as preventive and we will schedule another visit as preventative. 

At our preventative visit, we will also review appropriate screening tests that need to be scheduled including:

  • ColonoscopyColonoscopy: a screening test that looks for pre-cancerous cells in your intestine.
  • Mammography: an x-ray test that looks for early breast cancers
  • Bone Density Study: an x-ray test that checks the strength of your bones
  • Prostate Specific Antigen: a blood test that estimates your risk for prostate cancer.
  • Ultrasound Screening for Abdominal Aortic Aneurysm
  • Screening for dementia, depression, alcoholism
  • Human Immunodeficiency Virus (HIV) Screening
  • Cardiovascular Disease Screening Blood Tests

We may also discuss “Advanced Directives.”  This is where we talk about your wishes as it relates to end of life care. Obviously, this talk is best done when you are NOT at the end of your life, and any decisions you make are not binding . . . in other words you can always change your mind or put off making a decision.  It is always good to know your options.

GLH Walking in exam roomThe annual preventive health exam is a great time to clarify any questions about prevention, screening, advanced directives and more.

Ask questions and get answers!

 

 

Links

Medicare Resources

Medicare Benefit

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Sees Jehovah’s Witness Patients

Treats Jehovah's Witness Patients

Doctor Treats Jehovah’s Witness Patients

Dr. Greg Hall treats Jehovah’s Witness patients for a variety of disorders for over the last 20 years. While treating many families, Dr. Hall understands and respects Jehovah Witnesses’ beliefs as it relates to blood product use, and will vehemently defend their wishes to avoid blood and blood products, while exploring all of the many options that are available instead of transfusions. 

Other than avoiding transfusions, Jehovah’s Witnesses want and expect the best medical care with the latest clinical interventions available.

“Cleveland and Northeast Ohio Jehovah Witnesses are a great diverse community of friends, and I am honored that so many are my loyal patients.”

Jehovah’s Witnesses expect the same high clinical standards as any other religion, their only expectation is the exclusion of blood product use. With modern medicine and incredible advances, the avoidance of blood products does not complicate the healing process in any way. And with blood borne infections as they are, the risk – benefit of any one transfusion can easily be debated.

Knowing a patient’s wishes in advance allows sufficient time for planning and proper clinical management in any case.  The national drive toward “patient-centered care” stresses putting the patient, and their wishes and preferences, at the center of  the medical decision-making process.

“Avoidance of blood does not tie a physicians hands any more than the physician allows.”  

Greg Hall, MD

Sees Jehovah’s Witness PatientsJehovah’s Witnesses and blood avoidance . . . WHY?

This is a religious issue and NOT a medical or clinical issue. Both the Old and New Testaments have references to “abstain from blood.” (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29) Historically (and in the bible), blood has repeatedly been seen as “representing life.” (Leviticus 17:14) Jehovah’s Witnesses avoid taking blood not only in obedience to God, but also out of respect for him as the Giver of life.

For more information, CLICK HERE

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