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Testing my patients

By | March 23, 2014

What is a screening test?
It is a test performed on somebody with no symptoms.

What is a screening test not?
A screening test is not a diagnostic test. It indicates the need for a diagnostic test, if it is positive.

We don’t screen everybody, all the time. Why not?
Because of the peculiar statistical reality that if your actual risk of a problem is very very low, then your risk of a false positive screening test is even higher than you would expect.

i want to be

Even if a test is very accurate, it can’t be absolutely perfect. Therefore, practically all positive results, on screening tests, are false positives. But we can’t tell you for sure if it is a false positive, without doing more invasive diagnostic tests – and those tests also may yield false-positive results – especially if your real risk of having the disease is very low.

How did I learn this?

I once worked in a place where the basic rule of thumb was that every “well woman” gynecological exam included routine tests for gonorrhea and chlamydia. I didn’t think twice about it.

So when an older Puerto Rican Catholic lady came in for her yearly Pap test, naturally I also checked the box on the form adding the “routine” test for gonorrhea – which came back positive. (Her chlamydia screen was negative.) The nurse phoned her promptly with the results, and asked her to come in with her partner for treatment, which was also routine.

Then all hell broke loose.

vd poster

…Okay, well, not all hell. But a very grim-faced husband accompanied her, and tears were shed. Each were convinced that the other had been unfaithful. They were married in the Church as teenagers, and at this point in their lives they only rarely had sex; he was retired, and stayed at home almost all of the time – neither of them had any reason to be suspicious, other than that stupid lab test. Nothing like this had ever happened to them before.

For the eighty millionth time I regretted not learning to speak Spanish; now I also regretted not having considered the basic statistics of screening tests applied inappropriately. (I only mention that they were Puerto Rican, Catholic, and married as teenagers because they emphasized these characteristics to me, in protesting their innocence.)

west side story

I know you must be thinking, what a bone-headed blunder. Seems obvious, right? But sometimes in medicine, we just go through our set procedures without overthinking every little bit of what we do, especially when it comes to something as superficially harmless as a “routine screening.” Think about this the next time your doctor orders “routine tests” – or the next time you yourself go to the doctor to request what you think is a simple set of screenings.

A friendly colleague looked up the statistics on the test for me and showed me where I went wrong. I don’t have those figures today. I wish I’d held onto our back-of-the-envelope calculations!

In general, though, the gonorrhea tests I perform today in my two medical offices have “sensitivity [probability of true-positive results], 87.5-100%, and specificity [probability of true-negative results] 98.1-99.6%.”

(That possible 100% sensitivity, for a screening test, raises my eyebrows. No false positives? None? Only if the lab tech is somehow actually going back and visualizing the actual bacteria swimming around in the samples every time – hard to feature.)

microscope

Let’s say I estimated that the older married lady had only a one-in-a-thousand chance of actually having gonorrhea. If the true-positive rate of my test was 87.5%, like it says, then the chance that her positive result meant she really had gonorrhea would actually be only 0.7%. (See here for a calculator you can use to figure this out.)

See? She could have a one-in-a-thousand chance of really having the disease, but still have a positive test. Yet even with that positive test, her chance of really having gonorrhea would only be seven in a thousand.

If your true risk of a disease is near zero, then practically every positive test is going to be an error, no matter how accurate the test is. (An “accurate” test has a high rate of truthful results: few false positives and few false negatives.)

My lady had a false-positive result on a test that never should have been performed in the first place.

We worked it out, and were friends again by the end of the visit, but it changed the way I work.

sunset

In the example above, with a screening test that has 87.5% sensitivity (true-positive rate), if a person’s real risk is maybe 1 in 4, the chance that a positive test really indicates true disease might go up to 70%. The test results are more reliable.
If the risk is higher, say 3 in 4 or 75%, then the trustworthiness of a positive test result goes up to 95%. Pretty darned good.

But how do we decide these risks?

We eyeball them – maybe accurately, maybe not. How much of the disease is around in our area? What are the chances of individual exposure and vulnerability, given various lifestyle details (frequency of unprotected sex, relative immunosuppression, etc.)? These are things to be considered, when choosing screening tests – and experience has shown us that we often overestimate people’s risk of serious rare diseases, just because the stakes would be so high for any given individual.

~ Sometimes you simply don’t believe, or can’t explain, screening test results, without more invasive testing.
~ Sometimes that follow-up testing carries medical risks of its own.
~ Sometimes people receive treatment – and side effects of treatment – that they didn’t actually need, on the basis of screening tests that we now know were performed inappropriately.
~ Sometimes people get mad hearing all this, because they are convinced that their lives were saved by treatments that I suggest might not have been necessary.

People have been even more confused over the last few years, because screening recommendations have been changing.

bayes

For example, one chronology shows that in the 1980s, we told women to get a “baseline” mammogram starting at age 35, then a screening mammogram yearly after age 40, and to examine their breasts at home monthly.

Then in the 1990s, we said to get a mammogram every 1-2 years after age 40, yearly after 50 and keep checking those breasts at home.

In the 2000s, we said mammogram yearly after 40. Home exams became optional.

Now we say, mammogram every 2 years, age 50-74. No home exams, and office doctor exams really aren’t necessary, because doctor exams aren’t as reliable as mammograms are. And people feel nervous. They wonder if we’re being less careful these days, less cautious.

However, this isn’t the case. It’s because with better data, our screening parameters have to change. It’s really important that they change.

pap

As the years roll on, and more and more data are collected, we understand better how to minimize the risk of getting a lot of false positives, even while we try to avoid false negatives.

Here is a list of cancer screening tests recommended, under appropriate circumstances, by the Preventive Services Task Force (USPSTF), our #1 recommendation agency:

~ Pap test, for women who have a cervix, every 3 years, ages 21-65, or every 5 years for ages 30-65 if their HPV (cancer virus) test is negative (for cervical cancer)
~ Mammogram every 2 years, ages 50-74 (for breast cancer – recommendations currently under revision)
~ Family history questionnaire, for women with reproductive cancers in the family, to see if they should get genetic counseling (for hereditary breast and ovarian cancers)
~ Stool card yearly or colonoscopy every 10 years, ages 50-75 (for colon cancer)
~ Low-dose CT scan yearly for smokers aged 55-80, who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years (for lung cancer)

Here are some cancers that we don’t have good screening tests for: mouth/throat, ovarian, pancreatic, prostate, bladder, skin, testicular, and thyroid. There might be screening approaches that have been tried or are under investigation for these cancers, but they aren’t good enough to assure you of a low risk of the test results being wrong.

Medical science is simply not perfect – and approaches we used to think were “good enough” are now known to be unacceptably poor.

bloodletting

We also do screening tests for cardiovascular problems:
~ Blood pressure measurement, for everyone age 18 and up. Did you know it’s a screening test? It is.
~ Weight checks as screening for medically-defined obesity, in all adults. (Medical obesity is defined as a body mass index of 30 or more – for example a 5′ person who weighs 155 lbs or more, a 5’6″ person at 185 lbs or more, or a 6′ person at 220 lbs plus. “Obesity” in this setting is a medical category, not a judgement.)
~ Blood test for diabetes, in adults who have high blood pressure.
~ Cholesterol test, all men 35 and up regardless of risk, or starting at age 20 if they are at higher risk. Same test for women 20 and up, only if they are at higher risk. (Risks include overweight, high blood pressure, smoking, high blood sugar.)
~ Aortic ultrasound for men aged 65-75 who have ever smoked. This checks for an aortic aneurysm, which can be caused by smoking, and which can kill you if it ruptures.

But we don’t screen for:
~ Heart risk factors that don’t have enough evidence to be used as screening tests: high-sensitivity C-reactive protein (hs-CRP), coronary calcium score or “heart scan” (CAC), homocysteine level, and lipoprotein(a) level.
~ Resting “routine” EKG, and treadmill stress test, are not used as screening tests in people without heart-disease symptoms, regardless of their risk.
~ We also don’t do screening tests of the leg or neck arteries – the so-called ankle-brachial index or the carotid intimal media thickness.

We screen for infectious diseases:
~ Chlamydia (in heterosexually active women under age 25)
~ Gonorrhea (in women at risk)
~ HIV (ages 15-65)
~ Hepatitis C (if born 1945-1965)
~ Tuberculosis (in folks at high risk of exposure)
~ Syphilis, rubella, and hepatitis B in pregnant ladies, and bacteria in the urine at 3-4 months of pregnancy.

Pregnant women, newborns, kids and teens get a lot of screening tests – too many to detail here.

We don’t have any screening test for herpes. (I get a lot of questions about this, and have even written a whole handout just on that subject.)

We screen adults for depression, if our office has resources to help with depression. We screen everybody 18 and up for risky alcohol use. We screen women of childbearing age for family or partner violence, by asking them questions. All of these “psychosocial” screens are a simple set of questions. You might not even be aware your doctor is screening you for these.

We screen women 65 and older for osteoporosis (thinning of the bones, a risk for fractures) – younger if they are at higher risk, for example from an early menopause.

We don’t have any guidelines yet for when and how to screen for vitamin deficiencies, including vitamin D and vitamin B-12.

We don’t screen older folks for visual acuity, glaucoma, or hearing loss. Once again, screening is for people without symptoms. If the person has symptoms, they might need diagnostic testing to confirm the diagnosis and assess its severity.

You might be interested to know that the screenings – and other recommendations – listed by the Preventive Services have been incorporated into the Affordable Care Act, so that insurances are now required to provide them without additional cost to you.

early

A couple of final counter-intuitive facts about screening tests.

For years, we’ve been given the rule that “Early detection saves lives” regarding cancer, but that isn’t always true.

For example, if a cancer keeps killing people at the same age regardless of how early it is detected, then early detection isn’t saving lives. You can spin the statistics to make it sound like “people are living longer after diagnosis,” but if they aren’t actually having longer lives, then earlier diagnosis is kind of a sleight of hand trick.

Also, it is easier to “early detect” slow-growing cancers that are less dangerous. More men die with prostate cancer than die from prostate cancer, for example – meaning, you could have a growth in your prostate for many years, without even knowing it, without it making you sick, without requiring treatment.

Once you know it’s there, you and your doctor are both likely to demand treatment, regardless of the unpleasant and sometimes dangerous side effects of treating this cancer which may never have actually harmed you – but this is because our cultural standard is to treat cancer aggressively, not because it is medically necessary to save your life and your health. “Watchful waiting” (a.k.a. “active surveillance”) may be a preferable option in many cases. This means monitoring the cancer on a regular basis, but not intervening unless or until it progresses.

Actor Sir Ian McKellen, for example, has had prostate cancer for years. He says, “I have waitful watching. I am examined regularly, and it’s just contained, it’s not spreading. I’ve not had any treatment.”

gandalf and magneto

You may have read the recent hullaballoo over a huge study demonstrating that, simply put, screening mammograms don’t save lives at all (explained in detail here – scroll down for the bottom line, if you’re in a hurry). The USPSTF recommendations don’t reflect this game-changer yet, but I expect they will.

Some scientists even suggest that some “cancers” found through routine screening should not even be called that – a small semantic difference that changes the way we think about these issues. In the Journal of the American Medical Association, Esserman et al. said “use of the term ‘cancer’ should be reserved for describing lesions with a likelihood of lethal progression if left untreated.” Not all “early detections” are alike:

“Screening for breast cancer and prostate cancer appears to detect more cancers that are potentially clinically insignificant. Lung cancer may follow this pattern if high-risk screening is adopted. Barrett esophagus and ductal carcinoma are examples for which the detection and removal of lesions considered precancerous have not led to lower incidence of invasive cancer. In contrast, colon and cervical cancer are examples of effective screening programs.”

See what they’re saying? Inappropriate screening doesn’t equal early detection, and doesn’t save lives.

This is why the guidelines keep changing, and we should be glad that they do.

swat the fly

My take-home messages:

Ask your primary care provider what the screening guidelines are for you as an individual.
Remember that screenings are for people who don’t have symptoms, but who might have risk factors.
Don’t be suspicious of math and science.
Expect that more will be revealed.
Stay tuned.

public health hipster

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This is your heart. This is your heart on statins.

By | January 5, 2014

The “musician’s musician,” Alex Chilton (of the Box Tops, Big Star, and others), died when he was 59 years old. His story has haunted me since I read it, in the spring of 2010.

“At least twice in the week before his fatal heart attack, Chilton experienced shortness of breath and chills while cutting grass. But he did not seek medical attention… Chilton called [his wife] after suffering another episode; she arrived home before the ambulance, and drove him to the hospital. He lost consciousness a block from the emergency room, after urging [her] to run the red light.”

alex chilton

Like everyone, I’m familiar with the scary calculus we perform to decide whether or not to go to the emergency room. It costs on average 40% more for one emergency room visit than it costs for a whole month’s rent. What if you go, and it’s just indigestion? Here’s what:

“When Mike complained of indigestion, Susan became alarmed. She had just read about the symptoms of heart disease in the local paper… Fifteen minutes later he was on a gurney rolling through the double doors of the emergency department… He left the hospital the following Tuesday… with a clean bill of health and a diagnosis of “gastric reflux.” …I looked at his hospital bill. Charges for everything… came to just under $11,000.”

That was three years ago. Not sure what the charges would be today – whether more or fewer, fancier or simpler tests would be performed.

ed view

Heart issues are scary.

Today in my office, a patient told me, “Somebody has a heart attack in the US every 34 seconds.” I went back to the source material – the Heart Association’s 2013 Statistical Update – to verify this fact (it’s on page 186).

About every 60 seconds, someone dies from one of these heart attacks.
73% of these deaths occur outside of the hospital – as with Alex Chilton.
20% of these deaths are of people younger than 65. (Chilton was 59.)
50% of men, and 64% of women, who die suddenly from a heart attack, had no previous symptoms of heart disease. (E.g., “experienced shortness of breath and chills while cutting grass.”)

What is heart disease? I study about it all the time, because as a primary physician, I worry. I don’t have a crystal ball, a coronary scanner, a magic wand, or an intravascular ultrasound probe, to tell you whether you have serious blood-vessel problems. Every time I see you, I tell you how to lower your risk of damage to the heart vessels, but “lifestyle measures” prove to be too difficult for most people, at least just on my say-so. (If you survive a heart attack or stroke, you’ll find “lifestyle measures” right at the top of your personal priority list, though.)

You often ask me for a pill to help you quit smoking, or get to sleep, or quell your anxiety – but then, you don’t want me to give you a pill to lower your blood pressure or your cholesterol. It puts me in a bind.

That bind is about to get worse.

doctor science

But let’s back up.

I just finished re-reading “Broken Hearts: The Tangled History of Cardiac Care” by David S. Jones – a history of what we know, and what we don’t, about heart disease – its natural history, and its treatment.

In times past, it was recognized that type-A hotheads could give themselves heart attacks with fits of temper, and nervous intellectuals could literally die of a broken heart. But then, on the other hand, a “plumbing” model, of coronary blood vessels as “clogged pipes” needing to either be reamed out or bypassed, became popular. I’d guess that these stories are the ones which most people on the street usually use, to understand the situation.

But that’s not what doctors currently believe.

pipes

The story we believe now is this:

LDL, which is “bad cholesterol”…

To start with, it’s not really cholesterol. It’s a fatty protein, like a balloon, full of cholesterol. LDL carries cholesterol around in the bloodstream, delivering it from the liver to various places.

LDL tends to burrow into the walls of weakened blood vessels, where it becomes rancid (oxidizes) and causes an immune reaction. The immune system basically tries to kill it.

Important note: This situation is made much worse when the LDL is sugar-coated, as occurs with pre/diabetes, impaired glucose tolerance, and metabolic syndrome.

Immune white blood cells enter the area and try to eat up the gunk, turning into “foam cells” and producing inflammatory changes, like forming a crust of calcium, and stimulating growth of arterial muscle cells. This mess of crud is called “plaque” or “atheroma”. The resulting hardening of the arteries is also called “atherosclerosis” (“ATH-er-oh–skla-ROH-sis”).

atheroinflammo

It occurs in blood vessels throughout the whole body, but becomes most problematic when it occurs in the arteries that nourish our hardest-working muscle of all, the heart. If conditions make the surface of the plaque unstable, and it “ruptures,” this causes bleeding and clotting, and can block off the normal blood flow.

Then you have it: a heart attack – the heart muscle cells starved of oxygen, and dying, replaced by scar tissue.

Unstable plaques, and resulting thrombi (clots of blood and crud) and emboli (traveling clots) – can block off blood flow and cause cell death, in other parts of the body, as well – from head (stroke) to toe (peripheral artery disease), and everything in between, including belly (mesenteric ischemia), and even the “naughty bits”/”special parts”: “Atherosclerosis… often affects the penis first… Erectile Dysfunction can be a warning sign that a heart attack or a stroke may follow, often in the next 3 to 5 years.”

Basically, if one artery has a bunch of crud building up in it, all the others do, too.

athero kidney

This is the situation primary doctors worry about: blood vessels that aren’t great to begin with, due to too little exercise, too little peace, too much air pollution, too many trans fats, metabolic problems and smoldering inflammation. It’s the American way of life, starting from our Happy-Mealy, X-Boxed, high-stress childhoods. Then come years and decades of high cholesterol, and the development of inflammatory plaques, with their relative in/stability.

Primary doctors got in enough trouble a few years ago, when we said that studies show obesity and high blood sugar and high blood pressure and high cholesterol are not only major killers, via arterial diseases, but are also preventable.

We made it worse this year by formally classifying obesity as a disease.
“Disease: a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms.”

Although the shoe seems to fit, and 78,400,000 adults and 12,700,000 children are currently wearing it, “those arguing against it say that there are no specific symptoms associated with [obesity] and that it is more a risk factor for other conditions than a disease in its own right. They also say that ‘medicalizing’ obesity by declaring it a disease would define one-third of Americans as being ill.”

Hmmm… Well, a third of female deaths already are from heart disease, and a quarter of male deaths are from heart disease, so I personally don’t find it shocking or controversial that a large bunch of folks could be “defined as being ill” despite not already being in the hospital.

fat fit

Now, more trouble: the newest guidelines say to consider using statins – cholesterol-lowering medicines – for primary prevention — to prevent arterial plaques and clots from developing in the first place.

And even though most of us think an ounce of prevention is definitely worth a pound of cure, many folks draw the line when it comes to statins. To be specific: patients tell me “I want to be healthy, but I certainly won’t take a statin.”

Why is this?

Here is what statins do:

They reduce the liver’s output of LDL and are anti-inflammatory. They stabilize plaques by reducing the foam cells’ feeding frenzy in the artery wall. Ultrasound studies show plaques physically, measurably shrinking away, when people take statins.

So far, statins have prevented 18 “major events” (heart attacks and strokes) in every 1000 people who take them for 5 years. For example, “the Jupiter Trial was a randomized, double-blind, placebo-controlled, multicenter trial that involved 1,315 sites in 26 countries. Participants were randomly chosen to be part of one of two groups: those who took rosuvastatin 20 mg daily or those who took a placebo (a pill containing no drug). The trial was scheduled to run for five years, but it was terminated after 1.9 years because there was an overwhelming amount of data that showed that participants who were taking a statin had a reduced risk of CVD [cardiovascular disease].” This kind of result has been shown again and again.

Fun fact: did you know that many of the “side effects” people used to fear from statins, have pretty much been solved? For example, the water-soluble statins, pravastatin (generic and as cheap $4 a month) and rosuvastatin (not generic yet, still very spendy) aren’t significantly metabolized by the liver and therefore don’t significantly interact with other substances or medications that are (e.g., you can eat all the grapefruit you want). Pravastatin reduces your risk of diabetes. People who experience muscle pains when they take a statin usually don’t experience them again, if they stop the statin and then start it again. (Muscle pains are often associated with vitamin D deficiency, which is awfully common, so fixing that while lowering cholesterol is an obvious win-win.) Some statins, rosuvastatin in particular, can be taken just once or twice a week. Also: Do statins cause dementia? Short answer: No. Opposite.

leopard fit

Statins make the inner lining of the blood vessels healthier. For this reason, they’re under investigation for sickle cell disease. They do a bunch of other stuff, too; they have been associated with a lower risk of some cancers, especially reproductive cancers like those of prostate and breast, and also colon cancers. They strengthen bones, reducing the risk of fractures in old age. They improve wound healing and reduce bacterial infections, even in life-threatening severe sepsis. They improve health and lower mortality in people with COPD, the chronic lung disease usually caused by smoking.

Eventually, IMHO, the action of statins on arterial plaques may turn out to have been just one useful side effect related to their immuno-modulating activities, which are beneficial for those of us who have a ton of “lifestyle”-induced chronically out-of-control immune activity a.k.a. “inflammation.”

even a slight one

The new guidelines say statins aren’t only for people who are obviously sick, or who are obviously high-risk for heart attacks and strokes. Now, they’re for anybody who wants to reduce their risk before it becomes obvious.

The new guidelines also say, we don’t have to treat the lab test any more. This is a big change in thinking! There’s no generic “goal LDL” anymore. If you already know you’re at risk, it doesn’t matter that much what your cholesterol levels are. It only matters that you reduce your risk, which will very likely include taking a statin.

(Incidentally, the other meds that were invented to lower cholesterol, including prescription niacin and fibric acids? They turned out not to save lives. Only statins, in the huge big studies that have been done over the last 30 years, have finally been shown to save lives in a significant way.)

Fancy new brand-name-only statin, or tried-and-true $4 generic? It doesn’t matter. Lower your LDL, lower your risk.

we can do it

The new guidelines also detail necessary “lifestyle changes” that reduce the risk of heart attack and stroke. These don’t appear, to me, to be much different from what my patients and I have been telling each other for years. Don’t use tobacco; exercise every day; don’t drink a lot; go easy on the salt and fat and starches. Are your weight and blood pressure normal? Your blood sugar and cholesterol? Not really? Fix them.

Over a certain age, the way the evidence stacks up, you’re likely to be categorized as “at risk,” and that’s just because… you are. Over a certain age (bio-men, 45; bio-women, 55), you are simply at more risk of a heart attack or stroke — the biggest killers, by far, in our nation — as well as all the other blood-vessel-dysfunction diseases (stroke = #4 after cancers and COPD).

It becomes much more important that you do something now, not next week or next month or next year.

It’s not just “medicalization.” It’s the awful truth.

Nobody likes to hear this! The reaction has been vitriolic.

resolution

An article from Natural News asserts,
“Big Pharma-backed groups are pushing to more than double the number of people currently taking statin drugs.” [And so on.]
Comments include:
“Most Doctors are just Shills and Sales Proffessionals to Promote Big Phama’s POISONS.”
“MD’s aka moronic dickheads are basically shooting the firemen who show up at the scene to put out the fire. I am not going to an MD for anything ever again, unless I break a bone or something. They are all hilariously unqualified with virtually all health issues.”
“I seen this coming for a while when some moronic doctors were stating in articles that all Americans should be on statins.”

Et cetera.

Joseph Mercola, “alternative medicine proponent, osteopathic physician, and web entrepreneur, who markets a variety of controversial dietary supplements and medical devices,” says,
New treatment guidelines for high cholesterol will likely DOUBLE the number of Americans being prescribed these dangerous drugs… Panel members have concocted a bizarre justification for these actions… This truly appears to be a recipe for disaster.” [And so on.]
The comments, all 150, begin:
“Statins kill five times as many people each year as all the terrorist related deaths ever recorded on American soil.”
…and run all the way through to:
“These drugs are dangerously harmful and unnecessary. I wouldn’t worry so much about cholesterol ‘numbers’, and instead of statins, just take a lot more vitamin C.”
Et cetera.

TV personality Dr Oz says, “I believe that many people can improve their cholesterol and their overall heart attack risk without resorting to statins. A Mediterranean diet, smoking cessation and exercise have been shown to lower the risk of (and sometimes even resolve) heart disease and diabetes.”

This makes me think he didn’t read the entirety of the guidelines, which are in four parts and address “Blood Cholesterol, Obesity, Healthy Living, and Risk Assessment.”

Alternatively, he may simply know, and therefore say, what his listeners want to hear, as indicated by the comments:
“I firmly believe that sugar and processed foods are the heart disease culprits. Medical professionals are way too diligent at prescribing statins.”
“I look forward to the day when the mainstream health world accepts the fact that cholesterol isn’t really the problem… Then medical professional may stop cramming statin drugs down our throats!”

Et cetera.

dr oz

I know my patients’ first reactions may be similar, at first.

Everybody wants to believe that they can reverse course, turn this Titanic around, lower their risk, and/or prevent the heartbreak of unexpected death or disability — just by “eating right” [vaguely stated], “exercising” [vaguely stated], maybe doing a “cleanse” or taking a supplement recommended by Dr. Oz [$148 or so] — sometime real soon.

They are good people, and they truly want to protect themselves and their families from the heart-disease bummer they’ve already seen their older generations go through.

Selfishly, I would like them to protect me from the heart-disease bummer I’ve walked many others through.

grampy

But many of them I’ve known for years now, and they weigh more, not less, than they used to.

They’re more stressed, not less. Exercise and meditation are still on their to-do list, not their daily-routine list.

One by one, they’re getting danger signs that really alarm me.

“It’s like something pressing on my chest, and I get so tired…”
“I get this pain in my shoulder that takes my breath away…”
“My legs cramp up when I walk half a block…”
“I get dizzy, and I can hear my heartbeat swishing in my ears…”
“…so I have to sit down.”
“…so I go back to bed.”
“…so I don’t go out much anymore.”
“…so I can’t walk the dog anymore.”

beautiful heart

An online patient forum includes these voices, filed under “I Had A Heart Attack”:

“I had a mild heart attack and had to have two stents placed. This was about 6-7 weeks ago. The problem is that I am feeling so tired still that I can’t seem to do anything. I have not been able to get back to work, nor do anything other than go out for about an hour a day. Even a phone call can wipe me out.”

“My father had a heart attack. He was on his way to work when he felt pain in his chest and it was hard for him to breathe. He called his brother to take him to the hospital, the doctors saved him. The problem is that he is very tired, sleeps a lot, depressed. He is not the same person again. This changed the environment at home.”

“I turned 56 in June. August 10th I had a heart attack. I had no idea what was happening. I was taken to ER… The first stent failed when I was in ICU. Back to surgery I went… Now I’m faced with all kinds of changes iny life and I don’t know how to cope with all this.”

“I haven’t even reached the year mark yet and somehow my heart is sick again. It just is a constant cycle of all my illness’s making my life so unmanageable at times it gets scary knowing that I’m not in control. And at this point my illness has morphed into who I am is that crazy?”

sad

After all this reading – of cardiovascular physiology and biochemistry, of drug trials and epidemiology, of patient forums and patient charts – I now feel it’s ridiculous to be afraid of statins, to be more afraid of statins than one is of heart disease.

Yes, I’ll continue advising patients to reduce their stress (often, however hard it is to hear, by telling them to reduce their exposure to toxic workplaces and toxic family situations, as well as de-escalating their chronic stress responses over the long term)…

And to lower their dependence on “comfort calories”, “maintenance stimulants,” and “misery relievers,” and to walk outside for 20 minutes every day…

And you betcha, Dr. Oz, I’ll also suggest fish oil and walnuts and vitamin D, as most of us off-camera primary-care types have done for years

But I’ll also recommend a statin, for most of y’all. And I’ll take one myself.

…Partly in memory of Alex Chilton.

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Dr. Leigh and Obamacare: Day 1

By | October 3, 2013

I was surprised to see Cover Oregon up and running on October 1st, as scheduled.

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When I logged on in the middle of the day, it hadn’t crashed and wasn’t still under construction. The national website, of course, had some struggles. That’s the one folks use if they live in a state that refused to create its own website. “The Department of Health and Human Services said 2.8 million people visited the federal HealthCare.gov since midnight, with 81,000 reaching out to call centers and 60,000 requesting live chats.” One estimate said a million users before 7:00 a.m. on Day 1. That’s a popular website.

Here in Oregon, on Day 1, 80,000 visitors to coveroregon.com looked at 750,000 insurance pages, so apparently there were hiccups, though I didn’t see them.

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I went to the “find out about insurance” page on Cover Oregon to find out more detailed information about what individual plans would offer my family. I thought the search engine was very flexible and user-friendly.

I entered the ages and smoking status of my household members and our estimated income.

This allowed me to browse plans, which I could sort and filter, by quality rating, price, deductible, and out-of-pocket expenses (low to high, or high to low, on each of these).

My discount, called my “APTC,” was given both as a yearly and as a monthly total. (“APTC stands for advance payment of premium tax credit.”)

I could also filter my results by level of plan – Bronze, Silver, Gold, Platinum – as well as by insurance company and plan type: EPO or PPO, and by HSA-qualified or not.

What does all that mean?

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First, when you use this kind of website, you can “filter” your results by specifying what choices you want to see — for example, only Silver plans, or only high-deductible plans.

Second, when you get a list of results, you can re-order or “sort” them, for example in order of deductible, low to high, so the first results at the top of the list would have the lowest deductible. Or you could sort them by quality rating, high to low, so the start of the list would have 4-star plans, followed by 3-star plans. (Quality ratings come from consumer reports.)

A deductible is the amount you would have to pay before the insurance would start paying for anything. (Monthly premium payments don’t count towards your deductible.) However, even with higher deductible plans, preventive care is still going to be free of charge, by law.

“Level” of plan refers to how much of the expenses it will cover. Bronze plans cover 60%, and you pay the other 40%, for example. Silver plans cover 70%, Gold plans cover 80%, and Platinum plans cover 90%.

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How can you figure out what those expenses will be? After all, 40% of $500 is a lot more than 40% of $100. One way to estimate costs might be to use the Health Care Blue Book website. It allows you to enter your zip code and then search for estimated costs of health care.

For example, in my zip code, they estimate an “Office Visit, Established Patient, Level 4 – Moderate or higher problem(s) requiring counseling and treatment, possibly coordination of care with other providers– approximately 25 minutes with the doctor” to cost $173.

If you had a Bronze plan, you would pay about $69; Silver, $52; Gold, $35; Platinum, $17.

(If we lived in Jackson, Mississippi, the same visit would cost $161. If we lived in central Washington, D.C., it would cost $211. That is one of the values of the Health Care Blue Book – eyeballing different rates for different places.)

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About the acronyms:
~~ EPO plans are “Exclusive Provider Organization” plans, and they don’t cover anything out-of-network except in case of emergency. If your insurance was EPO, you could *not* go to a practitioner who wasn’t contracted to that insurance. Out-of-network practitioners are “excluded” by an EPO. If you ask Dr. Google, you should know that most of the rules for HMO plans also apply to EPO plans.

~~ PPO plans are “Preferred Provider” plans. Basically, the insurance “prefers” that you see one of their contractors, but they *will* pay some amount for out-of-network care.

~~ An HSA is a Health Savings Account. It allows you to save money for health issues. They are not taxed, they accumulate from year to year, and they can be bequeathed and inherited.

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So I entered our projected taxable income as $51,000 for 2 nonsmokers in the 40s-50s age ranges. (Remember, your insurance discount is based on what you declare as income for your taxes.)

I got back a list of plans. I ordered them by deductible, low to high. I would prefer no deductible at all, because, like everybody, I will delay seeing a doctor if I have to pay for the whole thing ($173?!) without any insurance help.

~~ The Co-op PPO Bronze plan (60% of expenses covered), with no deductible, which I like, is $751/month, less our estimated discount of $154/month, for a total of $597/month for two adults. That’s $298 apiece each month.
~~ Their Silver plan (70% of expenses covered) is $712/month for two, after discount, again with no deductible.

Other plans carry deductibles. Remember, this is the amount you have to pay out of pocket for healthcare before insurance starts paying anything.
~~ Lifewise has a Gold plan (pays 80% of expenses) with a $500 deductible for $658/month after discount.
~~ Moda has a Gold plan with a $750 deductible for $559/month, after discount.
~~ A Moda Silver plan (70% covered) with a $1000 deductible costs $475/month, for two, after discount.

Don’t forget, these are estimated prices specifically for our family’s situation – not yours. We make too much money to be eligible for Medicaid, but you yourself might qualify, in which case you would pay *zero.*

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If my twentysomething daughter, who lives with us, chooses to be counted as a dependent on our taxes, she can be included in the policy. (Alternatively, she could file separately and as a low-income adult, she would be eligible for Medicaid. Under the ACA, her Medicaid policy would be required to provide just as good coverage as our private policy would – something that wasn’t true in the past.)

If she were included, her well-below-poverty income would be added to ours, for an estimated $60,000 taxable income. Now our discount is estimated at $256/month.

For three folks:

Co-op Bronze, no deductible, $727/month after discount. ($242 each.)
Co-op Silver, no deductible, $879/month after discount. ($293 each.)
Co-op Gold, no deductible, $1090/month after discount. ($363 each.)
Lifewise Gold, $500 deductible, $807/month after discount. ($269 each.)
Moda Gold, $750 deductible, $678/month after discount. ($226 each.)
Moda Silver, $1000 deductible, $568/month after discount. ($189 each.)

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You can’t look at the complete plans online as yet, to find out precisely what it means, for example, to have 60% or 80% of your costs covered. This part of the website is still rolling out. Instead the site can connect you with multiple helpers trained by the state. It says,

“Find a certified insurance agent or community partner to help you apply for health insurance and financial help through Cover Oregon…at no cost to you! Certified agents can sell health insurance through Cover Oregon and can offer advice about carriers and plans. Certified community partners are trained to help you apply and enroll, but they cannot give advice on carriers or plans. You will be able to apply online without help from an agent or partner soon.”

Many are already insurance agents, but others are working just on this project – for example, in my home town, one whose “organization” is listed as “Oregon insurance lady.”

Later this month you will be able to complete the entire process online.

The Dental plans were not open online today. Again, they give numbers to call to get personalized help.

The website also lets you see what practitioners are already contracted with these plans, so you can figure out if your doctor, or a doctor you’d like, is contracted to that company. The Co-op in which I’m interested has a provider list that is 6,566 pages long (pdf file). The list for Providence is 32,767 pages long. It takes a loooooong time to run a < control-f > provider search.

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How do we use this information? How do you pick a plan? What we have to figure out – each of us – is:

~~ How often do we need to see a primary care doctor? Their preventive care will be free (generally once a year). If you only go in once a year for a checkup, and if you have a cushion of savings or access to financial help in case of trouble, you might want a higher deductible, lower-monthly-premium plan.

~~ How often do we need to see a specialist? Their fees, and the costs of their diagnostic procedures, are much higher. You might be able to meet a $500 deductible with a single visit to a cardiologist.

~~ How likely are we to need surgery, multiple spendy treatments, or expensive diagnostic testing? Some of these can cost thousands of dollars at one shot, and whether you prefer to have a moderate deductible and lower out-of-pocket cost sharing (e.g. a Gold plan), may depend on your cash flow.

~~ How expensive are our medicines? If you buy expensive medicines every month – well, first ask your doctor for a lower-priced equivalent – but then you might want lower cost sharing, like a Gold plan, so you just pay 20% of your medicine expenses.

(I’m not a financial expert. You can maybe think of other considerations, and how to handle them. “What if I broke my arm skateboarding? What are the realistic odds of that happening?” or “I know I have diabetes and my kidneys have suffered, but I’ve put off going to the doctor. How much medical work will I need? How many prescriptions? Insulin is super expensive.” or “My kid is 5 years old and if I’m going to have another one maybe I should do it soon.” or “These wisdom teeth need to come out NOW.” Et cetera.)

When I looked at my list of plans, in general, the “OOP” – total maximum out of pocket costs per year – were listed in the $6000-$6350 range. This means that if I had a very high set of medical bills, the insurance would have to pay for all medically necessary care, after I already paid that amount. Would this reduce the potential for people to be forced into medical bankruptcy by hundreds of thousands of dollars of medical bills? Stay tuned…

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A final word.

For my family – earning about as much as a high school math teacher with a part-time-employed spouse – it may cost $500-700 a month for insurance, and more, eventually, for dental coverage too. That’s a lot. Like everybody, I’d greatly prefer insurance that was quite a bit cheaper!

However, my spouse and daughter and I haven’t had any insurance for years. We all have medical conditions – dental, eye, autoimmune, etc. – that have been only occasionally and partially treated. Like most people, we have muddled along, while our conditions have gradually worsened. We also have outstanding medical bills we haven’t been able to pay yet – some owed to personal physician-friends! Did you think a physician would be immune from these problems? Not in the US of A.

I got an email from an angry reader who said, “I’ll be paying for your health insurance for the next 20 years.” I replied, “Thanks so much – and I’ll be paying for yours, and your family’s.” The Affordable Care Act is a first step in treating healthcare as a human right – a common good that everybody pitches in to support.

Are you angry that your insurance estimates aren’t cheaper? Then please contact your legislators, tell your neighbors, and organize. Tell them you want free healthcare for all, because healthcare is a human right, just like clean water and fire protection and public education and safe highways.

Obviously there’s no point in agitating to go back to the old status quo. The whole nation has gotten sicker under the system that existed mainly to line the pockets of CEOs and shareholders in giant insurance corporations. This system continues to support them – but at least it’s less purely focused on denial of care.

It’s going to be a significant challenge to pay for our insurance, but I’ll be glad to have it, because as a physician I DO know the consequences of undiagnosed, untreated, and often preventable (with preventive care) health problems, and I’d rather take on the equivalent of a car payment now, than deal with the costs – financial, social, and emotional – of disease and disability later.

Just saying.

Live long in Oregon.

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Dr Leigh and Obamacare, Part 2: Nuts and bolts

By | September 15, 2013

If you haven’t read Part 1 of this series, at least watch the cute video at the start of it, so you will be humming the tune as you read this.

I have been learning so much about Obamacare! One major thing I have learned is that many folks have the exact wrong idea about it. I mean, what they think is true is the opposite of what is true.

For example, one woman told me, “If you can’t afford to pay for insurance, they just add the cost to your taxes.”
Another person told me, “They give you a penalty that costs more than the insurance, and that’s how they get you to sign up.”
Another person said, “It doesn’t cover medications, so you have to pay the full price for all your medicine.”
Yet another person said, “If you have Medicare, you have to buy Obamacare as your secondary insurance.”
There’s a lot of confusion, partly because corporate profiteers are spreading disinformation and lies.

Here is the way I understand it. And please remember that I am vitally concerned, since I have been denied health insurance, due to a pre-existing condition, for the past 4 years. (In other words, under the current system, now that I badly need health care, I can’t get coverage to help pay for it.)

What? A doctor can’t get health insurance? You heard me right. As an old-fashioned neighborhood MD, I am a small business owner, not a salaried employee of a giant healthcare corporation. I look forward to signing up for Obamacare at Cover Oregon, and I urgently want to know what it will cover, and how much it will cost.

Cover Oregon is the insurance marketplace (a.k.a. “exchange”) for Oregon. It’s a website. When you hear “exchange” or “marketplace,” think “website.”

It’s where you can go to shop for insurance, starting October 1st this year – two weeks away, at this writing. Of course, rolling out a huge website can be tricky, so I won’t panic if it’s glitchy at first. The insurance coverage starts on January 1st, 2014.

There are a whole bunch of insurances available at Cover Oregon, including insurances that never existed before, and insurance co-ops owned by members rather than by giant corporations. Applications for Medicaid, also known as the Oregon Health Plan (OHP), will be there too. OHP won’t have a waiting list or a lottery anymore. Ditto OMIP (the Oregon Medical Insurance Pool).

Medicare is not included. Medicare has its own website. Nothing new is happening to Medicare due to Obamacare.

Individuals and small businesses who buy insurance at the Cover Oregon website are eligible for discounts, to make the insurance affordable. Other insurances – for example, giant-corporation insurance, provided by a large employer, outside of the website – don’t get these discounts. (Large-employer insurances are not expected to change much as a result of Obamacare. They’re completely separate from the brand-new Cover Oregon insurances.)

How do these discounts work?

The discounts are technically called “tax credits.” As far as I can tell, they are called that as a result of a bunch of political mumbo-jumbo. Some lawmakers don’t like the idea of people simply getting discounts, so they label them as tax credits. It doesn’t matter. It’s money off, so you don’t pay as much for insurance.

Some folks start feeling confused as soon as they hear the word “tax.” Taxes usually involve a lot of math, and they don’t like thinking about it. Some people are also calling them “subsidies.” When I hear “tax credit” or “subsidy,” I think, discounts.

According to this brochure explaining the rules (pdf), when you sign up for insurance at Cover Oregon, you can “Tell them you want the tax credit ‘in advance,’” and then your insurance premiums (the amount you pay each month) cost less. You get the discount up front. Your insurance comes at a lower cost every month.

When tax time rolls around, your insurance will send you a statement showing how much ‘tax credit’ you already received (as a discount on your insurance), and you file your taxes with that information.

OR ELSE, when you sign up for insurance, you can tell them you do NOT want the ‘tax credit’ in advance; you pay the full premium every month, without any discount.

But then when tax time rolls around, you get the money back. The government owes you the ‘tax credit’. You pay lower taxes, or you get a bigger refund.

The amount of discount you get depends on your income.
~~ If you don’t make much money, you get a bigger discount, to make the insurance affordable. If you make a lot of money, you don’t need as big a discount, to make it affordable.
~~ If your income changes, or if your family size changes, you call your insurance and have them adjust your discount.
~~ If you have a situation that makes your income change every month, you can even take a ‘partial credit,’ so you pay a lower insurance premium every month, and then you take a smaller credit at tax time. You are the one in control of how much discount you get.

Obviously, I am explaining here about insuring individuals and families. The program is very similar for small businesses insuring their employees.

Here is a real-life example.

I am 52 years old and expect to make about $50,000 this year. I have three adults in my household. According to the website calculator, as a rough estimate, an average insurance policy would be worth $1,486 per month. However, due to our household income, we are eligible for a 77% discount. We’d pay $342 per month after this “up-front” discount.

As required by law, the insurances on the website have listed their projected prices. Interpreting these must be done carefully. You have probably heard a lot of nonsense already about high premium prices. Because of the Affordable Care Act, what the premiums cost is not always the same as what you may pay.

How much will you pay?

There are several levels of coverage to choose from: Bronze, Silver, Gold, and Platinum. Each of these offers the exact same set of services – but they cost different amounts.

Bronze coverage pays for 60% of your healthcare costs, and you pay the rest, in some combination of deductibles, copays, and coinsurance charges. Silver pays for 70%, Gold for 80%, and Platinum, 90%.

Bronze insurance has the cheapest monthly premium cost, for example, but whenever you use it, you have to pay 40% of the doctor bill.

Each insurance company on the exchange will offer each of these plans, and different companies will charge different amounts. The website allows you to easily choose which one you like the best.

Let me explain how insurers decide how much to charge for premiums.

Every year, insurances submit to the State their proposals for how much they want to charge consumers, in premiums and other fees. The State then argues with them, to try to get consumers the best deal. They reach an agreement, and the results are published for all the world to see.

This process has been in place forever, because otherwise, corporations would charge even more money, and deny even more care.

This year, the new “Obamacare” insurances on Cover Oregon submitted their proposals and made their arguments along with all the other corporations, and then the state published the results.

Here are some representative premiums allowed, by State law under Obamacare, to be paid to insurers. These examples are for the Eugene area where I live (pdf-linked as “Eugene area/ Benton, Lane, and Linn counties: Individual” approved rates).

PacificSource would charge $187 monthly for a Bronze plan (covering 60% of medical expenses), for a single 40-yr-old nonsmoker. (By law, under the ACA, it doesn’t matter any more whether it is a man or a woman.)

The Moda company would charge $271 monthly, for a Gold plan covering 80% of expenses, for the same person. (Moda is the Obamacare alias for the ODS corporation.)

There’s quite a range between insurance companies.
~~ Moda would charge $469/month for a Silver plan (covering 70% of expenses) for a single nonsmoking 60-yr-old.
~~ Trillium would charge $724/mo for the same level (Silver), for the same person.
What is the difference? You’d have to see what these corporations offer in their policies, to tell the difference, and to decide which one is better for you.

Note: Moda might charge $469 a month for that policy – but it doesn’t mean the person has to pay that much! Depending on income, they would receive discounts to make the premiums affordable; the government would pay the remainder of the Moda bill.

As you can see, the Federal and State governments have a huge incentive to keep these corporations in line.

There’s also quite a range in the difference between what the insurances first asked for, vs. what the State commission approved. This also was published.
~~ For example, Trillium took a 32.4% cut in the premiums they’d wanted to charge. (This might mean they’d originally hoped to get $960/mo for the Silver plan mentioned above.)
~~ However, LifeWise was more reasonable, and received just a 1.5% cut in the premiums they originally asked for. These differences are also published (by law).

Remember: the Obamacare premiums you see listed in news stories are NOT necessarily what customers have to pay. Rather, they are the amount the insurance corporations expect to collect: the maximum allowed by law, with the State’s approval, re-negotiated every year as usual.

For people who are the lowest income, who can’t afford any of these levels, Medicaid (OHP) is also available on the website, which is health insurance that is free of charge.

The Affordable Care Act has expanded Medicaid eligibility. This means that people who were denied Medicaid in the past, for whatever reasons, might be eligible for it now. In Oregon, the Medicaid program was so under-funded that there was a long waiting list, just to join the lottery that determined whether you were eligible. The new funding from the government means no more waiting list and no more lottery.

For the time being, there are also some “catastrophic” plans that are offered, but only to people under 30 who are very low-income. Just like pre-Obamacare days, these policies are very high-deductible (meaning, you have to pay thousands out-of-pocket before the corporation pays anything), but have very cheap monthly premiums. They are designed to just cover expensive hospitalizations in the case of a medical catastrophe, like getting hit by a bus. They aren’t usually a good deal. Very few people have literally zero medical needs outside of catastrophe.

Once again, whether you pick Bronze, Silver, Gold, or Platinum, your policy is required to provide the same coverage, including “doctor visits, hospital stays, maternity care, mental health care, emergency room care, prescriptions, preventive care, vision coverage for kids and more. Some plans cover alternative care, too. Dental coverage is also available.” (Dental coverage is usually surprisingly cheap!)

The only difference between the levels is how big a portion you have to pay. If it costs a hundred dollars to go to your doctor, you’ll pay about $40 with a Bronze plan or $20 with a Gold plan – but it’s the same doctor visit that is covered, the same actual care.

Of course the website – the “marketplace” or “insurance exchange” – is only just one part of Obamacare overall. Most of the other parts have already been in place for years! You’re probably already used to them:
~~ Young adults are allowed to stay on their parents’ insurance after they turn 18.
~~ Children can’t be denied insurance due to a pre-existing condition.
~~ People can’t be kicked off their insurance for getting sick or injured.
~~ The Medicare “doughnut hole,” a deal George W. Bush made to fatten corporate pharma’s profits by charging seniors more for medicines, is being closed.
~~ Insurance policies have to provide preventive services, like checkups and mammograms, for free.
~~ Corporations are required to spend 80-85% of their earnings on actual care, not on CEO bonuses.

Remember how the opposite used to be true? When you hear Republicans complain that they want to get rid of “Obamacare,” that’s all the stuff they mean – not just simply the Cover Oregon website. It’s the whole ball of wax that rubs profiteers the wrong way. They prefer to just collect premiums and deny care.

It’s easy for me to see why some people don’t like Obamacare. I don’t mean the ordinary people who don’t understand it yet. I mean corporate profiteers who aren’t in business for health, but for money.

Part of the point of the Obamacare law overall is to make healthcare understandable, accessible, and affordable. But profiteers have made billions and billions of dollars by keeping it mystifying, exclusive, and expensive – in some cases, trying to buy elections to ensure it.

It is silly to think that it’s “the government” or “the doctors” that made it that way. Take a look at where the money goes, and you’ll know who benefits from a care-denying, care-excluding system. They stand to lose by making the system fair, and they know it. That’s why they’re putting up billboards ads and billboards full of lies, and throwing up roadblocks in Congress. Fortunately, Obamacare has already been law for 3 years, and it’s not going away.

Oh, and about that penalty?

It’s $95 per person for 2014, or 1% of your household income, whichever is less. That is what you have to pay if you decide not to have any health insurance whatsoever. “There are, however, a number of exemptions to the penalty. For instance, Americans who qualify for Medicaid coverage but live in states that have not taken part in the law’s expanded Medicaid will not be charged. Neither will people who are temporarily uninsured while between jobs, those who are opposed to having insurance coverage for religious reasons, or members of Indian tribes.”

The penalty will go up.
~~ In 2015, it will be $325 per person (18 and up), or 2% of income.
~~ In 2016, it will be $695 or 2.5% of income.
~~ In subsequent years, it will be $695 + a “cost of living” increase.

Kids under 18 are half-price.

The penalty was a classic Republican strategy, to make sure that people have to bear at least part of the burden of their care – so that when uninsured people end up in the emergency room, taxpayers don’t foot the entire bill. If you think about it, it is fair. You aren’t forced to sign up for health insurance, but you do have to chip in on the public funds that cover you (partly or fully), if you do get hit by that bus.

More info:
FAQs for individuals and families: http://www.coveroregon.com/who-we-help/individuals-and-families/
FAQs for small businesses: http://www.coveroregon.com/who-we-help/small-businesses/
Watch Oregon-made Youtube videos that explain the program, linked at: http://www.coveroregon.com/cover-oregon-launches-new-tv-ads/

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Bad week

By | September 15, 2013

I have been having a hell of a week – by which I mean, a lot of people I know have been having a hell of a summer, and they came in to tell me about it.

For example, I know two different young professionals, unrelated – they don’t know each other, but I know each of them – who each suddenly suffered profound brain injuries, involving multiple surgeries and extended-term treatment. I was discussing these events with their families.

The formerly-upper-middle-class families are now readying themselves for bankruptcy, having emptied their personal and retirement savings accounts, in a hurry; the repossessions and foreclosures are moving ahead. One spouse, a medical practitioner, said, “I can’t even get a credit card anymore.”

Both of these young professionals had “good” insurance. It did not provide “good” protection. They didn’t find this out until now.

Another person this week told me their formerly-fit, middle-aged spouse unexpectedly had a series of heart attacks. “We didn’t have any insurance. We moved here planning buy a house. Now we never will.” This spouse will never “retire.” This spouse will need to continue working, at whatever blue- and pink-collar jobs they can get, until disabled themselves, because they owe so much in hospital and doctor bills, and all their resources are gone.

Another person told me how their young(ish) relative died of an aggressive form of a rare cancer, after receiving oncology treatments he didn’t understand and didn’t want.

He had been a small business owner who never could afford health insurance, but also had been too healthy to worry about it. Oncologists kept telling the family that chemotherapy and radiation would “extend his life,” but it turned out the “extension” really only meant a few extra weeks of suffering. He didn’t live long enough to enter hospice, which was delayed because his doctors were focused on his “life extension” treatments. At least, that’s the way the grieving family understands it. The bank is now foreclosing on the dead man’s house.

One of my patients, an elderly disabled musician, came in after missing four appointments with me this summer – didn’t cancel them, just simply no-showed (four times!) – because, it turned out, his spouse had moved out and his monthly disability check is not enough to live on. The cable and internet were turned off, and the bank is foreclosing on the house. He doesn’t think he can pay this month’s light bill. No living family members to ask for help, no friends with money or resources, no savings. He couldn’t afford to keep his doctor appointments, and hadn’t filled any of his prescriptions for the last couple of months.

It appeared he just came in to say goodbye. He confided, “I’ve held my gun up to my head a few times this week.” I was able to talk him into going down to the hospital for emergency help, but he declined to get rid of the gun. “I can’t live in the homeless shelter with my kitties, and I can’t get a job.” His description of having nothing whatsoever to live for was compelling, even though it’s my job to disagree.

One story of economic disaster after another, provoked or intolerably exacerbated by medical hardship.

Cover Oregon, our state Obamacare agency, recently held a
question-and-answer forum on reddit dot com
. I guess they didn’t expect the volume of questions they received. Comments included:

“I’m a divorced 53 year old Oregonian with an income of less than $20,000 a year where it used to be over $30,000 ten years ago. After child support, I don’t even make enough to live in a place of my own, let alone pay for health insurance at any price.”

“I have had cancer and require monthly medication for the rest of my life… I currently am taking care of my elderly, ill mother and am unemployed and have exhausted all unemployment benefits. I do not got any payment for taking care of my mother as well, who can not be left alone due to Alzheimers.”

“I am 52 years old, I live with my disabled husband in subsidized housing in Ontario, OR. He receives healthcare and SNAP benefits [food stamps] from the state of Oregon as well as SSI benefits [Social Security]. I have had my name on the healthcare lottery list since relocating to Oregon a year and a half ago. Will I be able to sign up for healthcare and finally receive it?”

“I have had insurance for years. We pay $900 a month with a $10,000 deductible. We own our business and make under $60,000 a year. Is there relief in sight?”

“I’m in the Public Employee Retirement System, on a Public Employee health plan… Our monthly premium is about $1500 per month, about half of my take-home pension.”

“My daughter in Oregon has no assets other than a car and I provide her with other resources such as an apartment and food. Can she still qualify for Medicaid?”

“I am a terminal cancer patient just now moving onto Long Term Disability. How do you determine income? As you can imagine, my income dropped substantially when I left work.”

Fortunately, in many, if not most, cases, Obamacare has good news, which I will detail in another post. But for now, I’m just saying, it’s been a hell of a week: I am saturated with alarming and heartbreaking stories, just among the people I know personally.

Again, please note that many of the folks I’ve been talking to already have health insurance. They have it, but it doesn’t pay for what they need, or they have been impoverished by paying for it (“Our monthly premium is about about half of my pension”). In many cases, their health insurance seemed just fine, until they got sick – got cancer, or had a ruptured aneurysm, or had a heart attack, or two.

They weren’t lucky enough to get old and get Medicare before they got sick. It happened when they were 32 – or 45 – or 53. And the necessity of health care led to the financial ruination of their lives. And sometimes that ruination can lead to suicide.

As a doctor, I’ve got to say, I really, really, really, really don’t like this. Our health care delivery system is the equivalent of putting a slow acting poison in the water. The most vulnerable succumb first, but in the end, everybody gets it.

What does this mean?
“Last month, the labor force participation rate dropped to 63.2%, its lowest level in thirty-five years. That’s pretty remarkable, especially for an economy that is supposedly in its fifth year of recovery.”

What does that mean?
“Employers added 169,000 jobs in August… and the unemployment rate fell to 7.3%… not because people found jobs but because they gave up looking… The share of the population that is working or looking for work – a measure known as the participation rate – fell to its lowest level since 1978.”

Here is what it means.
“Estimates for 2013:
… Nearly 17 million American adults (ages 19-64) will receive a lower credit rating on account of their high medical bills.
… Over 15 million American adults (ages 19-64) will use up all their savings to pay medical bills.
… Nearly 10 million American adults (ages 19-64) will be unable to pay for basic necessities like rent, food, and heat due to their medical bills.
… Despite having year-round insurance coverage, 10 million insured Americans aged 19-64 will face bills they are unable to pay.
… 1.7 million Americans live in households that will declare bankruptcy due to their inability to pay their medical bills.
…Furthermore, 25 million people hesitate to take their medications in order to control their medical costs. Unfortunately this can lead to even worse financial outcomes.”

The implications might surprise you.
“White women lacking a high school diploma experienced a five-year decline in average life expectancy from 1990-2008, the largest of any demographic… Such a drop is almost unheard of for any demographic in the history of the U.S… With fewer opportunities for those without high school diplomas, declining health is likely a result of poverty itself.”

…And that’s what I’m seeing. People who recently led normal, productive, relatively-happy lives, are currently dying, disabled, dislocated, disconsolate – for want of the unimaginable amounts of money necessary to buy their health and safety. The bell tolls for all of us, and for our future.

Obamacare might not be perfect – I was rooting for very simple socialized medicine, available to everyone regardless of social class, rather than for multinational insurance corporations to win and take all – but the fact is, it’s at least a taste of what’s been desperately needed for so many years now. I had a bad week, and my friends had a bad summer, but I do have good news about Obamacare. See next post.

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Transgender news

By | August 8, 2013

I keep running across interesting news stories that seem to paint a picture of the world we live in these days, and I usually post them to Facebook. However, it’s pretty hard to ever find them again, on Facebook… So I’d better start posting them here!

In that spirit, here’s a wee roundup from the Internets of the New Millenium – Summer edition. What’s been going on in the world of gender variance?

In May of 2012, Tom Gabel, lead singer of punk band Against Me!, shocked the music world by announcing that he was transgender and had started the process of becoming a woman, taking the name Laura Jane Grace.

…Grace’s wife… speaks openly about standing by the singer through the transition. “In my mind, I married a person with whom I fell deeply in love… I’d always thought I was just straight. But now I know that really the right girl hadn’t come along yet.”

Gender-nonconforming media personality B. Scott, who is openly gay, is suing Black Entertainment Television (BET) for discrimination… B. Scott was hired as a Style Stage Correspondent for the Ford Red Carpet before the 2013 BET Awards in Los Angeles in June… The plaintiff claims he was dressed in a pre-approved black tunic and pants. After the first segment, however, he was allegedly pulled backstage, told his outfit was unacceptable and asked to change. He was later replaced by singer Adrienne Bailon, even though he changed into men’s clothing.

He explained in a statement on his website that he accepts the term “transgender” and he feels his spirit lies somewhere “in between.” He feels it is because of that very identity he faced discrimination. (Editor’s note: …We have used male pronouns but have been told that B. Scott does not object to female pronouns either.)

An ABC News editor… Don Ennis, who in May asked friends and colleagues to call him Dawn after what he said was a seven-year battle with his identity, is reverting to his former gender after a two-day bout of amnesia.

After just a three-month stint as a woman, Dawn Ennis was rushed to hospital because he thought he was having a seizure, according to the New York Post, and he was experiencing a loss of memory… The confused news editor, a father-of-three, thought the year was 1999, and couldn’t understand why he was a woman. Mr Ennis’s memory has now fully returned, and while he remembers choosing to go through the gender switch, taking hormones to change his body, he now says: ‘It appears I’m not transgender after all.’

…The Connecticut journalist explains that while his memories of the last 14 years have returned, his female identity did not. He says he is no longer wearing women’s clothes… However, he vows to be a staunch advocate for equal rights and LGBT issues.

The 49-year-old journalist told friends and colleagues in May this year that he believed his gender mix-up was linked to his mother giving him oestrogen as a child to prolong his childhood acting career. However, he says he ended up developing breasts and thinking as a woman. After years of living with a condition which doctors were unable to explain, he said, he finally decided to switch genders.

…He now hopes that friends and colleagues will not think his reverting back to be a male again is a joke, or because the change was too hard.

Chris Beck spent two decades as a Navy Seal, fought in Iraq, worked in secret behind enemy lines and saw more death and destruction than most of us could handle. All the while, he harbored a secret: he identified as a woman trapped in a man’s body.

After retiring from the Navy Seals (his unit went on to be the one to perform the raid on Osama Bin Laden’s compound), Chris decided to do something about this: he came out as transgender. Chris is now Kristin, and he has never been happier.

…”My Seal team brothers said, ‘you stood the watch in the field for 20 years and you did a great job. I don’t understand it one bit but I support you 100% and I hope I can learn more about this and see you at the next reunion.’”

Transgender Americans are twice as likely as their cisgender (non-trans) peers to serve in the Armed Forces, according to a study’s findings released today by the Williams Institute at the University of California Los Angeles’ School of Law. Twenty percent of trans people surveyed have served in the military, compared with just 10% of cisgender people. Nearly 30% of trans women reported serving in the military, while nine percent of all trans veterans surveyed said they were discharged for reasons relating to their gender identity.

…The study also revealed that trans and gender non-conforming veterans were more likely than their cisgender peers to have lost a job, due to anti-transgender bias, with 36% reporting they were fired because of their gender identity, and 53% reporting they were not hired by a prospective employer because of their trans status.

It has been nearly two years since the end of “Don’t Ask, Don’t Tell” (DADT)… However, being transgender is still grounds for “rejection for military service.” …By the letter of the law in military regulations therapists have turn in anyone who is transgender.

…Some transgender service members have leadership willing to turn a blind eye to the situation because they don’t see a need to lose a top performing Soldier, Sailor, Airman, or Marine. Others have found acceptance from their peers. Often the most disapproving people in the military are the people who are supposed to be the most accepting: Chaplains.

Increasingly, the situation for transgender people in the military looks like it did for lesbians and gays during the final decade of DADT.

The Palm Center, a California-based research institute that examined issues associated with the military’s “don’t ask, don’t tell” policy for more than a decade, received a $1.35 million grant to study transgender service in the American military.

A recent census of the homeless population in San Francisco found that 29 percent of them identify as gay. That is twice the share of the city’s total population that is gay, lesbian or transgender… It’s typical for young gays, who have often fled hostile environments, to make up a large proportion of the homeless who are under 25 — perhaps as much as 40 percent in major cities such as Boston and Los Angeles.

But the generation of gays who came of age in the 1970s and 1980s — those who saw their friends decimated by AIDS — are now overrepresented among the homeless, as well.

…”The fact that folks weren’t able to legally marry and have those traditional ways of being able to set up retirement, those folks are particularly impacted,” says Lisa Marie Alatorre, a human rights organizer… Many — particularly those who are older or transgender — have been wary of going to existing shelters for fear of discrimination or abuse.

Rep. Mark Pocan, a Democrat from Wisconsin, introduced a bill last week to bar homeless shelters from discriminating against people on the basis of sexual orientation or gender.

The Runaway & Homeless Youth Act, co-sponsored by Rep. Gwen Moore, also a Democrat of Wisconsin, would rescind federal funding for any organization violating the directive… As many as 40 percent of the people seeking services at homeless shelters in some areas may be young gays and lesbians… Many religious organizations spurn such clientele.

A 16-year-old transgender teen from Manteca, Calif., on Wednesday delivered petitions containing more that 6,000 signatures urging Gov. Jerry Brown to sign legislation that would change the way California public schools treat transgender students… The bill would require public K-12 schools to let transgender students choose which restrooms they use and which school teams they join based on their gender identity instead of their chromosomes.

Some school districts around the country have implemented similar policies, but the bill’s author says Brown’s approval would mark the first time a state has mandated such treatment by statute. “It’ll let me be a regular boy at my school,” said Ashton.

[Op-ed:] California is probably about to become the first state to spell out in the law what school districts must do so that transgender students aren’t discriminated against… It’s already a crime to not acknowledge and accommodate a person’s gender identity. Even if not a crime, plain ol’ good manners demand it.

So make the accommodation and move on. Just as a number of school districts have done. Los Angeles Unified, the nation’s second largest school district, passed a policy in 2004, updated in 2011, aimed at preventing discrimination against transgender pupils. The district has yet to log an incident or a lawsuit from a parent horrified at boys in the girls’ bathroom or a transgender kid saying their needs weren’t being appropriately addressed.

San Francisco Unified School District has had a policy for a while. Also Willits Unified School District in Mendocino County and San Rafael City Schools, for example.

… Transgender is the Advanced Placement test on LGBT equality.

Starting this summer, more than 500,000 students in the 34 institutions that make up the Washington State Community and Technical College System are being asked to answer optional questions about their sexual orientation and their gender identity on registration forms. This is the first time that an entire system of two-year colleges will track data on students who identify as LGBTQ.

…In 2011, Elmhurst College, a private institution in Illinois, became the first college to ask such questions on an undergraduate admission application. One year later, the Massachusetts Institute of Technology also added a question about students’ sexual orientation/gender identity on its admissions application. In 2012, the University of Iowa became the first public institution to add questions about sexual orientation and gender identity.

…If a college becomes aware that it has a number of transgender students, for example, it can take steps to address the needs of that community — such as creating gender-neutral restrooms and housing on campus.

Focus on the Family continues to oppose inclusive policies for transgender students, encouraging those who agree to urge California Gov. Jerry Brown (D) to veto a bill that would create gender identity protections in schools. In a guest post from its California affiliate, the California Family Alliance, Focus on the Family argues that such protections will force teachers to become “identity keepers” for “confused” children.

The graduation ceremony at St. Pius X High School in Albuquerque, N.M., on Wednesday was one student short, as a transgender teen refused to participate in the commencement exercises because the school told him he would have to wear a female student gown.

District of Columbia mayor Vincent Gray on Tuesday signed a bill that would make it easier for transgender people to obtain new birth certificates reflecting their change in gender identity… requiring only a certified statement from a medical doctor. Previously, a change would have required public notification in classified newspaper advertisement and surgical requirements.

Governor Kitzhaber has signed House Bill 2093, making Oregon just one of a handful of states to remove the onerous surgery requirement imposed on transgender Oregonians seeking an accurate birth certificate. Transgender Oregonians will now be able to access a legal change of gender without costly, undesired or unobtainable surgeries.

Additionally, the Social Security Administration announced they will remove the surgery requirement for transgender people nationwide seeking to amend their gender marker on a social security card.

…The removal of the [Oregon] surgery requirement becomes effective on January 1, 2014… To obtain a legal change of gender court order… you will need a letter from a health care provider stating that 1) you have had appropriate treatment for the purpose of gender transition, and 2) that you have completed sexual reassignment… You can save time and money by obtaining the name change and a legal change of gender in the same court proceeding.

President Obama’s impatience with Russia flared when he criticized the country’s new anti-gay law… “I’ve been very clear that when you are discriminating on the basis of race, religion, gender or sexual orientation, you are violating the basic morality that I think should transcend every country,” Obama said, according to a transcript of the Tuesday night interview. “And I have no patience for countries that try to treat gays or lesbians or transgender persons in ways that intimidate them or are harmful to them.”

Twenty-five percent of Fortune 100 companies offer trans-inclusive health benefits, according to a Human Rights Campaign fact sheet… Public bodies like the cities of Portland and San Francisco, and Multnomah County (where Portland is located), have also offered trans-inclusive care to their employees in the last few years.

More employers have started offering benefits to work around the fact that most private insurers either provide limited access to transition care (hormones, but not surgery) or issue policies with clauses explicitly refusing to cover any medical care related to gender transitioning.

Those clauses give insurers the ability to reject all kinds of claims… Getting even ordinary claims accepted can be tougher: a [transgendered man] was asked to pay out-of-pocket to set a stress fracture in his leg, after the insurer argued that hormone therapy must have increased the likelihood that the bone would break.

California, Oregon, Colorado, Vermont, and Washington, D.C. have all passed laws prohibiting insurers from issuing policies with clauses that discriminate against transgender patients.

Mary Going, 46, a former non-profit consultant from Oakland, California, wanted to wear a suit to her same-sex wedding in 2008, but found the shopping process demoralising. Nothing fitted and often there were no dressing rooms. And salesmen looked at her strangely when they realised she wasn’t shopping for a son. “They didn’t want to serve me,” says Going. “You could feel it.”

She soon learned that she was not alone, and last year Going started an online suit store, Saint Harridan, that specialises in classic men’s suits tailored for women. It joins a fresh crop of untraditional fashion brands and style blogs that cater to butch lesbians, transgender men, the androgynous and tomboys – underserved customers who might call themselves “masculine of centre.”

…Unlike traditional women’s suits, which often emphasise feminine curves like breasts and hips, Saint Harridan’s suits create a masculine silhouette. To do so, every aspect of the suit was re-engineered. Shoulders were narrowed to fit smaller frames, lapels were tweaked to lie flat over the bust, and pants that accommodate hips.

Chrysalis… claims to be the first lingerie line designed for and by transgender women. The brand’s mission is twofold: It aims to provide a solution to transwomen and make them feel beautiful and sexy, as well as change negative preexisting views of the transgender community.

…The bra comes equipped with hidden pockets to hold full-cup silicone inserts, and the panty, cleverly named a T-string (a play on the G-string for transgender women), is made of power mesh elastic and specially developed technology that tucks in and lifts the “venis”—Lauz’s term for a penis on a woman—to create a seamless look.

Chrysalis Lingerie’s new line debuted this week… I eagerly clicked the link for the store. My jaw subsequently hit the floor, and I don’t mean that in a good way.

…Chrysalis claims that this is their basic line, meant for “everyday wear.” Which means you would need at least seven of the underwear at $85 apiece if you planned to wear them every day (totaling $595). Chrysalis’s price tag is simply not feasible for most trans women.

…Since the company caters to transgender women, I figured it would go without saying that I would find the higher band sizes and smaller cup sizes that my body requires. For most trans women, our bone structure makes our shoulders and chests quite robust… The largest band size that Chrysalis is currently selling as of the launch of their website is a 38D. They don’t sell a 38A, 38B, or 38C.

…A word of advice to trans women: Go to your nearest Target. Buy a two pack of push-up bras ($24 for 2), and Target’s bra inserts ($12). Then go to Herroom.com and buy the Vasserette Control Shapewear Panties ($2.50 each), they do wonders for helping your tuck. There you go! You just saved yourself a lot of money, you can afford to buy enough to wear every day, and best of all you look fabulous.

Trans Etiquette for Non-Trans People [Please see original for details.]

…1. Treat trans people as you would treat anyone else. Don’t do things to call attention to a trans person, even if your goal is to let that person know that you accept him or her – no winking, smiling, little innuendos.

…2. Use the correct name and pronoun. The correct name is whatever the person has given you. The correct pronoun is whatever gender the person is presenting. Most cultures have clothing or other appearance markers that designate gender for that culture – that are considered masculine or feminine.

…3. If you make a mistake with a pronoun or name, move on. Don’t make a big deal out of it. If you are alone with the person, apologize and drop it. If you are in a crowd, just move on.

…4. Don’t say, “I’ll never get that pronoun (or name) right.” When you say this, you are saying, “I don’t care enough to try.”

…5. Don’t say, “You will always be a man (or woman) to me.”

…6. Don’t touch the person inappropriately or ask personal questions unless you are invited to do so… Touching something on a person to see if it is “real” or asking personal questions about a person’s body or sex life is inappropriate.

…7. Don’t “out” a trans person. If you see a person on the street that you know to be trans, it is a private matter and not appropriate to tell your friends.

…8. Don’t make assumptions. Don’t assume that the trans person you are talking to is politically liberal (or conservative), straight (or gay), happy (or unhappy), poor (or rich), and so on. We are all very different. And don’t assume that this person wants to educate you about trans issues or even discuss them.


Dr Leigh’s advice: Love one another (just saying)

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Dr Leigh and Obamacare!

By | July 10, 2013

Out of the 75% of respondents who indicated they have a doctor, half have not had their doctor comment on Obamacare.

But I’ve been talking to my patients about Obamacare! It’s a subject I am super concerned about.


In my dreams – this is me, singing directly to you.

Here’s why (real people whose identities have been obscured for privacy):

Patient A has a catastrophic-only policy, because premiums are unaffordable otherwise. This means if he tries to get the colonoscopy he needs, he will have to pay thousands of dollars out-of-pocket for it. This means I exert my ingenuities to help him weigh the pros and cons of delaying versus trying to locate an affordable endoscopy place within reasonable driving distance.

Patient B has no insurance and has been delaying getting blood tests for a long time. The blood tests distinguish one kind of diabetes from another, and they are not cheap. Different kinds of diabetes ultimately need different kinds of treatment, although you can get along for a while doing your basic blood-sugar-lowering and lifestyle treatments.

Patient C has the same situation, only the issue is an EKG and echocardiogram to tell us whether the irregular heartbeat is a danger or not.

Patient D has been delaying getting a Pap test, a follow-up from a previous abnormal one, and patient E has an unusual mole that should be biopsied. I don’t charge extra for collecting the samples, but there’s the pathologist’s fee. Most patients don’t even know what a pathologist is. It is a doctor who examines tissue samples under the microscope to see if they are cancer.

Patients F, G, H, I, J, and K have been delaying a visit to a urologist/ allergist/ pain specialist/ gastroenterologist/ gynecologist/ rheumatologist. I’ve come to the end of what I can advise them.

They are definitely unwell, with abnormal history, physical exam, and lab tests; they need specialized testing and a treatment plan I am unable to provide.

Don’t get me started on the cost of, and difficulty obtaining, psychiatric consultation, to help guide the prescription of dangerous, but possibly life-saving, drugs.

These people all may have manageable health conditions that can become unmanageable, as they delay due to finances.

In many cases, they have insurance. In most cases, they used to have better insurance, but over the past 5 years their benefits have been trimmed away while their premiums went up and up. Others found their policies got worse after they required treatment for an injury or had a baby.

As I have complained before, so many times, their earnings and standard of living have been held in stasis as their employer is obliged to pay an ever-bigger chunk for health insurance.

Don’t get me started on the people I know who stay in jobs and marriages that are unhealthy for them and make them sicker, just so they can hold on to the insurance policy they have.

When I say, “What do you understand about the new healthcare law?”
People reply, “All I know is, I’ve heard it’s bad.”

Where did they hear this? Television and talk radio, bought and paid for by corporations with a vested interest in maintaining the status quo – the same-old same-old deal, by which you delay going to the dentist until you can’t stand the pain anymore, ignore the blood on the toilet paper, stay up late asking Dr. Google for advice, and get older, sicker, and more worried every year — paying more to get less.

The new healthcare law requires insurance policies to be accessible, affordable, and meaningful – for example, you get your yearly prevention checkup for free, so you don’t avoid it longer than you should.

Insurance corporations, which prefer to make profits without providing any services, just simply hate this law (even though it gives them a captive audience, with everybody required to carry health insurance).

Since they have a ton of influence over some politicians and are able to buy plenty of media time, they start or support ‘astroturf’ (fake grassroots) organizations, complaining that the new law is “bad.” So then… “All I know is, I’ve heard it’s bad.”

Americans for Prosperity, a conservative advocacy group financed in part by Charles and David Koch, will begin running television commercials this week asserting that the law will limit Americans’ health care choices… The ads will be broadcast on cable and network television during programs popular with women.

The commercial opens with “Julie,” a mother of two, who tells the camera that she “has some questions about Obamacare.” …JULIE: “If we can’t pick our own doctor, how do I know our family is going to get the care they need?”
…Nothing in the law prevents patients from choosing their own doctors.
…Critics of the health law spent a whopping $400 million on television spots criticizing the law since 2010, over five times the $75 million that the law’s supporters have spent on ads promoting it. Analysts expect $1 billion in expenditures by 2015.

Don’t be fooled!

Here’s the truth about the new healthcare law:

Starting next year (on 1/1/14), basically everybody will be required to carry health insurance. (People who refuse will have to chip in on the cost of their care by paying a penalty. The penalty isn’t allowed to be higher than the cost of the cheapest local insurance.)

And from now on, insurances will be required to be worth the money – even the policy your employer already signed you up for, which may have been looking pretty crummy last year.

The Affordable Care Act forces insurance companies to play by the rules, prohibiting them from dropping your coverage if you get sick, billing you into bankruptcy because of an annual or lifetime limit, or, soon, discriminating against anyone with a pre-existing condition. All Americans will have the security of knowing that they don’t have to worry about losing coverage if they’re laid off or change jobs. And insurance companies now have to cover your preventive care like mammograms and other cancer screenings.

The law goes into effect next January 1st, but people can start signing up for new insurance policies starting October 1st. The “insurance Exchange,” a.k.a. “insurance Marketplace,” will be open. Each state has their own. Where I live, it’s called “Cover Oregon.”

What is the Marketplace?

Simple: it’s a website.

If you’ve ever booked airline tickets online, it may seem familiar. On the website, you enter in your data (how old you are, whereabouts you live, how many people will be on the policy and their ages, etc.).

Then the program offers you a selection of everything they have available, that can meet your needs. You choose the one/s you think are best, including most affordable.

A single application form is electronically sent to all the insurances you’re interested in. Then they each can make you an offer. You pick which one you want.

Gone forever will be the days when we couldn’t compare one health plan with another or figure out how much our out-of-pocket expenses might be if we get sick or injured or have a baby. Insurance companies will at long last have to provide us with information to enable us to do that — in concise language we can actually understand. Imagine that.
–Wendell Potter, recovering insurance corporation propagandist.

The advantages will also be considerable for small businesses: shops with less than 50 employees can shop in the marketplace for, again, the best policy as they see it. If you’ve never had to shop for insurance for yourself or others, you won’t fully grasp how streamlined, simple, and hassle-free this process is.

Only some insurances have signed up for the Marketplace so far this year. The larger, old-school insurance corporations seem to be waiting-and-seeing, because it’s clear that Marketplace insurances aim to provide care for patients, rather than profits for investors.

However, this means that innovative insurances that never existed before have taken the lead in the marketplace, including insurance co-ops owned by the policyholders rather than by heartless corporations.

Here are the insurers who (at last report) have signed up to enter the Marketplace and offer individual and family policies: ATRIO, BridgeSpan (owned by the owners of Regence BCBS), Oregon’s Health CO-OP, FamilyCare, Freelancer’s CO-OP, Health Net, Kaiser, LifeWise, Moda (owned by ODS), PacificSource, Providence, Trillium.

Insurers who will be offering small business policies include ATRIO, Oregon’s Health CO-OP, Freelancer’s CO-OP, Kaiser, Moda (ODS), PacificSource, Providence, Trillium.

The Cover Oregon website is under construction, but it already has a ton of information, including a calculator to help you figure out how much policies would cost you through the Marketplace.

Oh, did I mention that when you buy insurance through the Marketplace, you’re eligible for subsidies (whether you’re an individual, a family, or a small business person), to make the premiums affordable?

That’s built into the law, because everybody knows you can’t require everybody to carry health insurance if it isn’t made affordable. Since it appears to be impossible to compel corporations to lower their prices, then at least the law provides a bit of a sliding scale subsidy.

Individuals and small employers who shop through Cover Oregon will enjoy unique benefits.

…Small employers that offer coverage through Cover Oregon will be able to provide their employees with more plan choices. And, only through Cover Oregon, small employers will be able to apply for the small business tax credit.

…By enrolling in a health plan through Cover Oregon, you may qualify to receive help paying for coverage… For example, an individual earning up to $45,900 a year or a family of four earning up to $94,200 a year will get a tax credit to help cover the cost of their premiums.

You may also be eligible for cost-sharing assistance to help pay for copays, deductibles, and other out-of-pocket costs.

That cost-sharing is available “for people with incomes up to 250% of the federal poverty level ($58,875 for a family of four in 2013).”

The other part of the health law that will make a huge difference to many of my patients is that they will now be eligible for Medicaid, even if they were denied in the past – like a married mom I know, currently recovering from her second cesarean, who was kicked off of Medicaid as soon as she left the hospital, despite needing ongoing care.

Medicaid (not Medicare) is the Federal- and State-funded health insurance available for low-income citizens. (It also pays for most nursing home care.) It is administered differently in every state. In Oregon, Medicaid is administered by the Oregon Health Plan, and people call it OHP for short. Eligibility is determined by a lottery that is (in)famous worldwide.

It used to be that no other state asked its citizens to buy a lottery ticket for healthcare coverage – until Tennessee added its own little game. Again, don’t get me started… Health care is a human right.

The Oregon Health Authority budget passed the House… The health budget is 21.6% higher in total funds than 2011-13, reflecting the state’s move to expand the Oregon Health Plan to 138% of the federal poverty level and provide coverage to 180,000 to 260,000 more Oregonians starting next January.

The cost for those new health plan recipients will be completely covered by federal dollars through 2017 under the Affordable Care Act. “This budget opens the Oregon Health Plan to low-income Oregonians in 2014, ending the healthcare lottery that created healthcare winners and losers,” Gov. John Kitzhaber [creator of that same lottery] wrote.

…In a study prepared in conjunction with Oregon Health & Science University and the State Health Access Data Assistance Center, the state budget will actually save $79 million by accepting federal money through 2020, at the same time offering insurance to 260,000 more people and expanding care to 65,000 adults currently on the Oregon Health Plan.

…The study still anticipates about $47 million in general fund costs in 2019 – which, in a $15 billion budget, is “a rounding error… It’s not free,” the economist said. “It’s about as close to free as you can get.”

The Oregon Health Authority budget, also known as House Bill 5030, still must pass the Senate.

…And now you know what kind of conversations I’m having with my patients, regarding the “new health care law.”

You’ve heard me explain before how I myself am uninsured; well, now, like everybody else, I can no longer be denied coverage, and will be shopping for insurance in the Marketplace this October. I’ll keep you posted.

Meantime, watch out for lying Koch-funded advertisements, eat your fruits and vegetables, exercise outdoors daily, and get ready for better healthcare!

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That’s no spider bite! Watching out for MRSA

By | July 5, 2013

Do you hate and fear spiders? Or, are you neutral towards spiders in most cases, but think you got a spider-bite on your hand or leg? You’re pretty sure, because it’s like a bump, that is itchy and painful, and red, or even turning purple. Maybe you just ignored it for a few days, then you tried to open it up and drain it; pus came out.

That’s no spider bite!

Whenever someone tells me they have a spiderbite (or an ‘infected pimple,’ or an ‘ingrown hair’), I look for MRSA. More about that below. But first, a bit more about spiders.

Almost all spiders make venom, but in most species, the fangs are too small to puncture human skin. WIMPY FANGS.

Oregon, where I live, really only has one dangerous spider: the black widow. The black widow belongs to the “tangle-web” family. They have giant round bellies and are shiny jet-black. Their webs are a tangled mess, found in dark places.

They do not attack, but they will bite to defend themselves if they think you attacked them! The bite is painful, but not medically dangerous in most cases. It can cause muscle cramps, and make all the vital signs go up – fast heart rate, fast breathing, high blood pressure. If the bite causes these changes in the vital signs, the person should be seen by a doctor.

Other spiders: Brown recluse spiders don’t live in Oregon, a well known fact. They live in the south-central U.S. – Oklahoma, Arkansas, Missouri, Tennessee, etc. Oregon does have hobo spiders (hairy, brown, with long legs and front feelers) and yellow-sac spiders (light yellow in color).

These spiders come out at night. They are medically harmless! They are very unlikely to ever bite a human (WIMPY FANGS), and the venom doesn’t cause medical illness.

77% of patients presenting with soft-tissue infections are showing up with MRSA… Most of these patients attribute the infection to spider bites.

Pediatricians know about the MRSA and spider bites connection now, so they automatically think MRSA when someone comes in complaining of a spider bite.

A 10-year-old girl was brought to the clinic by her mother for a lesion to her left lower extremity that the family thought was caused by a spider bite… Her wound culture was positive for CA-MRSA [community-acquired MRSA]… Her mother had been treated 2 weeks earlier for a similar infection and was told by the emergency department physician that her infection was the result of a spider bite.

…A 24-year-old man presented to the clinic with a 4-day history of painful raised pustules to his left hip that the patient attributed to spider bites. A culture of these lesions proved positive for CA-MRSA… His girlfriend had been treated at our clinic for a similar infection 4 months earlier… His girlfriend’s sister had been hospitalized for an abscess on her abdomen caused by a “spider bite” during that same period.

…A 43-year-old man recently released from prison was treated at the clinic for multiple pustules… positive for CA-MRSA. This patient had been treated several times while in prison for similar lesions and was told they were the result of spider bites.

What is MRSA (“mersa”)?

The -SA stands for Staph aureus. This is the name of one of the bazillions of bacteria that naturally live on our skin. Most of the time, it doesn’t bother us at all. If it gets under the skin or inside the body, though, it provokes a vigorous immune reaction that produces a lot of swelling and pus – an abscess, like an “infected pimple” in appearance, though often much larger.

Here is what the MR- part of MRSA means: Back in the 1960s, due to antibiotic overuse, Staph germs in the hospital were found to be resistant to penicillin, which previously had been a wonder drug. Methicillin was developed as a “super-penicillin,” but the hospital Staph germs quickly became resistant to methicillin, too, which was very alarming. These germs were named “Methicillin-Resistant Staph Aureus,” MRSA for short. However, they are resistant to multiple penicillin-type antibiotics, not just methicillin.

In the 1980s, these antibiotic-resistant Staph bacteria were also appearing in the community, not just in hospitals. These began to be called CA-MRSA (for “community-acquired”). The hospital germs were big killers, but the community version wasn’t as dangerous. However, it appeared to be more communicable – it was spreading through communities very quickly. Simple “spiderbites” on the skin might be readily treated with incision and drainage, sometimes also antibiotics (ironically). However, deep abscesses tracking up between muscle layers, or in the lungs, can cause an immune-system meltdown called ‘sepsis’ that can be life-threatening and required urgent hospitalization.

You can see that prevention and early treatment is important – and this is why it’s important to know that That’s no spiderbite! …Stop blaming spiders, and address the problem directly.

Here’s a quick rundown.

How to recognize MRSA:
A skin infection that forms a bump, boil, or pustule. It feels itchy-painful, and the surrounding skin becomes inflamed. When it gets worse, the bump becomes large and may drain spontaneously. Other skin infections – for example, an infection from a splinter or thorn – can look like MRSA, but it’s okay to treat it the same way regardless of the germ involved.

How to treat an early case:
There are 3 keys to early treatment: boost the circulation, apply antibiotic ointment, and protect the area.

~ 1. Boost the circulation by applying a hot compress 4-6 times a day (Before meals and between meals, and at bedtime).
Here’s how: soak a pad (relatively-clean washcloth, towel, t-shirt, wad of paper towels, etc.) in water as hot as you can tolerate, and wring so it doesn’t drip. Apply to the area. “Compress” doesn’t mean you have to apply pressure, just hold it on the area until it cools down to skin temperature (3-4 minutes). Then dry off the area and go on about your business.

The purpose of a hot compress is to locally dilate the blood vessels and boost the circulation. This brings new blood, with oxygen and nutrients, to the area, and takes away toxins and waste products of infection.
Note: taking a sauna or a hot bath is not the same as boosting the circulation to the local area with a hot compress.

~ 2. Between hot compresses, apply over-the-counter antibiotic ointment to the area.

~ 3. Cover the area with a bandage after applying ointment. This protects it from damage and prevents spread of the bacterium to other parts of the body and to other people.

When to see a medical practitioner:
~~ If the infection is not improving after a week of treatment – including really, truly using hot compresses 4-6 times a day – please see a medical practitioner.
~~ If the infection is large or otherwise alarming, call a practitioner.
~~ If you develop swollen lymph nodes in the groin, armpit, or nearby area, and/or run a fever (>100.3F) or have shaking chills, call help.

What to expect:
If you see a practitioner because you have a large, painful boil, the best treatment is to drain it. You may never need to take oral antibiotics; studies show that drainage and cleanup is more effective than ortal medications are. The practitioner will numb the area, them make a small cut, and squeeze out the infection.

Taking a culture from the wound with a cotton swab does not usually change the recommended treatment, so if you are unable to afford a lab test, make sure you mention this to the practitioner. Often it is not necessary to identify the exact kind of bacterium, to treat the infection.

If your whole body is sick from the infection, you may need to be admitted to the hospital, to save your health or your life. Don’t wait too long before asking for help, to prevent needing this extreme intervention!

How to decolonize:
Some people and some families develop MRSA infections over and over. In this case, it is useful to culture the wound, to verify the choice of treatment.
We consider some people to be “colonized” with a bacterium. The specific kind of bacterium can be tested by taking a culture from a cotton swab rubbed under the nose and between the legs.

If a person is colonized with MRSA, it’s likely their sleeping partner or household family members are, too. The germ may not cause infection in each member of a household (and we do not really know why this is). However, colonized housemates readily pass the germ back and forth, re-infecting susceptible members.

Although I’m not aware of studies showing this, it stands to reason that any clothing, bedding, or other materials in contact with active infections should be washed with a mild laundry bleach and machine-dried at reasonably high heat. If materials can’t be washed and dried, they should be dry-cleaned. Meanwhile, decolonize the body!

The ‘standard’ way to decolonize the body consists of brand-name antibiotic ointments and soaps, simply because they were the first method tried and studied. There is nothing magical about these particular ingredients – although they can be horrendously expensive if you pay for them out of pocket. See below for two methods, the expensive ‘brand name’ method, and the low-cost ‘generic’ method.

1. Buy mupirocin (“Bactroban”) antibiotic ointment, and chlorhexidine antimicrobial soap (“Hibiclens” and others). Apply muprocin ointment inside the nostrils daily for 5 days. Meanwhile, wash with chlorhexidine soap (from the neck down, apply all over and leave it on for 5 minutes before rinsing) for 5 days. Note: mupirocin ointment is available by prescription only.

2. Buy over-the-counter antibiotic ointment, and liquid laundry bleach (sodium hypochlorite 5-6%).
Apply the ointment inside the nostrils daily for 5 days.
Meanwhile, add 1/2 cup laundry bleach to a warm (not hot) bath, filling the tub halfway (about 25 gallons). Soak in the tub, washing from the neck down (no soap necessary), for 20-30 minutes. Repeat daily for 5 days.

This mild solution is safe to use for little old elders as well as young children. At this dilution, it is equivalent to about 1 tsp of bleach per 1 gallon (the proportion you would choose for a baby’s bathtub). This is about the same strength as a public swimming pool – you can tell by the smell. Note: bleach proportions vary widely from study to study, but this is a moderate strength.

Sometimes when a household “decolonizes,” they catch the bacteria back again. It’s a community-acquired bacterium, so this makes sense. They can simply repeat the decolonization process as needed.

How to prevent:
The most important way to prevent the spread of virulent skin bacteria is to WASH YOUR HANDS, early and often. Prevent the spread of infection from person to person by keeping boils covered with antibiotic ointment and bandages until healed. Decolonize if infections are recurrent. Support your doctor or nurse practitioner in not prescribing antibiotics for any reason unless absolutely necessary. Support the movement to reduce the use of routine antibiotics in agricultural animal feed.

And don’t blame the spiders!

You may be wondering why you should put antibiotic ointment on a likely MRSA infection, and whether it might make the problem worse. You might also be wondering why a person sick with MRSA in the hospital would be given hardcore antibiotics, when this is how the issue started to begin with!
We know that MRSA is still susceptible to the antibiotics in common over-the-counter antibiotic ointment, even though it’s not susceptible to penicillins. When we culture a bacterium, we also test the culture against different antibiotics to find out which ones it’s most susceptible to, so we don’t give you the wrong antibiotic in the hospital.
Early characterization, appropriate antibiotic use, and interventions like enforced hand-washing and “space suits” to prevent spread in the hospital, are saving lives today!

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Need a refill? Want me to call in an antibiotic?

By | June 6, 2013

This piece illustrated with real behind-the-scenes footage!

I have a new policy. Actually, it’s an old policy, but now it is explicit. If you need a medication refill, or a new prescription medication, in most cases, you need to come in and see me for an office visit.

This may seem unfair! More and more people, in this stressed-depressed economy, are hoping to save $60 on a doctor visit, and ask me to “just call it in” – since they already know exactly what they need.

I do the same thing to my doctor: “Sorry for the late notice, but could you just call in a prescription for…”

However, it’s never “just call in.” Here’s a peek behind the scenes: Instead of “calling it in,” your personal physician…

~~ (Stops what I’m doing and) Boots up the computer
~~ Loads the electronic record program (slow-pokey!)
~~ Opens your individual chart
~~ Reviews your medical history, allergies, and previous medications
(Is the prescription already part of your treatment plan? Are we monitoring it properly? Should I recheck drug interactions? Is there anything else that slipped through the cracks?)

~~ I often open up my secure email, too, and review our recent conversations. Were we talking about changing your care plan? (This demonstrates that it’s never “just an email conversation”, either. Communicating over email usually involves all the above steps, too.)

~~ If it’s a DEA-controlled medication (including muscle relaxers, ADHD medicines, sleeping pills, cough syrup, anti-anxiety and pain meds), I log into the secure state drug database, enter your ID, and review when and where you last refilled it. Are you overusing it, or underusing it? Either one usually indicates we need to review the usefulness of that med. I print a copy of the database for your records.

~~ Then the clinical decision tree – Are the risks of this drug, to you individually, outweighed by the expected benefits? Are there other, safer therapies? Might it be better to do nothing, watch and wait? Is more testing necessary, or is the diagnosis well characterized? Have there been changes in the guidelines for your condition, or for that medication? Better Google it… All before I pick up the phone.

Blood pressure medicine… but I haven’t laid eyes on you for more than a year? I really need to check your blood pressure first. Has it gotten worse, or better?
If you lowered your blood pressure naturally with diet and exercise (and fewer drinks and cigarettes, and lower stress, too), I don’t want to keep giving you pills that will drop your blood pressure too low and make you dizzy – people break a hip doing that!
If it’s gotten worse (how about that diet and exercise, smoking, drinking, stress?), then you might need more or different medications, as well as a realistic and sustainable health plan (including diet, exercise, smoking, drinking, stress).

“Nerve pills” for your anxiety? Didn’t we just have a conversation about tapering off of them, and dealing with your anxiety more directly?
Where are you at, in that taper? I don’t want to prescribe too many pills, and delay your recovery.
Anxiety is not caused by a Valium deficiency – have you gotten to the bottom of your stress? Why not?

Inhaler, nose spray, special eyedrops – for severe seasonal allergies that you never mentioned to me before?
If your insurance doesn’t want to pay for it, and demands to see your records showing the indication for the medicine – then the fact that you never mentioned it to me before, and I did not examine and diagnose you, could mean you pay for those $250 allergy meds yourself.

Antibiotic for a sinus infection, urinary infection, bad cough?
But what if you don’t actually have the infection you think you have (for example, you may have a virus or allergy, rather than a bacterium)?
A physical exam is in order – because, what if you have a bad reaction to the antibiotic?
~~ One of my patients suffered permanent nerve damage from an antibiotic considered so safe that we routinely give it to pregnant ladies. (I wasn’t the prescriber. Antibiotics should never be given “routinely”!)
~~ Another patient has been given antibiotics for “sinus infections,” for years, that finally went away when she was treated for migraine headaches instead (as may happen in about half of recurrent sinus symptom cases). Another has been given antibiotics over and over again, usually in Urgent Care settings, for painful bladder syndrome – which is not an infection. Hello, Superbugs
~~ I myself suffered multiple GI and skin reactions, with weeks of repercussions – including trying to care for my own patients while the skin was peeling off my fingers and lips (gross!) – from an antibiotic my ear doctor gave me “just to be on the safe side.” (I’d taken this drug with no problems several times in the past!)
You have to twist my arm pretty darned hard these days, to get me to prescribe an antibiotic sight unseen – even if you’ve “always taken it” for this problem – especially if you’ve “always taken it” for this problem, in which case I definitely want to re-check that diagnosis.
Bacterial infections don’t happen over and over and over for no reason!

It is very inconvenient for both of us to shoehorn a doctor visit into both our busy schedules, and it would be awesome if it were safe to “just phone it in.” But it’s usually not.

Sometimes I ask you to run a test at home, to verify the nature of the condition (thermometer, blood pressure, blood sugar, blood thinner check, urine bacteria test, etc.). Sometimes I’ll ask you to send me a cellphone picture of the problem (for example, a skin rash). Often, we have a very lengthy conversation about your symptoms. You often sound impatient, like I’m making a big deal out of nothing – which makes me feel embarrassed! It’s my duty to be thorough, even if it’s just over the phone, text, or email.

Our conversation must be documented just like an office visit is, including making copies of emails and text messages, for inclusion in your chart.

Incidentally, when I get a fax from a pharmacy asking to refill your prostate medicine, your diabetes or cholesterol medicine, your asthma medicine, your hormones or birth control that I prescribed a year ago – it’s the same deal. I boot up your chart, review your plan, check your state database, look at recent emails, sometimes research latest developments on your condition and medication warnings, do the order, document the update…

All of this may take the same amount of time as a visit in my office would! –Without the added benefit of a hands- and eyes-on physical exam, which you’d get in the office.

And all you’re really aware of is that you called the pharmacy, or left me a voicemail with (what you thought was) a simple request.

And that is why I will probably ask you to come in and see me, instead of “phoning it in,” even when you are absolutely certain you already know what you need.

Now you know what’s happening behind the scenes!


“There is a pestilence upon this land; nothing is sacred: even those who arrange and design shrubberies are under considerable economic stress, in this period in history.”
–Roger the Shrubber, in Monty Python and the Holy Grail

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Weight Loss Secrets

By | May 28, 2013

When I see people who have intentionally lost a bunch of weight, I ask them, “What’s your secret?” Then I write down what they say on a little scrap of paper, and tack it to the wall.

Although these people have lost some weight, they mostly still haven’t reached their personal fitness goals. But, they tell me, things are looking up. I asked a psychology professor once, “How can a person overcome learned helplessness?” He replied, “They must experience success.” That’s what these folks are doing.

Most of them told me they were surprised to find they feel better overall than they’d expected. It’s like when you quit smoking and discover that now your favorite perfume smells even better – you didn’t expect this, but it makes you happy. They’re finding they sleep better, have more sexual energy, are in a better mood, and things are just generally going better for them. (What I measure, however, are the improvements in their medical conditions.)

Here are the weight loss secrets I’ve collected since the start of this year.

Lost 50 lbs in two years by bike commuting. “My car broke down and I couldn’t buy another one.”
Lost 60 lbs in one year by riding a stationary bike at the gym three times a week and not eating after 6 pm.
Lost 14 lbs after starting CPAP, the nighttime “breathing machine” for sleep apnea.
Lost 80 lbs over 2 years when started going to AA meetings and became sober.
Lost 100 lbs over 18 months, and ‘cured’ their diabetes and sleep apnea, using the South Beach Diet and “no white foods”. Also started bike riding once or twice a week for exercise.
Lost 75 lbs over 18 months, spouse of the above person, adopted the same lifestyle.

Lost 38 lbs over 4 years by walking 3 miles a day.
Lost 30 lbs in 1 year by getting divorced: “the stress diet.”
Lost 50 lbs in 1 year when couldn’t afford internet service anymore. “Stopped playing video games.”
Lost 35 lbs in 1 year without noticeable lifestyle changes “when I wasn’t depressed anymore.” Goal: Lose 200 lbs.
Lost 50 lbs in 1 year when quit using all dairy products. (Still eats meat and eggs.)
Lost 60 lbs after starting CPAP, the nighttime “breathing machine” for sleep apnea.
Lost 20 lbs in 4 months with Weight Watchers.

Lost 40 lbs in 1 year and ‘cured’ diabetes, cholesterol, and high blood pressure, using “the diabetic diet.” Eliminated 4 medications.
Lost 20 lbs in 1 month, “just with portion control… It’s a lifestyle change, like quitting smoking.”
Lost 60 lbs using “Advocare shakes” in place of meals (similar to SlimFast or Instant Breakfast, but with extra protein and costs 300% more).
Lost 35 lbs in 4 months when stopped using salt, chocolate, and “white things.” Also “gave up the 4th meal” after supper.
Lost 60 lbs in 2 months when stopped taking depakote, olanzapine, and narcotics for chronic pain; started bike commuting.
Lost 45 lbs when “my wife had to go to Alaska for ten weeks. She wasn’t making me biscuits and gravy anymore.”
Lost 40 lbs in 1 year by eliminating french fries and soda, and taking a walk every day.

Lost 70 lbs in less than 3 months by “eating half as much of everything,” and cut out all bread and sugar.
Lost 50 lbs over 5 years by eliminating soda and french fries, and walking everywhere. “Gas is too expensive.”
Lost 40 lbs in 1 year after diagnosed with “prediabetes.” Was already on “white food diet” to manage irritable bowel. Reduced the amount of starches. “I’m more energetic now.”
Lost 100 lbs in 1 year by walking 3.2 miles every day, increasing protein and reducing carbohydrates, eating frequent small meals.
Lost 50 lbs in 1 year after diagnosed as “borderline diabetic.” Stopped all fast food and pasta, only eats “healthy food cooked at home.”
Lost 18 lbs in 1 year when eliminated all wheat. No longer diabetic.

These are all patients who have been diagnosed with serious medical illnesses – not healthy young people who just want to look buff. The reason I am seeing them is that I’m their doctor. I weighed them, recorded the results, and asked them, “What’s your secret?”

Like most sick and injured people, they spent a period of time with limited mobility, depressed and worried, taking multiple medications for their illnesses, and for side effects, both of illness and of treatment.

Many, if not most, have found that their complicated health pictures became much simpler when they made the “lifestyle changes” that helped them drop some of the extra baggage – including prescriptions they no longer need.

I’ve been surprised at how small many of these lifestyle changes are, and how individualized. One person cuts out “white foods,” and another one turns off the TV. One person stops going to restaurants, and another one buys a bicycle. Some of these stories are cautionary for doctors: treating sleep apnea might help; a detailed discussion of metabolic syndrome and “prediabetes” might help; discontinuing sedating pain, sleep, and mood medications might help a LOT.

…I’ve seen the snowball-to-avalanche effect many times.

~~ People were strong and healthy, even athletic, as teenagers, but as they got older, they kept eating the same hungry-teenager-sized portions and having a few drinks a few times a week. Working full time, they didn’t have time for sports or the gym. Raising a family, they added a few pounds with each new baby, which never went away.
~~ As they matured, their metabolisms gradually slowed down, and they became noticeably heavier. They planned to start working out, but never could find the time or money for it. They went on a few diets, and took supplements they saw on TV, but ended up heavier than before.
~~ Their blood pressure went up, and after resisting it for a year or two, they started taking blood pressure medicine. High blood pressure causes heart attacks, strokes, and kidney failure, so the medicine was a good idea.
~~ They kept putting on a few pounds a year, sometimes a few a month. They needed to start taking a cholesterol medicine, too. High cholesterol causes heart attacks and strokes, so that medicine was also a good idea.
~~ Life happened, stress happened, they became a little depressed. They weren’t sleeping as well, and their sexuality wasn’t what it used to be. They might have started a few different medicines for these problems, too. These medicines did not lower the stress levels – just masked the symptoms.

~~ Then they got hurt – usually back or knee. They took the narcotic pain medicines they were prescribed, and may also have started other medicines to help with the side effects. These meds are sedating and lower the energy level and sex drive. Relationships at home and work suffered, causing more stress.
~~ When the body is stressed (anxious, pained, depressed), it clings to calories. Weeks-to-months of lower activity added a few more pounds, and thinned out the bones and muscles, making exercise more difficult and uncomfortable. Physical therapy and a daily exercise program was postponed a little longer.
~~ Increased mechanical pressure on the stomach from belly fat made acid reflux a daily problem, so they started taking medicine for this, too. With the reflux, sleep got worse, so multiple prescription and over-the-counter sleeping pills became a daily part of life.
~~ Now the doctor was warning them about “metabolic syndrome,” “prediabetes,” and “fatty organ syndrome.” One blood pressure medicine wasn’t as effective anymore, so a second one was added.
~~ Now they were taking 2 blood pressure medicines, 1 cholesterol medicine, 1 antidepressant, 1 sleeping pill, possibly 1 long-acting and 1 short-acting narcotic, possibly 1 anti-inflammatory, 1 acid-stomach pill, and 1 laxative every day, and sometimes a sex-enhancement pill: a dozen pills a day or so. They also had to get blood and urine tests about every 3 months.

~~ People often develop gout, and other forms of inflammatory arthritis, at a certain level of overweight. More pills are taken, to prevent permanent damage to the joints, and to improve mobility.
~~ They were feeling old before their time. They diagnosed themselves with fibromyalgia and chronic fatigue after looking on the internet. They knew there wasn’t any cure for these.
~~ In some cases, they got a surgery – spinal surgery, knee or hip replacement, rotator cuff repair – that wasn’t very successful and made them need more pain pills, and rendered them less and less active. In other cases, because of the weight, they “weren’t a good candidate” for surgery, and just took more pain meds.
~~ Eventually they had to start diabetes medicines, with their own side effects. This also was depressing, and they privately wondered if life was really worth living anymore. They finally agreed to try an antidepressant. It didn’t work very well, so an antipsychotic was added, “to make it work better.” The psychiatric nurse practitioner warned them that it could cause weight gain. It did.

~~ High blood pressure is more dangerous for people with diabetes, so they had to take even more blood pressure pills to meet their new, lower blood pressure goal. The combinations of medicines kept changing, because of side effects.
~~ As a consequence of diabetes, they developed neuropathic pain. They now “couldn’t live” without their pain medicines. They weren’t able to imagine taking on an exercise program, even though their doctor said they needed one, because of the osteopenia or osteoporosis.
~~ Due to the snowball-to-avalanche of health problems, many of them lost their jobs, then their health insurance. Their world shrank. They realized they’d never be able to take a vacation, or buy a home, or move somewhere else – any of the things they had kept postponing while their health deteriorated. They really felt trapped. It was hard to understand why their life had fallen apart in just a few years.

These are some of the people I know, who are struggling right now. I’m not exaggerating at all.

…But these are also some of the exact same people who told me their weight loss secrets! The exact same people who were starting to get off the medical merry-go-round, or at least find a more comfortable seat.

It’s easy to see, in this snowball-avalanche story, a number of points where the process could have been turned around. It’s easy from the outside, looking in. In some cases, the person simply didn’t know the likely consequences of letting things get out of hand. In other cases, they just crossed their fingers and hoped they’d be okay – but that trick never works. In still other cases, they were misled by health professionals, internet experts, and/or folklore, including family-history folklore.

As a consequence of the conversations I’ve had with people over the years, my beliefs have changed.

~~ I no longer believe that ideas about poor health resulting from too much body fat are part of “fat oppression” and “body hatred.” I’ve seen too many people reverse serious health conditions, by reducing extra body fat, to believe this anymore.
~~ Nor do I believe that pounds and inches are adequate measures of health. I’m indifferent to appearance, medically speaking – it’s the inflammatory, hormonal, and metabolically dysfunctional aspects of too much adipose tissue that I want to treat. And not by simply masking symptoms with feel-better drugs, either.
~~ I don’t believe that weight loss or metabolic change is a simple matter of “calories in vs. calories out.” Many people plateau, or even gain pounds and inches, as a consequence of limited-calorie diets, while others start losing weight when they start eating breakfast. Overcrowd rats in a cage – the easiest way to stress them out – and they will gain weight, even if calories in/out don’t change. Certain drugs will do the same.
~~ I don’t believe there’s one diet or supplement or exercise routine that will make anybody “the biggest loser.” I think the yo-yo pattern is medically dangerous – gaining and losing and gaining and losing.
~~ I’m frankly angry about approaches that are only available to people with plenty of money. For example, I’ve never seen an un- or under-insured person who could get sleep apnea evaluated or treated. I’m also angry about approaches that exclude people with disabilities – like exercise programs demanding an entry level of fitness that sick people can’t attain on their own, and locker rooms too cramped and crowded for people with limited mobility.

~~ I believe that many people – I am talking about people with serious medical problems, who also are significantly overweight – become “stuck” when they identify themselves as a certain kind of damaged person. When they see themselves as “a fat person,” “a pain patient,” “a diabetic,” etc., they are more vulnerable to suggestions that these conditions are irreversible and progressive. I think they need to remember who they originally wanted to be, before all these bad things happened, before they needed to protect themselves – and bring that person back to life, as part of their planning for how they will move forward.
~~ I believe that there’s a self-image, a part of our mind that is intimately connected to and protective of our physical body, that resists physical change. It is a “phantom self,” similar to what makes a “phantom” foot still hurt or burn or itch, long after it’s been amputated. The pain is real, but the foot is not; the foot lives in the mind, as part of the self-image of the whole person. Our mind and body work together to keep things whole. The self-image must embrace change, before the body will embrace it. Maybe this is part of the effectiveness of gym membership or yoga class or diabetes group or Weight Watchers. You change who you hang around with, and what you’re working on together, and it changes your self-image. Your body, like other parts of your world, comes into focus to match the person you (consciously or subconsciously) believe yourself to be.

But I don’t mean to get too flowery on you, there. This is a long way down the road from “Lost 45 lbs when my wife had to go to Alaska.”

I’m just saying, for every person I know who desperately longs to lose a hundred pounds, I know another who is well on their way to achieving the exact same goal. And they didn’t get there by adding another prescription, or buying the latest thing on late-night TV, or even following their doctor’s diet plan.

And for every person who tells me their life was ruined forever by that one car crash, or fall-off-a-ladder, or surgery-gone-wrong, I know another who says they used to feel the exact same way, but things are a lot better now. And they didn’t get there by giving up or staying in denial.

I’m not saying you should try to “think yourself thin” – I’m just saying that, even if you can’t see a brighter future for yourself… I can.

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