Establishing Trust When Patients Distrust Doctors

Distrust DoctorsDistrust Doctors ??

Multiple studies over an extended period of time confirm what most doctors and providers already knew, African Americans are more likely to distrust doctors and other healthcare providers than patients of other racial or ethnic groups.

What many of us did not know was why.  As providers, we spent many years training to help others.  Medicine is a service profession. Why would anyone suspect our intentions, question our motives, or assign us collectively as untrustworthy?  The answer lies in the historical experience African Americans had with America’s doctors, hospitals, and researchers.

A History of Abuse

While the Tuskegee Syphilis Study is a ‘classic example’ of abuse based purely on race, unfortunately the American experience has many more examples of why African Americans mistrust the medical community.

From African American’s earliest days in this country, abuse based on race was commonplace.  Slaves were frequently used as subjects for dissection, surgical experimentation, and medical testing. J. Marion Sims, MD, the so-called father of modern gynecology perfected many of his surgical techniques on slave girls without anesthesia. Stories of doctors kidnapping and killing southern blacks for experimentation consistently appear in literature throughout American history.

Distrust DoctorsAs Vanesa Northington Gamble, MD, PhD put in her article “Under the Shadow of Tuskegee: African Americans and Health Care” tales of ‘medical student’ grave robbers, recount the exploitation of southern blacks as their deceased family members would be stolen and sent to northern medical schools for anatomy dissection.  Dr. Gable writes:

“These historical examples clearly demonstrate that African Americans’ distrust of the medical profession has a longer history than the public revelations of the Tuskegee Syphilis Study. There is a collective memory among African Americans about their exploitation by the medical establishment.”

Racial Differences in Trust

Chanita Hughes Halbert published a study in JAMA in 2006 looking at racial differences in trust in healthcare providers. Her study of almost one thousand white American and African American patients found that “compared with whites, African Americans were most likely to report low trust in health care providers.”

“Trust has been described as an expectation that medical care providers (physicians, nurses, and others) will act in ways that demonstrate that the patient’s interests are a priority. Trust is a multidimensional construct that includes perceptions of the health care provider’s technical ability, interpersonal skills, and the extent to which the patient perceives that his or her welfare is placed above other considerations. Trust is an important determinant of adherence to treatment and screening recommendations and the length and quality of relationships with health care providers.”

Fortunately, the level of trust a patient has for any specific provider is not stagnant, it can be earned.  Increased exposure to providers in general, and to the same provider in specific, has been shown to improve trust.

Physician Bias

In the “Medscape Internist Lifestyle Report 2017“, Carol Peckham looked at internist’s admitted explicit biases “toward specific types or groups of patients” and found wide differences between racial groups in bias for a number of influences.  The study further examined if the physician bias actually impacted care delivery, and almost one in five providers (18%) admitted that their bias did impact the quality of their care.

Generally these biases are positive toward white American patients and negative toward African American patients as a study by Oliver et al demonstrated at the University of Virginia. They found providers explicitly preferred white Americans to African Americans with “significantly higher feelings of warmth toward white people” and also found that white American patients were “more medically cooperative than African Americans”.  This study found no significant difference in the quality of care between the racial groups.

“physicians demonstrated implicit pro-white bias, reported an explicit preference for white people, had beliefs that blacks were less medically cooperative than whites, and believed that subconscious biases could influence their clinical decision making.”

Unconscious Bias

Biases that effect medical care can be consciously counteracted, and admitting the existence of biases is the critical first step in canceling its effect on medical care. Having a doctor who professes to treating “everyone the same” will undoubtedly provide inferior care to patients that are different.

A study done at Johns Hopkins by Lisa Cooper and colleagues found that primary care physicians who hold unconscious racial biases tend to dominate conversations with African-American patients during routine visits, paying less attention to patients’ social and emotional needs, and making these patients feel less involved in decision making related to their health. These patients also reported reduced trust in their doctors, less respectful treatment, and a lower likelihood of recommending the physician to a friend.

Because there are a limited number of physicians to provide care to African Americans, many patients simply “put up” with biases and unequal treatment . . . with others avoiding healthcare altogether until they they arrive in Emergency Departments with very advanced disease.

Patient Centered Care Improves Quality

Patient centered care can positively improve care, specifically for African Americans.  Although this seems obvious, spending time with patients is an easy approach to establishing trust. Fiscella and colleagues measured patient trust against the time spent with a patient and found a one-to-one correlation: the more time spent led to more perceived trust on the part of the patient. Making suggestions about diet changes requires a trusting relationship that involves a non-judgmental regard for the current diet.

Many delays in diagnosis and treatment are simply an outgrowth of the lack of trust. You will not accept someones advice if you don’t trust them.

Find a physician you trust.

Kidney Disease in African Americans

Kidney disease in African Americans

Kidney disease in African Americans is one the most dramatically different occurrences of a disease, and results in significant suffering and death.  Generally kidney disease is the result of diabetes and high blood pressure, and given the increased number of both of these in African Americans, there is a six to twelve-fold increased occurrence compared to whites.  Additionally, there is a 17-fold greater rate of high blood pressure as a cause of kidney failure in African Americans.  If you have high blood pressure or diabetes, or both, your risk for kidney failure resulting in needing dialysis is MUCH higher if you are African American.
Having diabetes and high blood pressure that is controlled on medications almost erases this increased risk. This is why it is critical that if you have high blood pressure, you should take medication to bring it down. If you have diabetes, you should make sure your blood sugars are controlled because if you don’t, your risk for needing dialysis is very high.
Kidney disease in African Americans

Risk for Requiring Dialysis is High

While African Americans are 13 percent of the general population, we make up 35 percent of all patients on chronic dialysis.  Diabetes as the leading cause of kidney failure and high blood pressure is the second most common cause.
Not having medical insurance or access to medical facilities and the increased number of people with high blood pressure contribute greatly to kidney disease in African Americans.  Having high blood pressure but being on the wrong medications can contribute as well.

Well designed studies have failed to fully account for the excess proportion of kidney disease in Blacks.  Anatomically, despite equivalent age, blood pressure, and other factors, African Americans tend to have reduced kidney blood flow. Despite similar dietary salt intake, the kidney’s processing of bodily fluids are somewhat different in African Americans compared to whites.  Reducing salt in your diet can greatly improve health.

A Possible Genetic Cause?

The Tsetse Fly transmits the African Sleeping Sickness. By International Atomic Energy Agency

Some of the increased risk for kidney disease in African Americans is attributed to a genetic variant (APOL1) found in more than 30% of African Americans and largely absent in white Americans.  It is thought that this gene offered protection from African Sleeping Sickness (a frequently deadly disease known in medical circles as African trypanosomiasis) that was carried by the Tsetse fly. Basically, having this gene gave protection from the African Sleeping Sickness and was beneficial in African regions where the tsetse fly lived.
Scientists believe that the increased risk for kidney disease seen in African Americans is equal to the increased occurrence of the same gene that offered protection from the deadly African Sleeping Sickness.

Obesity Can Lead to Kidney Problems Too

In addition to these genetic differences, researchers also suspect that increased obesity in African Americans is driving up kidney disease.  They found that as your BMI (Body Mass Index is calculated based on your weight and height) gets higher, the risk for kidney problems increases.

With all of the kidney disease in the African American community, there is one last bit of curious news.  African Americans have a better survival rate on dialysis than white Americans.  This paradox of improved survival in African Americans after initiation of dialysis has puzzled researchers.  Researchers at the Wake Forest School of Medicine suggest that the improved survival may also be due to the very gene that causes the problem . . . the APOL1 gene.  In this case the APOL1 gene gives protection against hardening of the arteries while on dialysis.

Kidney Disease in African AmericansHere’s What You Need To Do . . .

Kidney disease in African Americans can be a confusing topic to understand and there is a lot to consider.  The most important points are:

  1. If you have high blood pressure, take your medicine and watch your salt intake so that your pressure stays normal. That will allow your kidneys to stay normal.
  2. If you have diabetes, take your medicine and watch your diet so that your blood sugars stay normal.
  3. Watch your weight because the bigger you are, the higher your chance for kidney disease.


Atrial Fibrillation in African Americans

Atrial Fibrillation in African Americans

Atrial fibrillation in African Americans, also called “A Fib”, effects one in nine before the age of 80 and is the most prevalent arrhythmia in the US and is associated with significant bad outcomes that include stroke, heart failure, and increased death.  Surprisingly, studies also confirm a decreased atrial fibrillation incidence in African Americans (41% lower risk of being diagnosed than European Americans) but a greatly increased occurrence of stroke and sudden death in African Americans with atrial fibrillation. So compared to whites, African Americans are less likely to get atrial fibrillation, more commonly called “A Fib”, but if they get it, are more likely to have complications. This is just one of many “important differences” that exist in the care of African Americans.

“Racial Paradox?”

Some have suggested that the decreased incidence of atrial fibrillation in African Americans is actually under-diagnosis, but others have called it a “racial paradox” where despite atrial fibrillation being a result of increased high blood pressure, diabetes, over-weight, heart failure, and heart attacks, all of which are higher in African Americans, the incidence of atrial fibrillation is surprisingly lower.

Atrial Fibrillation In African AmericansAfrican Americans were also less likely to be aware they have A Fib, and much less likely to be treated with blood thinners like warfarin (Coumadin, Jantoven) that prevent the heart attacks and strokes that having A Fib causes.   Even more surprising was this decreased use of warfarin in African Americans was regardless of whether the person had insurance or made more money.   It is truly stunning that a medication to prevent strokes is used LESS in a group of people who are prone to have MORE strokes and this was found in a study by Meschia and colleagues who looked at over 30,000 patients:

“We also found that among those who were aware that they had AF (atrial fibrillation) and who had confirmation of the diagnosis of AF, (African Americans) were about one quarter as likely to be treated with warfarin as whites. In striking contrast, risk of stroke as stratified by the CHADS2 score was not a predictor of warfarin use. The fact that risk of future stroke did not significantly alter the likelihood of warfarin use would seem to reflect an evidence-practice gap.”

A Higher Risk for Death

The risk for death in the presence of atrial fibrillation (A Fib) in the first four months after diagnosis was very high with heart disease, heart failure and stroke accounting for the most of the deaths, the study also found.  The risk for hospitalization in African Americans from atrial fibrillation doubled as did the risk for recurrent stroke, and related dementia from repeated “little strokes” (multi-infarct dementia).

What is the Best Medication for A Fib?

So the medical evidence would suggest that African Americans should receive MORE treatment with blood thinning medications like warfarin and other newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis) . . . and in fact they receive LESS.

Some of the complaints about warfarin is the need to have relatively frequent blood tests to confirm the “thin-ness” of your blood.  These tests called “PT / INR” shoots for an INR between 2.0 and 3.0.  Less than 2.0 means your blood is “too thick” and more than 3.0 means it is “too thin.”  The newer medications to replace warfarin do not need blood tests.

Keep in mind that African Americans have an increased risk for complications from bleeding on some of these newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis), so although it can be more inconvenient with frequent blood draws, warfarin may be best for now until more information is available. There is also significant evidence that there are warfarin dosing differences between European Americans and African Americans that need to be anticipated and considered.

What You Need to Know . . .

While this topic may seem a little confusing, here are the main points:

  1. If you have atrial fibrillation (A Fib), you are at a much greater risk for stroke or another major event.
  2. Being on a blood thinner, like warfarin, can significantly decrease your risk for stroke (or another event).
  3. Being on a blood thinner increases your risk for bleeding . . . but not as much as it decreases your risk for stroke. So while you risk a bleed, your risk for stroke is much higher.
  4. The newer “blood thinners” do not require as many lab tests as warfarin, but they also may not be as safe in African Americans (this is controversial and not clear).

Here is a video on anticoagulation and warfarin:

 

Love Your Kids, Not Your Guns

Love kids not guns

It’s silly that I have to write an article about something so obvious: Love your kids, not your guns.  I’ve wrongly stayed neutral about gun control because so many of my patients have and love guns.  And frankly, I didn’t want to alienate them.  I’ve said to myself, if they want to have assault weapons and an arsenal in the basement of their home, who am I to say what they do . . . . or what they have? Some people collect stamps and other people collect guns.  Collecting stamps never impacted so many other lives as collecting guns. The people that collect stamps really get into it.  They travel to foreign lands just to personally buy incredibly valuable stamps, and many I’m told, can never stop.  Their stamp collection is never complete.  Many of my friends and patients with guns have the same “story” where they collect various guns of different fashions and capacities . . . and their collections seem boundless as well.  Up to one third of adults engage in some form of “collecting” and for many Americans, guns are their passion.

357 Million Guns

Americans, by far, own the most guns per capita in the world, with over one gun per person. But gun ownership is highly concentrated with only about a third of Americans admitting to owning one.  And these numbers are decreasing from numbers in the 1970’s where the majority of Americans had guns. Among these “normal” gun owners is a small subset of “gun super-owners” who have huge collections that can result in well over one hundred guns.  Once they collect the usual hand guns and rifles for hunting or home protection, they migrate into bigger and more impressive gun collections that have the capacity for wide-spread devastation.  They buy rapid fire machine guns, grenades, silencers, and more.  They are not planning to attack anyone, but if someone attacks them . . . there’s going to be trouble.   This small number of law-abiding collectors do not want their ability, or access, to guns and ammunition impeded by laws that restrict what they can “collect.”

Why have all of these guns?

When admiring their gun collection, some “super owners” confess to imagining jumping into action at a moment’s notice.  They fantasize about heroic acts that will finally validate their collection.  Do I have enough guns to fight off an invasion of aliens like in the movie “Independence Day?”   What if aliens attack us?  Who will protect us?  The neighbor “gun super-owner” will come to our rescue. That’s silly.  Aliens won’t attack. Love kids not gunsWhat about some virus that “goes bad” and turns half of the world into the “Walking Dead” or zombies like in “World War Z”?  Then I’d bet you wish you had rapid fire assault machine guns to kill all of those “walkers”!   But how much ammunition would you need? Would it run out? Love kids not gunsWait.  That’s silly.  You couldn’t store enough ammunition for that.  The zombies would eventually get us. What about some sort of invasion of the Russians (or whoever), and somehow the United States military would “break down” and then we would need to defend our homes and community from “the enemy?” Then we’d be happy we had military grade guns and ammunition to defend our freedom. That’s silly too.  They would just drop a bomb.

These “gun super-owners” are collectors.

They are not mass murderers.  They are also not saviors from some potential apocalyptic attack.  They are collectors that are simply obsessed with guns.  But their well-meaning obsession puts highly destructive weapons within the reach of other people who shouldn’t have them.  The gun collectors, like the stamp collectors, think they pose no threat.  But they do, and they have. That basement arsenal can be accessed by children, grandchildren, friends, neighbors, or simple criminals who would have no other access to these weapons except for your less-than-secure home security system. Are you ready to take responsibility for your guns no matter where they go, or what they do? The usual approach of "guns don't kill people, people kill people" can no longer apply.  Over-prescribing opioids by doctors has been rightfully blamed for some of the opioid epidemic.  If the pills had not been in the medicine cabinet, the kids wouldn't have experimented, and the addiction could have been avoided in some.   A massive campaign has begun to decrease the amount of opioids that are readily available . . . and no one has objected.  Where are the "pain pills don't kill people, abusing pain pills kills people" objectors? They simply do not exist because its a silly argument. Gun super-owners mean well, but their right to bear arms (or collect arms) shouldn’t extend into our ability to educate our children in an environment free of military-style attacks. Assault weapons have no place in a civilized society. Love your kids, not your guns. Love kids not guns

The health and social issues with tattoos

The health and social issues with tattoos

Greg Hall, MD

Almost half of people between 18 and 35 have tattoos, and almost one in four regrets it, according to a 2016 Harris Poll. Based on an estimate of about 60 million people in that age group, that would mean that about 7.5 million people have tattoo regret.

As a primary care physician, I’ve noticed anecdotally that many of my younger patients have regrets about their tattoos. When I ask about them, many say that they got them when they were young, and at the time put little or no research into the decision.

With no source (reliable or otherwise) of tattoo information to suggest to my patients, I began to investigate the topic myself. My goal was to write a quick reference for teens that reviewed the health and social issues they might encounter after getting a tattoo.

What I found was myriad unexpected and sometimes shocking concerns that everyone should know. To my surprise, there were a host of reports of ink complications, infections, toxin effects, scarring, burns, chronic irritations and much more.

The ink goes more than skin deep

Iron Oxide Oxide RedAmong the concerns are the long-term effects tattoo inks can have on the immune system, pathology specimen interpretation and other unforeseen health complications.

Certain tattoo inks can be toxic, with some containing carcinogenic compounds, a 2012 Danish Environmental Protection Agency found. In fact, one in five tattoo inks contained carcinogenic chemicals, and a vast majority of the inks tested did not comply with international health safety standards for ink composition, an Australian government-sponsored study found. Even more concerning, carcinogens were identified in 83 percent of black inks – by far the most popular color for tattoos.

The European Society of Tattoo and Pigment Research was established in 2013 with a mission of educating the public about the “fundamental facts about tattooing” which many in the younger generations ignore. That group found barium, copper, mercury and other unsafe components in tattoo inks. Their research also found a disheartening mismatch between the listed ink container contents and its actual chemical composition found on testing.

More recently, the Food and Drug Administration has become more involved with tattoo inks, stating “Many pigments used in tattoo inks are industrial-grade colors suitable for printers’ ink or automobile paint.” Like the studies started overseas, the agency is now examining the chemical composition of inks and pigments and how they break down in the body, as well their short- and long-term safety.

Tattoos have led to errors in medical treatment, testing

Metal-based ink tattoos can react with magnetic resonance imaging studies. For instance, two case studies detail patients who suffered MRI-induced burns in their tattoos that were attributed to iron compounds in tattoo pigments. Radiologists say this magnet-based reaction is rare, but some have suggested simply avoiding iron-based tattoo inks.

Pathologists, meanwhile, are reporting tattoo ink in surgical biopsy specimens of lymph nodes. For instance, a 2015 report in the journal Obstetrics and Gynecology detailed the case of a young woman with cervical cancer which doctors believed had spread to her lymph nodes. After surgery to remove the nodes, they discovered that what appeared to be malignant cells in a scan was actually tattoo ink. A similar misdiagnosis occurred in another patient with melanoma.

And then there are the infections

Hep-CThe most common infections associated with tattooing involve staphylococcus aureus or pseudomonas bacteria arising from poor skin preparation or equipment sterilization. “Staph” skin infections can become serious and even life-threatening, as antibiotic-resistant strains become more prevalent.

Three percent of tattoos get infected, and almost four percent of people who get tattoos recount pain lasting more than a month, a 2015 study from Tulane University School of Medicine found. About 22 percent of participants with new tattoos reported persistent itching that lasted more than a month.

A spate of mycobacterial skin infections in 22 people across four states in 2011 and 2012 was tied to a few specific brands of ink. The Centers for Disease Control and Prevention, in conjunction with local departments of public health, were able to contain these infections through intense tracking and investigation.

More serious tattoo-induced skin disorders like sarcoidosis, lichen planis and lupus-like reactions are increasingly reported in current literature. These skin problems can be more long-lasting and leave permanent scarring.

A study reported in Hepatology found that “tattoo exposure is associated with HCV (hepatitis C virus) infection, even among those without traditional risk factors. All patients who have tattoos should be considered at higher risk for HCV infection and should be offered HCV counseling and testing.”

Hepatitis, which is 10 times more infectious than HIV, can be transmitted through needles used by tattoo artists. It is the reason the American Red Cross restricts blood donations from individuals with newer tattoos done outside of regulated tattoo facilities.

A study from Tulane University added credence to these blood donation restrictions by showing that 17 percent of all participants had at least one tattoo done somewhere other than a tattoo parlor, and 21 percent admitted to being intoxicated while receiving at least one of their tattoos.

A youthful decision with adult implications

The primary reason Harris Poll respondents reported tattoo regret was they “were too young when they had it done.” The second most common reason, which coincides with the first, is the tattoo “didn’t fit their present lifestyle.”

Whether a tattoo depicts a name, a person, a place or a thing, its meaning and perception are in constant flux. Eric Madfis and Tammi Arford, writing about the dilemma of symbols and tattoo regret, note that “Symbols are dynamic in that they are time-specific, ever-changing, and always in a state of gradual transition.”

Tattoos have a different meaning depending on the interpreter, their relative history and knowledge, and they are dynamic because they can take on different meanings through time and experience. The first person to get a barbed wire tattoo on an upper arm could be seen as clever, inventive, unique and trail-blazing. The one-hundredth person to get the same tattoo was none of these things, and with time, if either was seen in public, both would receive the same reaction.

The “emotional response in the beholder” of any given tattoo can be based on “social stratification” and is not consistently predictable, according to Andrew Timmings at the University of St Andrews in the United Kingdom. Their interviews of hiring managers showed that tattoos can actually hurt job prospects.

Another study, at the University of Tampa, confirmed that 86 percent of students believe that having a visible tattoo is a detriment to their business prospects.

Researchers at the Harris Poll found that older respondents are less tolerant of visible tattoos as the prestige of the job position rises. While a vast majority of people age 51 and above are comfortable with professional athletes having tattoos, the acceptance decreases significantly when doctors, primary school teachers and presidential candidates are included.

Understandably, people who have many friends and family with tattoos are generally less stigmatized regarding their tattoo, and tend to suffer less tattoo regret, a study in The Social Science Journal reported in 2014. But the study also found that when tattooed respondents were exposed to individuals without tattoos, like in the workplace or institutions of higher learning, more stigma victimization occurred, and those impacted were more likely to suffer regret and ponder removal.

People often regret getting married when young, just as they do with tattoos. From www.shutterstock.com

Getting a tattoo, which is akin to a life-changing (and body-changing) decision, when young is really no different from getting married young (32 percent regret rate) or choosing a college major (37 percent change rate). For many, making a major decision when young is rife with regret. The difference with tattoos is having to face that regret on a daily basis.

As the pure number who have tattoos grow, the market for getting these tattoos removed has also found its niche. Laser tattoo removal services have rapidly grown across the nation and have become a multi-million dollar business, with additional potential for growth as the younger, highly tattooed, generations age.

But some problem tattoos can’t be removed

Laser with screenCurrent lasers still have limitations in the colors they can erase with added difficulty stemming from more vibrant tattoo colors. Darker pigmented people tend to have less success with certain lasers and require more sessions to avoid skin damage.

Because the laser shatters the pigment particles under the skin for removal by the body, the issues with infections, scarring and the ink spreading become a concern again. Tattoos covering extensive areas of the body are simply too large to tackle in one session, and could take years to remove.

Laser complications include pain, blistering, scarring and, in some cases, a darkening of the tattoo ink can occur, according to dermatologists.

As technology and the demand for tattoo removal advances, some of the limitations of current lasers will shrink. Newer, easy-to-remove inks are being patented, which may represent a healthier approach due to biodegradable ingredients, and a more predictable laser response. Picosecond lasers are also dramatically decreasing the number of sessions needed in select populations.

Teens Tattoos Piercings Front Cover aEducation is the key

With such a large number considering tattoos at a young age, informing young people of the health and social risks could help them avoid tattoos they may come to regret. Adding permanent body art education to health classes could mitigate some of these mistakes and decrease later regret.

The ConversationGreg Hall, Assistant Clinical Professor, Case Western Reserve University

This article was originally published on The Conversation. Read the original article.

Do Great Music Artists Die Young?

With the startling death of Prince at the age of 57,

many began to reflect on the seemingly ‘premature’ death of ground-breaking artists like Michael Jackson,  Elvis Presley, or Hank Williams.   Even as a physician, I began to wonder a number of questions.  Do great music artists die young?  Are there certain conditions that are more likely to cause a star’s demise?  And finally, is there some lesson to be learned that might help our remaining beloved music artists?

music artists die young
Prince in 2008. Photo curtesy of Micahmedia at en.wikipedia

I began by tabulating the vital statistics on the 252 members of Rolling Stone Magazine’s “100 Greatest Artists” from the music industry. The list ranged from the #1 group The Beatles with two members that met a premature death (John Lennon at age 40 and George Harrison at age 58) to the #100 group The Talking Heads without a death amongst them.  In between, were stars like Jimi Hendricks who died at age 27 from a drug overdose, Bob Marley who passed at 36 from skin cancer, and Marvin Gaye who was shot and killed by his father at age 44.  In all, 82 of the 252 members of this elite group had died.

Homicides and Accidental Deaths

music artists die young
Sam Cooke in 1961

There were six homicides for various reasons ranging from a psychiatric obsession that lead to the shooting of John Lennon, to the planned ‘hits’ on rappers Tupac Shakur and Jam Master Jay.  There is still a good deal of controversy surrounding the shooting of Sam Cooke by a female hotel manager who was likely protecting a prostitute who had robbed him.  Al Jackson Jr., the renowned drummer with Booker T & the MGs, was shot 5 times in the back by a burglar in his home amongst mysterious circumstances that still baffle authorities.

An accident can happen to anyone, but the “100 Greatest ” have more than their share. There were numerous accidental overdoses including  Sid Vicious of the Sex Pistols at age 21, David Ruffin of the Temptations at age 50, Rudy Lewis at age 27 of The Drifters, and country great Gram Parsons who was found dead at age 26.

While your odds of dying in a plane crash are about 1 in 5 million, if you are one of the “100 Greatest” those odds jump to 1 in 84.  Buddy Holly, Otis Redding, and Ronnie Van Zant of the Lynyrd Skynyrd Band all died in airplane accidents while on tour.

Increased Liver Disease

music artists die young
The Doors
By Elektra Records-Joel Brodsky

While liver-related diseases make up only 1.4% of the general population’s cause of death, it comprised over three times that number among the “100 Greatest Artists” deaths.  The increased occurrence of these diseases is probably related to the elevated alcohol and drug use in this group. Liver bile duct cancers that are normally extremely rare in the general population ran suspiciously high in our small but esteemed group with Ray Manzarek of The Doors and Tommy Ramone of the Ramones both dying prematurely from a condition that normally effects less than one in a thousand .

Tobacco Use Effects

music artists die young
Eddie Kendricks of the Temptations

The vast majority of the “Great 100” were born in the 1940’s and reached maturity during the 1960’s when tobacco smoking peaked.  As a result, an increased number of artists died from lung cancer including George Harrison age 58 of the Beatles, Carl Wilson of the Beachboys at age 51, Richard White of Pink Floyd at age 65, Eddie Kendricks of the Temptations at age 52, and Obie Benson of the Four Tops at age 69.  Throat cancer, also linked with smoking, caused the deaths of country great Carl Perkins at 65 and Levon Helm of The Band at 71.

A good number of the “100 Greatest” had heart attacks or heart failure  and included Ian Stewart age 47 of the Rolling Stones, blues greats Muddy Waters age 70, Howlin Wolf age 65, Roy Orbison age 52,  and Jackie Wilson at age 49.

We recently saw Glenn Frey succumb to pneumonia, but so did Jackie Wilson at age 49, nine years after a having a massive heart attack.  James Brown complained of a persistent cough and declining health before he passed at age 73 with the cause listed as congestive heart failure as a result of pneumonia.

Among those dead, the average age was 49.

One of the two shocking outcomes deals with life expectancy. While the average American male has a life expectancy of about 75 years, the males in the “100 Greatest Artists” who have died had an average age of just over 49 years and makes up almost one third of the entire group. Factoring their birth year and a life expectancy of 75 years, only 44  should have died by now, instead of the 82.  Incidentally, of the 44 that should have died based on life expectancy, 19 are still alive.

Alcohol and drug abuse

Dr Greg Hall
Click LINK to read more about alcohol abuse.

The second shocking outcome was the sobering and disproportional occurrence of alcohol and drug-related deaths ranging from Kurt Cobain’s gunshot suicide while intoxicated to Duane Allman of the Allman Brothers accidental death on a motorcycle while impaired. Members of legendary bands like The Who (John Entwistle age 57 and Keith Moon age 32), The Doors (Jim Morrison age 27), The Byrds (Gene Clark age 46 and Micheal Clarke age 47), The Band (Rick Danko age 55 and Richard Manuel age 42), and others all succumbing to alcohol or drug-induced death.

There were many including The Grateful Dead’s Jerry Garcia and country star Hank Williams who declined more slowly over the years from substance abuse while their organs deteriorated, and the official cause of death was heart-related, but in reality the cause may have been more directly related to substance abuse.

Alcohol and drugs accounted for at least one in ten deaths of these great artists, while nationally substance abuse as a cause of death effects one in 33. The threefold difference points to the much greater access and use of drugs and alcohol among these ultra-talented artists.

 

Too Much Opioid Use & Abuse

Dr Greg HallCurrently, the US is in the midst of a opioid abuse epidemic with heroin and prescription drug overdoses setting records across the country. Elvis Presley, Jimi Hendrix, Janis Joplin, Sid Vicious, Gram Parsons, Whitney Houston (who didn’t make this 100 Greatest List), Michael Jackson, and now possibly Prince all dying from accidental opioid overdose. While it is still unclear what the cause of death will be in Prince’s case, early evidence points toward opioids.

Controlling  the effects of oxycodone, fentanyl, heroin or morphine and thereby reducing accidental death is difficult, and for these stars and countless others across the world, in the end . . . impossible.  Put another way, without the inappropriate use of opioids or their addiction, all of these stars could still be alive.

What music could those who died young have created if they were given the chance to live and flourish? And more importantly for us, who’s next?

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.

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!!!

 

Flu Shot

Why it’s your job to get a flu shot – and call in sick if you do get the flu

Patricia Schnabel Ruppert, Columbia University Medical Center

Seasonal influenza is a major global health concern. Worldwide, annual influenza epidemics result in three to five million cases of severe illness, and about 250,000 to 500,000 deaths. In industrialized countries, most deaths associated with influenza occur among people age 65 or older, who are also 10-30 times more likely to be hospitalized due to influenza-related complications.

In the United States, the overall burden of influenza disease during 2014-2015 across all ages was 40 million flu illnesses, 19 million flu-associated medical visits and 970,000 flu-associated hospitalizations resulting in more than 36,000 deaths due to influenza-related complications.

You play an important role in stopping the spread of flu, not just to yourself but to others. As a doctor and public health professional who has treated many people with influenza, I’ll explain why.

And no, getting the vaccine will not give you the flu.

Protecting yourself also helps others

Almost everyone should get a flu shot, preferably before the end of October, though flu vaccine should still be administered until the season is over, usually by late spring. The influenza vaccine has been shown to be one of the most important preventive measures against the flu. Almost everyone can receive the flu vaccine. Exceptions include babies younger than six months and people who have serious reactions to the flu vaccine, like anaphylaxis, a serious and life-threatening reaction.

Some people gets hives from eggs, but this is not considered a serious reaction. If you are one of these people, it is still OK for you to get a flu shot from standard providers. Even those who have a serious egg allergy can get the flu vaccine in a medical setting.

Flu vaccine via Shutterstock. From www.shutterstock.com

For the 2014–15 influenza season, the CDC estimates that influenza vaccination prevented about 67,000 influenza-associated hospitalizations, an estimated 1.9 million illnesses and 966,000 medical visits associated with influenza.

Getting the vaccine is not just good for you but also for the larger community. About 70 percent of the population needs to receive the flu vaccine to ensure what we call “herd immunity.” That happens when a critical portion of a community is immunized against a contagious disease.

When that occurs, most members of the community, including those who are not vaccinated, are protected against that disease because there is little opportunity for an outbreak. Even those who are not eligible for certain vaccines get some protection because the spread of contagious disease is contained. This can effectively stop the spread of disease in the community.

Matching the flu vaccine with the strains

The seasonal flu vaccine protects against the influenza viruses that research indicates will be the most common that season. In
16 of the past 20 influenza seasons, the viruses in the influenza vaccine were well matched to the predominant circulating viruses. Due to the large numbers of flu-associated illnesses and deaths in the United States, combined with the evidence from many studies showing that flu vaccination is not only safe, but provides protection, the current recommendations for flu vaccination are supported.

The World Health Organization works with labs that collect specimens from hundreds of countries to determine which viruses might be most common each year. Since flu strains move fairly predictably around the world, the decision of which strains of flu should be included in the annual vaccine is made months in advance.

There are three main types of influenza virus that cause disease in humans; A, B and C. Influenzas A and B are associated with more severe illness and are included by the WHO in the flu vaccine each year.

Sometimes, there are three strains in the flu vaccine, two A’s and one B. There is also a vaccine with four strains, with two each of A and B.

For influenza A, there are two major antigens, or proteins, on the influenza virus. The body reacts to an antigen with an immune response by producing antibodies.

Influenza antibodies develop in the body about two weeks after vaccination and provide protection against infection with the strains that are in the vaccine. They may also be of benefit for closely related strains.

The major antigens on the influenza A virus are H (hemagglutinin) and N (neuraminidase). They both have multiple subtypes and can combine as different strains of influenza, such as H1N1 and H3N2. Influenza B is named for the location and year first identified and the lineage, for example, B/Brisbane/60/2008-like virus (Victoria lineage).

Typically, hens’ eggs are used to make influenza vaccine. Vaccine manufacturers inject influenza viruses into fertilized hens’ eggs, which are then incubated for several days to allow replication. The virus-containing fluid is harvested from the eggs and formulated into the vaccine.

In injectable vaccine, the influenza viruses are inactivated, or killed. The intranasal vaccine is live, but is made from weakened flu virus. The CDC is not recommending the intranasal vaccine this year due to concerns of effectiveness.

Neither influenza vaccine causes the flu, but you may still get the flu even if you are vaccinated. That can happen if you are exposed to a strain that is not in the vaccine, or if you were exposed within two weeks of being vaccinated. Also remember that although no vaccine provides 100 percent protection, the vaccine can make what would have been a bad case of the flu a much milder one.

The CDC conducts studies to measure the benefits of seasonal flu vaccination each year. These vaccine effectiveness studies confirm the value of flu vaccination as a public health intervention. While vaccine effectiveness can vary, studies show vaccine reduces the risk of flu illness by about 50 to 60 percent among the overall population during seasons when most circulating flu viruses are like the vaccine viruses.

This effectiveness is a major benefit because the flu affects five to 10 percent of adults and 20 to 30 percent of children each year. For the 2015-2016 flu season, the adjusted overall effectiveness of the flu vaccine was 47 percent.

And remember, even if it’s not a perfect match, it can protect you and your loved ones from getting a potentially life-threatening, yet preventable, disease.

Other things to do, too

While the vaccine has been shown to be one of the most important preventive measures against the flu, you can do other things, too. Wash your hands. If you cough or sneeze, cover your mouth or nose with your sleeve, not your hands. Avoid those who are ill.

Cough into your elbow, not your hands. Via Shutterstock. From www.shutterstock.com

Antiviral medication can help you feel better if you contract the flu, but it must be started early in your illness, so call your health provider when symptoms begin.

Good advice: Stay home if you have the flu.
Better advice: Get a flu shot!

The ConversationPatricia Schnabel Ruppert, Commissioner of Health, Fellows Ambassador New York Academy of Medicine, Distinguished Lecturer in Epidemiology and Community Medicine, New York Medical College, Assistant Professor of Medicine, Columbia University Medical Center

This article was originally published on The Conversation. Read the original article.

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!

 

 

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