Medical

Heartburn

by timryanmd

If you are taking a Proton Pump Inhibitor (PPI) like Prilosec or Nexium for heartburn or GERD, you should do what you can to get off it.   The long-term effects may not be good for your health.

PPIs are very effective at reducing the amount of acid in our stomachs. While there are some rare medical conditions that cause increased acid production and require chronic PPIs, most people are not taking these medications because they have too much acid. They are taking them because they have GERD (Gastroesophageal Reflux Disease).

GERD is a condition where acid from the stomach is getting into the esophagus where it doesn’t belong. With GERD the “trap door” or sphincter between the esophagus and stomach is not functioning properly and is causing reflux.  PPIs help because reducing the amount of acid in your stomach will also reduce the amount of acid that gets into your esophagus.

You might ask, “Isn’t just reducing the acid in your stomach avoiding the real problem which really has to do with that sphincter”?  And you might also ask, “Don’t we need acid in our stomachs for proper digestion?” Yes, we make hydrochloric acid for a reason. It helps digest food and is necessary for optimal absorption of a lot of nutrients. It also helps kill germs that enter our GI tract.

In fact, studies now are showing that PPIs contribute to certain deficiencies like Vitamin B12 and Magnesium. PPIs can also increase your risk of infections with germs like H.Pylori and C.difficile. They increase your risk of pneumonia. Some studies are even correlating chronic PPI with heart conditions and possibly kidney disease.

Stopping PPIs is not easy because of what is called “PPI rebound acid hypersecretion”. This is when the stomach cells generate (temporarily) MORE acid when the medication is stopped, thus more symptoms and so people resume their medications and end up dependent on the PPI.

What can you do? First, talk to your doctor about your symptoms and tell them about your medication use. Ask your doctor if it is safe for you to try and stop your medication. You may need other tests to establish a proper diagnosis.

If you have GERD, there are things you can do to improve the function of your “trap-door” LES:

  1. If you are overweight you must lose weight. Go here for advice on that, or make an appointment here.
  2. Don’t skip #1. Be sure and do that first!
  3. Eat smaller portions.
  4. Avoid foods that are known to contribute to reflux like alcohol, peppermint, citrus, tomato based foods, chocolate and caffeine.
  5. Elevate the head of your bed 6-8 inches

If you decide to stop your PPI, you need to be patient and do it slowly. There are no established recommendations on how to do this, but basically you would wean slowly over the course of weeks or months. You may make the transition with the use of other medicines like Zantac or Tums. Your doctor could probably give you advice.

Concierge and Direct Pay

by timryanmd

I’m occasionally asked, “Do you have a Concierge practice?”  My answer is, “Yes and no” because it depends on how you define “concierge”.  If you define “concierge” as the type of practice that provides individualized care, great service and the attention you deserve when you see a doctor then yes, I have a concierge practice.

But most people who ask about a “concierge” practice (now often called “Direct Pay”) are probably asking about a kind of practice where patients become members by paying a fee of usually about $1,500/year.

This membership fee promises service for patients beyond what they might otherwise receive.  Better service is possible because the Direct Pay doctor keeps his panel of patients very small, maybe 500, so he therefore has more time to spend with each patient.  This arrangement is very good for the doctor because he has few patients and a lucrative income.  It is pretty good for the patient because they get more time with the doctor and improved access if they can afford it.  I don’t have this new type of “Concierge Practice”.

The main reason I don’t have this type of practice is because I don’t think paying all that money provides nearly as much value for patients as a straight fee-for-service model like what I offer at my office.

It is also often the case that people who need the most medical care do not have the resources to pay for entry to a Concierge Practice.  Who is going to see them?  I think my system can do it best.  My prices are reasonable and a good value for everybody.

Concierge, or Direct Pay, is an interesting alternative style of practice and I’m confident it will grow.  I hope the future of medicine allows good doctors to establish their own unique practices so patients can find the individualized care that suits them best.

No Insurance Here

by timryanmd

Years ago, the doctor was paid directly by his patient.  While not a perfect arrangement, it worked very well for doctors and patients.  If someone was ill and didn’t have the money to pay, the doctor would help them anyway and receive payment later or not at all.  Patients were grateful and if they couldn’t pay, they would probably send other patients who could.  Doctors’ incomes didn’t suffer too much and they had great satisfaction in helping their neighbor or a stranger in need.  This is still the way it works at my office.

Taking money from an insurance company to treat a patient never seemed right to me.   It seems simple and honest for me to receive payment directly from the patients I treat.

Some might object, “but I can’t afford to pay the doctor!”  You might be surprised.  Let me show you a few reasons why it is better to pay your doctor directly.

First of all, you should actually be a little uneasy when a doctor is paid by a third-party because that means his loyalties will be divided.  The cold fact is that the doctor needs to accommodate those who pay him lest he go out of business or find himself unemployed.  Therefore the doctor will ultimately do what the insurance company says, and the insurance company requires doctors to do all sorts of irrelevant and wasteful tasks that have nothing to do with your care.

Third parties can also complicate reasonable decisions.  Imagine the scenario where a patient might have a simple, straight-forward problem like a tension headache.  If they are paying their own bill, they will be relieved when I tell them, “this sounds like a simple tension headache.  Try these few things and just let me know how things go.  You do not need a lot of tests or an MRI….”

If they have insurance, they are more likely to ask about the “free” MRI “just to be sure”.  And the doctor is more likely to order it.  Most of the time tests like this are a waste of time and money.

In addition, imagine how much money your doctor actually spends on overhead to deal with insurance!  He must purchase computers, software, printers, phone lines and pay for office space and staff in order to manage the insurance company.  What a headache.  Those costs are passed on to the patient one way or another.

Not using insurance can also make your visit safer.  Insurance rules are burdensome and confusing. They can turn a simple encounter into a labyrinth of documentation, approvals, unnecessary testing and other distractions that can cause chaos at your doctor’s office and more mistakes are likely.

Your doctor’s visit should be private.  Despite all you hear about HIPAA and patient privacy, the ironic fact is that the records in almost all doctor’s offices and hospitals are anything but private.  If you have insurance, your name is attached to a lot of billing and diagnosis codes that can be seen by a lot of bureaucrats who work for your  insurance company and the government.  Your data is not private unless you come to my office or one like it.  I do not send any information about you anywhere unless you tell me to or I am ordered by the courts.

You will be surprised how much farther your dollar will go and how much better your medical care will be when you pay directly. Look here and here for examples.

Have any questions? Just call 770-382-1984 or visit.

ER visits on the rise

by timryanmd

An article in WSJ points out that ER visits are on the rise.  This is the opposite of what was intended by the Affordable Care Act yet it is predictable for several reasons.

1. Primary Care doctors are already busy and already have a difficult time seeing sick patients urgently or on the same day.  They send patients to the ER.  This pattern will get worse because the ACA pays doctors more to do preventative care stuff like check cholesterol levels or order mammograms or do an Annual Exam.  Primary Care doctors will therefore fill their schedules with the preventative care visits and have less time to see sick patients.  The sick people will funnel to the ER more.

2. People with the exchange plans have limited options for a primary care physician.  The networks are small and the “primary care” doctor may not be nearby.  This might change over time, but I don’t think so.  The local ER will be an option.

3. Most of the new insurance plans have a high deductible (which is good) and unless they go here they won’t be to afford to see their doctor so they will go to ER .  Yes, the ER is much more expensive but in reality it is often “free” to the patient because they just don’t pay the bills.  The ERs and hospitals are required to see all-comers no matter what.

Most of the effects of the ACA will be the opposite of what was intended.

Quality at the VA

by timryanmd

The VA hospitals were under pressure from the top of the organization to increase the number of patients who could be seen within 30 days.   The VA employees quickly rigged a system to make the charting look like people were being seen timely when they actually weren’t.  Yes, one way to improve quality of care is to cook the books.

There is intense pressure to make changes like this because there are countless regulations that flow downhill from the bureaucracy.  Many of the regulations are silly and almost all are burdensome to an organization and ultimately result in compromising care rather than improving it.  Fudging the numbers and making something look different on paper is unfortunately common.

Should I take Cholesterol Pills?

by timryanmd

A lot of people wonder “Is my cholesterol too high?  Do I need to take a cholesterol medication prevent a heart attack?”  The answers are not that simple but the chance that taking a cholesterol pill (Statin) will help you is  low even if you’ve had a heart attack.  Plus, taking Statins is not without risk.

If you have a heart attack, the studies (which are arguably biased) show that taking a Statin will help prevent a second heart attack (secondary prevention) in a small percentage of people.  If you compared two groups of people and one group took a Statin and the other took a sugar pill for 5 years, the first group would have about 3-4% fewer heart attacks and maybe 2% fewer deaths.   In other words, about 96% of people treated with a Statin would not benefit from taking it.  But 4% would benefit.  As a doctor, I will have to treat 83 patients every day for 5 years with a Statin to prevent one death.

Other interventions are much better like committing to a Mediterranean diet, exercising, enjoying your work, or stopping cigarettes.

If you’ve never had a heart attack, the benefit of Statin drugs is not settled, but if they do prevent heart attacks, the percent of people who would benefit is very small.

TheNNT.com has brief and insightful summaries of the evidence.

This graph from the Framingham study is interesting.  According to Framingham, a Cholesterol of 210 was the most prevalent reading for those who never had a Heart Attack and 225 was the most prevalent reading for those who did.  There is obviously some correlation between elevated Cholesterol and increased risk of heart attack.   But correlation does not mean causation.  High cholesterol does not cause heart attacks.  If it did, the graphs would look much different.

The 2013 Cholesterol Guidelines are an improvement in several important areas.  I will comment on those guidelines in another post.