2014: An Empowered Patient’s Guide to Health Care Reform - FREE Report

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In a quest to actually understand the Affordable Care Act (Obamacare), I researched and then wrote an easy to read report that I am offering to you for FREE. It’s called, 2014: An Empowered Patient’s Guide to Health Care Reform. I personally wanted to get past all the hype and hysteria and I wanted to help patients and consumers understand it, too.

I set a goal to keep politics out of it (there’s more than enough of that out there already). I vetted the final report with readers on both ends of the political spectrum and they told me I succeeded in keeping it apolitical. Do you agree? I hope you will download it and that you will find it helpful. (Please do let me know.)

I wanted to know what the Affordable Care Act (Obamacare) is exactly, what it is intended to do and how it intends to do it? I learned that, even though it is the law, it is actually more an “idea” than it is an actual “plan”. And, as is becoming painfully clear, all the players – insurance companies, the government, employers, medical professionals, and consumers – are literally just figuring it out as they go along. No one knows how, or whether, it will ultimately work. Like other major health care reforms (Medicare and Medicare, Part D, for example) it has had a very inauspicious beginning.

We all want to know if Obamacare will be a good thing or a bad thing. (Some have made up their minds already.) Will it work – eventually? No one has any way of knowing for sure. There are too many moving parts and too much is still unknown. Inevitably some parts of it will work – and other parts will fail. There are already winners and losers. Certainly the bumbling way it’s been launched has fueled the massive uncertainty that surrounds it. Past health reform initiatives have sorted themselves out eventually. Will Obamacare?

The uncertainty about it has fueled so much political hysteria that consumers looking for strait forward, unbiased information are finding it hard to find. Everyone has opinions, dreads and hopes but very few people have facts. That’s why I wrote this report.

One fact is indisputable. No one – not even the people who wrote the law – can predict the future with certainty. There are just too many unknowns. How will insurance companies adapt to it? Will healthy young people (a backbone of the idea) embrace it? How will the states adopt it over time? Will it be successful at making affordable health care available for all Americans?

Time will eventually tell but that is going to take years, not months. As for all the prognosticators, they are simply guessing. Whether the gloomy or glowing predictions turn out to be true or false we’ll just have to stay tuned. In the meantime, read my report. At least you will know what the game board looks like.

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Symptoms and Causes of Diabetes

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Insulin resistance is a silent condition with no symptoms that, because it goes unrecognized and untreated, causes diabetes. According to the Centers for Disease Control and Prevention, 57 million adults are estimated to have insulin resistance – also known as (AKA) “impaired glucose tolerance”, “impaired fasting glucose”, “prediabetes” and “metabolic syndrome”.

And you know what? You have more power over this condition than your health professional does. A diagnosis of diabetes is a life changing event. So head diabetes off at the pass and prevent it.

What is insulin?

Insulin is a hormone made in the pancreas that takes sugar (glucose) out of the blood and transports it into the cells where it can be used for energy. Higher than normal amounts of sugar (glucose) in the blood is not only useless – it’s dangerous. It can lead to diabetes, heart disease, and stroke.

What is insulin resistance?

Insulin resistance is a metabolic condition in which the tissues in the body – liver, muscles and fat cells – do not respond properly to insulin. It’s like a car sitting in a driveway not able to pull into the garage because the garage door is closed.

So what the body does is it makes more insulin. The pancreas churns out as much insulin as it can (to try to get that garge door open) and that works for a while. That’s why you can still have normal blood sugars for years, but your pancreas is working on overdrive trying to keep up with your ever increasing insulin needs.

If nothing changes eventually the pancreas burns out – it just can’t keep up anymore. And – BOOM – you have diabetes. It may seem to come on suddenly, but it’s actually been coming on for years.

Who is at risk for insulin resistance?

People who have a family history of diabetes may have genes that make them more likely to become diabetic. But being overweight, not getting enough exercise and poor diet are the main causes of insulin resistance – regardless of your family history. It is our lifestyles more than our genes that are responsible for the epidemic of diabetes that has occurred.

What can I do about it?

Control your weight and get adequate exercise. As for diet, you don’t have to eat perfect – you just need to eat better.

Weight Control

Weight loss schemes are a billion dollar business. I try to post helpful and sound advice on this blog. Here are a couple of links on this site you might want to look at:

This post is the whole nine yards on weight and the human body.

This is a short post on weight that I hope makes the point that it doesn’t have to be complicated and it doesn’t matter how you do it – it just needs to get done.

Exercise – How Much and What Kind?

Here’s post, also on this blog, about the amount of exercise needed to achieve weight loss that is recommended by the American College of Sports Medicine.

In the January 2009 issue of the Archives of Internal Medicine researchers published a study comparing resistance exercise versus aerobic exercise versus resistance and aerobic exercise combined. Their subjects were 136 older, sedentary obese adults studied over 6 months. Researchers found resistance exercise alone did not alter insulin resistance. But insulin resistance improved in both the aerobic group and the resistance plus aerobic group. Not surprisingly, the group that did both aerobics and resistance exercise improved insulin resistance the most. Where exercise is concerned the more the better.

What to Eat

If you are insulin resistant it’s the carbs you want to watch. If you are a sugar freak and consume a lot of refined sugar – cakes, candies, cookies, and non-diet sodas – you are really stressing your pancreas and may speed up its burn out. If pasta, bread and potatoes are your thing, try to pair them with lean proteins, watch your portion sizes.

Try meals with only lean proteins and vegetables a couple of nights a week and leave off the carbs altogether. It will give your pancreas a rest. Try going vegetarian a couple of days a week. Most of us do not get enough fruits and vegetables. Check out local fresh produce and figure out how prepare it without a lot of fat and salt.

Instead of thinking about cutting things out or restricting yourself, try to find things to put into your diet that you like and are good for you. The goal is to crowd out habits that hurt you with habits that help you.

Here’s more info from the National Institutes of Health on Insulin Resistance

Good luck!

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Diabetes Diagnosed - Now What?

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When you are diagnosed with diabetes for the first time, you get a whole lot of information pushed at you in a very short time. I strongly encourage you to attend formal diabetic education classes. If you are a newly diagnosed diabetic, here’s a checklist of things it’s important to learn about and understand. Once you know this stuff, you’ll find handling your diabetes isn’t such a big hairy deal after all. Everything will start to fall into place.

Diabetes is a lifestyle disease.

While there is often a family history of diabetes, lifestyle behaviors provoke the disease and lifestyle behaviors treat the disease.

14 things every diabetic should know:

  1. Diabetes is a “cardiovascular risk equivalent”. That means you have as much risk for a heart attack or stroke as someone who has already had a heart attack or stroke. If your diabetes is not controlled you are also at risk for blindness, kidney disease, neuropathy, vascular disease and amputation of toes, feet or legs.
  2. Your diet, exercise and medications are all aimed at one goal – to keep your blood sugar between 80 and 180 (80 to 160 is even better) at all times.
  3. If you are overweight, lose 10 to 15% of your current total body weight and it will pay huge dividends – possibly even reverse your diabetes.
  4. Construct a healthy and enjoyable diet that facilitates weight loss if necessary and prevents your blood sugar from going either too high or too low. (Remember this: as long as your diet is out of control so, too, will be your diabetes.)
  5. Exercise, particularly aerobic exercise, burns up sugar, burns up cholesterol, helps with weight management and comes with a whole host of other benefits, too. (See your health provider before starting an exercise program if you have not been physically active.)
  6. It may take one to four (or more) diabetes medicines, and possibly insulin, to manage your diabetes depending on how well or poorly controlled it is.
  7. Know how to test your blood sugar. A machine called a glucometer does this. Be sure to keep a record of all your blood sugars in a logbook.
  8. Know what an A1c is. (It’s blood test that measures your three month blood sugar average and it should be between 6.0 and 6.5, definitely less than 7.0. )
  9. Take a low dose aspirin (81 mg) daily unless you are allergic or have any other condition that makes aspirin inadvisable.
  10. Get your blood pressure to less than 130/80 and take either an ACE inhibitor OR an angiotensin receptor blocker (ARB) blood pressure medication to both control your blood pressure and protect your kidneys.
  11. Take a statin drug to lower cholesterol – and get your LDL cholesterol to less than 100 mg/dl.
  12. If you smoke you should quit – yesterday!
  13. Have a dilated eye exam by an eye doctor every year.
  14. Inspect your feet daily and have your health provider inspect them at each visit, too. You should not cut your own toenails – that should be done by a podiatrist (foot doctor).

Here are some other helpful links:

American Diabetes Association

National Diabetes Education Program

National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Don’t feel discouraged!

When you are first getting started, this list can look a little daunting. But just take things one step at a time and everything will fall into place pretty quickly. I have seen this happen over and over again. I can’t tell you how many patients I’ve diagnosed with diabetes for the first time who had it licked three to six months later. Continued monitoring by your health care provider is VERY important, though.

Bottom line – a healthy diet, adequate exercise and weight control will rescue you from diabetes – and its risks – regardless of what your blood sugars look like today!

Hey, all you veteran diabetics out there, how about posting some comments here to help out the newbies?

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Why NPs Need Full Practice and Prescriptive Authority

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For Nurse Practitioner World News, May-June 2009
By Carla Mills, ARNP

I believe I should be in charge of my own practice. I’m a nurse practitioner and primary care provider with over 25 years of clinical experience. Yet every day I am forced to negotiate around practice restrictions that interfere with my ability to deliver optimal care to my patients. This is frustrating, both philosophically and practically. Valuable time and resources are wasted in the process.

What is most limiting to the effectiveness of nurse practitioners is the lack of full practice and prescriptive authority. According to the 2009 Pearson Report (see http://www.webnp.net), only 22 states and Washington, DC, have legislated NPs to have full practice authority. Only 12 states plus Washington, DC, have legislated full prescriptive authority. I practice in Florida, a state where we have neither full practice nor full prescriptive authority. We have been working hard in Florida for years to change that, but so far without success.

Doctors’ Arguments Against Independent NP Practice

Physician organizations oppose independent practice by NPs. They have long insisted that NPs practice only under a doctor’s supervision. They express concerns that unsupervised NPs will misdiagnose, miss less obvious and potentially life-threatening problems, and make prescribing errors. They state that NPs lack the skill to manage complex patients with multisystem diseases. They have presumed that NPs will order more tests than necessary and be quicker to send patients to the hospital, thus driving up health care costs.

For over 40 years now, NP practice has been studied extensively, and none of these concerns has been found to be valid. Many of them have been debunked entirely. Errors have not been found to occur more frequently in NP practice than in physician practice. NP case management has actually proven to dramatically reduce hospital visits, resulting in significant decreases in health care costs. As for chronic disease management, it is by its very nature a multisystem, complex problem that is rooted in lifestyle behaviors—an area of medicine that NPs are very well suited to manage, in both the short term and the
long term.

Regarding prescribing errors, Dr. Kenneth Brummel-Smith, chair of the department of geriatrics at Florida State University College of Medicine, wrote in a recent letter to the editor of the online newspaper, Tallahassee.com: “There simply is a ton of evidence that physicians often do not do a good job of prescribing [controlled drugs] and very little [evidence] that nurse practitioners do a bad job. Giving prescriptive authority to nurse practitioners will improve patients’ access to needed care and should be approved.”

Physician vs NP Care

Studies have shown that a nurse practitioner’s scope of practice is about 80% of that of a physician. For medical problems that fall within that 80% scope, NPs have proven to be as capable as physicians and sometimes even superior. For medical problems outside that 80%, the patient needs to see a physician. In these cases, the NP refers to a physician exactly the same way physician generalists refer to physician specialists. There is no evidence to date that NPs are reckless or unsafe in either their decision making or prescribing practices. Ultimately, it is a matter of putting trust in NPs’ judgment the same way we put trust in physicians’ judgment.

Doctors and NPs share a responsibility to see that every patient is treated with the highest quality of care possible. Like doctors, NPs have varying degrees of experience and education. The issue is not who is providing the care; the issue is whether the care provided is safe, appropriate, and of the highest professional caliber.

Independent Practice and NP–Physician Relationships

Full practice and prescriptive authority will make NPs more efficient and effective team players. It is unlikely that full practice and prescriptive authority for NPs will affect physician practices negatively. On the contrary, it will save doctors time and busy work. It will promote innovation in health care delivery. And it will enable a larger and more agile work force of qualified health professionals who can react quickly to emergencies. This was demonstrated after Hurricane Katrina, when NPs reached patients who otherwise would have been abandoned.

Nurse practitioners will never replace physicians and, speaking for myself, have no desire to. If I had wanted to become a doctor, I would have gone to medical school. I am proud to be a nurse practitioner. I deserve respect for what I am, not denigration for what I am not — a “nonphysician,” “physician extender,” or “midlevel provider.” In the best interests of patients, I want to be recognized as an NP, and I want control over my own practice.

NPs practice in many settings in every corner of the medical care system. The degree of autonomy each practitioner needs will depend upon the setting in which the NP works and the experience of the individual practitioner. Let’s look at just two examples.

I know a neurosurgical NP who manages the pre-op and post-op care and is the first surgical assistant for a brain surgeon. This NP will not be doing, nor does she aspire to do, brain surgery. But full practice and prescriptive authority will enable her to more efficiently manage pre-op and post-op pain, make home health referrals, and follow up independently. (She does this already, but with a great deal of hassle and red tape because of existing restrictions.)

In my own case, I share an internal medical practice with a DO. Ours is a high-acuity, medically complex practice with a lot of multisystem chronic disease. Because we are in south Florida, many of our patients are elderly—a significant number over age 80. Even when the doctor is in the office, my inability to write prescriptions for controlled drugs is a hassle for patients, the doctor, and me. When she is out of the office, my ability to manage pain and sleep and anxiety problems is hindered even more. Although I have years of home health experience and understand home care needs at least as well as the doctor with whom I work, as an NP I may not order or direct care for patients requiring home health services.

Having the practice and prescriptive authority I need to function to my fullest will not change my current practice arrangement at all. It will, however, make our practice and the care we offer our patients more efficient and more streamlined, and it will facilitate better use of the doctor’s time, my time, and our staff ’s time.

What I Believe

I believe that if patients are to receive the highest possible quality of care (and thus achieve the best health outcomes), every qualified medical professional should be able to work to the full extent of his or her education, experience, and expertise. I also believe that a more democratic process that promotes nonpartisan relationships among various provider groups will result in better communication and coordination of care and will add to a higher quality of care.

Experience shows that physicians and nurse practitioners are more effective as a team than either is alone. Patients should have the right to seek and receive care from their health professional of choice. Neither doctors nor NPs should be shackled with unnecessary supervisory responsibilities or practice restrictions that impede the delivery of high-quality care.

It doesn’t really matter whether the physician–NP collaboration happens in a single office or across town. When respect and collegiality promote interdisciplinary communication and mind-sharing, everyone will benefit—patients most of all.

Our country is facing severe shortages of primary care providers. Nurse practitioners, 147,000 strong, stand trained and ready to step in immediately to address many of the pressing health needs the nation faces. I believe empowering NPs is an urgent and critical step if health care reform is to have any chance at all for success.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Osteoporosis Risk: Keeping Bones Dense

Note: This post was updated with new information on November, 21 2008. After reading this, click here, for more information about medicaions and how long you should take them.

Osteopenia and osteoporosis are conditions where thinning of the bones increase the risk for fracture – most commonly in the hip and spine. Fractures can lead to chronic pain, disability and even death. Treatment is aimed at early identification and prevention in order to avoid these three potential life-altering events. Compare the picture on the left of healthy dense bone to the one on the right of osteoporetic bone. The healthy bone is dense and sturdy while the osteoporetic bone would fracture easily if enough force were exerted on it, from a fall, for example.

Osteopenia and osteoporosis occur most often in post-menopausal women due to the lack of estrogen after menopause. (Estrogen helps keep bones strong.) But they can also occur in men, too (see the list of risk factors below). Osteopenia is “pre-osteoporosis.” In other words, the bones have thinned some, but not to the extent that they have in full blown osteoporosis.

An easy way to understand this is to picture a slice of swiss cheese. If there are only a few holes, the bones remain strong. If there are a few more holes but the slice is still more cheese than holes, that’s what osteopenia is like. If there are more holes than there is cheese (as in our picture) then the scaffold that supports the bone is weak and will easily fracture.

Osteopenia and osteoporosis have no symptoms and do not cause pain. So if you aren’t screened for them with a bone density test, they might go undetected until a fracture occurs. Bone density can be measured with a test called a DEXA scan. It is painless and takes only a few moments to perform. To learn more about bone density testing, click here.

Risk Factors for Osteopenia and Osteoporosis

  • Post-menopausal females (lack of estrogen leads to bone thinning).
  • Being Caucasian or from Southeast Asia.
  • Thin body frame (and that’s true for both both men & women).
  • Being an alcoholic (again, that’s for both men & women).
  • Long term treatment with steroids now or in the past (men and women).
  • Taking Depo-Provera for birth control.
  • Being malnourished or having an eating disorder like anorexia or bulimia (men and women).
  • Avoiding or not getting enough weight bearing exercise.
  • Being treated with a high a dose of thyroid medicine or have an overactive thyroid gland.
  • Having a family with history of osteopenia or osteoporosis.
  • Not getting enough calcium and vitamin D intake daily (1200 to 1500 mgs/day of calcium and 400IU of Vitamin D).

Treatment for Osteopenia and Osteoporosis

Treatment to maintain your current bone density and prevent further thinning of your bones employs lifestyle modifications and sometimes medication. Maintaining bone density with lifestyle and adequate calcium and vitamin D early in life (meaning starting in your teens) is the best way to build and maintain bone density. Medication can preserve thinning bones and reduce fractures in those who are older and at high risk according to their FRAX score. If you have any problems with this link just Google “FRAX score”.

Lifestyle Behaviors

Lifestyle behaviors that help prevent and slow the progress of osteopenia and osteoporosis include a diet with adequate amounts of vitamin D and calcium plus weight bearing exercise. If you are at risk, daily dosages of 400-800 IU of vitamin D plus 1200-1500 mg of calcium are recommended. If you are not getting that much vitamin D and calcium in your diet, you should take quality vitamin supplements. Exercise should be targeted to achieve three results:

  1. Increased weight bearing to maintain bone density (i.e. walking or running versus biking or swimming).
  2. Improving balance to reduce your fall risk (yoga, physical therapy, and Tai Chi are all great ways to improve your balance).
  3. Training with weights to build muscle strength (elderly body builders achieve more improvement in their strength than younger people do)!

Medications

Most of the common medications used for osteopenia and osteporosis do not build bone, they just prevent further thinning. All the various medications used to treat osteoporosis and osteopenia are reviewed here.

Do you need medication?

At the present time, treatment with medication is recommended for those who have full-blown osteoporosis as measured by their bone density test. Younger post-menopausal women with osteopenia and low risk on their FRAX score may postpone treatment with medication and engage in those lifestyle behaviors that maintain their bone density. All women after menopause should have their bone density tested every two years. Check with your provider about the costs and coverage of DEXA scanning.

Links to More Info on Osteopenia and Osteoporosis

  1. This is a 3 minute story from NPR about a new online tool created by the World Health Organization that measures your risk.
  2. Here’s the risk tool talked about in the NPR story in English: FRAX – Fracture Risk Assessment Tool. It is available in other languages at this link.
  3. Here is a link to the National Osteoporosis Foundation..
  4. Finally, here is a mother lode of great information at the National Institutes of Health website: Medline on Osteoporosis

So what are you doing to stay strong!

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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About Bisphosphonates - When to Stop Them

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Medical treatments are continually studied and recommendations to medical professionals are regularly revised. In this post I will update you on the latest recommendations related to the drugs used to treat osteoporosis and osteopenia (pre-osteoporosis). Click here if you would like to review an my post about the risk factors, detection and prevention of these conditions.

If you take Fosamax, Atelvia, Actonel, Boniva or Reclast (or if your health professional has recommended you take one of them) read this post to learn how get the most benefit from them.

What Do These Drugs Do?

Bone is living tissue and it is constantly breaking down and rebuilding itself (this is referred to as “bone turnover or remodeling“). In some women after menopause (and under certain conditions in some men), bone breaks down more quickly than it builds up. Gradually the bones become fragile, weak and prone to fractures.

Fosamax, Actonel, Boniva and Reclast all come from the same class of drugs (called bisphosphonates). What bisphosphonates do is slow the breakdown of bone. They do this by inhibiting the cells that breakdown bone (called osteoclasts). For a year or so after starting the any of these drugs the bones actually become stronger because there is still bone turnover going on. And because the osteoclasts are being inhibited, bone builds up faster than it breaks down.

Over time, though, these drugs supress bone turnover and remodeling so bone metabolism becomes static. While the medications stop the osteoclasts from breaking down more bone, formation of new bone is also stopped. In the first 5 years on these drugs bone strength increases and risk of fracture decreases – that’s a good thing and is what the medication is prescribed to do.

What Are the Long Term Effects of These Medications?

It is not known what the long term effects of these medications are beyond 5 to 7 years. There is concern that after 5 to 7 years there may be increased risk for other types of fractures, particularly in long bones (as opposed to spine and hip where most osteoporosis fractures occur). It is believed this may be because the drugs prevent bones from remodeling and repairing small injuries. Jennifer P. Schneider, M.D. posted an interesting case study illustrating this concern, you can click here to read it.

What About the Jaw Problems I Have Heard About?

That’s a condition called osteonecrosis of the jaw (meaning death of the jaw bone) and it is an awful thing. In 22 years I have only seen one case of it. It is very rare and is usually only seen in people receiving bisphosphonate drugs as part of cancer chemotherapy at much, much higher doses than those that are given for osteoporosis. One source I found estimates its risk at osteoporosis treatment doses is about 1 in 60,000. Click here to view that source and read more about osteonecrosis of the jaw. Other sources I read put the risk at 1 in 100,000. It is very rare.

What is the Take Home Message?

  • If you have been on bisphosphonate medication for 5 years or more schedule an appointment to discuss your treatment plan with a health professional.
  • Do not be afraid of medications that treat osteoporosis and osteopenia.
  • You will live with your condition for many years and there are no hard and fast rules about when and how long to treat. The best plan is the one that is tailored specifically for you.
  • There are a variety of strategies that can be put to use to protect your bones, prevent fractures and make the best use of the medications available.
  • Read my other post on osteoporosis and osteopenia to learn the lifestyle behaviors and vitamins you can take to slow or prevent the progression of the disease.
  • Finally, do NOT fall!!!

If you want to learn more you can find more detailed information at this link. It’s an academic site maintained by Susan Ott, MD, Associate Professor, Department of Medicine at the University of Washington about bisphosphonates.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Democrats and Republicans Should All Be Mavericks about Health

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Four years ago, before the last presidential election, I wrote this post. I think it’s worth revisiting again. The media branded the last Republican presidential candidate a “maverick” and it made the word suddenly popular and in vogue. But the politics obscured its meaning – as politics so often do. Being a maverick means a lot more than simply not always voting with one’s own political party.

Being a maverick means you make up your own mind about everything, you don’t “run with the herd”, you determine your plan of action and you then have the guts to follow through on your plan. Maverick Health was founded on these principles. Here are some thoughts on why – whether you are a Democrat or a Republican – you should absolutely be a maverick about your health.

Health Care Reform Will Not Cure What Ails Us

  • The majority of our occupations and many of our recreational activities are sedentary. In order for our bodies to function properly we simply must budget extra time into already busy lives to exercise. There is no kind of health care reform that can help with this – we are the only ones who can reform our own behaviors.
  • Most of our neighborhoods and communities are designed so we have to drive everywhere. If we could walk or bike to work, school, the drug store and our children’s’ sports events we might build some physical activity into our daily lives. It will take decades to rebuild our towns and neighborhoods so they are friendlier to our health, in the meantime we can only adapt our behaviors to current circumstances.
  • Our diets have too many calories, too much fat and too few nutrients. The result? We are plagued with epidemics of obesity and diabetes both of which lead to a long list of other chronic diseases. Plus they increase our risk of catastrophic events, too, like heart attacks and strokes. When we demand and purchase healthier foods and close our wallets to unhealthy convenience foods then more and more healthy food will be made available to us. Buy it and it will come.
  • Many of us obtain our sense of community and citizenship from passive consumption of an ever-present media instead of from active participation in local service. This leaves us feeling alienated and adds to our stress levels. Perhaps it is time to turn off the TV and put our money and energies into local efforts where we can have both a direct impact and the comfort of interpersonal connections.
  • Our “health” care system only pays to treat sickness (and that’s only IF you are lucky enough to have access to it). Doctors and other health professionals are short on time and many lack the skills required to keep you well. That’s because most were trained to treat you only after you get sick. Staying healthy has been left entirely up to you.

How to Be a Maverick about Your Health – 3 Steps

  1. Learn what your own health risks are and how they should be treated – by both you and your health professional. (This is what makes you a maverick – you are not leaving your health to someone else or to chance – you are taking charge.)
  2. Make any lifestyle changes that will reduce your risks and talk to your health professional about whether you need any tests or medications.
  3. Measure your efforts. Whether it is how many minutes you exercise, how many calories you eat, your weight, your blood pressure or blood sugar, you won’t know if you are succeeding unless you measure.

Being a Successful Maverick

Some of my patients succeed and some fail at risk reduction. In my practice, unlike here on the Web, I am able to make sure each person knows his or her particular risks and what should be done about them – both by them and by me. So, if they all have the information they need, why do some succeed in reducing their risks while others don’t? Three factors seem to lead to a fourth one – and it’s the fourth one that finally guarantees success:

  1. Knowledge and understanding – thinking through the pros and cons of changing versus not changing behaviors.
  2. Time – it takes time for this knowledge and understanding to mature into action.
  3. A (usually frightening) life event OR a pact with a loved one – that’s what seems to prompt action to be taken.
  4. Finally – the person makes up his or her own mind to make a change.

Every single successful person I’ve talked to has said the same thing. Change was impossible until they made up their own mind. That’s what mavericks do – they make up their own mind. Everyone tells me that once they did that the change wasn’t hard at all. Go figure.

Are you a maverick? If so – why? If not – why not?

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Do You Take Omega 3 Fish Oils? Are You Taking Enough?

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The American Heart Association recommends that patients with elevated triglycerides take 2 to 4 grams (that’s 2000 to 4000 mgs) of omega 3 fish oils a day. In my practice, I recommend 4 grams per day for almost everyone – particularly those people with abnormal cholesterol profiles, Metabolic Syndrome, diabetes, and/or cardiovascular disease.

That’s the dose I take myself – for prevention – even though my cholesterol profile is normal. But when I ask my patients how much they take, most of the time they say “one a day” – and that is not enough. More omega 3s are better than not enough.

First, what are omega 3s and what do they do?

Omega 3 fish oils contain essential fatty acids our bodies need but can not produce – that’s why we have to get them from our diet and why they they are called essential!

Omega 3s beneficial health effects are:

  • lowering triglycerides.
  • lowering blood pressure (but only slightly).
  • decreasing inflammation.
  • slowing the progression of plaque (also known as “hardening of the arteries”) in blood vessels.
  • decreasing clotting tendencies.
  • improving brain function.
  • decreasing the risk of heart attack and stroke.
  • perhaps decreasing heart arrythmias (or irregular heart beats) – but that is still under study.

The three most important omega 3s fatty acids are:

  • eicosapentaenoic acid (EPA)
  • docosahexaenoic acid (DHA)
  • alpha-linolenic acid (ALA)

How do you get enough omega 3s?

One way is to eat foods that contain high amounts of omega 3s. Oily fishes such as salmon, halibut, albacore tuna, sardines, mackerel, herring and trout are good sources of EPA and DHA. There is ALA in nuts like walnuts and oils such as flaxseed, canola, and olive – but ALA, though a healthy fat, has only a fraction of the beneficial effects that EPA and DHA have.

Most Americans get more omega 6 fatty acids than omega 3s in their diets. Omega 6s are found in vegetable oils containing linoleic acid including corn, safflower, sesame, soybean, sunflower, walnut, and wheat germ.

Since omega 3s and omega 6s compete with each other to be converted by the body, you can increase how much omega 3s you get either by reducing your intake of omega 6 fatty acids or increasing your intake omega-3 fatty acids.

Omega 3 dietary supplements come in either 1000 mg capsules or 1200 mg capsules. The benefit of supplements is that, if purchased from a reputable manufacturer, they have gone through a purification process to remove any mercury, heavy metals, PCBs and other contaminants that may be present in the fish themselves.

How much is enough?

If you have high triglycerides, high blood pressure, are on medication for either of them or have other cardiovascular risks (i.e. Metabolic Syndrome or diabetes, for example), 4 grams, which is equal to 4000mgs per day is optimum.

Take either two 1000 mg capsules in the morning and two 1000 mgs capsules at night or take four 1000 mg capsules together following a meal. (I take four 1000 mg capsules after my evening meal along with my other vitamins.) If the supplement you buy is 1200 mgs then take three capsules a day.

In my clinical practice, I see much more dramatic improvements in cholesterol profiles at the 4 gram/4000 mg dose of omega 3s than at 2 grams/2000 mg or less. So if you are going to take them at all – take enough to get the effect you are seeking.

Are there side effects?

The most common complaint I hear from people about omega 3s is a fishy after taste with some supplements. I have not found this with the high quality (but not expensive one) that I buy at a health food store. For those people I recommend trying another brand. Also, if you keep the capsules in the refrigerator – that helps, too.

Because omega 3s reduce clotting there is some risk of bleeding, though I have not observed this in clinical practice. If you are planning surgery, discontinue them 7 to 14 days before your procedure and resume them again after. If you are on blood thinners such as Coumadin/warfarin make sure you keep up with your protime blood tests to monitor your medication dosage. Be sure to discuss all your medications and supplements with your health provider.

A fish oil by prescription.

For people with good insurance there is a fish oil capsule by prescription called Lovaza (it used to be called Omacor but they changed the name).

This is a pharmaceutical grade fish oil meaning, unlike over the counter supplements, it is produced with the oversite of the FDA (Federal Drug Administration) to insure quality. Dietary supplements are not subject to this FDA oversite. The dose is the same – 4 grams or 4000 mgs per day. If you don’t have insurance that covers, it is expensive so just buy over the counter high quality supplements.

Quality fish oil supplements are very affordable considering the potential benefit to be gained by taking them. There is strong scientific and clinical evidence behind making fish oils a part of your daily health and nutrition plan.

So – don’t stop at a half dose, take the full 4 grams/4000 mgs a day to get the full benefit from omega 3 fish oils – OK?

Other Resources on Omega 3s:

U.S. National Library of Medicine

American Heart Association

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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The Vytorin Controversy: What’s a Patient to Do?

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This post was originally published on May 15, 2008 and updated updated on January 16, 2009. Click here to read the update. This has remained one of the most frequently read posts on this blog.

When all the controversy about Vytorin hit the popular press in January 2008, patients immediately began calling my office for more information. They are asking a lot of good questions. They want to know whether they should stay on the drug or stop it; whether it is doing them any good – or more importantly, whether it is doing them any harm. I’m going to try to explain what the controversy is all about and give you some information that will help you figure out what to do.

About These Drugs

Vytorin is a cholesterol lowering drug that combines two drugs in one pill – Zocor (also now available as a generic – simvastatin) and Zetia.

Zocor (simvastatin) is from a class of drugs called statins. Other drugs in the statin class are: Lipitor (atorvastatin), Pravachol (pravastatin), Mevacor (lovastatin), Crestor (rosuvastatin), and Lescol (fluvastatin). These medications work in the liver to decrease the amount of cholesterol produced there. We actually make most of cholesterol in our bodies ourselves to digest fat – that’s why a high fat diet raises cholesterol. Only part of the cholesterol in our bodies comes from food.

Zetia, on the other hand, is a drug that works in the gut to block the absorption of cholesterol there and it lowers total cholesterol more than a statin alone. It has been used primarily as an add-on drug along with statin to achieve greater overall reductions in cholesterol levels – though it is occasionally used alone.

About the Controversy

This whole controversy is part grandstanding, part muck-raking, part politics, part marketing and part witch-hunting – none of which is helpful to patients trying to figure out what they should be doing.

I went poking around the Internet and found this post on the Wired Science blog called The Vytorin Controversy for Dummies. I think it unmasks much of the skullduggery surrounding this issue quite nicely. It also makes the point that for all the media bluster and all the ink that’s been spilled, patients have no better information on which to base their treatment decisions now than they did before the controversy. In fact, like with most of these pharmaceutical disputes, they create more confusion than clarity.

Poor Richard

I was particularly moved when I read this comment to the Wired Science article posted by: Richard on Apr 11, 2008 at 2:09:53 PM:

I think one of the most obvious aspects of this drug problem has been overlooked.
Vytorin is a combination drug of Zocor and Zetia. Zocor is a statin, Zetia is not a statin.
So, what is the issue with Vytorin?
Is the issue with statin alone; is the issue with Zocor; is the issue with Zetia; is the issue with statin in combination with Zetia; is the issue with Vytorin alone?
I was taking Vytorin for a while prescribed by my then cardiologist. My internist, who is not the most informed pharmacologist, decided that Lipitor is better and switched me to that. When my cholesterol numbers still didn’t come down enough my new cardiologist prescribed Zetia. So at this point I am taking Zetia and Lipitor. On my next to last visit to the cardio he says why don’t you take Vytorin?
Meanwhile I didn’t tell you about how I went between 20 40 mgs on the statin in both drugs—relevant?
Duh! So I switch back to Vytorin.
PLEASE HELP (I mean it)

Answers to Richard’s Questions

CARLA: Richard, I wish I knew how to reach you so I could send you a link to this post. I think you are asking great questions! So I am going take them one by one and try to answer them. Here goes:

RICHARD: I think one of the most obvious aspects of this drug problem has been overlooked. Vytorin is a combination drug of Zocor and Zetia. Zocor is a statin, Zetia is not a statin. So, what is the issue with Vytorin?

CARLA: The issue is whether the combination of Zocor (a statin) and Zetia together reduce plaque in the arteries less than, the same as, or more than Zocor (or another statin) alone. Critics say if Vytorin either causes an increase in plaque (which has neither been proven nor disproven) or doesn’t reduce plaque any more than a statin alone then there is no point in taking it. The rub comes because it’s well known that this drug combination lowers both total cholesterol and LDL (the bad cholesterol) more than a statin will alone. So, the answer to your question is: the issue is the degree of plaque reduction in the blood vessels. What makes this confusing is that plaque that’s already in the blood vessels got there as a result of long term high cholesterol in the bloodstream. So the other question that needs to be answered is: Will overall reduction of cholesterol decrease plaque deposition even if it doesn’t decrease the plaque that’s already there? (Sorry to answer your question with another question – but I’m trying to explain where the tipping point is here.)

RICHARD: Is the issue with statin alone; is the issue with Zocor; is the issue with Zetia; is the issue with statin in combination with Zetia; is the issue with Vytorin alone?

CARLA: The issue is whether Zetia combined with any statin will increase, decrease or make no difference in the effectiveness of the statin. It is known that statins do reduce plaque somewhat (though to different degrees depending on which statin and at what dose). What is being questioned is whether adding Zetia interferes, adds to or has no effect on statins ability to reduce plaque.

RICHARD: I was taking Vytorin for a while prescribed by my then cardiologist. My internist, who is not the most informed pharmacologist, decided that Lipitor is better and switched me to that. When my cholesterol numbers still didn’t come down enough my new cardiologist prescribed Zetia. So at this point I am taking Zetia and Lipitor. On my next to last visit to the cardio he says why don’t you take Vytorin?

CARLA: Here is how I would help you decide for yourself. Let’s look at three patients on Vytorin and you see where you fit into these scenarios:

Patient #1: Has a history of having already had a heart attack, has had coronary artery bypass surgery, and a family history of high cholesterol just like the people in the ENHANCE study that started all this controversy. This patient’s cholesterol is well controlled to target numbers on Vytorin 10/40 mgs. In light of the questions the controversy has raised, it would be reasonable to switch this patient to Zocor/simvastation at 80mg (or another statin at an equivalent dose) and watch their cholesterol and liver function tests. If both remained normal and to target, based on what we now know, this person might get slightly better reduction of plaque on a higher dose of the statin alone than with the combo therapy. But if the cholesterol numbers went up, restarting the Zetia would be reasonable. Remember high cholesterol is what grew the plaque in the first place.

Patient # 2: Is middle aged, has no history of cardiovascular disease, but cholesterol levels are too high in spite of three months of lifestyle modifications to a low fat/low cholesterol diet and regular aerobic exercise. This patient is prescribed Zocor/simvastatin 20 mg alone (or an equivalent dose of another statin) and encouraged to continue the lifestyle modifications. After three months, this patient’s cholesterol numbers still do not reach goal. At this point, adding Zetia to the Zocor (which is Vytorin 10/20 – Zetia 10 mg/Zocor 20 mg) would be reasonable. If, after another three months, the cholesterol levels are not to goal, increasing Vytorin to 10/40 could be tried and three months after that increasing it again to 10/80 if necessary.

Patient #3: This patient has no insurance and pays cash for all prescriptions. There is a family history of cardiovascular disease and the patient’s cholesterol profile is too high in spite of lifestyle modifications. Going with generic simvastatin or pravastatin (the only two generic statins on the market) and increasing the dose every three months while following liver function and cholesterol numbers will be the most cost effective, safe and aggressive therapy to prevent a future cardiovascular accident. And it would be a respectful way to prescribe given the patient’s lack of insurance.

RICHARD: Meanwhile I didn’t tell you about how I went between 20-40 mgs on the statin in both drugs—relevant?

CARLA: Take whatever dose is necessary to achieve target numbers. Don’t be afraid of higher doses if your numbers are not to target. Many treatment failures occur because maximum therapeutic doses are not reached, so don’t stop short of reaching your goal. Your health provider should be following your liver function tests with each dose change and you should report any side effects you have. According to a joint report by the National Heart. Lung, and Blood Institute; American Heart Association; and the American College of Cardiology these medications are under-prescribed and safe for the overwhelming majority of people who need them.

RICHARD: Duh! So I switch back to Vytorin.

CARLA: If it gets your numbers to target, don’t worry about it. Take your medicines properly, follow a healthy lifestyle and see your health provider regularly – that’s your best chance for avoiding problems.

RICHARD: PLEASE HELP (I mean it)

CARLA: I hope this answers Richard’s questions – and yours. Do you have any comments, information to add, or other questions?

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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The Vytorin Controversy One Year Later - An Update

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On January 8, 2009, the FDA issued the following safety review of Vytorin and concluded: “patients should not stop taking Vytorin or other cholesterol lowering medications and should talk to their [health provider] if they have any questions about these medications.”

Dear patient, you have been drawn into a medical slugfest that is being fought among leading cardiologists, so what are you to do? Read my prior post to get some background on the Vytorin controversy and then read this post to see where we are one year later.

The ENHANCE Study

In January of 2008 a study called ENHANCE was published and the cardiologists started swinging. This study showed the cholesterol drug Vytorin (which is a combination pill that contains two drugs – Zocor/simvastatin and Zetia/ezetimibe) did not reduce plaque in carotid arteries more than Zocor/simvastatin alone did.

In spite of The American Heart Association (AHA) and the American College of Cardiology (ACC) issuing a joint statement the very next day stating that Vytorin did not appear to be unsafe, calls flooded into millions of medical practices, including mine, from concerned patients. My estimate is that about 30% of the patients in my practice who had been taking Vytorin asked to be switched to another drug. I do not know how many just quit taking their medication altogether without calling or coming in to discuss it.

Now, one year later, the FDA’s safety review is complete and thier conclusion is “the levels of LDL (the bad) cholesterol decreased by 56% in the Vytorin group and decreased by 39% in the Zocor/simvastatin (alone) group. Patients should not stop taking Vytorin or other cholesterol lowering medications and should talk to their [health provider] if they have any questions about these medications.”

LDL is a known risk factor for cardiovascular disease and reducing LDL is a primary goal of cholesterol lowering medication. Plaque in the arteries is the result of years of increased LDL levels.

The primary purpose of cholesterol lowering medications is to prevent or slow the build-up of paque, it is not to get rid of plaque that’s already there. So dear patients, as Roseann Roannadanna would have said (and, according to the FDA this week), “Never mind.

My advice is continue to take your medication faithfully and get your cholesterol profile to target – nothing has changed.

The SEAS Trial

Later in 2008 a study called SEAS was published. In this study they were testing whether lowering LDL (the bad) cholesterol with Vytorin would reduce the risk of major cardiovascular events (in this study they were looking at aortic valve replacements, episodes of congestive heart failure, and heart attacks or strokes in individuals with aortic stenosis – a tight heart valve).

SEAS data showed there was more cancer diagnosed in patients taking Vytorin when compared to those taking a placebo (a pill with no medication in it). Another cloud was cast over this drug.

The IMPROVE-IT and SHARP Trials

So when the cancer findings became known, an independent analysis of two other studies of Zetia/ ezetimibe (the IMPROVE-IT and SHARP trials) was done to see if the cancer risk seen in the SEAS trial was real or chance. Those studies, which are still underway, showed no increased cancer risk.

One of the leading cardiologists in the slugfest was quoted as saying “the medical community will have to live with uncertainty regarding Vytorin based on the SEAS trial”. That is the medical community – and you – dear patient.

My Opinion as an NP

This whole controversy makes me angry. I firmly believe patients should be kept informed about their medications and treatments – both their risks and their benefits. But when leading physicians start playing “I’m a better expert than you” in the media over inconclusive and ongoing research, I think it is a disservice to both medical research and the patients it is meant to serve.

Nothing I have read over the last year about this controversy has led me to believe that Vytorin or Zetia pose a greater danger to patients than the high cholesterol they have been proven to effectively treat. I don’t have a crystal ball. I don’t know what will be discovered in the future about these or any other commonly prescribed drugs. I counsel my patients that nothing is without risk and we make the best decisions we can with the information that we have.

This whole controversy is just too much information about too few proven facts. So you world famous cardiologists out there – do us all a favor and thrash it out among yourselves before dragging the media and the public into it. Patients have enough to worry about without being frightened into believing they have problems they might not have.

Just for the record, I have no financial or clinical involvement with either the makers of Vytorin and Zetia or the any of above named studies. I’m a clinician who has followed this story in the clinical literature and the popular press over the last year. I haven’t seen anything yet that makes me think this is anything more than much ado about nothing.

Links I read to write this post:

American College of Cardiology Statement on ENHANCE Trial, January 15, 2008

Cleveland Clinic Journal of Medicine: Is ezetimibe/simvastatin no better than simvastatin alone? Lessons learned and clinical implications, July 2008

FDA Investigates a Report from the SEAS Trial, August 28, 2008

FDA Safety Update, January 8, 2009

CNN Money, FDA Completes Review of Clinical Trial for Vytorin, January 08, 2009

Debate about ezetimibe not over yet: Experts again weigh in on cancer risk, January 8, 2009

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Mammogram Guidelines – What to Do Now?

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The U.S. Preventive Task Force Services (USPTF) has recommended that screening mammograms were no longer routinely required for women in their 40s and that self-breast exam is no longer advised. What!? Is this just cost-cutting or is this good medicine?

Mammogram Recommendation for Whom?

Before deciding how to react to these guidelines and whether to follow them or not, the first order of business is to put them in perspective in terms of your own personal and comprehensive health care plan. It is our position here at Maverick Health that neither doctors, task forces, organized medicine nor insurance companies should be in charge of your health and health care – you should.

Government agencies (like the USPTF), doctors and insurance companies exist to serve you – not to dictate to you. To get the most out of these services, you must be the one in charge. This means taking on more responsibility for knowing your own circumstances. That’s how you will be able to determine where you fit into these new guidelines. These government agencies come up with these recommendations for whole populations – but treatment decisions must be made by and for individuals.

Health Risk Screening in General

Cancer and, in fact, all health screenings are designed to discover and treat diseases that may not yet be causing symptoms. The goal of screening is early detection to (hopefully) cure but at least treat problems before they develop into chronic diseases or cause death.

Different people have different levels of risk for a long list of chronic diseases and cancers. Risks are the result of family history, personal lifestyle behaviors and, to some extent, luck. I wrote my book, A Nurse Practitioner’s Guide to Smart Health Choices, specifically to help non-medical readers determine their particular risk profile so they are able to direct their health and health care intelligently.

Different individuals have different risk tolerances and your choice about what to do about these recommendations depends a lot on your own personal risk tolerance. You may love taking risks. Does jumping out of airplanes sound fun to you? Or you may hate risk. Do you find stepping outside your own home so risky you dread doing it? Most of us fall somewhere in between these two extremes, but our attitudes about risk determine how we choose to handle our health and health care. One size does not fit all.

The USPTF Mammogram Recommendation

The USPTF recommendation statement was directed at “women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation (i.e. a strong family history of breast cancer or known BRCA 1 or BRCA 2 genes from prior genetic testing) or a history of chest radiation.” The six USPTF conclusions were:

  1. For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women—who will not develop breast cancer—and therefore use the number needed to screen to save 1 life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.
  2. For biennial screening mammography in women aged 50 to 74 years, there is moderate certainty that the net benefit is moderate.
  3. For screening mammography in women 75 years or older, evidence is lacking and the balance of benefits and harms cannot be determined.
  4. For the teaching of BSE (breast self exam), there is moderate certainty that the harms outweigh the benefits.
  5. For CBE (clinical breast exam) as a supplement to mammography, evidence is lacking and the balance of benefits and harms cannot be determined.
  6. For digital mammography and MRI as a replacement for mammography, the evidence is lacking and the balance of benefits and harms cannot be determined.

What I Tell My Patients

  1. My clinical concern and responsibility is taking care of individuals, not populations. A single case missed is one too many as far as I am concerned. Even though mammography is not the most perfect test in the world, particularly in women under age 50, the practice of combination screening with mammography, an annual clinical breast exam and monthly or bimonthly self breast exam is the best we’ve got at present in my opinion. I plan to continue to recommend a baseline mammogram between age 35 and 40 and will determine frequency after that based on each woman’s particular risks and her financial ability to pay for the mammogram. As for the issue of “adverse consequences” raised by the task force (i.e. anxiety surrounding testing or additional testing such as ultrasounds or biopsies if the mammogram is questionable), that is a non-issue in my opinion. A little anxiety surrounding screening or diagnostic testing pales in comparison to the anxiety associated with a diagnosis of breast cancer. If the mammogram is questionable additional testing clarifies an individual’s breast status at any age.
  2. For women 50 to 74 years I’ll continue to recommend annual breast surveillance consisting of screening mammography, annual clinical breast exam and monthly or bimonthly self breast exam.
  3. Breast cancer risk increases with age. For women 75 and older in good health I will continue to recommend annual breast surveillance consisting of screening mammography, annual clinical breast exam and monthly or bimonthly self breast exam. Exceptions are when women are in poor health and would not be good candidates for breast cancer treatment or women who tell me that if they learned they had breast cancer they would not want any treatment.
  4. This recommendation I really do not understand. What possible “harms” can come from examining one’s own breasts for lumps and who exactly would be harmed? Why anyone would recommend women stop self breast exams is beyond me. My sister picked up her own breast cancer with self breast exam only a few months after her mammogram missed it. Because she caught it early her treatment was less invasive and more likely to have resulted in a cure. I will continue to encourage and teach self breast exams to my patients.
  5. For clinical breast exam (done by your health professional at your physical exam) they are saying they don’t know if it does any good or not. I haven’t picked up many breast cancers that way over the years, but I’ve picked up a few. In my practice we recommend annual physical exams, though the “benefit” of those too is under question. It’s an opportunity to do a very detailed exam of the whole body (not just a gynecological exam), check on whether health screenings are all up to date, and teach things like self breast exams and self skin exams among other things.
  6. Digital mammography and breast MRI are also question marks as far as the task force is concerned. At present radiology centers are upgrading to digital and that will be the new standard. Skilled radiologists reading the films – whether plain or digital – are still an essential component. In in the last study I read radiologists are still beating the computers in reading digital mammograms. Breast MRIs are expensive and currently used only for high risk patients or as a follow up to abnormal mammograms.

Postscript on PAPs

Just a couple of days after the USPTF announced their new recommendations the American College of Obstetricians and Gynecologists (ACOG) in a press release announced their own new recommendations that PAP smears can now be delayed until age 21 and only need to be done every couple of years.

FYI: These two new recommendations released during the same week were completely coincidental. They were issued by two different and unrelated organizations and are in no way a “conspiracy” to deprive women of health care. For now mammograms are still being covered in the same way by insurance companies they have always been.

As for the PAPs, women younger than 21 who are sexually active should definitely see a health professional about their gynecological care every year. Topics for discussion are: birth control options, HPV vaccination, timing of PAP smears, sexually transmitted disease risks and safe sex practices.

Bottom line: The best person to take care of you is you. If you’re lucky you have a competent and understanding health professional in the form of a nurse practitioner, physician or physician assistant to help you and advocate for you. If you don’t – see if you can find one.

Your comments are welcomed.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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It Is a Mistake to Call a Nurse Practitioner a Nurse

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I do not like it when people call me a Nurse. I liked it when I was a Nurse, but for more than 17 years now I’ve been a Nurse Practitioner. The two titles are NOT interchangeable and the duties and responsibilites are NOT the same.

As a Nurse Practitioner I’m often asked “What should I call you?“. Doctors are addressed as “Doctor”, but if your doctor is a Nurse Practitioner, how should you address that person?

Call Me Carla, Just Don’t Call Me Late to Dinner

My patients are often not sure what to call me. When they ask me, I say “just call me Carla”. That’s my name. When patients call me Ms. Mills, it makes me feel like some stiff and formal version of myself - and that is not who I am as a health care provider. On the other hand, if you are my dry cleaner and just lost my best pair of black slacks, you will find Ms. Mills works a lot better for you.

Names Matter

Names matter. Don’t you dislike it when someone calls you by the wrong name? I think most of us do. Names call things what they are. A maple is a tree, but every tree is not a maple. A terrier is a dog, but every dog is not a terrier. A Nurse Practitioner is a Nurse, but every Nurse is not a Nurse Practitioner.

Types of Nurses and Their Correct Titles

I don’t know why my profession has chosen such confusing language to name the different types of nursing professionals but it’s no wonder you are confused about who does what.

Even among advanced practice nurses like Nurse Practitioners, there are other types of nurses who also have advanced clinical training. Those include Nurse Midwives, Nurse Anesthetists, and Clinical Specialists.

My purpose in writing this post is to help you get nurses’ names strainght. I will describe the three types of licensed professional nurses. I am also including CNAs, who are NOT nurses, but are healthcare workers that assist nurses. When you use the words “Nurse” or “Nurse Practitioner” I want you to know what you are talking about.

Correct Names of Nursing Professionals

Nurse Practitioner (NP) is a licensed registered nurse with advanced academic and clinical training at the master’s or doctoral level. NPs provide both medical and nursing care under their own license. NPs are licensed to give orders, prescribe medications, and direct medical care of patients. Depending on state law, NPs practice either independently or in collaboration with physicians. NP areas of specialization and certification include Family, Adult, Pediatric, Gerontologic, Women’s Health, Psychiatric, School and Occupational Health, Emergency, Neonatal, and Acute Care. NP education is shorter than physician education, and continuing education for certified NPs is 150 hours every five years and recertification is every five years. Click here for more about NP practice. Correct name: Nurse Practitioner or NP.

Registered Nurse (RN) is a licensed health professional who is a graduate nurse who has passed an examination for registration. Education required is an Associate’s or a Bachelor’s degree but may be a Master’s or Doctorate degree. RNs provide nursing care, administer medications, provide health counseling and teaching, and supervise less skilled personnel. The RN must have an order to administer any medications or give any treatments. RNs are NOT licensed to give orders, prescribe medications, or direct the medical care of patients. It is this difference in scope of practice between a NP and RN that makes calling a Nurse Practitioner a Nurse incorrect. Correct name: Nurse or RN.

Licensed Practical Nurse (LPN) is a licensed health professional who works under the supervision of an RN, NP, PA, MD, or DO; education required is a high school diploma and completion of a formal training program at a vocational school or community college that includes supervised clinical instruction. LPNs must also successfully complete a licensing examination. LPNs can perform many basic nursing functions including administering medications. Their scope of practice varies from state to state. Correct name: Nurse or LPN.

Certified Nurse Assistants (CNA): are NOT nurses. They are healthcare workers, unlicensed but certified, and are known by many names including CNA, Nurse Aides, Orderlies, Patient Care Technicians, and Home Health Aides. They are an important part of the healthcare team and provide direct, hands-on care to patients in a wide variety of settings. They give personal care such as bathing and feeding and other duties and work under the supervision of an LPN or RN. Education depends on the state, and requirements for certification vary anywhere from two weeks of training followed by a test to several months of clinical and classroom training. Correct name: CNA or Nurse’s Aide.

3 Ways to Support Nurses

NPs, RNs and LPNs work together with the collective goal of providing you the best care possible. You can return the favor by doing the following:

  • When you are treated by a Nurse Practitioner, say you saw a Nurse Practitioner and not a Nurse.
  • When you talk about nurses who have cared for you, identify them by their correct titles.
  • When you hear someone jumbling up our roles and titles - correct them.

We already love you, learning about our profession and understanding our titles are the best ways to love us back!

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Access denied: Florida lawmakers and doctors silence NPs - again

Florida is one of only two states in the country to restrict NP prescriptive authority for controlled substances. Florida is also the “pill mill” capital of the country. Seven Floridians die every day from controlled drugs prescribed by Florida physicians.

It is past time to bring the responsible medical community, including NPs, together to enable the use of these drugs properly and appropriately. It is past time to aggressively seek out and punish those physician rogues whose small numbers have caused such an enormous and deadly problem in Florida.

It is not Florida’s NPs but a small number of Florida’s licensed physicians who are the problem. Restricting NP practice will not solve a problem caused by physicians.

Watch this 3 minute YouTube video by NP Jana Esden who (silently) shows how Florida’s lawmakers and physicians have ignored the advice of experts and used politics to restrict patients’ access to care by restricting nurse practitioners’ practice and prescriptive authority in the state.

Florida citizens are being denied access to safe, proven quality health care by NP medical providers. Please write your lawmakers to protest these outdated restrictive laws that are hurting all Floridians.

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Nurse Practitioners—Valuable but Undervalued

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For Nurse Practitioner World News
May/June 2010
By Carla Mills, ARNP

The day healthcare reform was signed into law, the future prospects for nurse practitioners (NPs) changed—whether for better or worse remains to be seen. Thirty million newly insured patients will enter the healthcare system over the next few years, all seeking primary care. Community health centers have already been targeted to receive $11 billion dollars in government funding. But, as valuable as NPs are, the profession continues to be undervalued in terms of reimbursement and practice authority. Reduced Medicare reimbursement rates for NPs compared with physicians and the lack of direct reimbursement to NPs from most private insurers will make it difficult, if not impossible, to make NP run community health centers—or any NP care delivery site—financially viable.

Under present laws, NPs are reimbursed only 85% of the amount Medicare pays physicians for the same services. Private insurers usually tie their reimbursement practices to what Medicare allows. This is an open-and-shut case of unequal pay for equal work. If NPs’ payments were to drop to 85% of the proposed 21% cut to physicians’ pay, it will put NPs out of business altogether. When reimbursement falls below the cost of delivering care, no healthcare provider—whether a physician or an NP—can stay in business.

The assumption that the law of supply and demand will solve the provider shortage is flawed. It takes years of education and clinical experience to grow a skilled clinician, and we already have a shortage of providers, even before 30 million more people seek care. Medical professionals have been increasing their patient volumes for more than a decade in an effort to compensate for pay cuts. Current patient volumes have already dramatically reduced patient visit times, which has done nothing to either reduce costs or improve care.

There are nearly 150,000 NPs already trained and currently practicing, who are hampered at every turn by low reimbursement rates and restrictions against practicing to the full extent of their education and ability. The professional energy that NPs are spending to try to remove these barriers wastes valuable time that would be much better spent creating innovative, patient centered healthcare delivery systems. Community health centers and convenience-care clinics are just two examples of new ways NPs are finding to provide direct care to patients.

Valuing the Right Things

In the last 40 years, chronic diseases have become epidemic. Obesity and smoking are now the leading causes of preventable premature death. These problems and other unhealthy lifestyle behaviors lead directly to a host of other expensive and disabling chronic diseases. While physicians have insisted on having complete and final authority over every aspect of health and medical care in this country, the state of Americans’ health has continued to decline.

Historically, physicians have been the most valued and highly paid health providers in the system. They deserve and have received credit for giant strides made within their scope of practice, which is primarily treating diseases and performing many life-saving treatments and procedures. Although these functions are very important, they come late in the process, while disease prevention, which is the focus of many NPs’ practices, may result in greater overall cost savings for the individual and the healthcare system as a whole.

Purely medical fixes send the wrong message to patients: don’t bother taking care of yourself. Eat yourself into a diabetic state, and when you are 100+ pounds overweight, come to us and we’ll fix it. The focus on treating, not preventing, disease has created a country of uneducated and dependent patients. If there is to be any hope for health and healthcare reform, it will depend on independent, well-educated patients who are skilled in preventive self-care. It’s time to stop over-valuing those providers who treat the sick and under-valuing those providers who promote health. It’s time to empower NPs. It is the only way the healthcare system can be brought into balance.

The Value of NPs

Under the physician-controlled medical system, patient education has suffered more than any other aspect of care over the last 40 years. It is an area in which NPs have proven themselves to be superior providers. I am constantly shocked to see my patients making important health choices based on incomplete knowledge and/or misinformation.

Educating patients takes time and patience—two qualities that physicians freely admit are in short supply in their own practices. Patients need reassurance, support, good information, and acceptance in order to learn to how to effectively prevent or self-manage chronic diseases. Finding effective treatment approaches that fit an individual’s world view can be tedious and frustrating work. There are small victories and frequent setbacks. The work is far from glamorous, and there is absolutely no reimbursement for it under the current payment structure. This explains why physicians are opting out of primary care—no money, no glamour. They have become accustomed to having plenty of both.

Valuing NPs

There is a tsunami of patients on its way. More than thirty million patients will become insured over the next 10 years. It is predicted that 10 million of them will enter the system with chronic diseases that have never been diagnosed or treated. The remaining 20+ million are predicted to be younger and basically healthy.

Never has such an opportunity to put prevention into practice been offered to healthcare professionals. It’s a historic chance to start turning back the scourge of chronic disease. As Florence Nightingale transformed medical care over a century ago, NPs are poised to transform it for the next 100 years. How? By being creative and innovative!

NPs have a responsibility to make their value to the healthcare system clear to everyone involved. But NPs need support too—from their patients, from the physicians with whom they work, from the media, and, most urgently, from lawmakers. It’s time for everyone to stand up for NPs and acknowledge their value. It’s time to remove the practice barriers that prevent them from being as effective as they could be. It’s time for NPs to have full practice and prescriptive authority within their scope so that they can practice without dependence on physicians.

The principle of equal pay for equal work demands that NPs receive the same reimbursement from Medicare and private insurance companies that physicians do for providing the same services. If the value and valuation of NPs are not reconsidered and the crippling financial and practice restrictions persist, there is a very real danger that NPs’ unique brand of healthcare will disappear. And if it does, its innovations and insights will disappear with it.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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Putting Prevention into Practice

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For Nurse Practitioner World News
March/April 2010
By Carla Mills, ARNP

Who is responsible for putting prevention into practice: individuals or society? If it’s an individual’s responsibility, then what business does society (that is, health professionals, employers, insurance companies, and the government) have interfering in people’s personal lives? If it’s society’s responsibility, is it cheaper to practice preventive care, or should we just wait until people get sick and then treat them?

In fact, health is a shared responsibility between a society and its citizens. Society is responsible for maintaining a healthy environment: clean drinking water, safe and healthy food, nontoxic air and soil. Individuals are responsible for their own personal health habits and for paying the price for the choices they make.

Who Pays?

Current “health care reform” (more aptly called “insurance reform”) seeks a way to provide affordable, universal health insurance that will cover medical expenses for accidents and illness without limitations on preexisting conditions. But to expect insurance companies to cover both preventive care and disease management at a low price and to offer the same benefits to everyone is simply unrealistic. The reality is that the care an individual gets is going to depend on the care an individual is able to afford.

Insurance companies can stay in business only when they have a large pool of premium-paying customers who do not file claims. That’s how they get the money to pay for the people who do file claims. The situation today is that an aging population is moving into the years of highest medical utilization, and a younger population is choosing to opt out of health insurance because it’s too expensive and they are not required to buy it. When the uninsured end up in the emergency room, they receive the most expensive care; but lacking insurance, many have no means to pay for the care. This perfect storm has led to personal financial disasters and a failing health care system. The situation is in desperate need of reform.

Historically, health insurance has paid for the largest portion of total health care expenses. The public has shared little responsibility for the rising costs of care. Now the public wants health care reform to provide both medical and preventive services and to do it at a lower cost. This is an unrealistic attitude, and one that threatens to bankrupt our country and topple our economy.

Does Prevention Save Money?

An article titled “Does Preventive Care Save Money” in the February 2008 New England Journal of Medicine reported, “Some evidence does suggest that there are opportunities to save money and improve health through prevention.”

Yet in August 2009, the Congressional Budget Office sent a letter to the US House of Representatives Subcommittee on Health reporting that “Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.”

As with all complex problems, the devil is in the details. Some interventions save lives and save money; others save lives but cost more; and others save neither lives nor money.

From society’s standpoint, we must continue to identify those interventions that save both lives and money and aim to practice them—providers and patients alike—100% of the time. This is why evidence-based practice is advocated as the gold standard of quality health care.

From an individual’s standpoint, it’s time we recognize that everyone is going to be paying more for health care. We had all best start budgeting for it. Not everyone will be able to afford a new Jaguar; some may be able to afford only a used Volkswagen. We must each tailor our expectations for what we can personally afford.

The cheapest way to save money and reform health care is to decrease utilization, that is, to stay out of the system as much as possible. The best way for each person to do that is to stay healthy, pay for routine screenings (out of pocket, if necessary), and make smart health choices that put prevention into practice in our personal lives.

Does Prevention Save Lives?

Only a few preventive interventions have been analyzed from both a cost and a lives-saved perspective. The same New England Journal of Medicine article reported that the following interventions have been shown to be both life-saving and cost-saving. But they are not practiced nearly enough.

  • Daily aspirin for adults—Fewer than 50% of American adults now take a daily aspirin.
  • Smoking cessation counseling by a health professional, including an offer for medication and other assistance to quit—Only 28% of smokers receive this counseling now.
  • Colon screenings for adults age 50 and older—Only 50% of people in this age group keep up to date with colon screening.
  • Annual flu shots for adults age 50 and older—Only 37% get them now.
  • Breast cancer screening for women age 40 and older at least every 2 years— Currently, 67% of women have recommended breast cancer screenings.
  • Annual chlamydia screening for sexually active young women, which would prevent 30,000 cases of pelvic inflammatory disease—Only 40% of the target population gets screened regularly now.

The New England Journal of Medicine article also listed the following as worthy of further study:

  • Screening for diabetes, hypertension, high cholesterol, depression, stress and anxiety, medication compliance, exercise behaviors, weight status, and dietary habits
  • The cost-effectiveness and clinical outcomes of health risk assessments and counseling of adults and children
  • Effectiveness of smoking cessation programs for youths and adults
  • Role of fast food in chronic disease risk development, and whether health warnings should be placed on these foods as they are on tobacco products

Smart Health Choices

A free society cannot and should not dictate personal health behaviors, even if they prevent disease. It is unreasonable to think a health professional, an employer, an insurance company, or the government can keep people healthy.

Ultimately, health is a personal responsibility, personal expense, and personal effort. Every individual must choose his or her own life habits and path. Knowing how to stay healthy and how to reduce the need for expensive sick care services is the most cost effective way to prevent disease and lower health care costs and utilization. Each of us will personally bear the costs of our own health choices and health outcomes, in terms of both money and quality of life.

Nurse practitioners’ preventive interventions beg further study. My book, A Nurse Practitioner’s Guide to Smart Health Choices, outlines the national treatment guidelines for those health risks the New England Journal of Medicine article deemed worthy of further study. The book details simple measurements that NPs, and patients themselves, can use to determine if preventive interventions work.

Nurse practitioners manage chronic illnesses and teach people how to stay well. NPs promote healthy behaviors, see that screenings are up to date, and educate patients how to make smart health choices. NPs put prevention into practice.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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