PMH @ Home Newsletter

PMH@Home is the newsletter that Premium Medical Home publishes quarterly. We publish here the introduction to each of the articles published

It is our effort to bring important and interesting information from the world of medical research and our medical community to our subscribers. We want to focus on information that will be useful to PMH members. We want to illustrate how medical care works through research to make progress in small and large steps. Finally, in the section called "A PMH Story" we tell how a Premium Medical Home has made a difference in the care and experience of our members.

Expertise, direct connection, a focus on convenience and optimal practice size promote not only medical care but also the comfort and confidence of PMH members. Subscribe to Premium Medical Home today and the quarterly PMH@Home newsletter will be delivered to you.

Summer 2018

TIMELY CARE - A PMH STORY

The patient was an older gentleman who had been declining in health and vigor. A blood count on Friday showed there was significant anemia. The cause of anemia was not clear.

Dr. Kelly called the gentleman and reviewed the findings, offering to either address this problem in the hospital or at the office. As there were no acute symptoms and the patient lived nearby with his wife, he felt safe at home. Dr. Kelly asked him to start oral treatment for the anemia and return to the office on Monday.

That Saturday, Dr. Kelly sent a brief text message to a hematology colleague about the patient and asked if he would be able to see the patient early in the coming week. Records were faxed to the hematologist’s office.

On Monday the patient came to Dr. Kelly’s office and the findings were reviewed with him and his wife. He was feeling weak. The hematologist’s office had already contacted the patient and told him that he could be seen at 2 p.m. that same day. Appropriate studies were completed and the patient was seen. The correct diagnosis was made and treatment was already underway.

We live in a place where we can get care when we need it and in a manner that we prefer. While sitting in the waiting room the next morning, the patient overheard a conversation: “Isn’t it nice to have a doctor that you can see so quickly?” The day before, his wife had exclaimed, “Thank God we don’t live in Canada!”

This is a story about the care all physicians want to give their patients and the kind of care that patients want to get from their doctor – even in Canada. PMH delivers the opportunity, time, training and experience to organize such care, in a manner preferred by PMH subscribers.

Robert H. Kelly, MD, FACP

IT’S THE PATIENT, NOT THE MRI THAT MATTERS

A study was done of 67 individuals who had never had back problems or sciatica. In The Journal of Bone and Joint Surgery study, three neurologists reviewed each MRI. Volunteers were recruited through advertising, mostly younger than 60 years of age.

Robert H. Kelly, MD FACP
FEED A COLD, STARVE A FEVER

An experiment on mice was done at Yale University. Researchers asked: is there benefit to feeding or not feeding animals infected with virus or infected with bacteria? Half of the mice were infected with bacteria, half with virus. Each group was then divided into two groups: one given food via a tube into the animal’s stomach, and the other given no food, only water. Appetite was poor in both groups, especially in the bacteria infected group. In the bacterial group given nutrition none lived: 0% survived. In the fasting group 40% survived. In the viral group given artificial feeding: none died, 100% survival. But in the fasting virus infected group there were deaths.

Robert H. Kelly, MD, FACP
COFFEE, TEA AND OTHER POPULAR BEVERAGES

We have written recently about the safety of tea. Tea and coffee are among popular caffeinated beverages. The coffee shop and the teapot are icons of western society.

Allan R. Kelly, MD, FACP
OVERDOSE DEATHS AND THE OPIATE CRISIS

Because of the rapid increase in the number of Americans dying from opiates and renewed caution about opiate use, doctors are trying to learn how this trouble came about. In a recent Annals of Internal Medicine, researchers from National Institutes of Health analyzed opiate deaths in 2015 and 2016.

Allan R. Kelly, M.D. FACP
PMH QUOTATIONS

“Doctors who want shift work, who see the relationship with their patients as an arms’ length transaction, who value their private time more than their patients’ comfort, will thrive in today’s world of medicine. But those doctors … have settled for less”

Joseph Mambu, M.D., (2017)

“It is my own practice to avoid drugs as much as possible, and I more frequently find it more difficult to persuade people to abstain from using drugs than to induce them to take drugs.... It is a very narrow and unjust view of the practice of medicine to suppose it to consist altogether in the use of powerful drugs or drugs of any kind. Far from it.””

James Jackson, M.D., (1856)
Guest Editors

Hannah Nguyen, MS-2
Texas College of Osteopathic Medicine

Christina Kelly
University of Texas at Austin

Spring 2018

PMH STORY

Continuity of care is one component of good care. We try to use our records, but there is much in life that is not written down or indexed. How much paper and how many computer screens can we look through in trying to make a good decision? But there is also human memory, the knowledge that comes from being with someone, working with them, and getting to know them.

The PMH doctor admitted the patient to the intensive care unit. She had fallen down the stairs, and we suspected that she had struck her head and suffered brain injury. She was unconscious, on life support, unable to breathe or protect her airway, and comatose.

The next morning there was no improvement. Multiple calls were made to the doctor by the Ethics Committee and other members of the team at the hospital. The suggestion was to stop life support. As it happened, Dr. Gordon Kelly was retired but in the office having a cup of coffee. He had known this patient for decades. The PMH doctor asked Dr. Kelly if he would like to make rounds. He said yes.

We went up to the intensive care unit. There was a crowd outside the door and inside the room: the pulmonary specialist, the neurologist, the nursing team, and family. The nurses and neurologist went through a detailed presentation of what had been happening since the patient was found on the stairs. The prognosis was grim. The assembled professionals thought that the ventilator should be stopped and care withdrawn. At this point, Dr. Gordon Kelly made the following comment: This is exactly what happened to her after her aneurysm surgery in 1990 resulted in a series of seizures.

We had no paper or computer records from 1990. The family could not remember what had happened in 1990. With Dr. Kelly’s recollection of those events, we concluded that a possible diagnosis was seizure with postictal coma. We decided to continue supporting the patient. Over the next three days, the woman regained consciousness, was able to be taken off the ventilator, and she lived happily with her family at home for another 7 years, up on her feet and back to life.

This is a story of continuity that changed the minds of everyone in the room, and it changed the life of a family. Continuity in smaller doses and less dramatic fashion is helpful to nurses, doctors, patients, and families.

Allan R. Kelly, MD, FACP

TEA CAN ALSO BE A FRIEND

Tea is the most widely consumed beverage worldwide. Where more tea is consumed, there is less heart disease, perhaps because tea replaces soft drinks or alcohol, but it may be because there is something good about the tea itself.

Robert H. Kelly, MD FACP
NARCOTICS FOR PAIN

New research continues exploring narcotic therapy for pain. Narcotics as opium have been available to humans for thousands of years. Opium consists of equal amounts of codeine and morphine. It is easily available throughout the world.

Allan R. Kelly, MD, FACP
Robert H. Kelly, MD, FACP
TOO MUCH INFORMATION

For patients with non-insulin-treated diabetes, there may be no benefit to home testing of blood sugar. The dogma is that diabetics should do self-monitoring, “an important complement” to measurement of A1C. But finger stick glucose monitoring imposes cost and inconvenience on the diabetic. Researchers sought to prove that self-monitoring makes a difference.

Robert H. Kelly, MD FACP
SHINGLES VACCINATION

There is a new shingles vaccine that the Centers for Disease Control recommends for everyone over 50.

Allan R. Kelly, MD, FACP
CHRONIC BACK PAIN

In Portugal, 97 patients with low back pain were randomized. Half got a placebo and were told the pill was a placebo. Half got no pill at all.

Robert H. Kelly, MD FACP
PMH QUOTATIONS

“The landscape in which medicine is practiced today presents a moral hazard for most practitioners. The rules are set in the boardrooms, the paycheck guaranteed and the creative tension at the bedside vanquished. The result is a joyless practice of medicine devoid of medicines’ artistry and burgeoning with frustrated physicians…”

Joseph Mambu, M.D., 2017

“The sick room is the field of your labors. To everything which occurs there you are to give your attention and every step there should be under your direction. Questions of the deepest importance are constantly arising there for your solution….Let it be remembered that the true physician takes care of his patient without claiming to control the diseases in all cases….The true physician on the other hand cannot fail to be modest in his pretentions; for he is aware how his knowledge and power are limited while he feels the magnitude of his task.”

James Jackson, M.D., 1956

Winter 2018

PMH STORY

Premium Medical Home doctors remain active in the medical community.

Recently, I was asked to care for a hospice patient (whom I had never met) admitted to a nursing home. The resident was totally dependent upon her daughter and was in for a short respite stay. After visiting the patient and the nurses, I called the daughter.

On identifying myself to the daughter, the daughter was confused. She said, "Had there been an emergency?" I advised that there had not. She said that in the years she had been providing the care for her mother, including in and out of hospitals and nursing homes, a physician had never called her on the phone.

This is not the first, nor will it be the last, time that a family member expresses surprise and, naturally, appreciation for a doctor's personal attention to their loved one. I shared with the daughter my own personal experience serving as my father's physician. In his last months while in hospice, he had a problem and I was unsure how to proceed.

I called one of the specialists here in town and left a message on their answering service: I was just another patient's family member asking for help. Within minutes, the doctor called me back. We reviewed the issue and he stated that it sounded like I was doing the right thing. He offered to come over or see my father, or have us visit the next morning in his clinic. With the phone call, I had the information I needed and a visit was not necessary. But like the daughter of this hospice respite patient at the nursing home, like any of us when we are sick and do not know for sure what is wrong and what to do, I felt deep appreciation for this doctor who was able, willing and available to help, and willing to talk to me on the phone. We have experienced both sides of the relationship. We want our patients and families to have that support and relationship always at hand.
Robert H. Kelly, MD, FACP

WHAT IS BEST FOR PAIN?

People have been using narcotic analgesics for thousands of years. But are the narcotics any better than new drugs, such as ibuprofen and acetaminophen?

NEW BLOOD PRESSURE GUIDELINES

The American College of Cardiology and the American Heart Association issued new guidelines for the diagnosis and treatment of hypertension. For most of our patients, there will be little change. There are two groups that will notice a significant change.

DO ANTIDEPRESSANTS REDUCE DEPRESSION IN PATIENTS WITH COMPLEX CHRONIC ILLNESS?

Major depression is frequently experienced as a lack of interest in anything that would generally bring pleasure and as an unexplained sense of persistent blueness and depression. Treatment of depression is important. But randomized controlled trials of depression exclude patients with chronic and serious illnesses: cancer, heart disease, kidney disease, and others. Facing such serious illness, patients and their families commonly ask about treatment of depression symptoms.

COFFEE – STILL OUR FRIEND

In a randomized controlled trial, heart patients in Brazil were off coffee for 7 days. Then each person took five doses in 5 hours of 100 mg of caffeine as coffee. This is about the same as five 8-ounce cups of coffee. The placebo group drank coffee. Blood tests, electrocardiogram and stress tests were done. The results showed no adverse or positive effect of coffee on skipped beats, duration of exercise, heart rate, or blood pressure. People like coffee, and it appears that coffee is not dangerous, even in the face of heart failure and arrhythmia.

OSTEOPOROSIS

Long term prednisone use causes a 60% - 100% increase in fracture risk. An experiment was done with 3600 patients in Sweden who were taking prednisone. Fosamax or placebo was started 1-3 months after the initiation of prednisone. Over the 1.3 years, there was a hip fracture rate of 9/1000 in the Fosamax group versus 27/1000 in the placebo group.

PMH QUOTES

"I have come to believe that patient trust in the physician is one of the most important therapeutic elements in our armamentarium. Such trust can be built only when a lasting relationship is forged between the patient and the physician."

William Mayo, M.D.

"Many chronically ill elderly patients should be spared from spending their last hours in the grip of medical technology."

Michael Gordon, M.D., 1985.

"There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale."

Donna Zulman, M.D., 2016.

FALL 2017

PMH STORY
HOSPICE

By now, all older adults know that hospice is a choice they may consider for themselves or their loved ones as illness progresses and goals change.

The PMH patient was an elderly gentleman with progressive neurological disease causing paralysis. His wife had worked for years to care for him at home even as he became bedfast. The spouse took beautiful and effective care of her husband.

As he worsened, he could no longer breathe adequately. Should he transfer to the hospital for usual, aggressive care, or remain at home? The PMH doctor met with the family and the patient in the emergency room. Respiratory failure was impending. At the ER, we could quickly assess that this was nota reversible disease. The patient and his wife were asked, "Do you want to be cared for at home or do you want to be cared for in the hospital?" Both firmly expressed they wanted him to be cared for at home. A daughter, in the room, also wanted his care at the home. With this decision, hospice was offered and a referral completed.

His PMH doctor talked to the hospice team before he left, and also talked to the familyabout his condition and family goals and wishes. The family returned home but delayed starting hospice; "it didn’t feel quite right." She wanted to think about it another day or two.

Two days later, she called and said she wanted to talk to a different hospice company and the PMH doctor made that referral. The following day, the hospice referral was completed and the family had signed up with the hospice company. Thankfully, the family had the time at home that they treasured.

The patient's wife and children needed time, conversation, and the options to explore their own best choice and their own feelings and decisions. The time required to explore and understand is important and worth taking.

We believe that where there is good communication between patient, doctor and family, the decisions will be more gentle, more careful, and better for all concerned. This is why we have created PMH. We want the patients and families to have time, attention, and thought appropriate for the difficulty and magnitude of the decisions they face.
Allan R. Kelly, MD, FACP

PMH FEES

A REMINDER - Dr. Allan Kelly's new PMH fees went into effect on October 1, 2017. They are posted on our web site, PremiumMedicalHome.com and are also available by calling the office. You will be billed for the new rate on your annual PMH renewal date.
Allan R. Kelly, MD, FACP

EXERCISE, COGNITION AND FALLS IN OLDER ADULTS

Falling is a big problem for the elderly. Falling can cause injury and loss of independence,and force a move out of the home and into assisted living.

Can we reduce fall risk in those who have had a single fall? One step is to review and simplify medications. Also,we should look at the environment and reduce anything that could result in tripping, and recommend ramps, grab bars and other changes. We will often send patients to physical therapy.

Physical therapy can help and so can almost any exercise program. The exercise program need not be supervised by a physical therapist or physician. An example of this comes from Australia where persons with cognitive impairment but no dementia were randomized to receive several weeks of Tai Chi training versus no intervention. Tai Chi was provided for three weeks at an exercise center, and then the intervention group received 12 weeks of home-based encouragement and exercise, but no home visits by a physical therapist or instructor. The study looked at memory function and strength.

Individuals randomized to the Tai Chi group improved cognition and reduced falls compared to individuals randomized to usual care. Tai Chi is likely no different from other exercise programs. Commonly, intervention with exercise can improve strength, improve cognition, and reduce fall risk and injury. If you have not started an exercise program, go ahead and get it going. It can be as simple as 5 or 10 minutes of walking, Tai Chi, or other exercise of your choice.
Allan R. Kelly, MD, FACP

REDUCING NURSING HOME HOSPITALIZATIONS

Medicare wants to reduce the hospital admissions of nursing home residents. Currently, admissions are based on judgment by nurses and physicians depending on patient needs.

Researchers from the University of Minnesota studied a program to reduce hospital admissions from 85 nursing homes. Half received an intervention program developed by the research team (called "INTERACT"), and half received no intervention at all. The scope and intensity of the intervention INTERACT was remarkable: there were 12 weeks of training for the nursing home in house "champion" alone, who was responsible for implementing INTERACT. Interventions included intensive advanced care planning tools, medication reconciliation worksheets, care packs, acute change in condition file cards, reporting to CMS, hospital communication tools, hospitalization tracking tool, and quality improvement tools. This all contributed to a single "quality improvement program" that was used to "apply learning to improve care processes and education."

The results: no improvement in the hospitalization rates after this intensive intervention. Why INTERACT failed is unclear, but the authors attribute a possible cause to be "the quality of the nursing home staff and physicians." They feel that the nursing home staff failed, that they did not have enough enthusiasm for the program, and did not attend sessions reliably as they should have, (30% of meetings were missed).

In short, the authors blame the failure of this multi-million dollar trial on the nurses, doctors and administrators who were actually providing patient care. Easy for them to say!

It is likely that we will see more of this in the future. And complex administrative programs will often fail, I suspect, so long as a doctor or nurse remains committed to each individual. Trying to change this basic human responsibility is difficult. We hope that this basic human commitment remains preeminent.
Allan R. Kelly, MD, FACP

CORTICOSTEROIDS FOR IRRITATING COUGH

Patients with asthma predictably respond well to steroid therapy along with antibiotic treatment for acute bronchitis. About 15% of adults without asthma who have a lower respiratory tract infection (like bronchitis or a cold) are treated with corticosteroids. But after the acute infection, some are often left with lingering cough. The role for antibiotic treatment is negligible in reducing symptoms. Would steroids help reduce these symptoms in the person without asthma?

There were 360 persons who had been ill for 10 days or longer – average was more than three weeks. For ten days half the patients received 20mg prednisone and half with placebo. About 40% in both groups were also given antibiotics. The patients were not suspected to have acute infection, asthma or COPD when enrolled. There was no measured benefit from the prednisone therapy

Once you have had a cough for 10 or 14 days, assuming there is no fever, blood in the phlegm, or shortness of breath, this is probably a viral illness that will run its course. Treatment, whether with antibiotics or with a corticosteroid, is unlikely to be of significant benefit.
Robert H. Kelly, MD, FACP

OSTEOARTHRITIS

The National Institute of Health and Duke University studied whether intensive and complex intervention for the treatment of osteoarthritis, (a universal, degenerative condition)can make a difference

The researchers studied whether or not a planned multifaceted program of care would be superior to ordinary care. Ordinary care is people providing for their own needs at their own pace and with a doctor's participation when requested.

The experimental intervention took place over 12 months and included telephone calls, counseling, programmed interventions focused on physical activity, weight management (all subjects were overweight), and cognitive behavioral strategies for managing pain. A total of 18 telephone conferences/interviews were provided by trained clinicians. There was also intervention training for physicians of these patients – use of guidelines and recommendations for physical therapy, knee brace use, weight management programs, physical education programs, topical nonsteroidal anti-inflammatories and knee injection therapy.

In the program intervention group, there was a significant increase in use of pain medication and joint replacement surgery compared to the usual care. Also, there was no significant improvement in the intervention group.

In short, a sophisticated, expensive and intrusive program (18 phone calls from strangers to patient's homes and classroom time for the doctor) had no benefit for the individual patients compared to the physical activity and naturally selected treatments by patients and doctors collaborating together in the nonintervention group. Normal, everyday patients and doctors operating together can prudently design a treatment program which on average is superior to one designed by agencies, academic institutions and administrators.
Robert H. Kelly, MD, FACP

PMH QUOTATIONS FALL 2017

"The experience in that tiny hut [in Africa] was a reminder to stop talking, be still, and focus on the patient. The patients will tell us what's wrong with them if we listen." Ann Elise Kutzler, second year medical student, 2017.

"Listening and thinking are still what patients expect from their physicians."

Frank Sparandero, M.D., September 2017

"No disease that can be treated with diet should be treated by any other means."

Maimonides. A Physician, 1135-1204 AD

SPRING 2017

PMH STORY

Premium Medical Home is a way of running our offices and serving the public that we think is better. PMH principles are professionalism, directness, continuity of care, and enough time to give care. The fifth is affordability.

The PMH member had retired. He was careful with his money, as we all try to be, so he was surprised when he went to pick up a refill of his medications. He found that a medicine that had previously been affordable was now expensive, $300 for three months instead of $50. He called pharmacies that used his insurance and found a similar price. Knowing that his PMH doctor is committed to affordability, he called the doctor's office to ask for advice.

The staff and the doctor are aware of the financial problems and cost problems that patients face. Getting a call like this from a member is not unusual. He lived in another city, so the office called the lower cost retailers in that city and asked for a cash price. What would it cost to just buy the medication if you had no insurance at all? We found that Costco offered the product for a cash price of $30 for three months. We called the member, we sent the prescription to Costco, and the member's medical care became more affordable.

Affordability is a complex topic. At PMH we focus on affordability, like accepting insurance. We also try to be aware of what cost choices there are out there, and to pay attention to the relative benefits and risks of the drugs we prescribe. We don’t know when our members will face affordability issues, but we will help them when this arises.

Allan R. Kelly, MD, FACP

NEW ANTICOAGULANTS: XARELTO, ELIQUIS, PRADAXA vs. WARFARIN

We continue to see information on new drugs for anticoagulation. Atrial fibrillation can cause blood clots and strokes.New anticoagulants have been licensed to reduce this stroke risk. Researchers in the Journal of the AmericanCollege of Cardiology, 2016 reviewed the impact of new oral anticoagulants on all-cause mortality compared with warfarin. Looking at over 70,000 individuals who were taking one of the anticoagulants, the all-cause mortality rate during the course of the study was 8% in the new anticoagulants, and 9% in the warfarin group.

OBESITY SURGERY AND DIABETES

We continue to watch the development of treatment for the extremely obese persons with body mass indexes over 40. The Mayo Clinic has recommended gastric bypass surgery for decades for patients whose obesity problems have become unsupportable.

STEM CELLS

There is much interest in stem cell injections for degenerative joint disease. Attempts have been made to use stem cells to treat other age-related diseases. In the New England Journalof Medicine, a study looked at two patients cared for at a university in Japan. Vast efforts were made by a large team of specialists ethically using stem cells to reverse macular degeneration – the efforts failed. Other stem cell research in the eye has failed dramatically.

TESTOSTERONE AND MALE AGING

In a recent experiment, 170 men were randomized to testosterone or placebo to see the effects of testosterone replacement on coronary artery calcification or plaque. Testosterone effects on cholesterol plaque were measured by CT.

SKIPPING BREAKFAST

There has been talk about the benefit of eating breakfast when weight loss is desired: You have to eat breakfast if you want to lose weight, some said. This has been called into question with recent research.

KNEE ARTHRITIS

For decades, doctors have used intraarticular joint injections to try to relieve pain in people with chronic arthritis. However, the development of new imaging techniques and our ongoing commitment to experimental methods have led to new insights in the use of steroids for knee arthritis.

PMH QUOTATIONS

"I now see that the medical system is layered to shield the doctor from direct contact with the patient (except for the appointment time)."
Carl Norden, M.D.,2016

"I’ve learned to be intolerant of stereotypes, to recognize that every person has a unique story. When we are privileged as physicians to hear another person's story, we shouldn’t take it for granted."
Adam Hill, M.D., 2017

"This total commitment to the welfare of the patient has been undervalued in the formulation of ethical guidelines, whereas the assumption that such personalized care would be provided by the healthcare system has been over credited."
Chris Feudtner, M.D., 2001

Winter 2017

PMH STORY - THANK YOU

A big and heartfelt thank you to all of our patients and their families.

For many years, we have invited medical students to work in our offices. We want medical students to have the opportunity to work with internists who are active in their community, office, nursing home, hospital, and other facilities where our patients receive care. This is a voluntary effort on the part of the doctors. No reimbursement or payment is sought or expected, and the experience contributes to education and training of doctors for the future. Our work is endorsed by UNT Health Science Center (we are both adjunct clinical assistant professors) and by The American College of Physicians where Dr. Allan Kelly received the Texas Chapter Emerald Award for service in education.

It is your choice whether to allow the student to be part of your care. We believe that having a student involved does not distract from good care and at times has positively contributed. There will be times when a patient doesn’t want a student involved, when they don’t want to meet a new person, when they just want to work with the doctor with whom they are familiar. When a student is introduced to participate in your care, please don’t hesitate to say you would rather see the nurse or doctor. At times when you are open to working with these young people, we thank you very much. We aim to limit student participation to just two or three months out of the year.

Premium Medical Home is about running an office in a way that is good for our patients, their families, and the community. Helping young doctors and encouraging them to work in our city is good for everyone.

Allan R. Kelly, MD FACP and Robert H. Kelly, MD FACP

FALLS

When you are young, falls are embarrassing, and sometimes may be dangerous. At any age, no one wants to fall and all of us want to avoid injury.

As we age, falls are more likely to be dangerous and should be reported to your doctor. Your doctor will then likely consider what may have played a role in the fall and what measures can be taken to avoid future falls. At any age, medications should be reviewed. Strength and balance training may help.

READY FOR DISCHARGE?

When a person is admitted to the hospital, there may be uncertainty whether they are ready to go home when discharge arrives. The doctor and the nurses may all feel good about that discharge, but from time to time the patient or the family is not so sure and wonders if they are being sent home too soon. A recent report in The American Journal of Medicine looked at all discharges from hospitals in Edmonton, Alberta from October 2013 until November 2014. Patients discharged were questioned about whether or not they were ready for discharge. Twenty-three percent of patients discharged reported "being unready for discharge." Being unready for discharge was associated with disability, cognitive impairment, dementia, poor education, and multiple hospital admissions. But the risk for hospital readmission and the risk for death did not differ between the two groups over the course of the next 30 days. Specifically, only 15% of those who felt unready for discharge were readmitted, versus 18% of those who felt ready for discharge.

OVARIAN CANCER SCREENING DOES NOT WORK

Doctors recommend cancer screening in order to reduce death rates and disability from cancer. We have found that cancer screening is successful for some cancers, but not for others. One of the most important lessons of the past 20 years is the failure of ovarian cancer screening. An American study published in 2011 randomized 68,000 women between ages 55 and 74 to screen for ovarian cancer with combined blood testing and pelvic sonography. There was no difference in death rates, nor was there any difference in stage of cancer upon diagnosis. The screening failed to save lives.

METFORMIN AND COLON POLYP PREVENTION

It looks like a common medication, metformin, may reduce colon cancer risk with medical treatment. In a recent experiment, people who had had polyps removed at colonoscopy were told to come back in one year. One-half of these persons were randomly assigned to take metformin 750mg daily; the other one-half were given placebo.

NARCOTICS AND CHRONIC PAIN

In persons suffering chronic back pain, hydrocodone (an opioid narcotic) was compared with placebo to see if it was effective for chronic pain control. Pain was measured on a 100-point scale: a change in pain score of 20 points was considered significant. Nearly 50% of patients treated with hydrocodone, compared to placebo, withdrew because of side effects. Moreover, those continuing to use hydrocodone did not receive significant pain relief. Opioids, compared to placebo, reduced pain insignificantly for those patients with back pain. Other research shows that long acting opiates appear to increase the relative risk of death more than 50% compared to persons whose back pain is treated with antidepressants or medications such as gabapentin.

PMH QUOTATIONS WINTER 2017
"Clinical excellence remains the best medicine."

Burke Cunha, M.D., 2017


"I now see that the medical system is layered to shield the doctor from direct contact with the patient (except for the appointment time)."

Carl Norden, M.D., 2016


"The computer has taken over our offices. This rise of the machines…has led to more and more angst and physician burnout…we work harder, with longer hours, and more time doing meaningless, useless tasks. The physician patient relationship has been eroded almost irreparably because we so often spend too much time staring at computer screens and not enough time actually connecting with those we serve."

Hujefa Vora, M.D., 2017


Fall 2016

PMH STORY

PMH is about continuity and knowledge.

The patient was in his early 90's. The PMH doctor cared for the man and his wife for over 20 years. The wife died 15 years ago. Family always thought the PMH doctor took good care of mom, even though she died, and always had confidence in the doctor's care of their father.

A gradual downhill course eventually pointed to approaching end of life for the father. His illnesses were severe. He was comfortable and surrounded by his family in the hospital room. But it was time to confront that there was nothing else that the doctors could do to get him back on his feet and to recover his strength.

In a meeting with the family, the doctor was able to recall the patient's history dating back decades, to reflect upon the spouse's death, and to talk about the future and how to take good care of a good man, even at the end of life. The doctor had cared for the patient in the office, at the nursing home, and was sitting at the patient's bedside in the hospital. With transition to hospice, the doctor would again be by his patient's side.

The trusted and longtime physician at the patient's bedside is valuable, a good thing. Regardless of what may be happening elsewhere in hospitals and nursing homes, at PMH we are committed to this continuity of care over time. We believe continuity of care is good for the patient, the family, the doctor, and those who support the patient, even at the end of life.

Allan R. Kelly, MD FACP

ANNOUNCEMENT

Dr. Robert Kelly's Subscription Fees will be increasing as of January 1, 2017. The new fees are posted on our web site, www.PremiumMedicalHome.com and are also available by calling the office. As your PMH renewal becomes effective, you will be billed for the new 2017 fees.

BLOOD TRANSFUSIONS: IS BLOOD FROM MEN AND WOMEN DIFFERENT?

In the popular media there is all this talk about gender, malehood, femalehood, etc. Doctors have always known the truth: There is a difference.

But even we were surprised when JAMA 2016 presented data on male and female blood donors. The advent of big data has allowed for tracking outcomes in new and comprehensive ways.

ANTIBIOTIC TREATMENT: SHORTER CAN BE BETTER

We all remember the doctor's instruction when we had strep throat infections: Take the antibiotics for ten days until they were all gone. Children and young parents became accustomed to the idea of taking antibiotics for one to two weeks, even after we got better.

But times have changed. Over the past fifteen years, multiple studies have compared shorter versus longer courses of antibiotics. Dr. Brad Spellberg recently reported experiments of shorter versus longer duration therapy. For example, in community-acquired pneumonia, stopping antibiotics after five days was superior to continuing antibiotics for 7 to 10 days. Other studies included pyelonephritis (7 versus 14 days), intraabdominal infection (4 versus 10 days), sinusitis (5 versus 10 days), and cellulitis (6 versus 10 days). According to Dr. Spellberg, shorter duration beats longer duration in these clinical syndromes. I believe these new studies will lead to a change in clinical practice.

PAREGORIC, OPIUM, MORPHINE: PAST AND PRESENT

Paregoric represented an ancient tradition of care, its components in use for thousands of years. The active ingredient is a natural product from poppies, and used by people of all social statuses, all incomes, and all educations in every country since the time of Marco Polo.

Older people may remember paregoric, used for many purposes in the home. It was used for a teething child who was restless or uncomfortable with colic. It was used for people with diarrhea and stomach cramps and pain. It was available without a doctor's prescription at every drugstore. Mr. Bill Whitten, a pharmacist who built up Whitten's Pharmacy chain in Fort Worth, said he always had paregoric available over the counter. He would keep an eye on it, and if he thought that a person was buying too much, he would turn them away.

INFECTION – WARNING SIGNS

Paying attention to a worsening infection before it requires hospital care is important. One key to transition between infection that can be treated at home and infection that requires hospital care is when infection changes to a syndrome called sepsis. Sepsis is a serious problem with a mortality rate of 15-30%.

REDUCING COLON CANCER RISK

Prudently reducing the risk of colon cancer and colon polyps is important. Cancer tends to develop in a polyp, so reducing polyp formation is desirable. Though the frequency of colon cancer is relatively low for any individual, colon cancer ranks third after breast and lung cancer as a cause of death from cancer in the United States.

Americans are open to medical treatment that reduces risk. Examples are low-dose aspirin and statin drugs for those at risk for coronary disease, tobacco cessation, and bisphosphonates for osteoporosis. And now, maybe metformin for colon polyps. A recent experiment in Japan recruited persons with high risk of forming colon polyps and randomly assigned them to two groups. One group was given metformin 250 mg daily (lower than used for diabetes) and the other given placebo. Colonoscopies were performed after one year. The number and prevalence of adenomas and polyps was then measured and found to be significantly lower in the metformin group. In the metformin group, only 38% of persons had some form of polyp or adenoma on the follow-up colonoscopy, whereas nearly 60% in the placebo group. The risk of colon polyp or adenoma was reduced by almost half.

PMH QUOTATIONS FALL 2016
"The true core of good medicine is not an institution but a relationship, a relationship between two human beings. The better those two human beings know one another, the greater the potential that their relationship will prove effective and fulfilling for both."

Richard Gunderman, M.D., 2016


"He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."

William Osler, M.D., Aequanimitas, 1904


Summer 2016

PMH STORY

The patient was in her 90's. She had been the caregiver for her husband. He passed away, and she had lived now a decade as a widow.

The patient had been part of the PMH practice since 1985, and before coming under the care of the PMH doctor, had been under the care of that doctor's father.

The patient's dementia had been inexorable, causing gradual loss of ability to care for herself, to recognize people, and to understand what they were doing. She moved from her home to assisted living, then to a nursing home, and then to hospice. She could no longer walk. She had neither children nor brothers or sisters in the area.

The doctor had cared for her at the office, the hospital, the emergency room, at the home, the assisted living facility, the nursing home, and now in hospice. Despite all these changes, her doctor did not change.

After she moved to hospice, the PMH doctor came to see her. She was in a wheelchair in a common area. He asked her how she felt and she did not answer. She seemed not to focus. He said to her, "Do you know my name?" She looked up, smiled and said, "Allan Rowan Kelly."

What does it mean to a patient with severe dementia to know the doctor who comes to her side? How important is it? In some practices, doctors do not have the opportunity to ponder this question, as they do not maintain that continuity of care from place to place and time to time. But for the PMH doctor, he felt that it was a balm for this person to recognize him, to see his familiar face, to speak a familiar name, and to smile.

As doctors, we are grateful to be able to care for those who know us and have trusted us for years. It gives meaning to our work. If we must care for strangers, so be it: It is good to care for the stranger. But it is also good to care for those we have known over time. It is important to our patients, and it is important to our doctors and nurses. We call it continuity of care, but it is a basic principle of PMH. Continuity of care is important, valuable, and helpful.

Allan R. Kelly, MD FACP

PALLIATIVE CARE By Allan R. Kelly, MD FACP

Over the past 15 years, a loss of continuity of care and other changes in medical care have led to the creation of palliative care teams in hospitals. Do they help?

The National Institutes of Health funded a large and expensive study at multiple sites in the United States, including Harvard, National Institutes of Health, and Cornell, to see if this concept worked (Carson, et al, JAMA, 2016). The study randomized 365 families whose loved ones had been in the intensive care unit for at least 7 days. Half of the group received usual care from the doctors and nurses in the ICU. The other half received usual care plus palliative care intervention, a complex effort including "…brochures…coordinators…information team…palliative care physician…nurse practitioner…social workers…chaplains…or other disciplines." This palliative care team met with the family of the sick patient in the ICU: "These important information meetings were structured according to a set of objectives and recommended topics…they were allowed some flexibility for adapting the content of the meetings to the particular needs of each family." Everyone involved had a major stake in the outcome. Massive amounts of money were spent.

BASIC LIFESUPPORT? ADVANCEDLIFE SUPPORT? IS LESSMORE? By Robert H. Kelly, MD FACP

It is often worth questioning assumptions. One assumption is that advanced life support (ALS) provided by ambulance personnel will be superior to basic life support (BLS). This question was addressed in a recent study of emergency medical care given to Medicare beneficiaries by emergency medical personnel (EMS). Sixty-five percent of the EMS crews were ALS trained. Thirty-five percent were BLS trained. Was ALS or BLS better? Did higher level training (ALS) of ambulance crews improve outcome?

ZIKA VIRUS IN TEXAS – WHAT IS THE RISK? By Jacob Underwood, MS2 and Robert H. Kelly, MD FACP

Zika virus is spread to humans through the bite of an Aedesegypti mosquito which became infected itself by biting a human with the virus in their blood – whether that human was having symptoms or not. The virus can also spread from person to person through intimate contact. In July, Utah reported a case without known mechanism of transmission. In August, Miami reported mosquito transmission in the U.S.

NOT TOO BUSY By Allan R. Kelly, MD FACP

The patient was a female physician in her late 70's. She had a perplexing syndrome of chest pain. After a stay in the hospital, there was still no specific diagnosis. She made a new patient appointment with a PMH doctor.

The PMH physician was part of the medical staff at the same hospital and so directly accessed her medical records.

PMH QUOTATIONS Summer 2016
"A good physician treats the disease; the great physician treats the patient who has the disease."

Bennett Clark, MD, 2016


"And since we’ve come to think of the hospital as serving the function of a train station – moving people down the line as fast as possible – we shouldn’t be surprised to learn that some patients’ experiences in the hospital have all the warmth of rush hour in Penn Station."

AmandaFantry, MD, 2016


"Sure typing is a little bit faster, but I’ll bet a lot of doctors agree that their clinical thinking was better when their notes were scrawled long hand"

B. Ryan Brady, April, 2016


Spring 2016

PMH STORY

A woman in her late 70's was having trouble breathing. Her cardiologist referred her directly to a pulmonary specialist who prescribed three different inhalers and multiple tests. The patient tried taking the prescribed medications. She felt certain that the medications were of no help, and made her feel worse instead of better. She did not call the pulmonologist's office or staff or report the problems with her new medications. Neither did the husband or the patient receive reports or a call with results of the diagnostic studies that were done. Three weeks later, driving to the pulmonologist's office for a follow-up appointment, the patient became more short of breath and decided to go directly to the emergency room. In the emergency room, it was clear that her problems had grown much worse, and her PMH doctor was called.

The PMH doctor saw the patient in the emergency room and cared for her in the ICU over the next several days. The husband complained to the doctor about their experience with the pulmonary office.

It is not easy to complain. If you know you can tell your story to someone and not be seen as a complainer, you can tell your story in more detail and with confidence. Hearing the complaints of the patient's husband was very helpful to the PMH doctor, and was helpful to the pulmonologist and the pulmonology team to understand how they might better serve other patients.

The nature of the PMH practice allowed the patient and her husband to feel entitled to express themselves fully to their doctor. They know their doctor. Working with a doctor over time, knowing that the doctor will join you when you are sick in the hospital or the emergency room, and knowing that you can express yourself fully without judgment, can help everyone.

Allan R. Kelly, MD, FACP

THE MEDITERRANEAN DIET By Allan R. Kelly, MD, FACP

Almost a decade ago, Spanish doctors started the PREDIMED Study on the Mediterranean Diet versus a low fat diet to answer the question, "Can diet recommendations change health outcomes?" Investigators in Spain looked at 7147 persons between the ages of 55 and 80 years. Group one received a low fat diet teaching. Group two received a Mediterranean Diet teaching plus 5 ounces of free mixed nuts per week. Group three received the Mediterranean Diet instruction plus 1 liter of extra virgin olive oil (EVO) per week to be used by themselves, family, and friends.

DAYLIGHT SAVING SYNDROME By Robert H. Kelly, MD, FACP

There may well be differences of opinion, but transition to daylight saving time may not be a harmless government regulation. Not only does it require every American to take time out to reprogram clocks and watches (fortunately, our computers and iPhones can do this on their own), but it appears to have adverse health effects. A recent study (Cipila, et al) was presented at the 2016 American Academy of Neurology Annual Meeting in Vancouver, Canada.

BREAST CANCER SCREENING By Allan R. Kelly, MD, FACP

All women know that for years prudent self-care included breast cancer screening. Since the 1980's, women have been told over and over again to learn about breast self-examination, to have an annual physician examination of the breasts, and to have an annual mammogram in order to follow the guidelines of the American Cancer Society.

PMH QUOTATIONS Spring 2016
"A good physician treats the disease; the great physician treats the patient who has the disease."

William Osler, M.D.


"Almost all the current practicing physicians at Dallas Diagnostic Association have reported decreased productivity and decreased satisfaction with the practice of medicine due to burdens imposed by EHR. Dallas Diagnostic Association experienced the premature retirement of 12 physicians in large part due to the adverse impact of EHR."

Lannie Hughes, 2016 (BUP 29, 2)


"Rather than sitting at the bedside and sharing the suffering of the patient, physicians now spend their time in clinical foxholes on computers and cell phones focusing more on the disease than the person or on technology than touch. . . Just remember the doctors of old – Model them and you’ll be fine."

Paul Rousseau, M.D., 2016 (JAGS, 64, 645-6)


Winter of 2016

PMH STORY

The PMH Story section has been a place where we have written about how our model of medical care benefits subscribers. We certainly try to look at things from the patient's, not the doctor's, point of view, although the two are closely aligned. We would like to invite any subscriber to submit a brief description of what PMH means to them. What does PMH do for you that is meaningful and desirable and is not generally available in a non-PMH practice?

You may submit these anonymously. Understand that if we do have a chance to publish this, we will change names and dates (and sometimes even gender) to make sure that the patient cannot be identified as a unique individual in our practice though the story will be true and unique.

DEHYDRATION AND HYPERTENSION MEDICATIONS

Every summer we see patients who have fallen or fainted due to dehydration. Here's a heads up to stay healthier during hot weather. A recent correlation has been made between summertime and increased risk for dehydration and fainting-syncope. Fainting spells accounted for 700,000 emergency admissions last year in the USA. Problems with dehydration accounted for at least one-quarter of these. In Arizona, it is called "summer syncope syndrome." Key features include low blood pressure and blood pressure that falls when standing up. The most common symptom is light headedness.

BACON GETS NO RESPECT BY Robert H. Kelly, MD FACP

The World Health Organization recently called red meat a probable carcinogen and processed meat as a known carcinogen. Other known carcinogens include asbestos and tobacco. If a drug was a known carcinogen, the FDA would likely not approve it for sale. And yet, of course, many of us enjoy red meat and processed meat. One wonders if there is a certain degree of anxiety at the World Health Organization.

TRANSPLANTATION: BLOOD, PLASMA, STOOL By Allan R. Kelly, MD FACP

The development of transfusion and transplantation is one of the great triumphs of modern medicine. All the way from plasma for hemophiliacs, to skin for burn victims, or a whole heart, the ability to donate a healthy organ to another in need is a good thing. Doctors are now studying stool (also called fecal) transplants.

HERNIA REPAIR…WITH MOSQUITO NET By Allan R. Kelly, MD FACP

Why is American medical care more expensive than in other countries?The January 14, 2016 New England Journal of Medicine may shed some light. Lofgren and others performed a "randomized trial of low cost mesh in groin hernia repair." The authors compared two types of mesh for hernia repair. One type of mesh was produced by a prominent medical products company, Covidien. The second mesh used in this randomized and controlled experiment was a simple mosquito net produced by a plastics company in India. The Covidien mesh was polypropylene. The Indian mesh was polyethylene. The Covidien mesh cost $125.00 when purchased in Uganda. The Indian mesh was less than $1.00 for an entire mosquito net. The mosquito net was cut up into smaller pieces which were washed and sterilized.

OUT-OF-HOSPITAL OR IN-HOSPITAL BIRTHS By Allan R. Kelly, MD FACP

In our modern world there is a paradoxical interest in out-of-hospital births for pregnant women. Pregnancy and delivery are not common issues at PMH, but I thought our readers would be interested because,for some patients, out-of-hospital birth is considered highly desirable.

PMH QUOTATIONS Winter 2016
"The death of common sense is neither pretty nor fast…we are distracted by the need to fill out irrelevant information and are subsequently left with less time to get through the important parts of our visit."