Volume 15 • Number 5 • May 2014

There are several issues that make the practice of medicine a bit… trying. One of them is patients demanding prescriptions of antibiotics and controlled substances. Many patients have stopped seeing me because I did not prescribe an antibiotic for their cough. In my opinion they had a viral bronchitis. I will never forget the family who turned me in to the Utah Medical Association for not prescribing antibiotics for acne. First, they have been associated with arthritis, even Lupus in the future, to say nothing about the harm done to the gut microbiome.

The point is “patient satisfaction,” which is surveyed to evaluate a doctor’s performance. Doctors have strong feelings about this issue. Read the article quoted in its entirety below.

Hugo Rodier, MD

Patient satisfaction is overrated.”[1]

“I recently was at the Scientific Assembly of the American Academy of Family Physicians (AAFP) in San Diego, giving a lecture to a large audience of Academy members on respiratory syncytial virus (RSV) bronchiolitis. I mentioned why I thought identifying the RSV virus was important. I stated that if you tell the family the infant has RSV and that there is the expectation that cough will last 1-2 months, this may forestall them going to the ER or urgent care center. In those assembly lines of healthcare, they will be told that their child has “bronchitis” and will receive the inevitable azithromycin script. This will make the parents happy, free the healthcare provider of the need for further explanations, and result in a satisfying visit for the administrators of that facility. The trouble, of course, is that an antibiotic has again been used to treat a self-limited viral infection.

A physician came up to me afterwards and agreed with me but said that he had no choice. He works in one of those venues and is subject to surveys to measure “quality.” For him, quality is measured in 2 ways: The first is by getting the patient door-to-door in 45 minutes, and the second is by a Press Ganey survey to see if the patient was happy. Because of these measures, he is forced to abandon his role as a responsible steward of antibiotic use to keep his job and get a bonus. Another physician in the audience told the crowd that he was able to increase his satisfaction score by 7% simply by prescribing an antibiotic to all patients who call with a complaint of cough, sore throat, or sinus headache. One doctor reported to the media that he had to give Dilaudid® for minor pain because his Press Ganey score was low the previous month.

I believe that this little-known company, Press Ganey, from South Bend, Indiana, has become a bigger threat to the practice of good medicine than trial lawyers. They are the leading provider of patient satisfaction surveys for hospitals and physicians. For the past decade, the government and healthcare administrators have embraced the “patient is always right” model and will punish providers that fail to rate well in these surveys. Press Ganey’s CEO, Patrick Ryan, said, “Nobody wants to be evaluated; it’s a tough thing to see a bad score, but when I meet with physician groups I tell them the train has left the station. Measurement is going to occur.” Obamacare has budgeted $850 million in reduced Medicare reimbursement for hospitals with lower scores.

The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission. One emergency room with poor survey scores started offering hydrocodone “goody bags” to discharged patients in order to improve their ratings. And doctors face the reality that uncomfortable discussions on behavioral topics — say, smoking or obesity — come with the risk of a pay cut. If you tell a patient that their knee pain is related to weight, that their smoking is worsening their child’s asthma, or that they can’t lose weight because of French fries and not a glandular problem, your ratings and pay will take a hit.

Satisfied patients are not healthy patients. In a paper published in 2012, researchers at the University of California, Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on healthcare and prescription drugs. They were 12% more likely to be admitted to the hospital and accounted for 9% more in total healthcare costs. Strikingly, they were also the ones more likely to die.

Over treatment is a silent killer. We can over treat and over prescribe. The patients will be happy, give us good ratings, yet be worse off. We must have the ability to deny treatment for a patient’s own good. Patients aren’t the best judge of what is best for them. Several years ago, an elderly female patient wanted me to write a prescription for tamsulosin because she got a coupon in the mail. It did not matter that she lacked a prostate.

We should try to be kind to our patients and take time to understand them, but we must resist these misguided pressures and do the right thing. Sometimes patients have to be told “no,” and the leadership in healthcare must understand this. Take heart in the words of Mark Twain: “Always do what is right. It will gratify half of mankind and astound the other.””

Oxidation, testosterone and the brain

While testosterone may be beneficial under conditions of low oxidative stress, testosterone appears to have negative consequences under conditions of elevated oxidative stress, but only in Caucasians. Mexican-Americans, however, were protected from any deleterious effects of testosterone, potentially due to higher levels of endogenous antioxidant defenses such as Glutathione.”[2]

This is a very important article in view of the recent reports associating heart attacks with testosterone treatment for low testosterone. As predicted, heart attacks are reported to be more likely in men whose arteries are oxidized. Too much excitement will then stress said arteries leading to spasms and even clotting. This article suggests that men check their levels of antioxidants when considering treatment with testosterone. They recommend checking Homocysteine, the oxidant that goes up when we lack B vitamins; these vitamins are involved in maintaining the lining of our arteries in good repair.

Other laboratory markers for oxidation that could be checked are GGT, Methylmalonic acid, Myeloperoxidase and CRP-hs. The GGT is particularly important. Even in people in the upper quartile of normal it signals a deficiency in the antioxidant Glutathione which the researchers also focused on. As previously discussed, Glutathione is extremely important to keep ALL cells from oxidizing, particularly in the brain, liver and arteries. To keep healthy glutathione levels eat fruits and veggies, cocoa and consider supplements like Alpha Lipoic acid 600 mg, and the amino acid N-Acetyl-Cysteine 600mg. Milk thistle and whey also increase glutathione.

Thus, glutathione has also been shown to reduce the risk of Alzheimer’s disease. Think of your brain getting oxidized, which increases the risk of neuro-degeneration:

“With millions of older individuals presently suffering from Alzheimer’s disease (AD) worldwide, AD is an unduly common form of dementia that exacts a heavy toll from affected individuals and their families. One of the emerging causative factors associated with AD pathology is oxidative stress. This AD-related increase in oxidative stress has been attributed to decreased levels of the brain antioxidant, glutathione (GSH). In this article, we review the role of GSH in AD from a pathological as well as a diagnostic point of view. We recapitulate the literature that has assessed the role of GSH in AD onset and progression. We discuss the various methodologies through which alterations in GSH levels might be monitored, and highlight the yet uncharted potential of assaying GSH levels in vivo with magnetic resonance spectroscopy in AD therapeutics and prognostics. Finally, the present manuscript integrates findings from various studies to elucidate the possible molecular mechanisms through which disruptions in GSH homeostasis may contribute to AD pathology.” [3]

If you like coffee here is another reason to drink it: it increases levels of glutathione.[4] But, do not drink more than two cups a day since it may affect cardiovascular system negatively.

Hydraulics

Viagra is OK, but, patients need to be informed of potential side effects like blue vision, and low blood pressure, especially when taken with nitrates. Now add to that list a higher risk of melanomas.[5] And for young men who have problems with premature ejaculation, think twice before using antidepressants. It is better to try pelvic floor exercises.[6] Google “Kegel.”

[1] Fall 2013 issue of Keystone Physician, a publication of the Pennsylvania Academy of Family Physicians.

[2] “Oxidative stress, Testosterone, and Cognition among Caucasian and Mexican-American Men with and without Alzheimer’s Disease,”
J. Alzheimer’s Disease Volume 40, Number 3, IN PRESS Epub April 18 2014

[3] “The Emerging Role of Glutathione in Alzheimer’s Disease,” J. Alzheimer’s Disease Volume 40, Number 3, IN PRESS Epub April 18 2014

[4] “Lifestyle and the development of increased serum gamma-glutamyltransferase in middle-aged Japanese men. Scand J Clin Lab Invest. 2000;60:429-438

[5] “Sildenafil Use and Increased Risk of Incident Melanoma in US Men : A Prospective Cohort Study,”
JAMA Intern Med
. Published online April 07, 2014. doi:10.1001/jamainternmed.2014.594

[6] April 13 at the annual congress of the European Association of Urology in Stockholm

Hugo Rodier, MD is an integrative physician based in Draper, Utah who specializes in healing chronic disease at the cellular level by blending proper nutrition, lifestyle changes, & allopathic practices when necessary.

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