Fall 2024

PMH STORY

The patient was a hospital administrator with decades of experience. She was familiar with physicians, hospitals, and outpatient clinics. She had medical problems and required the care of her internal medicine doctor and her consultants. This is a story about how doctors’ offices answer their phones.

Her cardiologist had cared for her for over a decade. She came to the PMH office for a follow-up appointment and mentioned that she has had to change her cardiology doctor. She said that whenever she tried to talk to the doctor or to call the doctor’s nurse, she always had to go through a long, computerized message, then various choices, and number pressing. In the end, she would leave a message. She did not know who would get the message. Increasingly, she had noticed that the messages seemed not to be acted on or returned. All she wanted to do was change an appointment time. Even though sophisticated in medical matters, she could not understand the website, the instructions, or the voice messages to successfully change her appointment. She changed to another cardiology office where the phones were answered more quickly, though still with a long series of messages. It was better. She remarked that the computerized answering machines and such seemed to be an unavoidable barrier to Care.

At our PMH office, we also run into this: when calling doctor’s offices or hospitals where it is difficult to get through to a person. We are aware of how hard this can be on our patients and their families. We continue to use an employee answering the phone promptly with human voice, human resources, and human ingenuity to address the questions, problems, or concerns of our patients, families, or colleagues who need help from our office. We believe this type of answering is helpful and meaningful to patients and other people who need our office to help them. It does add to the “work” as phones must be monitored and answered. It is one important way doctors serve their community: by answering the phone quickly and responding intelligently, thoughtfully, and promptly even if it is simply to change an appointment.

For many of our younger patients, online access to making appointments or dealing with problems is outstanding, but that does not work for everyone, and it is the frailest and the elderly who need direct, personal attention the most. Also, people who are sick, in trouble, or facing an emergency are helped the most by a quick human answer to their call. 

PMH helps patients and families.

Allan R. Kelly, MD FACP

CRANBERRY AND UTIs

A recent review was published in an online medical journal about cranberry tablets in reducing the risk of UTIs. Overall, there was a 27% reduction in the risk of UTIs in those using cranberry juice or cranberry juice capsules compared to placebo. There is a greater benefit with the juice compared to the capsules, possibly because of the extra water with the juice (i.e. hydration). Nevertheless, both reduce the frequency of UTIs. Other research shows that mannose, a carbohydrate supplement excreted in urine, adds to the preventive effects of cranberry. Together, mannose and cranberry are over the counter supplements that protect people from recurring bladder infection.

Robert H. Kelly, MD FACP

STATINS AFTER AGE 85

Guidelines in the past 20 years have not included statin therapy in people over the age of 85. We know that in older adults with cardiovascular disease statins are prudent, helpful, and meaningful. But how about adults over 85 with no history of cardiovascular disease? Researchers at University of Hong Kong did a trial, (Annals of Internal Medicine in May 2024), where initiators and non-initiators of statin therapy were closely matched and compared using statistical and medical comparisons. They were not randomized. Researchers showed that the value of statins in reducing health risks was greater in the over 85-year-old patients than the value in the 75 to 85 and in the under 75 population. All-cause mortality was reduced by 10 to 20%, more in the over 85 group compared to mortality risk reduction in the under 85 group.

The number of lives saved shows the value in the over 85. Specifically, the number of events was reduced by 12% in the over 85 group over a period of five years: from 39% death rate in the non-treated group and 26% death rate in the treated group. The incidence of adverse drug effects in the treated and untreated groups was the same – there was no reported increased risk of adverse effects in the statin treated Group.

This study calls into question the recommendations of the American College of Cardiology and the United States Preventative Services Task Force. I hope to see randomized controlled trials with older Americans soon. We hesitate to use words like cause and effect when it is not a randomized controlled trial. There is a movement afoot in some large journals, such as the New England Journal of Medicine, to allow researchers and doctors to use cause and effect language derived from observational trials. The authors in this Annals of Internal Medicine article do not indulge in cause- and-effect language. They prudently comment that this is what they observed.

Allan R. Kelly, MD FACP

SWEETS AND HEALTH

The Nurse’s Health Study recruited over 30,000 volunteers from 1984 to 2016 to study health outcomes related to individual choices. Research reported in 2024 showed there was a trend of increased autoimmune disorders, especially lupus, related to ultra- processed foods. Higher cumulative average daily intake of ultra-processed food was associated with a 56% increase in the incidence of lupus, especially lupus with anti- double stranded DNA antibody. Artificially sweetened beverages, and even sugar use, were also associated with autoimmune disorders. Body mass index, on the other hand, had no relation.

Avoiding ultra-processed food, concentrated sweets, and artificial sweeteners is good advice. There is the association with specific disease processes. In this example, an autoimmune disorder called lupus. For your better health, it is best to minimize ultra- processed and sweetened foods. Both natural and artificial sweeteners increase health Risks.

Robert H. Kelly, MD FACP

VITAMIN K AND MUSCLE CRAMPS

Muscle cramps are common, painful, disruptive, and generally not dangerous. In the past, quinine was used by our parents and grandparents; but now, quinine is seen as a potentially dangerous drug. Over-the-counter quinine has been removed from the market. Some muscle cramps are related to serious medical problems, such as atherosclerosis, inflammatory myositis, electrolyte disturbances, and serious motor neuron, and spinal cord disease. But these serious issues are uncommon. Most nocturnal muscle cramps are benign and idiosyncratic.

We know that exercise can reduce the frequency of cramps. Even a 5-to-10-minute walk before going to bed can make a big difference. But people are also interested in medication they might take at bedtime to help. Supplements like magnesium, potassium, or calcium are commonly used.

But persuasive data from randomized controlled trials supporting supplements is limited. That is why a report in JAMA Internal Medicine is important. Researchers in China, reported a randomized controlled trial in healthy adults over the age of 65 years. In this trial, participants with severe nocturnal muscle cramps received a vitamin K2 supplement or placebo. The K2 was 180 mcg, and is specifically menaquinone-7, abbreviated as MK-7 on bottles of these supplements. The participants were interviewed weekly to report on the incidence of muscle cramps that interfere with sleep. At baseline, the participants reported approximately 2.6 painful cramps per week. At the end of eight weeks, the placebo group was experiencing on average 3.63 painful cramps weekly. The vitamin K group was experiencing 0.96 painful cramps per week. The reduction in the number of cramps from approximately three weekly to less than one weekly is significant.

In summary, a randomized controlled trial, performed in China, showed convincing evidence that a Vitamin K3 can reduce the frequency of leg cramps in healthy individuals. I expect there will be other groups trying to confirm this information.

Allan R. Kelly, MD FACP

ZINC FOR COVID

In 2023, Abdallah, et al., reported results of an experiment where people with covid were randomized to placebo or zinc tablets. After diagnosis with a PCR test, patients were randomized to oral elemental zinc (25mg daily) or matching placebo. The patients were compared regarding duration of symptoms and adverse outcomes such as hospital admission and death. The mean age was 54 years. Poor outcome was 17% in the placebo group and 10% in the zinc group. There was no difference in the death rate between the two groups. The patients treated with zinc had milder symptoms by the 15 th day of their illness, and symptoms resolved sooner. Paxlovid and molnupiravir are effective treatments for covid illness but are also potentially very expensive and may cause side effects. Now we know that inexpensive, non-prescription zinc tablets also help people with a covid infection.

Robert H. Kelly, MD FACP

QUOTES

If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.

Hippocrates, 301 BC

No greater opportunity or obligation can fall to the lot of a human being than to be a physician. In the care of the suffering, she needs technical skill, scientific knowledge, and human understanding.

Tinsley Harrison, M.D. 1950

Instead, take these patients’ preferences seriously as a way to respect them aspersons and to protect their liberty. Physicians’ reluctance to treat patients over theirobjections may therefore reflect a well-founded moral intuition rather than mere self-interest or pragmatism.

Mark Navin, Ph.D. 2019

You survive in the new [medical care] system by giving the computer complete attention, the kind of attention we used to reserve for a patient. By default, the patient moves down to second place. As sad and horrifying as this sounds and feels, it is becoming the new reality.

Elizabeth Toll, M.D. 2020

If we are not careful, we might even convince society that the electronic medical record, and what it represents, is an end in itself, more important than taking care of the sick, training or successors, and finding cures for human disease. Or is it already too late? Has the door already closed behind us?

Martin Samuels, M.D. 2022

At its foundation, medicine is constituted by a particular kind of relationship, one based upon trust between a patient made vulnerable by illness and a doctor who professes to use his knowledge and skills always and only for the purpose of health and healing.

Aaron Kheriaty, M.D. 2024

Even though many physicians have traded the traditional shingle on the door for the big health system billboard, the obligation to provide the best care possible for each individual patient remains, physicians must continue to take personal ownership of every interaction with their patients. We must remember that despite the beautiful waterfall in the lobby and the self-playing piano in the cafeteria, the patient walks in the door seeking care from us, the physician, not from the system.

Isaac Opole, MD, 2024