Summer 2019
PMH STORY
A retired physician in California was increasingly worried about his sister in Fort Worth. The sister had never had children, and she was his only sibling. She designated her brother as her healthcare power of attorney. The brother was now in his 90s, and could no longer travel to Texas to be with her.
The brother faced multiple providers in multiple situations giving complex advice about the sister, which he found confusing and unsatisfactory. She had been in the hospital several times and each time encountering another team of doctors, never the same doctor. It was confusing. Primary care was provided by a home visit service, again several doctors, multiple nurse practitioners, and PAs, who rotated visiting the woman at her assisted living facility.
The family asked the PMH doctor to get involved. Over the next several weeks, the PMH doctor visited the sister at her assisted living facility. The doctor quickly realized that she was no longer suitable for assisted living and would need either memory care or skilled nursing facility. Then behaviors at the assisted living facility led to hospital admission. The PMH doctor saw her in the emergency room and followed her during her hospital stay. At discharge, the sister went to a skilled nursing facility where the PMH doctor was again her physician and made rounds at that facility. The PMH doctor saw the patient before, during, and after the second hospital visit reporting back to the family in California. We call this continuity of care.
While making his visits one morning, the PMH doctor sent a brief video to the family in California, showing the sister’s room, the hallway and the view outside her window. The PMH doctor will continue to visit the sister. During an office visit, the brother joined the sister and doctor on Face Time.
There are times like these when there can be too many doctors, too many communications, and too much confusion. It can be simplified when a doctor and a family agree to work together, and when the doctor maintains continuity of care. This continuity of care was important to the family in California, the family in Texas, and also to the patient with dementia. The sister now recognizes her PMH doctor and smiles whenever she sees him, calling him Doctor. Anonymity and multiplicity have been replaced by continuity by a decision made between a competent, loving sibling and a doctor who knows the patient and has followed her through her hospitalizations.
That’s part of the reason we have created PMH: To value continuity of care and to make the continuity of care available for a fee that is modest and affordable. Whether the fee is a good value will be the judgment of the patient and the patient’s family. If it is worth it, they will subscribe. If it’s not worth it, then they will continue with the prior pattern of care. Giving people the opportunity to make this decision and to make this choice is good.
Allan R. Kelly, MD, FACP
STATIN DRUGS CONTINUE TO BE OUR FRIEND IN NEED
Recent publications looked at the benefit of statin drugs in unexpected places. It will always be true that as many as 10% of patients taking statin drugs will perceive muscle aches and discomfort. It is a balancing act: side effects vs. benefits. There is a benefit to statin drugs with regard to atherosclerosis and cardiovascular disease, but there are also other benefits. This is often referred to as “pleomorphic” benefits of statins. One set of researchers looked at statin benefit in patients with dementia later in life and noted that there was an improvement in behavior and outcomes. An experiment from China randomized patients with subdural hematoma, to the statin Lipitor or to a placebo. There was a distinct improvement in those treated with Lipitor compared to those treated with placebo. Surgery was needed in 11% on a statin, 23% on placebo. There was clinical improvement in 46% of those on the statin but only 28% of those on taking a placebo. A third intriguing recent study looked at C. difficile colitis. This is also uncommon but is less likely to occur in a group taking statin drugs compared to those taking placebo.
Robert H. Kelly, MD, FACP
ASPIRIN LETS US DOWN
The incidence of strokes and heart attacks has fallen for decades in the US. This change now affects the value of preventative aspirin. Two randomized, placebo-controlled trials were published in the October 18, 2018 issue of the New England Journal of Medicine, on the effect of aspirin on the health of persons older than 65 years. In one, nearly 10,000 persons without a history of cardiovascular disease were randomized, one group taking 100 mg of aspirin.
Robert H. Kelly, MD. FACP
REPORT – SIRI VS. ALEXA
A study was done looking at the accuracy of Siri and Alexa in interpreting plain language medical questions. There were 54 subjects who recorded their instructions to the voice assistant.
Robert H. Kelly, M.D.
DON’T FALL DOWN!
Approximately 30% of adults over 65 who live in their homes fell in 2014. Patients living in nursing homes or assisted living facilities have a much higher incidence of falls. Risk factors include, for example, age, some medications, frailty, cognitive impairment or dementia, and other chronic illnesses.
Allan R. Kelly, MD, FACP
DEMENTIA
Treatments have failed; prevention works. Over the past 20 years, extensive research on dementia has focused on treatment, but billions of dollars invested in this research have come to naught. On the other hand, prevention strategies are helpful. Certainly, we know that education, removal of tobacco smoke, and prevention of head injury reduces the risk of dementia. We also know that treatment of hypertension in middle age and into the older years will reduce the lifetime risk of cognitive impairment and dementia. We know that statin drugs in selected high-risk patients, such as diabetics and individuals with high blood pressure, can reduce dementia risk.
Allan R. Kelly, MD, FACP
PMH QUOTATIONS
“The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course but a life course, for which the work of a few years under teachers is but preparation.”
William Osler, 1895
“A recent study found that US physicians spend only 24% of their time communicating with patients, while a staggering 44% of their time is spent facing computer screens…a highly trained US physician has become a data entry clerk, and this has grim implications.”
Muhammad Khan, MD, 2019
“The Mayo brothers were steadfast advocates for their patients. All faithfully collaborated to establish a broad and enduring covenant to serve others; a commitment to an empathic presence in the face of human suffering; and an abiding trust in the moral foundation of medical caregivers. ”
Editors, Mayo Clinic Proceedings, 2019