We take it for granted and get mad when it goes awry. Every time we swallow, our body performs a remarkable phenomenon. It gets solids and liquids to our stomach and keeps them away from our lungs. If we mess up this process we cough, sometimes violently, to clear our airway and restore our lungs.
As we get older, strokes and other illnesses can wreck havoc on this process. It is called aspiration. Silent aspiration is when the food or drink going into the lungs does not cause any reaction at all, it falls, you guessed it, silently, without causing a stir.
This problem is quite worrisome. It is the rue of many elderly patients. Not only can it lead to aspiration pneumonia, but ask a person on a modified diet, what does that taste like? You probably won’t appreciate the response. The textures of foods that have been pureed, whipped, or modified can ruin any taste. Imagine the mouthfeel of thickened liquids.
Thankfully, there are things we can do for this and an entire field dedicated to fixing it. Speech Therapists do a great job of working with patients, both on diet selection and swallowing exercises, as well as various techniques (chin tuck) to prevent or minimize aspiration. They do yeoman’s work, but rehabilitation of swallowing mechanisms in the elderly isn’t the same as an ACL rehab of a young, healthy athlete. In old age, our body doesn’t recover as quickly. We have multiple medical problems. It takes more work. We don’t have the same energy. And throw in the most complicating factor, our ability to listen, learn and follow directions. This can be ruined by strokes, hearing impairment, and dementia to name a few.
Despite aggressive therapy, some people will never get back to 100% in their ability to swallow properly and protect their airway. It is here in which the discussions about patient wishes begins.
If I have a patient who is tired of the modified diets, but is still an aspiration risk, we have to discuss the reasoning behind the diet. The diet is to help prevent aspiration which can lead to a pneumonia that perhaps causes death. Aspiration pneumonia certainly doesn’t happen every time aspiration occurs, if it did, nursing home populations would be much smaller. But there is a risk and we must acknowledge it. For a patient known to be at risk of aspiration, there is no way to predict when it may happen, when it will occur, and if a pneumonia arises, how swiftly and severely it will start. Will there be time to object to its course?
I am fully committed to allowing patients their autonomy, so if they would like to go back to a regular diet and normal consistency liquids, they may. But first, I want to make sure that both paths are explained as fully as possible. We should be in charge of our own lives and I believe its a physician’s role to explain the consequences.
At this point, it is still hard (but unfortunately getting easier) to understand that some patients have come to a point in their lives in which they are satisfied, content with the lives they have lived. Or, patients may feel their quality of life is either very low, or the biggest joy left in life is the pleasure of eating and drinking. These patients are willing to risk the chance of death to get the foods and drinks they want.
“I’d like to have my coffee without the thickener.”
Patients ask this question all of the time.
Of the medications that we prescribe, there are two main categories of medications. The first category are medications that make us feel better. The other category is medications that are designed to prevent something from happening.
The nice thing about the first category, these medications are usually used for the short term, so we can worry less about their burden on patients. Plus, patients usually don’t ask “Do I need to take this?” They are seeing because they feel poorly and want medications or treatment to feel better.
It is the medications in the second class where people wonder about the need to take medications. This is the art of medicine. I frame these medications, whether for diabetes, hypertension, etc… as “they are designed to help you live longer or live healthier.” I also use that as a criteria to eliminate medications that are not achieving these goals (i’m talking about you, zetia, fibrates, and niacin).
For example, when we are treating high blood pressure, I offer this.
“This is an opportunity for modern medicine to help you live longer. Blood pressure reduction will help prevent heart attacks, stroke and death. Think of these medications as helping you live longer rather than, you are a bad person, you have high blood pressure, you must take this medication (carrot vs. stick). Furthermore, it may be hard to take a medication that can cause a side effect you feel now when you will never know for sure that you benefitted (I can’t prove to my patients I prevented a stroke or heart attack, this also introduces the concept of numbers needed to treat [NNT]).”
In any chronic condition, or when using a drug to prevent something from happening, it helps to educate our patients so that they can make their own decisions. This is a huge area for reducing medication burden and empowering our patients.
The AUA (the governing college of the doctors who operate on prostates) came out with new guidelines regarding Prostate Cancer screening.
They still want to have some people screened, but they only want 55-69 year old men screened and at intervals of 2 years or more. In regards to 40-54 year old men, they still want those at high risk screened. The first sentence (55-69) is a move in the right direction, the second step is a loss. People considered at high risk are African-Americans and those with a positive family history. If the vast majority of prostate cancers already found were overdiagnosed, many men are going to have an “overdiagnosed” family history (overdiagnosed means being diagnosed with an illness that will not affect your health).
Almost all other major medical groups do not recommend screening for prostate cancer at all, but this is a hugestep for the overdiagnosis/overtreatment/EBM movement.
If there isn’t a media firestorm today about this, we could then discuss why there is a divide between breast cancer and prostate cancer media coverage/marketing (on another note, it looks like Komen for the Cure is stirring up trouble with its CEO salary [from Peggy Orenstein]).
I overheard my front office staff today asking a patient about the type of appointment they needed. I recalled how irritating this was as a patient before becoming a doctor. These are the two main reasons this is important.
Scheduling is terribly important. We have to know how much time to allow for visits depending on the reasons/appointment type. By different appointment types, I mean a physical/wellness exam, a follow-up of a prior issue or a new issue.
The appointment type leads directly to the second issue, billing. In primary care, there are two main criteria that guide our billing. These criteria are whether you are a new patient to the practice (if you have been seen in the office in three years, you are an established patient) and if you are there for a wellness/physical exam. Insurance companies vary in their coverage of wellness/physical exams. Some companies offer zero wellness coverage, others offer wellness coverage free of co-pay charge and others require a yearly wellness exam for discounts on premiums. Medicare recently changed their rules to offer yearly wellness exams for free (patients are confused because the exam is mostly talking, not a doctor physically examining the patient).
Physician front offices aren’t being nosy or trying to be annoying… they are trying to help you, even if it doesn’t feel like it.
I was excited to see the USPSTF (United States Preventive Services Task Force) come out against supplementing Vitamin D and Calcium for the prevention of fractures. But, I lost some of that excitement when I dove into the details. The recommendation was regarding doses of 400 IU and 1000 mg of Vitamin D and calcium respectively. For doses above this amount, we just don’t have the evidence.
So what do we do?
I imagine there are many women who fit these criteria and we can tell them to stop. Here’s my second but, do we tell them to stop that dose and INCREASE it? There are many women taking 400 IU of Vitamin D and 600 mg of Calcium twice a day. What do we tell them? Furthermore, there are other things to consider…
Vitamin D has been advocated to help prevent falls. The USPSTF itself recommends supplementation for falls, but only in those 65 and older who are community dwelling (not living in a hospital or nursing home) who are at increased risk for falls. That is awfully specific.
Furthermore, main-stream buzz surrounding calcium supplementation started to come under scrutiny due to this BMJ paper in 2010. This study linked calcium supplementation and cardiovascular events. With so many women taking calcium, it’s easy to see why it created such a stir. The problem with this study was that it looked at calcium supplementation without Vitamin D. I believe most women take calcium with Vitamin D. Personally, I didn’t like the study very much because it didn’t look at the combination of the supplements and it hyped non-statistically significant events (such as mortality and stroke).
More recently, two articles more notable articles were published. One declared that too much calcium was deadly in men and not in women (women not being “harmed” in this study was regarded as very surprising). The other suggested that women do indeed have increased risk of death from too much calcium.
The data from the these two studies suggest the risks of calcium look like a J-curve (figure 2 and the other study’s figure 2). J-curves represent this terrific notion that there is a sweet spot for something, not enough AND too much is a problem.
In regards to calcium intake, there seems to be a sweet spot of intake. The problem is knowing exactly where that sweet spot is, which is difficult, but not impossible (the high end of the sweet spot being 1000mg of supplemental calcium a day for men in the first study and the other study suggests too much is 1400mg of dietary calcium per day for women). The harder part is to know how we apply that to an individual’s diet on a daily basis.
I began this post with discussing calcium and vitamin D for fracture risk after seeing the USPSTF statement regarding the ineffectiveness of 1000 mg of calcium and 400 IU of Vitamin D daily. We don’t typically use that dose much, but does a higher dose mean success for fracture prevention (for which the USPSTF gives us an “I,” meaning, we don’t know)? It appears other studies warn us that too much calcium is bad for us. So a little (1000mg or less per day) calcium supplementation with Vitamin D (400 IU) give women kidney stones (rarely) and does nothing for fractures… too much calcium may harm us even more than kidney stones (death and heart attacks… not in that order, I haven’t heard, yet, of anyone having a heart attack after death).
These newly suggested findings are paving the way for a closer inspection of Vitamin D on its lonesome, perhaps, especially as it is the flavor of the month (actually years) in regards to potential health benefits such as fall prevention. It will be a tough road to hoe. Dogma is especially difficult to bring down, even if it was paved with mud streets (no evidence) rather than yellow bricks (Randomized Controlled Trials).
This is why its hard sometimes to be “authoritarian” and give patients a sure answer. A sure answer is hard to find.
Every time I see a study involving the use of CT calcium scoring, I cringe. CT calcium scoring, for those who don’t, know, is a CT scan of your heart. The CT scan picks up calcium deposited in your arteries. Calcium in your arteries isn’t bad by itself, it’s assumed to represent the bad plaques that clog our arteries (it’s a bit more complicated than this, but for the sake of simplicity, that’s how I’ll describe it).
I’m not sure why the medical profession is so eager to use a test that involves radiation for screening purposes. There is a mild uproar regarding the overuse of CT scans in diagnosing conditions (abdominal pain, little kids bumping their heads) where the yield would be presumably higher. Yet, we are willing to subject patients to radiation exposure of a CT scan to help assess risk (which is a screening intervention). The terrible part of this screening misadventure is that CT calcium scoring irradiates the chest. I believe there is major concern regarding breast cancer, so why would we be willing to expose women to radiation of the chest?
Anyway, here’s the study involving CT calcium scoring.
I only have access to the abstract. It appears this study suggests CT calcium scoring can help predict risk for future stroke.
Who cares? I’m not sure how this will help us prevent more strokes. We should already be getting our patients to stop smoking, exercising, and eating well. We should be addressing hypertension. Does having a high CT calcium score help us accomplish those things? If the answer is yes, we should get better at motivational interviewing. Testing shouldn’t be the stick we beat our patients into a healthy lifestyle.
Prevention saves lives.
BUT… prevention is getting off track. We are being bombarded with prevention being represented as the savior of medicine. Prevention is very important to us, but we have to think about what prevention really helps us versus what we “feel” like it helps us.
Clean water, sanitation, immunizations, exercise, eating healthy, seat belts, tobacco free, healthy weight, a job, strong social network, health insurance. These are things that will help you (and us, as a society) live longer. This is all a combination of public policy, government, healthcare, and individual choices.
As a doctor, I love prevention. But the prevention that yields fruits to my labors is narrow. Behaviors drive prevention, not medical testing. There are a few things that can be done medically to prevent diseases, but they are minuscule compared to healthy behaviors. Therefore, I need to be able to effectively improve my patients behaviors.
In the medical realm of prevention, doctors can screen for high blood pressure (treatment leads to reduced heart attacks, stroke, and death), diabetes (treatment leads to less kidney disease, nerve pain, and vision loss, it does not, as of yet, lead to less death), and several cancers (breast, colon, cervical), but certainly not all cancers. We can (and should) update immunizations as well, most importantly with infants, children, and the elderly.
Don’t be distracted. The most powerful prevention is behavior based (diet, activity/exercise, and tobacco). It is not locked up in your doctor’s black bag. Don’t be sold on fancy tests (ask why its important to your health, how it could improve your health, if it is recommended by the USPSTF, and if you really want to be a conspiracy theorist, ask who owns the testing equipment).
Along with some strong public policy (subsidize healthy food, insure everyone, subsidize physical activity, smoking bans, tobacco taxes), our behavior will drive the prevention “revolution.”
I had a patient ask for my opinion on Prolia, which is a new osteoporosis drug that is injected twice yearly. Why we talk about osteoporosis and not fractures is another point. This point clearly demonstrates our fascination with surrogate markers rather than clinically important end points that our patients are concerned about.
Anyway, another physician had recommended it to her and she wanted a second opinion. Fortunately, the patient had the nicely printed Prolia pamphlet that included the packaging insert. I went right to the data section of the insert and walked the patient through the data. Here we go…
But first, let me share a few important ideas about osteoporosis.
1) We should care about fractures more importantly than osteoporosis
2) Hip fractures are the most damaging of fractures, they are significantly associated with death
3) Other fractures are important as well, but just not as important. Wrist and verterbral fractures can cause problems with health and function as well as pain.
Now… here we go. The quoted trial in the insert was 3 years long. Almost 8000 women were studied. The absolute risk reduction of hip fracture (as seen here in the figure) is 0.3 percent. What does this mean? The difference in hip fracture rates between groups was 0.3% over the three years. To put it in a simpler term 333 women have to be treated with prolia over three years to prevent one hip fracture. 333 comes from 100/0.3. That is how an NNT is calculated. To take this a step further, let’s involve the costs. Exact Prolia costs are elusive. When the drug was first released, I heard it was around 1500-3000 per injection (two injections needed per year). “Officially,” the drug itself costs $1650 per year plus office visits, etc. Using that estimate, 333 women treated over 3 years at $1650 dollars/year = 1,648,350 dollars per hip fracture prevented. Again, this doesn’t include hospital/infusion/injection center charges or outpatient visits. I used a $1500 per injection estimate with my patient and that leads to a $3,000,000 price per hip fracture prevented.
Is that good enough? Is it worth it? At what price would it be worth it?
“That’s reasonable.” I’ll never forget hearing that for the first time in residency.
As a resident, once you see your patient in clinic, you must discuss the case with a supervising physician (an attending) to get approval of your plan for that patient. After my presentation to the attending, he told me “That’s reasonable.” Now, I’m not sure why I was so surprised by that at the time, but looking back, I had become so accustomed to knowing that there were right and wrong answers (from undergrad and medical school) that being told my plan was reasonable felt awkward. With that moment, the walls of black and white began to slowly crumble as I was introduced into a world of infinite (not 50) shades of gray.
I continue to struggle with the slow crumble. Let me show you how it affects both patient and physician.
Let’s take diabetes screening for example.
First, who do you screen?
Second, what test do you use?
Third, what do you do with the results? These are critically important questions that are fun to debate and hard to know the right answer. So, I’ll use my answers and skip to the third question to emphasize one point.
I use the A1c test to screen for diabetes in patients with elevated blood pressure (>135/80) per the USPSTF or as a screening tool for all patients >30 years old every 3-5 years per a Lancet study a few years ago. For diabetes to be diagnosed, per the American Diabetes Association, a patient must have an A1c of 6.5 or above and that this measurement must be obtained twice. That’s easy. The interesting topic concerns what we do with all of the numbers below 6.5.
At some point, the normal range was originally (from my training) between 5 and 6. Levels between 6 and 6.4 were considered prediabetes or increased risk for diabetes. In the last few years however, there has been a push to call 5.7-6.4 “increased risk for diabetes.” This is a big deal. There are numerous people who are in the 5.7-6.0 range. Once we start telling people that they are not normal, odd things happen. Healthy people can start to feel unhealthy, just by being given a diagnosis or label. Then, they get ACTIVELY involved in the healthcare system, which typically means more testing and this may or may not be helpful.
The next step would be what we do for the patient with these numbers. Patients with prediabetes or increased risk for diabetes need a follow-up A1c. Anywhere from 3 months to a year might be a reasonable approach. But if you just look at that 5.7-6.0 window, if they are normal, they could go potentially 3-5 years without another test versus being abnormal and going for another test in 3-12 months. A little bit more than a little difference. Furthermore, we could or could not offer these patients medication to help prevent diabetes.
There are studies to help guide our approaches to these dilemmas, but more questions are available than answers.
All of these differences in approach (who to screen, which screening test, what to do with the results) could lead to different outcomes and different expenses (both time and resources of patients, mental wellbeing included).
Finally, the most important variable might be what the patient would want. Does the patient want an “aggressive approach” with rechecking an A1c is 3 months, adding medications, following closely? Does an aggressive approach mean better (what does better mean and how would you measure it?)? Would the patient feel they had a more caring, knowledgeable doctor if she offered aggressive care versus a doctor who offered a conservative plan? Do patients want to know all of the options? If all of the options are presented, does the patient perceive the doctor as unknowledgeable and unsure of herself because they don’t firmly insist on a singular best option?
So a simple test leads to a world of possibilities. We see ambiguity frequently as patients and physicians. I don’t like that. I’d like it to be simple and clean, but the truth represents neither.
I better let my wall completely crumble.