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Demystifying Medicine One Month at a Time

Category: preventive health (page 2 of 10)

A New Hero

I have a new hero. Her name is Mona Hanna-Attisha, MD, MPH.

monahannaattishaDr. Hanna-Attisha is a pediatrician in Flint, Michigan. She grew up in a suburb of Detroit. She graduated from the University of Michigan before attending medical school at Michigan State University. During her clinical years (the 3rd and 4th years of medical school), she spent many months at Hurley Medical Center in Flint, which serves as a clinical training site for MSU medical students (far from the flagship campus — something I can relate to).

As you may know from recent news, Flint has had some problems — especially due to an overabundance of lead in its drinking water.

For cost-saving reasons, the city of Flint switched the source of its drinking water from the Detroit system to the Flint River in April 2014. Almost immediately residents of the town began noticing the water looked, smelled, and tasted different. It took nearly a year and half for both state and federal officials to acknowledge that there was too much lead in the Flint water — repeatedly questioning the evidence that it was so.

That’s where our new hero comes in.

Dr. Hanna-Attisha directs a pediatric residency training program at Hurley. There are 190 pediatric residency training programs in the United States, training in total about 2600 pediatricians every year.

I can relate to this part of her job — my most recent role was directing an Internal Medicine residency. Though the medical issues are different (kids vs. adults), residency program directors have three essential jobs: recruiting medical school graduates, charting the learning curriculum, and making sure the program stays accredited.

Program Directors become role models for trainees. We try to inspire and motivate residents, offering career and life advice during what is a demanding three year training curriclum.

On top of clearly being good at this role for her residents (7 per class for a total of 20 or so residents), Dr. Hanna-Attisha uses her MPH training to do science — in this particular case epidemiology.

She combed through records at her medical center and discovered that lead levels measured in children’s blood in Flint (as part of routine pediatric care) had on average nearly doubled since the time of the water source switch. Though her claims were at first disputed by state officials, Dr. Hanna-Attisha kept at it, talking to parents, hospital leadership, and advocating with state and federal officials.

In the end, the simple elegance of her team’s science got the message across. The story has now received national attention, including the declaration of a federally-recognized ‘State of Emergency’ in Flint over its water supply.

I was researching Dr. Hanna-Attisha, and came across this TED-like talk she gave at a Michigan State College of Medicine event in 2014. It predates the Flint water story, but it shows her to be a dedicated public servant — not only committed to her trainees and her patients, but beyond that to questioning the very core of what makes people unhealthy: the social determinants of health.

Take a look and let me know what you think.

Timing is Everything

IUDs & Implant

Quick: Which US state has the highest rate of unintended pregnancy?

I’ll reveal below, but I learned the answer and several other surprising facts in an interview with Mark Edwards, the co-founder of Upstream USA, a non-profit training organization that provides technical assistance to health enterprises (medical practices, clinics, public health departments) in the use of long-acting, reversible contraceptives (known in the trade as LARC).

LARC consists of two options: IUDs (intrauterine devices) and implants — which are small, match-sized, plastic rods that deliver a slow, steady dose of hormone to prevent pregnancy. They are planted in the upper arm of women to provide another form of hassle-free contraception.

Both of these methods can be discontinued at any time, at which point fertility returns — faster, I’m told, than in the case of oral contraceptives.

Here’s a fact that surprised me about oral contraceptives (aka “The Pill”): Though when taken reliably their ‘success rate’ as a means of preventing unwanted pregnancy is considered to be 99%, over a 10 year use period, due to the challenging nature of remembering to take a daily pill, it’s likely that 61% of those taking the pill exclusively for birth control will become pregnant. Most definitely not the intended outcome. (Source: here.)

Big picture: every year in the US, there are about 6.6 million pregnancies. Of those, 3.4 million, or slightly more than half, are accidental: either altogether unwanted or ‘significantly mistimed’ — what we in the health care business describe as a pregnancy occurring 2 or more years before desired. The vast majority of these accidental pregnancies occur in women in their 20s (though teen pregnancy is a concern, only 20% of unplanned pregnancies are in teens, and the vast majority of those are in women 18-19 years old. In fact, the teen pregnancy rate has fallen significantly in the last 25 years).

That’s why, regardless of your politics, offering LARC to any woman of childbearing age is crucial. At the very first visit. As a primary care doc myself, I know that ‘family planning’ often falls down the list of concerns for patients that I see because there are so many other issues people wish to bring up in our short office visits. Thus, opportunities to provide women with LARC often fall through the cracks.

Upstream USA’s methodology includes technical assistance: training staff up to ask every woman that comes in a simple question: “Do you intend to get pregnant in the next year?”

If ‘yes,’ let’s get her into preconception care (folic acid, multivitamins, etc.). If ‘no,’ offer LARC right then and there. And the provider (doctor, nurse practitioner, or physician assistant) is trained up to put in an IUD or implant on the spot. No waiting until next time.

Why is this so important? Women with unplanned pregnancies are at greater risk for staying or falling into poverty. Their opportunity to advance in their education is diminished. Children should be brought into the world wanted — with parents that are prepared — with the maturity and resources to succeed.

It’s a fundamental choice for a woman to decide if and when she wants to have children. Of course, fewer unplanned pregnancies also means less need for abortion.

So what Upstream USA is offering is win-win-win. It’s bipartisan — a rare area that people on all sides of the political spectrum can agree upon. Upstream USA’s first big success was in none other than Texas. The organization also has partnerships in a number of other Red and Blue states.

The state with the highest rate of unplanned pregnancy? Surprisingly, Delaware. Upstream USA is there, too. And going big — across the whole state.

Game Changer.

Well, 2016 is off and running. Though the markets seem in peril due to China’s economic cooling, the health care arena in the U.S continues to burn like a hot stove.

For one thing, a now-unified Republican Congress passed the 62nd or so attempted repeal of ObamaCare, which the President unsurprisingly vetoed. The new year will likely decide the fate of the Affordable Care Act — and whether it continues its evolution and improvement in providing coverage to more Americans and helping control health care costs, or whether it is substantially rolled back.

Whatever your position on the law, here are some incontestable facts about it:

  • marmotsdhThe law has survived two (2) different Supreme Court challenges.
  • More than 20 million Americans previously without insurance coverage now have it.
  • The percentage of uninsured Americans is the lowest since the government began tracking the statistic in 1972. [Percentages were much higher in the early 1960s before the passage of Medicare and Medicaid in 1965.]
  • Millions more are eligible to gain insurance through the law’s mechanisms, provided those people elect to sign up rather than pay a tax penalty.

But here’s what I find really interesting:

More than just a coverage law, the Affordable Care Act is also a health care delivery law. Parts of the statute are directed at improving how health care is delivered and how our menu(s) of options are developed and prioritized. Fundamentally, it’s reasonable to ask: If the U.S. spends the most in health care (both per capita and in aggregate), and our outcomes are worse than other nations (in measures like life expectancy, infant mortality, etc.), shouldn’t we seriously reconsider how we prioritize our health care spending?

CMS, the federal agency that administers Medicare and Medicaid announced this week its first ever pilot initiative to fund programs addressing social determinants of health: housing, food security, utilities, transportation. [Other key determinants not covered under this pilot are education and employment.]

This is a game changer because it’s the first time the biggest driver of health care services and innovation is directly attempting to address issues that undergird our collective poor health attainment. Rather than just continuing to pour money into “sick care” (i.e. where most of the spending in health care occurs), this initiative provides dollars “upstream” to see if together we can find ways to prevent both major and chronic illnesses.

Couple new initiatives like this with ongoing efforts to reform medical education, and one gets hopeful that we can change health care to become smarter, more compassionate, and achieve better results.

Sticking to Basics

I’m often asked for medical advice by friends, family members, even new acquaintances. It comes with the territory: What about this diet? What should I do about this symptom? What about this medication?

People are usually disappointed when I don’t share their enthusiasm about the latest health fads. Members of my family, in particular, are often underwhelmed by my medical advice.

I’ll be the first to admit that I do a poor job of conveying why I’m skeptical about the newest medical technology, reports of the latest health news and fashions, and even people’s symptoms. Most symptoms, after all, aren’t explainable, at least to the level of detail we all want.

“What’s causing my symptoms?” Is it a virus? Bacteria? Arterial blockage? In spite of all the science and technology in medicine, what we do is more about taking educated guesses (“playing the probabilities”) than providing precise diagnostic information.

But prevention is different. We know a lot about it, based on huge bodies of epidemiological research. Most of prevention is fairly straightforward. You’ve heard the advice again and again — so much so that it’s easy to tune out. There really aren’t shortcuts:

  • Get enough sleep.
  • Move your body — throughout the day.
  • Eat well — a healthy assortment of foods. Mostly plants, and not too much. [An idea popularized by author Michael Pollan.]
  • Interact socially. Isolation is not good for the body, soul, or mind.
  • Take some time to reflect.

Recently I’ve come across a couple of ‘content items’ that do a much better job of conveying these messages. One is a set of books and ideas around the world’s so called “Blue Zones.” If you haven’t heard about them, Blue Zones are the places in the world where people both live the healthiest and longest — people in these communities often live well beyond 100 years.bz_zones

  • Okinawa, Japan
  • Ikaria, Greece
  • Sardinia, Italy
  • Nicoya, Costa Rica
  • Loma Linda, California

In all of these places, people have preventive medicine embedded in their lives, without even having to think about it. Their daily activities involve walking most places, eating healthy diets rich in local plants, with a lot of intergenerational social interaction. Interestingly, folks in these communities do drink alcohol — but limit it to 1-2 drinks/day maximum. And they do eat meat — but not very often and in small portions. One thing that won’t surprise you: Blue Zoners do not eat refined sugars (all the convenience and packaged foods that we’re trained to eat because they’re cheap and widely available).

Summarizing these themes visually in under two minutes is another gem from the idea lab of Dr. Mike Evans from Toronto. You’ve seen some of his other videos here. I love them. Just watch the one below, and follow his advice. That’s what I’m trying to do in my own life.

From the Evans Health Lab:

What are your thoughts on Blue Zones and Dr. Mike’s advice?

Mammograms: Find Your Sanity

Fairly typical week in health news: Mammograms.

The big story is that the American Cancer Society issued an updated guideline recommending that women undergo mammography less frequently than before.

mammogramThis announcement was denounced on both “sides” of the perennial debate. Those in the “mammograms save lives” camp are outraged that a scientific society dedicated to cancer prevention and treatment would issue a proclamation that seems to run counter to the notion that “early detection saves lives.”

Those in the “putting scientific evidence in the forefront” camp are actually somewhat pleased that the ACS is finally “moving in the right direction,” but displeased that the society didn’t get all the way to the vicinity of, for example, the US Preventive Services Task Force, which has the most heavily-weighted (and least stringent) screening mammography recommendations: for women at average risk (i.e. those that don’t have a mother or sister with breast cancer), start breast cancer screening at age 50 and get a mammogram every 2 years until age 74.

The new ACS guideline: start screening at age 45 (well, 40 if you want to) and have mammograms annually until age 55, at which point you can go to every other year.

If a woman at average risk for breast cancer follows the USPSTF guideline to the letter (and is lucky enough to avoid a ‘call-back,’ i.e. further looks for a possible abnormality), she’d have 13 mammograms over 25 years. If she follows the new ACS guidelines to the letter, she’d have 20 mammograms, possibly more. Of course, every mammogram not only increases the cumulative total of lifetime radiation exposure, it increases the odds that an abnormality will be found and a call-back will be issued.

The best analysis regarding the new ACS recommendation (and actually, one of the best pieces about the whole breast cancer screening issue in general) is from FiveThirtyEight’s lead science writer, Christie Aschwanden, whose piece is titled, “Science Won’t Settle the Mammogram Debate.” Aschwanden correctly points out the ‘right thing’ depends on you, the patient, and your values. There is no right answer.

For some, not getting mammograms annually (or even at all) is the right choice. For the rest, following the ‘rules’ such as they are provides the best piece of mind.

And that’s OK.

Here’s the thing: because choosing to have mammograms or not is a personal decision, we should refrain from blaming people who choose one way or the other. People have their reasons. As with many social and medical issues, the personal has become very political, because people’s beliefs are strongly held. Ultimately, a lot of economics is impacted by the politics here. Pro-screening partisans are always uneasy when edicts cutting back on screening are issued, because the fear is that the health care ‘establishment’ (i.e. insurance companies) will stop covering the tests.

That’s simply not going to happen with mammography.

If we strip the emotion out of the issue and just try to stick to facts, what, at heart, is undergoing a mammogram like?

The video below comes from the the UK’s Cancer Institute. It’s just more than a minute, and is very matter-of-fact.

WARNING: THE VIDEO SHOWS AN ACTUAL WOMAN UNDERGOING AN ACTUAL MAMMOGRAM, THUS INCLUDES BARE BREASTS. Therefore, NSFW in most workplaces.

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