Spring 2024
PMH STORY
Sunday morning I went to the emergency room to meet a patient. This ER has more than 100 beds, and hallways are frequently used as well. As I walked to my patient’s room, I noted that 4 of the 20 people in hallway beds seemed healthy, looking well. I have learned over the last 10 years that they were here because they did not have a place to get medical information or to see a doctor other than in the emergency room. Sitting at the physician’s desk, I could see and overhear one of these younger couples. The man, wearing jeans and boots, around 35yo, reclined on an ER stretcher, his wife at his side. The clerk was going over the paperwork and told the patient that the estimated cost for the visit would be $7,347. The wife exclaimed, “$7,000!”
Several weeks later, a patient called me on a Saturday morning. There had been an operation several days earlier, and it took many attempts to get the IV in place before surgery. That day, he went home with good operative outcome. But the area where many nurses had tried to draw blood and start an IV was very sore. I asked him to come to the office to check this. Examination was favorable; advice and information was given. As the patient left the estimated cost would have been $50, for an office evaluation, not thousands of dollars.
PMH provides multiple benefits to physician and patients. For patients, it provides continuity of care, direct relationship with physicians, respect for the patient’s convenience, and a practice that is not too busy. One example is being able to call a doctor and ask if something is likely important or not. And you’re not talking to a stranger, but to a doctor that knows you, has seen you and spent time thinking about your care and your health. You’re able to see a doctor at short notice, to visit in person with a physician whether online, at the office, or in your home. I realized that not only does this serve the personal needs of the patients, but it reduces the times you may find yourself in the ER being told that the estimated cost to get an answer to your question is $7,000. A non-PMH model of care may be more expensive and less convenient. There is a charge for PMH, but we think it can be a way to save money.
Robert H. Kelly, MD FACP
GLP-1 DRUGS (LIKE OZEMPIC) VERSUS INSULIN
Sometimes diabetes is not easily controlled. All patients are encouraged to lose weight, to exercise, and to follow a diabetic safe diet. Ozempic and Mounjaro are the semaglutides (peptides) used to treat diabetes and obesity. A recent experiment compared Mounjaro to as-needed insulin in patients suffering with diabetes and already on once daily long-acting insulin. In years past, with the failure of such treatment, they would almost certainly be started on mealtime insulin, requiring one, two-, or three-times daily finger stick sugar measurements. Replacing 10 to 20 weekly injections of insulin and 10 to 20 weekly measurements of sugar with a once weekly injection of a peptide t would be a huge advance for patients.
In the experiment reported by researchers in Dallas and Spain, adults, average age 58, with poor control of diabetes despite long-acting insulin, were randomized either to Mounjaro once weekly or taking short-acting insulin three times daily. (With all volunteers continuing once daily long-acting insulin.) Mounjaro was significantly better than with insulin as far as improvement in diabetes control. Hemoglobin A1c improved dramatically in the Mounjaro group compared to the short acting insulin group. Worse for insulin, the short-acting insulin group suffered greatly from intermittent low sugars. Severe hypoglycemia occurred in 4% of the insulin-treated group and in none of the Mounjaro-treated group, and severe hypoglycemia is dangerous and can be deadly.
The complications of insulin therapy were prevented by using Mounjaro instead of short- acting insulin. There was nausea in some of the Mounjaro group. More serious adverse events did not differ. GLP-1 drugs, like Ozempic and Mounjaro, are better than what we have been doing before. Improving the care of diabetics, we believe, and expect, will save lives, prevent complications, and improve quality of life. The new drugs are better than insulin, according to this randomized controlled trial. This is a revolution in medical care.
Allan R. Kelly, MD FACP
HOME TESTING
Relaxing regulations gives people more options, improves care, and increases what people can do for themselves. High standards are important, but regulation limits who can provide care and the circumstances of care.
Over-the-counter self-testing kits continue to be an outstanding example of how deregulation improves care. The availability of over-the-counter pregnancy tests has changed the lives of many people. Then there is the ability to check urine for infection, to check sugars for diabetes The COVID emergency led to deregulation of viral testing at home. Having COVID testing at home improved care.
In January 2024, Pfizer began offering an at-home test for influenza A, influenza B, and COVID. But this test offers another breakthrough: it uses PCR testing, which is significantly better than the prior rapid antigen test. There was a battle to get this approved and deregulated so that Pfizer could offer something better to the public. It is too early to make any general statement. I am excited by the possibility of improving people’s ability to care for themselves, with or without the advice of a doctor, at home. And for people to learn if they or a family member has flu or COVID, improves the ability to protect health and save time and money in a prudent, reasonable, and loving way.
Congratulations to Pfizer Corporation. Thank you to the bureaucrats who allowed Pfizer to bring this product to market. And our deepest appreciation to those over the decades who have tried to bring better medical care into the homes of all of our patients.
Allan R. Kelly, MD FACP
PMH: CREATING AN ALTERNATIVE TO SHALLOWNESS
A mystery in the world of medicine today is the growing attention to physician “burnout.” We see it in our journals on a weekly basis. David Vermette, MD, in JAMA, April 23, 2024, is an example: “Burnout is rampant, imposter syndrome is endemic, and fatigue is the norm… [for physicians today]. Disillusionment with the practice of medicine can begin during medical school and often amplifies during residency. How does one reconcile their lived experience of being a physician with the ideals they envisioned when they first embarked on the journey?”
In our decision to embark on the PMH project, we wanted not only to create a medical practice that the patient and the patient’s family thought of as “better,” but also to create a work environment and a practice that would appeal to the doctors and nurses who work in our clinic. We have focused on this from the beginning. In part, we were responding to the increasing risks that medical practice was headed in the direction described by Dr. Vermette. We will continue our efforts to create a practice where burnout and its associated symptoms do not occur. We bring multiple medical students into our office every year to show them a possible future for themselves and their colleagues. We appreciate the support of our patients and patient’s families, as well as our colleagues, as we keep developing.
Allan R. Kelly, MD FACP
THYROID DOSE IS IMPORTANT
Persons with low thyroid are treated with thyroid hormone, either synthetic (levothyroxine) or natural (Nature-Throid, Armour Thyroid or thyroid hormone). As there is a narrow therapeutic index or margin between safe and not safe, monitoring is done to make sure the dose is correct. Dosing accuracy is determined based on hormone levels measured in the blood, either pituitary hormone TSH or levels of actual thyroid hormone (T3 or T4) in the blood, repeated approximately every 6-12 months. A study was done to look at the risk of dementia with excessive thyroid hormone treatment. The study populations were persons over the age of 75 years. The degree of excess thyroid hormone was either moderate or severe. The risk of dementia, all measured over the course of approximately up to nine years, was 50% to 60% higher in the severely overtreated group.
Even if you are feeling well on your current dose of thyroid hormone, it should be checked about every 6-12 months. If lab tests show excess replacement, then the dose should be reduced. Correct dose is not based on your own personal perception of treatment effect, though that is important to discuss. Accurate dosing is based on measurement of the levels of pituitary and thyroid hormone. The goal is for the hormone levels to be normal on treatment. Doctors love normal.
Robert H. Kelly, MD FACP
ORDINARY SUPPLEMENTS FALTER IN STUDY
Some common supplements do not have as much benefit as we had thought. Two recent articles on 3 omega fatty acids and vitamin D are examples. Researchers studied 3-omega fatty acid, 1 gram daily, used by volunteers over 65 years old for five years in a randomized double-blinded study looking for benefit in dry eyes. Dry eye disease was assessed at ophthalmology clinic visits. Between the group randomized to 3 omega fatty acids and those randomized to placebo, there was no difference in problems with dry eyes. The authors concluded that their research was “another disappointment for omega-3 fatty acid and dry eye disease.” The effort to prove 3- Omega benefit has been ongoing and repeatedly has failed.
In study of vitamin D supplementation, a randomized controlled trial with more than 20,000 people with normal Vitamin D levels published in the NEJM, showed that vitamin D supplementation did not have an effect on incidence of fractures, either vertebral fractures (spinal compression fracture) or hip fracture. We do, of course, recommend a Vitamin D supplement in persons with low vitamin D levels, because there is benefit.
For healthy people, especially those who go outdoors a few times a week or who have normal vitamin D levels, there is likely no need for vitamin D supplementation. Supplementation did lead to slightly increased bone mineral density, but this did not translate to reduced fracture risk.
Robert H. Kelly, MD FACP
QUOTES
Symptoms then, are in reality nothing but the cry from suffering organs.
Jean-Martin Charcot, M.D. 1868
Medicine has for its object the relief of suffering and the prolongation of life. There exist many limitations to the successful accomplishment of this object. The limitations of medicine are less numerous today than in the past, and many of the obstacles to success in the prevention of disease and the healing of the sick will be removed in the future.
The Editors, Journal of the American Medical Association, October 22, 1898
Every effort should be made not only to inculcate ethical ideals but to impress on a medical student the fact that success in medicine does not depend alone on exact diagnosis and successful treatment, and that in practice, you will have to treat patients, not cases.
The Editors, Journal of the American Medical Association, 1908
It is sometimes as dangerous to be run into by a microbe as by a trolley car.
James J Walsh, MD John Hopkins, 1910
I still find the most informative initial probe to be the simple query: “So, how are you feeling?
Robin Colgrove 2024
You are, once you sign up for (Medicare Advantage) plan, entering a complex contractual relationship with a for profit private company, and you must be able to discern what is best for you among the sleight of hand and obfuscation that is so rampant in medical care today.
Jerald Winakur, MD, 2024 Caring for the Ages, April 2024
A majority of physicians in the US are employees. Now, many also want to unionize. These doctors do not realize that they will miss out on one of the greatest lures of being a physician, that is, being your own boss.
Robert Doroghazi, MD, 2024
The quantitative fallacy: The human tendency to attach too much weight to factors that are easy to measure and not enough weight to more complex, hard to quantify variables. This inclination induces doctors and patients like to obsess over the crisp, objective, but highly nonspecific assessment of white blood cell count while ignoring the subjective impression of severity of illness as felt and seen by the patient, their family, and the physician.
Robin Colgrove, M.D., 2024