Ask Dr. Whittle

You need to know more about your medical condition - have an opinion!!

Posted at 11:08 PM on Saturday, November 14, 2009 by Dr Jeff

Last time I wrote that there were three things I would like every patient to do to get the most out of their doctor visits. These three things were: 1) Make sure you bring a list of your medications, including supplements and over the counter medicines, to your doctor visit. 2) Bring a list of the things you want to talk about to the appointment; and 3) As soon as possible after you are finished with the doctor, write down what you and the doctor agreed was the plan.If you don't like to write, tell a trusted friend or family member. I hope that all of you already wrote out your medication list. I suspect that many of you have had a chance to test out what happens when you bring a list of what you want to talk about to the doctor. I suspect that if you tried to write down what you and the doctor agreed on, it was harder than you thought it would be. For such a short visit, oftentimes a lot of topics are discussed. Like a lot of things, you will probably get better with practice.
The next step to helping your doctor is to know as much as possible about your medical condition. This means that you have to find out what they are!!! Even though I try to be a good doctor who talks to his patients, I am frequently surprised when I say "We will start you out at a low dose because of your kidney disease … " and the person replies "Since when have I had kidney disease!?!" So you may also be surprised by some of the conditions your doctor thinks you have. I used kidney disease as an example because most people with mild kidney disease don't have any symptoms. The same can happen when the blood count is just a little bit low, or if you have mild liver disease. It is very likely that your doctor knows you have these, and is considering these conditions in your treatment, but I think it is best if you know about them too. You may also find that your doctor thinks you have conditions that went away years ago, or are even genuine mistakes. And you may find the doctor does not know about some important conditions. This happens with the very best doctors. Since you are your doctor's partner, you need to help him or her.
A good way to find out is by talking to the doctor's nurse at the beginning or end of the visit. You can blame me or just say "You know, I am getting old enough that I am not sure I know about all my medical conditions. Do you and Dr. X have a list of my conditions? Another way to keep up with your conditions is to ask for a copy of the "discharge summary" when you leave the hospital. This is a document that the doctor who discharges you will write to summarize why you were in the hospital and what was done while you were there. Usually it includes a list of all your medical conditions. Good luck with your efforts to become a great partner for your doctor.

Physical activity

Posted at 11:04 PM on Saturday, November 14, 2009 by Dr Jeff

 

The last couple posts have asked that you work closely with your doctors. I hope that you are now asking your doctor or nurse more questions - asking about what medical conditions you have and why you take each of your medications. For many chronic conditions, including diabetes, high cholesterol and high blood pressure, you should know what your doctor thinks your goal should be, and where you are right now. I would be surprised if your doctor objects to you wanting to know such things, but if he does, tell him you heard it from me and have him email me at the VA – jwhittle167@gmail.com!!

But now I want to go back to things that are entirely in your control. Instead of talking about a disease, I would like to review physical activity. I get a lot of questions about exercise when I work with veterans or visit VFW posts to talk about health, but I like the words physical activity better. Exercise seems a little too much like a chore. The good news is that everyone does some physical activity, and that physical activity has a number of health effects. Because my space is limited, I want to focus on the benefits for weight and for heart health.

All physical activity has benefits for weight control. First, all activity burns calories. The more active you are, the more calories you burn. Many people know that walking one mile burns about 100 calories for a 200 pound man. What is perhaps more important is the idea that taking every stop helps some. So that person burns 1 calorie for every 25 – 30 steps that they take. They can do this walking in place, just as well as by walking a mile. And if you can take 200 steps while walking in place during every commercial break you burn an extra 8 calories each commercial break. If you watch 1 hour of TV a day, there will be a minimum of 4 commercial breaks, so you can burn 32 calories each day. It does not seem like much, but over a year, that is over 4 pounds and in five years that is 20 pounds!! For people with high blood pressure, that much of a weight change drops the blood pressure as much as taking another blood pressure medicine.

Physical activity also improves your heart health totally apart from its effect on weight. Once again, any physical activity seems to have some benefit. But in this case you get extra benefit by working hard enough that you can feel it, and especially if you can keep it up for more than 10 minutes at a time. A common measure of whether you are working hard enough is heart rate, but there are so many exceptions that I don't recommend it for most of the older people I see. Instead, use the guideline that you should work hard enough that you breathe noticeably harder than normal. For some people, this will mean walking at a slow pace. Other people may have to walk very briskly or carry some weights while they walk. You should try to find an activity that you can do for 10 minutes. So if walking makes your knees hurt so much that you have to stop in 3 minutes, you may want to try a stationary bicycle. See if you can find an activity that you enjoy while you do it. For some people this will be playing basketball, but for others it may simply be riding a stationary bike while watching a baseball game on TV.

I have another post coming up about exercise.

Is the VA Meeting the Pharmaceutical Needs of Veterans?

Posted at 9:31 PM on Tuesday, October 13, 2009 by Dr Jeff in VA news

Tuesday, October 13, 2009 - A veteran sent me this interesting link This link included interesting testimony from Richard F. Weidman, Executive Director for Policy and Governmental Affairs, Vietnam Veterans of America.

Unfortunately, I found that I did not agree with his arguments. Howevever, in the end I did agree with some of his recommendations. Veterans are correct to want to be fully engaged in the process of decision making around drugs. As a practicing physician who has to deal with formulary restrictions on a daily basis, I sympathize with people who feel that the rules are made without their input, even though they are the ones most directly affected. And I also agree that sometimes the decisions seem to worry more about the pharmacy short term bottom line than about the patient’s cost or the cost of the primary care doctor’s time as they try to work through the process.

But there is at least one area where he is just wrong. The idea that using more expensive drugs will generate cost savings is one that many people have studied. In essentially every case this is just not true. There is some evidence that one saves money by using certain vaccines compared to nothing, but not for most vaccines. Similarly, if one compares using low cost blood pressure medicine to not treating blood pressure at all may save money but only IN PEOPLE AT HIGH RISK. This may apply to cholesterol lowering therapy too, now that many of the most effective drugs have gone generic. However, when talking about the money that would be saved by using newer drugs to prevent expensive complications of disease, this has NEVER turned out the be the case, with the exception of a few studies that were paid for by the people making and selling an expensive drug . the methods that these people use are usually obviously flawed and designed to get the answer the manufacturer wants.

A second point i can't seem to follow is that he seems to think that spending more money on drugs does not have a downside for the veteran. Any increase in drug availability will come at the cost of some other service to veterans, one should be careful what one requests. That is, the VA gets a fixed amount of money – generally they spend it all each year, sometimes running out early as happened a couple years ago. If they spend more on expensive brand name drugs they can either take care of fewer people – probably those category 8’s the president is trying to give access – or they can spend less on other things – perhaps the expensive prosthetics that the recently wounded veterans sometimes get or the amount of rehab time for people who have traumatic brain injury or the home remodeling for people who have had a stroke and can no longer get around their home, or make it up their front stairs. This is not a case of giving veterans more. This is a case of giving some veterans more and other veterans less. The only clear winner is the manufacturer of the expensive drug.

Again, I want to emphasize that I am in full agreement with the conclusion is that veterans need to be at the table when decisions are made. I am very interested in trying to get veterans groups more involved in this debate. The VA money is supposed to be spent for the benefit of the veteran, and it would be wonderful to get more veteran involvement. But it is very hard to know which veterans should be added. Many of the people making the decisions are themselves veterans, after all.

Monitoring your blood sugar

Posted at 9:12 PM on Tuesday, October 13, 2009 by Dr Jeff in Diabetes

This is the fourth and last in a series of posts about diabetes. I would like to answer three questions I am frequently asked about self monitoring of blood glucose (BG). Remember that glucose is the kind of sugar that we measure in the blood, so some people call it blood sugar.

The first question is how often someone with diabetes should check their BG. This depends a lot on individual patients. I think that for people who are not taking insulin, and whose hemoglobin A1c is always at their goal when it is checked by the doctor, it may not be necessary to ever check your BG. However, even in these fortunate people, it is sometimes useful to be able to check BG. When a person is sick, the blood sugar usually goes up as part of the body's response to stress. However, if you are sick, you might not be eating, which would make your blood sugar lower. So it is hard to know whether to take your diabetes pills or drink fruit juices (a convenient source of sugar) if you can't check your blood sugar. It might save you a trip to your doctor's office if you can call in and tell them how high your BG has been running.

Most other diabetics should check their BG at least sometimes. If someone is taking pills and has to adjust them to push the blood sugar down further, it is helpful to be able to monitor the BG to see what the response is. For most people this can be done with just one BG check in the morning, before they eat anything. That is when the BG is lowest, so if it is not too low, it is likely that the new dose of medicine is not too high. Depending on your doctor, you may use this same BG value to decide if your dose is high enough. Once your medicine dose is set, just one or two checks a week is enough for many people to be sure that they are not gradually getting out of control. People who take insulin, but never change the dose depending on their BG may also be able to get by with checking BG just a few times a week, especially if they are only taking one shot of insulin a day. However, doctors can use the home values of BG to adjust the dose of insulin, so you may be asked to check it more frequently. People who take insulin more than twice a day are usually adjusting their dose based on their BG. They typically need to check it four times daily or even more for best results.

The second question is what the BG should be. Again, different people should have different goals. The timing in relation to food is also important. For most adults, their BG before they eat anything in the morning should be less than 150, and more than 90. If it is routinely higher than that, they likely need more medicine (or less food). If it is lower than 90 more than once a week, they may be taking too much medicine. For people who are young or who are trying to have very good control, doctors might lower these goals by 10 points, to between 140 and 80. I should emphasize that the doctor and patient both need to know the patient's goal blood sugar (and their goal hemoglobin A1c, blood cholesterol and blood pressure). Also, remembering that you are a partner with your doctor. Just like he should tell you what your goals are, you need to tell him what your BG is running. This means writing it down EVERY time, not just when it is good. It also means bringing that written record to every appointment with the doctor or nurse who cares for your diabetes.

The third question is how high does a blood sugar have to be before it is so dangerous they need to go to the emergency. This is different for each patient. At one time, showing up in the emergency room with a blood sugar over 400 just about guaranteed a person would be admitted to the hospital. But over the years, we have learned that most such people are better off if they go back home. The best rule of thumb is that if the blood sugar is more than 100 points over what it usually runs, you need to know why. If you just ate a jumbo sized candy bar, you probably don't need a lot of tests to figure that out. Even if it is not that obvious, it would be reasonable to drink a lot of water and recheck your blood sugar an hour or two later before you decide to call your doctor, assuming you are not otherwise sick. But if you are persistently running 100 points higher than usual, you should give your doctor's office a call.

That is all I want to say about diabetes. I would suggest that people who want to know more can go to the American Diabetes Association for information. They have a very useful website (http://www.diabetes.org/home.jsp) and also a lot of printed material. The Milwaukee chapter's phone number is 414-778-5500.

Who is in charge of your diabetes care?

Posted at 7:44 PM on Tuesday, October 13, 2009 by Dr Jeff in Working with your doctor

The most important thing about working on diabetes with your doctor is to make sure that you both agree on the plan. The plan has to include a choice of treatments and a choice of monitoring plans. Although the doctor will likely have some definite opinions on what works best, he should always be willing to discuss the plan with you. You may discover that he wants to use drugs that are not covered under your insurance plan. It is important to point out to him or her that you need to use something else. It is a bad idea to simply not fill the prescription and wait to tell the doctor at the time of the next appointment. The doctor may want you to check your own blood sugar 4 times a day. If you find that this is just too inconvenient for your lifestyle, you need to tell her so that you can work out a monitoring program that you can manage.

The treatment plan you work on with your doctor will include lifestyle. You need to come to an agreement on what you can do. If I had my way, all the 250 pound men I care for who have diabetes would lose 1-2 pounds every week by eating 1800 calories a day. They would know how many calories were in every bite that they ate. They would all walk 10,000 steps a day and if their arthritis did not let them walk they would use a swimming pool or arm weights for an hour or more every day. But usually they don't do this. Most of them want to get better, and they believe me when I tell them that doing these things will help. But it is hard to change lifestyle. I usually find it better to make a plan with them to make small changes and build them up over time. You need to help your doctor by telling him when his suggestions are not realistic. If he gives you general advice like "eat less" and "lose weight" try to get specifics from him on the goal for the first month. It is best to set short term goals, since then you find out quickly if you are going to be able to meet them. So if you want to cut back your number of calories, a good goal for the first month might be to learn how many calories you are eating now. This would require a $10 book of calorie counts and a pad of paper that you use to write down everything you eat, every meal of every day.

Self Monitoring of Blood Glucose

What BG does well, and hemoglobin A1c does not do well, is help people with diabetes learn diet or exercise affects their blood sugar. Many patients have told me that they know that their blood sugar is worse on mornings after they have a late night snack of ice cream. This can help patients to get useful feedback. The only problem is that so many things affect BG that it can give a confusing message. So someone who has been very careful with diet one day can still wake up the next morning with a high BG, perhaps because of a bad dream, or a minor illness that they don't recognize or something else. Always write down your values of BG in a logbook and make comments when you think there is a reason for an especially high or low value.  

Self checks of BG also help when blood sugars are running very high or low. For example, if someone has the stomach flu and is throwing up, the BG could be low (since they are not eating) or high (since the body is stressed by the illness). By checking the BG frequently, the person can know whether they should be trying to take in extra sugar (for example apple juice) or extra water, or whether they should be calling the doctor's office for advice (if BG is low and they can't eat, or if BG are very high).

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