Fever Fights Infection- GET OUT OF ITS WAY!

Dr. Mario TylenolSo I first started thinking about this one day when a nurse called me for an order for Tylenol for a patient with a fever of 101. I had received calls identical to this hundreds of times before but this time I stopped. I asked if the patient had any symptoms and she told me he did not. But that was just what she was used to. Patient has a fever give them Tylenol. Let me explain for those that do not work in the medical field. This situation is not unique. At almost all hospitals across the country, and certainly in every one I have worked in, if a patient gets a fever they will be given Tylenol. and if they do not have an order for Tylenol the nurse will call for one. And one must assume we do this for good reason. We are preventing brain damage, seizures, something right? Actually no. There is no evidence we are doing any good whatsoever.

The day I received this call I went to the literature to see what I should be doing. I found this wonderful article by Michael Ryan and Mitchell Levy from the journal Critical Care 2003. I suggest everyone read the article.

The case they lay out is compelling and shocking. Fever has been evolving for millions of years. Even reptiles when they have an infection seek out warmer areas to raise their temperature. And pretty much every warm-blooded animal gets fevers with infections. So why would animals do something that is energy wise so costly when they need all that energy to fight infection? Because the fever is fighting the infection. Fever helps release cytokines and other immune modulating chemicals that help the body to fight infection. It also causes the body to release what are called heat shock proteins that help protect the body during times of stress, inflammation or infection.

In this article and in a review of the literature there are no good human studies but there are many animals studies and they all show that fever is good and increases the survival from infection. And more over, multiple studies show that suppressing fever with medications such as acetaminophen (Tylenol) actually increase the risk of death from infection. Not one study has ever been done to show any benefit of suppressing fever on mortality or morbidity.

The only real concerning side effect of fevers is febrile seizures that really only happen in children and even then only 2 to 4% of children at that. And even with this as a rationale makes no sense because studies have been done and not one showed that suppressing the fever with medication decreased the risk for febrile seizure.

Brain damage from a fever does not happen until temperatures as high as 107 degrees. This rarely happens and I personally have never seen it, even without medication for the fever.

So we have a wide-spread use of a medication to suppress the bodies natural and very effective response to infection. We have been doing this for decades without any research to see if this has been beneficial or harmful. It is time we finally do that study. The body has spent millions of years to develop this effective response to infection. I think it is about time we get out of its way

the article Clinical Review: Fever in intensive care unit patients

Systemic review and meta-analysis of the effects of antipyretic medications on mortality in Streptococcus pneumoniae infection

The effect on mortality of antipyretics in the treatment of influenza infection: systemic review and meta-analysis

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Hypertension- Maybe Your Blood’s too Thick

BLOOD PRESSURE CHECK

While watching the documentary Forks Over Knives I heard a physician explain that it was possible that a vegan diet may lower blood pressure by lowering the blood viscosity (thickness). He stated this in passing but to me it was earth-shaking. I have had thousands of patients with high blood pressure and am treating it on a daily basis. I have sat through countless lectures on hypertension and still to this day we do not really know what causes it. The leading explanations include increased sympathetic activity (think high adrenaline, anxiety), decrease kidney function with age, increased hormone called angiotensin II, or complex interaction of genetic factors. However all of these fail to really explain why obesity, inactivity and diet raise blood pressure.

When I heard that it could be the viscosity (thickness) of the blood I was overwhelmed by the simplicity of it. If the blood is thicker it will take higher pressures to move it. Think of the pressure needed to move water through a pipe as opposed to oil. Thick liquids are harder to move though pipes so a higher pressure is needed. So maybe that is why we are having such a hard time finding a cause for high blood pressure. Because we view it as the problem. However, high blood pressure may not be a problem at all, but instead is the body’s adaptive response to keep the blood flowing when it gets thicker. The problem may be thick blood. However, none of the medications in my arsenal for hypertension treat high viscosity.

As usual I went to the research to see what foresighted researcher was working on this question. And yet again I found that it was looked at LONG ago. In 1981 in the American Journal of Medicine Dr. Letcher et al. showed a direct relationship between blood pressure and blood viscosity. As the blood gets thicker the blood pressure goes up. And those patients with high blood pressure have high blood viscosity. This correlation was further supported by another study by Dr. Letcher in 1983 published in the journal Hypertension.

It seems armed with this information pharmaceutical companies would have marched forward to find the magic drug to decrease blood viscosity and researchers would be toiling night and day to find the underlying cause of the high viscosity blood. However, that did not happen. Today hypertension drugs mostly act by dilating blood vessels (making the pipe wider) or decreasing the pumping action of the heart to decrease the pressure. This does give health benefits likely because it decreases the shear forces on the walls of the vessels. However, none of these medications fix the underlying issue that the body may have been trying to overcome, pushing thick blood around effectively.

And despite there being a simple test to measure blood viscosity it is rarely used and when it is it is not for hypertensive patients. In fact in all my years of practicing medicine I can only think of one patient who had their blood viscosity checked.

One of the culprits that may be causing this increased blood thickness is fibrinogen, a protein involved in the formation of blood clots. Fibrinogen seems to be closely correlated with blood viscosity and it is logical that blood clotting agents may thicken the blood. Also, it is known that a vegan diet lowers your levels of fibrinogen so this may be the pathway through which a vegan diet lowers blood pressure. Also, smoking is shown to raise fibrinogen levels and smoking raises blood pressure. Also there is a class of cholesterol medications called fibrates that are known to decrease fibrinogen levels and studies have shown that they also lower blood pressure.

I can attest personally to the blood pressure lowering effects of a vegetarian diet. My mother has very high blood pressure (she was 220/110 when she was diagnosed). She is on 4 separate blood pressure medications. I had this tendency as well and would run high even in college, my blood pressure was close to 140. After watching a documentary and hearing a piece on NPR about the conditions at cattle and pig farms and slaughter houses I decided to be vegetarian. Within months my blood pressure came down to an average of about 115.

To leave the question of what causes high blood pressure unanswered when the explanation may be so close at hand and has already been put forth 30 years ago seems negligent. Millions are suffering with high blood pressure and resultant strokes and heart attacks. If we could find the answer and a treatment that fixes the true underlying cause, the potential benefit to society and savings to our healthcare system would be almost impossible to measure.

Here is another great article summing up the research. Well what little there is.

Concierge Medicine- Better Medicine, but for Whom?

A patient having his blood pressure taken by a...

Concierge medicine goes by many names, direct care, retainer based medicine, boutique medicine. Basically what it means is that the patient pays an extra fee (usually in the $1000 to $2000 range) per year to have access to same day visits, emails or phone calls whenever needed with their physician. Also, visits tend to last longer, sometimes as much as an hour to two hours if needed. But of  course all this extra time the physician spends with their patients means they can see fewer of them so to make up the difference they charge the fee.

When I was an idealistic medical student I was completely against this idea. I saw it as healthcare for the privileged at the expense of the poor. I was already frustrated with the gap in the quality of care I saw between the rich and poor clinics I visited. This seemed like yet another way rich people would get better care than the poor and would pulling more resources away from those who desperately needed them. I kept this attitude through much of my residency but as I entered the world of private practice and left the confines of the academic institution I was exposed to what quality of primary care was really going on out there. I was appalled at what I saw. Patients often had medication lists that made no sense. Despite being highly educated individuals they had no knowledge of their medical conditions or medications and what they were for. And they all expressed to me the same frustration, that their doctors simply did not spend time with them explaining anything. I was amazed to hear that the short period of time I spent talking to them in the emergency room was the longest any physician had ever spoken to them.

One may read this and feel that I was witnessing the results of callous uncaring doctors who were only interested in making money, but that simply is NOT the case. Most of the primary care physicians I met in the area were wonderful, down to earth, kind, caring physicians with the best interest of their patients at heart. The problem was with insurance reimbursement for primary care getting smaller and smaller and cost of overhead going up, the only way to make ends meet was to see more patients. Many of them were seeing 20 to 30 patients a day. The average visit is scheduled for 15 minutes. But this is not 15 minutes of talking with the patient. That 15 minutes includes reviewing the chart, typing up a note documenting the entire visit, filling out orders for imaging or labs, insurance paperwork and pre-approvals and so on. It ends up being about 5 minutes of distracted talking between doctor and patient. At this rate no physician can really practice medicine.

Then I started to meet some of these concierge doctors and their patients. Their patients had medication lists that made sense. They knew about their illnesses and understood the treatments and what each medication was for. And the doctors were truly happy. They finally felt like they were practicing medicine and not just filling out paperwork, and I started to question my attitude towards this way of practicing. Clearly they were providing superior healthcare to their patients and who could fault them for that?

But there is no avoiding that there is a cost, both financially and to society. The fee of $1000 to $2000 a year is far outside the reach of most Americans. And those physicians treating only those who can pay that fee are that many fewer physicians not working in poor areas where there is already a devastating physician shortage.

I see only two ways address this.

The first would be for insurance companies to pay more for primary care. Currently even a primary care doctor seeing 20 to 30 patients a day is still one of the lowest paid physicians. And medicare and Medicaid at this point pay so little that they do not cover the clinic overhead. This has to change. There is a HUGE savings to be had by good primary care. If doctors have time to talk to their patients and address their concerns and make them informed about their diseases, treatments and what to expect. This translates into far fewer emergency room visits and medication errors and redundant or needless tests.

The other way to approach this is far more earth shattering. Currently our health insurance is being used for things insurance was never intended for, predictable planned life events like yearly physicals, mammograms, colonoscopies. This is analogous to car insurance covering oil changes and tune ups or home owners insurance paying to repaint the shutters. At some point we may need to stop letting insurance companies dictate how much to pay primary care doctors by lowering premiums and taking away primary care coverage. People who can afford it would be expected to pay out-of-pocket from the savings of lower healthcare insurance premiums for their own primary care. This could have the effect of causing many not to get primary care but it could also have a beneficial effect. If people pay for their primary care they may take it more seriously and be more likely to follow recommendations. Also, if physicians had to get people to pay out-of-pocket for visits there could be a very real increase in quality and patient satisfaction that comes from healthy competition and market forces.

However, there is one big thing keeping any of this from happening. Fee for service reimbursement of medicine. In our current system doctors are paid for seeing patients and doing tests or procedures. The more visits and the more tests done the more money made. If primary care doctors were all spending an hour with their patients talking about their cases and addressing their issues there would be much less need for consultants and tests. However, an overworked doctor who has not time to think will have to delegate responsibility to consultants or instead of getting a diagnosis through history taking may just need to skip to a CT scan or MRI. This makes more money for the multidisciplinary group or hospital that often employs the primary care doctor. So currently there is no motive to have better primary care and there are many incentives to actually continue the current system. That is unless the ACO model put forth by Obamacare takes hold. Then the incentives change dramatically.

Either way, many patients are voting with their pocket-book and paying the fee for concierge medicine. This trend combined with the effects of Obamacare extending insurance coverage are going to cause a catastrophic primary care shortage. Something needs to be done or we will continue to have the distinction as the country that spends the most on healthcare with the worst outcomes.

Our Private Capitalist Healthcare System- Not Even Close

Many people often refer to our healthcare system as private or capitalist. Unfortunately it is nothing of the sort. Many by now who read my blog may feel I am a hippy living on a commune campaigning for the socialist party. However, I am a firm believer in capitalism and the power of the free market. I even read Alan Greenspan’s book The Age of Turbulence and enjoyed it and agreed with almost all of its conclusions. Capitalism works for the economy because it allows natural forces created by supply and demand to adjust for product shortages and oversupply in an efficient and seamless way. With countless transactions going on every day there is absolutely no way a government can set quotas for supply or prices without collapsing an economy. When they do this they will inevitably set some prices or supply too high and some too low creating shortages or oversupply that cannot be easily corrected. But the free market does this every second of every day constantly adjusting supply and demand by price feedbacks on suppliers and buyers.

This system has no relation to what is going on in US healthcare today at all. First, a free market capitalist system cannot work well in healthcare because a reasonable price cannot be set on someone’s life. What is the price of chemotherapy for someone who has cancer, or a ventilator for someone who is dying of shortness of breath from pneumonia. They will pay anything in that circumstance because if they don’t they will die. Even if Bill Gates were to get sick, if he were actively dying the doctor or hospital could then set their price based on what is willing to be paid and of course Bill Gates would give his entire fortune if need be to survive. This takes away the feedback on the supplier (the doctor or hospital) of decreased demand that comes from prices that are too high.

Secondly, in our current system this is all irrelevant anyway because we have intermediate people standing between the supplier (doctors and hospitals) and the buyer (patients). Insurance companies usually see the price of the care provided not the patient. And often the doctor is also unaware of what was charged and paid for his or her medical billing service or the hospital does this for them. This leaves healthcare with no price feedback what so ever. Patient’s don’t care what it costs, all they care is if it is covered or not. The insurance company does not really care about the quality or amount of service provided as they are not the ones receiving the care. This whole process completely distorts price adjustment as should happen in a normal free market system.

Third, a large percentage of healthcare consumed in this country is paid for not by private insurance companies or out-of-pocket, it is paid for by the government. Hence that portion is essentially socialized medicine. This includes Medicare, Medicaid, Tricare, the VA system, and now with Obamacare, government subsidized private insurance.

I am NOT proposing we go to a completely capitalist, free market healthcare system. And for anyone who purports to want that, just imagine what that TRULY means. For it to be truly capitalist and free market hospitals and doctors can charge whatever they want, and if you can’t pay, you die. Emergency Rooms would be able to deny care to anyway even if they are brought in after a car accident and found not to have insurance. That is if the ambulance would even transport you when they find out you can’t pay. This is not a system I think anyone could tolerate. It is not humane, civil or ethical. And even this system still would not truly capitalist because as I stated earlier, there would still be no price feedback to the supplier because patients will pay anything. They are desperate.

However, I am not supporting socialized medicine either. As I mentioned earlier, the government is too slow and ineffective to set prices and supply for things without completely creating market distortions. Any veteran or any of my colleagues who have worked at a VA hospital can attest to the inefficiency of government-run healthcare.

I am not pretending to have some magic answer. If I did I would currently be in Washington telling everyone who would listen. But our current system is a mixture of the worst parts of socialism and capitalism. The rest of my posts show how the profit driven part of our healthcare system has deprived us of cheap effective remedies that go unstudied. And healthcare bills send thousands into bankruptcy every year. Yet we don’t get the benefits of capitalism for the reasons I delineated above. And we have millions of Americans covered by what is essentially socialized medicine through Medicare, Medicaid, Tricare and the VA yet these programs are inefficient and costly and there are still leave millions of Americans without health insurance. These programs do not collectively barter for better drug prices (something the pharmaceutical industry has made sure of in every healthcare law written). They do not streamline care such as in Taiwan making administrative costs low. These programs drain our tax payer dollars while delivering close to the worst healthcare outcomes of any industrialized country while costing us more per person and more per percentage of our GDP than any other country in the world.

We need instead more competition amongst insurance companies so their rates have to be good to stay in business. This would require them competing across state lines. They also need to be nonprofit. We simply cannot allow insurance companies to continue to make BILLIONS in profits which are nothing more than dollars taken from us for a rainy day for safe keeping and not given back to us in our time of need. If they are non-profit it will take away that drive but they still will want to do well as it will allow them to keep their jobs and possibly get a better salary. If this competition works well then we can start getting rid of Medicare and Medicaid and instead subsidize low-income people enough to pay for private insurance. These private insurance companies will have incentive to find ways to get their patient’s healthier to help keep down cost. Currently Medicare and Medicaid do not have that incentive. But, as long as we are stuck Medicare and Medicaid they MUST bargain with pharmaceutical companies for better rates on drugs. It is unacceptable that we continue to pay so much more for drugs than those in Canada simply because our government gives into the will of that industry and pays them whatever they want. If they weren’t making money at Canadian prices I am sure they would have stopped selling to Canada long ago.

Also, tying healthcare coverage to employment is a relic of a bygone age and has no place in a capitalist or socialist healthcare system and needs to be done away with immediately. I think we can all agree the unemployed deserve healthcare coverage as well. And tying your current insurance to your employer is ridiculous because as a physician I have personally seen thousands of people who were insured but of course when they get really sick they couldn’t work, they then lost their job and presto, they don’t have insurance any more, precisely when they need it.

We need a healthcare system that has universal coverage for all like a socialized medicine system but with the price and quality improvement that comes from competition in a free market type system.

Here is another blog that I felt was well written and stated on this topic