Actually, the recent results of the SPRINT study (published today in the NEJM) indicate that a large population of patients with hypertension are undertreated, including those >75 years old, who comprised ~30% of the study population. We can significantly reduce risk of stroke and heart attack by aggressively managing blood pressure. The benefit of aggressive blood pressure management was similar for patients >75 years old compared to their younger counterparts.
Notably, the patient in clinical vignette you discuss would not meet SPRINT trial entry criteria because he has diabetes. But, my point is, "deintensification" has its limits, and the doctors who responded to the survey indicating they would manage elderly patients aggressively are perhaps not as wrong as you suggest.
Notably, the patient in clinical vignette you discuss would not meet SPRINT trial entry criteria because he has diabetes. But, my point is, "deintensification" has its limits, and the doctors who responded to the survey indicating they would manage elderly patients aggressively are perhaps not as wrong as you suggest.
3
SPRINT was a single, as yet fully-evaluated study that contradicts a large number of studies-see the Cochrane Review. It's very early to take SPRINT seriously until someone is able to explain why SPRINT was right and so many other studies were wrong.
1
Not only are older patients over-treated, but the common and sometimes dire or debilitating consequences of nutritional deficits (protein,B12, minerals, fat soluble vitamin due to malabsorption...) are ignored. These deficits can make existing symptoms worse, or cause a new set of symptoms. Having gone through some of this myself, I agree with everyone who says you have to be an advocate for yourself. I'm a nutrition professional, so I know the issues. The average person does not; apparently the average doctor does not either.
13
My education for the older adult was to go low and slow with treatments. There are so many simple lifestyle changes that make dramatic improvements in health from diet, exercise, social support and spirit support including prayer and meditation. Mature adults are often very open to these modalities
8
Unless we remove the profit motive from US health care we will never solve the problem of over treatment. US health care costs 17% of GDP, the highest of any large country in the world.
I suspect half of this is pure profit and greed. Can you imagine cutting our health care costs in half by removing the profit motive?
I can. Medicare For All beginning with an immediate reduction in the age of eligibility to 45. Really, do insurance companies want to insure people between 45 and 65 anyway? This would give Medicare so much more power and providers much less power to not take Medicare.
Let us also import more providers, make more medical seats and provide free or subsidized tuition. We remove school debt, we remove the profit motive, we remove providers who only want to make money rather than practice good medicine.
I can see that!
I suspect half of this is pure profit and greed. Can you imagine cutting our health care costs in half by removing the profit motive?
I can. Medicare For All beginning with an immediate reduction in the age of eligibility to 45. Really, do insurance companies want to insure people between 45 and 65 anyway? This would give Medicare so much more power and providers much less power to not take Medicare.
Let us also import more providers, make more medical seats and provide free or subsidized tuition. We remove school debt, we remove the profit motive, we remove providers who only want to make money rather than practice good medicine.
I can see that!
26
I am one of those older patience, 78 in a few days with type 2 diabetes, and have traded in my meds for another form of treatment, exercise. That which some in my age group shudder at the thought. I've found that my mindset compels me to use my body which it was made for, not sit at home dropping pills, watching TV, and worrying. I train with weights about 3 times a week, ride a bicycle, and a new Danish machine called a Me-Mover which really gets the blood pumping while taking me places. Yes, I know there are a myriad of reasons why people poo poo the idea of exercise, such as "I'm too old", "haven't done anything for years", etc.. Remember we can adapt, we can, at any age, but only if you want to, ask yourselves, do you?
18
My aunt passed away this year at 93, in a nursing home, with advancing dementia. I worked for over a year to try and get her OFF OF medications. Even with POA and a health proxy, I was stymied by doctors and nurses and staff at the Assisted Living facility in which she lived. They were hellbent on treating her tiniest symptom; of course, they had a financial incentive. They got substantial fees for "medication management". They had staff nurses, doctors, x-ray techs and their own pharmacy -- all profit centers.
She had little wrong with her, but old age and dementia, neither one treatable. But they insisted on her taking meds for blood pressure readings of 128/85. (The new standards are UNDER 120/80.) They wanted her on thyroid meds for slight rises in her readings, even when the meds had serious side effects. When I objected, I was told I was trying to make her die -- that without BP meds, "your aunt might have a stroke!"
That is ridiculous, not to mention, what you die of -- assuming you don't die in an accident or cancer or heart attack -- is a stroke. It is normal. It is normal to die at 93. I did not wish my aunt to die, but prolonging life unnaturally over 90 years of age WITH DEMENTIA, is to guarantee the elderly person will end up in a nursing home, tied to a wheelchair and unaware of their surroundings.
What is appropriate preventative care at 65 or 75 or even 80, may NOT be appropriate after 85. The patient should decide, or if unable, their family.
She had little wrong with her, but old age and dementia, neither one treatable. But they insisted on her taking meds for blood pressure readings of 128/85. (The new standards are UNDER 120/80.) They wanted her on thyroid meds for slight rises in her readings, even when the meds had serious side effects. When I objected, I was told I was trying to make her die -- that without BP meds, "your aunt might have a stroke!"
That is ridiculous, not to mention, what you die of -- assuming you don't die in an accident or cancer or heart attack -- is a stroke. It is normal. It is normal to die at 93. I did not wish my aunt to die, but prolonging life unnaturally over 90 years of age WITH DEMENTIA, is to guarantee the elderly person will end up in a nursing home, tied to a wheelchair and unaware of their surroundings.
What is appropriate preventative care at 65 or 75 or even 80, may NOT be appropriate after 85. The patient should decide, or if unable, their family.
43
Doctors of Medicare patients lose money if their patients don't get mammograms or colonoscopies! The fecal blood test is a good alternative - safer and cheaper but is not encouraged! With seniors vastly overweight maybe it's time to promote diet and exercise!
7
On an office visit when my Mother was anxious about an ER visit the preceding week, her blood pressure was up from the preceding record. Her physician, without retesting it, and without advising about exercise, started her on a blood pressure medication. It slowed her down and diminished her energy. With lower activity, and weight gain. her blood pressure continued to rise, the dosage, over the next 19 years, was gradually increased and a diuretic added.
While she did not have, during this time, a fatal stroke, she had a series of tiny ones that took away, incrementally. her memory and judgment. The medicine did not prevent this. Nor did it prevent the stroke which eventually took her speech and swallowing, and led to her death.
Nor, as is always injected into these discussions, did it in any way contribute to her quality of life. She was aware of her decline and made miserable by it.
While she did not have, during this time, a fatal stroke, she had a series of tiny ones that took away, incrementally. her memory and judgment. The medicine did not prevent this. Nor did it prevent the stroke which eventually took her speech and swallowing, and led to her death.
Nor, as is always injected into these discussions, did it in any way contribute to her quality of life. She was aware of her decline and made miserable by it.
20
I'm sorry for your loss. Medical decision-making, however, should be based on large randomized trials, not personal vignettes. Your mother's doctors were not wrong to put her on blood pressure medications. In fact, they may not have prescribed medications aggressively enough, based on the results of the recently published SPRINT randomized trial. In patients whose hypertension was managed aggressively (most with ~3 blood pressure medications), the risk of stroke, heart attack and death was significantly lower (by 25-40%) compared to those managed more leniently.
2
Coincidentally, my pcp suggested during a checkup visit that I try "metroformin" to lower my blood sugar - even though I'm not diabetic. Coincidentally, I had been reading an article on that drug in his office that described numerous negative side-effects that outweighed any benefits . My reaction was "are you kidding me?" Demonstrates that our care-providers are clueless and don't read up on the drugs they're encouraged to prescribe. Big pharma obviously has great influence on our docs, but this time, I took responsibility for myself and lowered my glucose levels 56 points by giving up all sugars and carbs, and lost 22 lbs. in the process.
6
Great that you accomplished that. But what was your blood sugar before the decrease by 56 points?
1
It's Metformin, not metroformin, and it's been around for so many years and is one of the cheapest drugs (you can easily find 90 days supply for under $20) so I don't know how it would benefit big pharma very much. How much is a kickback on a drug that costs $6 a month? Metformin is actually one of the safest options and helps people lose weight, it's much less risky than the other treatment options for blood sugar.
3
A friend has Parkinson's. He takes a host of medications, but can barely keep awake. His type of Parkinson's is such that he has muscle stiffness, as opposed to tremors. Of course he takes a statin. Statins increase muscle discomfort. His mouth is always dry from his meds. His teeth and gums have suffered from dry mouth. He takes other meds for various reasons. The upshot is that he's rarely totally awake. So, though none of these meds will slow the progression of the disease, merely mask the symptoms, I think he would be better off attacking the problem with exercise and various supplements. I've advised COQ10, also advised by some neurologists, but he has resisted that, telling me his physician doesn't think it would help. I don't think what his physician is doing helps. Another friend's father had Parkinson's and was also rarely awake. She and her brother have decided not to take any meds and are prepping themselves for the possibility of the disease by doing lots of exercise, taking supplements, and trying to maintain a sensible diet. I think their plan has merit.
6
Many elderly people at least having Medicare insurance, and many also having Medi-gap policies on top of it. Combined with our fee-for-service approach to medicine, this guarantees that they will have too much health-care of the wrong kind provided for them by greedy medical practices, hospitals, and the doctors who head them up. Unless we change this system of medicine, which is unlikely, we will have over-treatment of the elderly.
I recently stopped being treated by a large, local urology clinic which kept testing me for urology problems on every visit for 4 years even though I only went there for testosterone replacement therapy, and showed no symptoms of urology problems. (For the critics out there: yes, I need it. My body makes no testosterone on its own. This isn't the classic 'low-T' situation. On a scale of about 900, I get a 20 without supplemental testosterone.) I consider the clinic to a be a Medicare billing mill. There are probably thousands of these in America. Between regular Federal payments and Medi-gap on top, these clinics make plenty of money.
4
The medical practices have issues, but let's remember a LOT of very elderly folks (I mean here, over 85 and often with cognitive issues) live in retirement homes, Assisted Living and nursing homes. Those places have THEIR OWN financial incentives. They CHARGE for what they call "medical management". My aunt lived in such place, and they charged $700 a month if you required even a daily multi-vitamin -- residents were FORBIDDEN to take even a vitamin themselves, or from family. That meant either no meds of any kind OR you had to pay $700 a month. If you took more than 5 meds, or required anything like a diabetic diet, it was more like $1500 extra a month. This is on top of about $4000 for the basic facility fee.
Frankly, it is a racket. From what I saw, there was NOTHING provided in terms of health care or maintenance, entertainment, room & board, that would justify a cost of $5000 or so a month, yet this is on the low end of what AL care costs and nursing homes are double that. These are private, for-profit businesses and run with virtually no state oversight or rules (at least, ones the facility cannot easily get around).
Frankly, it is a racket. From what I saw, there was NOTHING provided in terms of health care or maintenance, entertainment, room & board, that would justify a cost of $5000 or so a month, yet this is on the low end of what AL care costs and nursing homes are double that. These are private, for-profit businesses and run with virtually no state oversight or rules (at least, ones the facility cannot easily get around).
14
The great news is that Government will determine what levels they should be at from top down mandates. I am sure the have their finger on the pulse and will rapidly change their quality criteria as they develop.
2
If legions of medical experts make recommendations to change standards of care for the elderly, and the government is paying the medical bills for most elderly people, then a so-called top-down mandate seems entirely appropriate. If you're paying for it yourself, get whatever care your doctor will give you, even if it doesn't have benefits. In case you missed the point of the article, less is sometimes better. If only the medical establishment would recognize that.
3
People get the government they deserve.
(Good grief! In regard to my comment, "let's [sic] Medicare pick up the tab," the word "lets" should have no apostrophe. How did that slip in?)
Auto"correct" perhaps?
Older people should not just not be treated aggressively -- they should be treated altogether less.
I'm very much for a "Medicare-for-all" system of national health insurance. But I'm beginning to scratch my head over one elderly friend, perfectly competent, in her mid-90s, who treats doctor appointments as social visits and let's Medicare pick up the tab.
Last week alone she had three appointments. Everyone wants her back every three months. She gets a mammogram once a year. She had a full Dopler of both legs (which she had last year too); not a varicose vein in sight.
Heart good. Urine good. Blood good. Veins good. No cancer, no diabetes, no anything.
There is something wrong, though.
All those doctor visits.
I'm very much for a "Medicare-for-all" system of national health insurance. But I'm beginning to scratch my head over one elderly friend, perfectly competent, in her mid-90s, who treats doctor appointments as social visits and let's Medicare pick up the tab.
Last week alone she had three appointments. Everyone wants her back every three months. She gets a mammogram once a year. She had a full Dopler of both legs (which she had last year too); not a varicose vein in sight.
Heart good. Urine good. Blood good. Veins good. No cancer, no diabetes, no anything.
There is something wrong, though.
All those doctor visits.
20
My dear father in law passed this spring. A wonderful man, greatly missed.
However, the last 10 years or so of his life -- roughly from 75-85 -- he went to the doctor at least once a week. Maybe some weeks 3 times a week. He went for every ache or pain. He went because he felt "tired". He went because he had heartburn (well documented). He went because he felt dizzy -- had a full neurological workup, MRI, CAT scan, etc. -- turns out nothing physical was wrong. The doctor determined that drinking 14 (!!!!) cups of coffee each day was giving him headaches & dizzy spells. Pop refused to give up his beloved coffee....so he kept going to different doctors, complaining of headaches.
He died of something entirely unrelated. R.I.P., Pops.
But the last 10 years of his life, he probably ran up $50K or more in medical bills yearly -- for nothing. He liked visiting doctors. He loved the attention and fussing.
However, the last 10 years or so of his life -- roughly from 75-85 -- he went to the doctor at least once a week. Maybe some weeks 3 times a week. He went for every ache or pain. He went because he felt "tired". He went because he had heartburn (well documented). He went because he felt dizzy -- had a full neurological workup, MRI, CAT scan, etc. -- turns out nothing physical was wrong. The doctor determined that drinking 14 (!!!!) cups of coffee each day was giving him headaches & dizzy spells. Pop refused to give up his beloved coffee....so he kept going to different doctors, complaining of headaches.
He died of something entirely unrelated. R.I.P., Pops.
But the last 10 years of his life, he probably ran up $50K or more in medical bills yearly -- for nothing. He liked visiting doctors. He loved the attention and fussing.
6
I am a fifty-something year old hospital-based physician and do not manage outpatients. However, my elderly relatives often discuss their medical issues with me, revealing over and over that their physicians often treat numbers, or seek to reduce uncertainty, but rarely consider the patient's values in decision-making. Over- and under-treatment must be in relation to one patient's goals, not simply broad population-based averages. Patients must learn more about their health issues and be proactive in making their wishes known to physicians.
12
"Blood pressure readings, too, should be allowed to rise as patients age — up to 150 millimeters of mercury for systolic pressure. The previous goal was to keep it below 140."
What is the writer talking about? A study published in the last few months concluded that aggressively treating HPV had definite benefits despite the side effects of the drugs.
What is the writer talking about? A study published in the last few months concluded that aggressively treating HPV had definite benefits despite the side effects of the drugs.
2
Alas, more evidence that doctors & studies disagree -- driving patients nuts. Think of the debate over mammograms! or before that, HRT.
I can only tell you I know of many stories, including my own, where doctor's attempts to get BP numbers under 120/80 resulted in dizziness, falls, vertigo and misery. Is it worth it? does it give longer, better lives? I don't know.
I can only tell you I know of many stories, including my own, where doctor's attempts to get BP numbers under 120/80 resulted in dizziness, falls, vertigo and misery. Is it worth it? does it give longer, better lives? I don't know.
6
I entered the VA health system a couple years ago as a Vietnam veteran presumed to have been exposed to Agent Orange. I've never felt better. I have no health issues. Yet, when I go for my annual VA exam (required) it feels like their greatest interest is finding something wrong with me - rather than helping me keep off medications and out of the health system. This article will help me explain my position at my next exam. Thanks!
10
Too many of us, as patients, don't ask what happens if there is no treatment or no prescribed medication. Crucially relevant if one has advanced, progressive disease where the temptation to 'over treat' is often overwhelming.
6
My 85 year old mother, a diabetic with high blood pressure, high cholesterol, etc was taking eight prescriptions before she died. Even with Medicare the cost was high and once we entered the donut hole it put a huge dent in her monthly budget. After she died, a friend, the director of the local nursing home, said that considering her age and condition most of those meds weren't making a lick of difference.
I was speechless. Just think of all the fun we could have had with her money, all the trips and outings we could have had. Instead we scrimped, and she worried. Appalling.
I was speechless. Just think of all the fun we could have had with her money, all the trips and outings we could have had. Instead we scrimped, and she worried. Appalling.
17
I think you have to prepare for future health problems now - while you're still healthy. And a useful step is to read these Comments and the article.
3
What a shame.
It is different with folks under 80; they may truly benefit from longer healthier lives by taking SOME meds.
But past 85 -- the patient should choose. And longer life NOT be a good trade-off -- not if you have dementia or are in pain, if you are deaf or blind (or both), if you are alone with no family, if you must live in an institution with no real home.
It is different with folks under 80; they may truly benefit from longer healthier lives by taking SOME meds.
But past 85 -- the patient should choose. And longer life NOT be a good trade-off -- not if you have dementia or are in pain, if you are deaf or blind (or both), if you are alone with no family, if you must live in an institution with no real home.
4
Did i read you right? I thought you meant how much more fun your mother could have had in her last years if she had not taken all those drugs that did not make a difference and spent her money on trips and outings instead for herself.
Define old? over 75??? At about age 60-- already having type II diabetes (at that point in time not well enough controlled -- around *) and already with macular edema (the macula swells and lines of print become wavy not straight) I also developed lipids (little yellow balls of fat!!) on the macula in the same eye giving me dead areas of vision. Visiting my excellent retinologist -- he zapped the eye with laser which improved the edema somewhat-- he took one look at recently increased in size by about 25 lbs. me and said "how much do you weight?" and what is your A1C? It was 8 or 7.8 at that time. His comment was people's eyes do better when the A1C is lower!! I did lose lbs.. nearly 25 -- could do a few more --and become a size 10-- fine for a 5'6" female -- Eye improved slightly. The damage from the lipids might well be permanent. Just saying diabetes is a very nasty disease and of course I have hypercholesterolemia (nicely elevated cholesterol -- altho that is pretty well under control with the statins.
These articles always make me flinch... esp as they rarely mention weight loss and exercise which do as much for many oldsters of course -- as do the drugs. (And yeah with weight loss and a limited carb (starch and sugar) diet insulin resistence might improve.
These articles always make me flinch... esp as they rarely mention weight loss and exercise which do as much for many oldsters of course -- as do the drugs. (And yeah with weight loss and a limited carb (starch and sugar) diet insulin resistence might improve.
4
I am sorry you are going through all of this, but you speak words of wisdom from your experience. Thank you for that.
5
Weight loss is not easy for everyone, and PERMANENT weight loss has very poor results long term.
It is even harder if you are elderly -- frail -- have multiple physical problems -- osteoarthritis, so any exercise involves bone-on-bone pain -- bad backs, sore necks, stiff muscles.
It's not like advising a 30 year old to go out and "exercise and diet!"
It is even harder if you are elderly -- frail -- have multiple physical problems -- osteoarthritis, so any exercise involves bone-on-bone pain -- bad backs, sore necks, stiff muscles.
It's not like advising a 30 year old to go out and "exercise and diet!"
2
Although not related directly to this article, the blitz of 24/7 pharmaceutical advertising in this country is a disgrace and does the public a great disservice. In Germany and in most other countries, not only is pharmaceutical advertising forbidden, pharmaceutical bling is also banned.
The advertising is akin to the old snake oil salesmen. For every conceivable ill, there exists a miracle pill. Dry eyes? Dry mouth? Difficulty sleeping? Sadness? You name it, there's a pill. Meanwhile, in depth studies of some of these medications find their efficacy marginal at best. All in all, I believe we're less healthy.
I'd much rather trust my treating physician for medication recommendations, than some person on television shilling the latest, greatest in a multitude of pills and other pharmaceuticals.
The advertising is akin to the old snake oil salesmen. For every conceivable ill, there exists a miracle pill. Dry eyes? Dry mouth? Difficulty sleeping? Sadness? You name it, there's a pill. Meanwhile, in depth studies of some of these medications find their efficacy marginal at best. All in all, I believe we're less healthy.
I'd much rather trust my treating physician for medication recommendations, than some person on television shilling the latest, greatest in a multitude of pills and other pharmaceuticals.
14
These commercials you speak of are why we quit watching all commercial TV. We watch Turner Classic Movies or PBS. We are in our 40s and have kids. Nobody should have to watch that stuff. Yuck!
7
'These commercials you speak of are why we quit watching all commercial TV.'
Wait a minute. Are you trying to kill capitalism? Are you a socialist? You know that you can get arrested for being anti-capitalist in this country, don't you? (Or was that somewhere else?)
Wait a minute. Are you trying to kill capitalism? Are you a socialist? You know that you can get arrested for being anti-capitalist in this country, don't you? (Or was that somewhere else?)
2
I am wondering whether the second sentence of your piece provides a pair of serious flubs. I am pretty sure you meant to say that the patient's hemoglobin A1C level was 6.5 per cent.
But the A1C level is NOT the "glucose level" in the patient's blood; it is a marker of whether, and how much, chronic glucose elevation has affected the hemoglobin molecules circulating in the patient's blood.
But the A1C level is NOT the "glucose level" in the patient's blood; it is a marker of whether, and how much, chronic glucose elevation has affected the hemoglobin molecules circulating in the patient's blood.
3
Several readers have objected to that wording, Dr. Lee. The Michigan researchers, who acknowledge that these targets and readings can be confusing, felt it was reasonable to use "hemoglobin A1c levels" and "glucose levels" interchangeably for a lay readership. But we have clarified the terminology in the middle section of the column.
2
Re-aligning incentives would make it easier for doctors to pay more attention to patient wishes about quality of life; but that is a generational shift. Right now, most doctors are not going to make this happen. Patients and families have to do it.
It's a travesty that so many older patients are either heavily overtreated, with medications and procedures that they don't need or really want.
Similarly, others are underinvestigated--their symptoms dismissed or glossed over as vague.
But lifestyle measures--eating drinking sleeping exercising well, being out in nature, mitigating chronic stress--are actually the best medicine, too little taught in med school or compensated by insurers, including Medicare.
Much of medical care is becoming formulaic, and dictated by algorithms which reward adhering to insurance company guidelines, and copying and pasting notes from one electronic health record visit into another.
For most docs, the fear of having a patient suffer a stroke from a spiked blood pressure, an otherwise silent measure, overrides any interest in lessening BP medication.
To take this into your own hands, ask "what is this medicine for?" "how long do I need to take it to accomplish its goal?" "does it interact with my other meds?" and "is there something I can eat, drink, work out with, or change instead?"
n.b. 6.5 percent is the 77 year old's hemoglobin A1C (HbA1c) is, not his glucose level; HbA1c averages glucose level over the past several months.
It's a travesty that so many older patients are either heavily overtreated, with medications and procedures that they don't need or really want.
Similarly, others are underinvestigated--their symptoms dismissed or glossed over as vague.
But lifestyle measures--eating drinking sleeping exercising well, being out in nature, mitigating chronic stress--are actually the best medicine, too little taught in med school or compensated by insurers, including Medicare.
Much of medical care is becoming formulaic, and dictated by algorithms which reward adhering to insurance company guidelines, and copying and pasting notes from one electronic health record visit into another.
For most docs, the fear of having a patient suffer a stroke from a spiked blood pressure, an otherwise silent measure, overrides any interest in lessening BP medication.
To take this into your own hands, ask "what is this medicine for?" "how long do I need to take it to accomplish its goal?" "does it interact with my other meds?" and "is there something I can eat, drink, work out with, or change instead?"
n.b. 6.5 percent is the 77 year old's hemoglobin A1C (HbA1c) is, not his glucose level; HbA1c averages glucose level over the past several months.
7
I would include friends of various ages whom one sees fairly frequently to this list of healthy measures.
1
Absolutely!
I'm a family doctor for the last 32 years. I'm delighted to see this discussion in the NYT, which is consistent with Atul Gawande's observations in "Being Mortal". It takes time to listen to older patients and treat them as individuals. The style of medicine promoted by CMS for the last 15 years emphasizes and pays for recording massive amounts of data, much of which matters only to the computer system collecting it. That takes resources and thoughtfulness away from the patient's concerns. There is no science to justify this, especially in the elderly. It's amazingly dysfunctional.
Moreover, the preferential payment of "facility fees" (I call it welfare for hospitals) to hospital owned practices has pretty much destroyed physician owned practice. So patients have no choice of practice styles. Before this shift occurred, there were certainly problems with physician practice, but there was never any attempt to identify and build upon what was done well.
Right now, we are facing a "perfect storm" in the demographic bulge of the baby boomers who are now entering their 70s, and the retirement of same age physicians. The current state of US medicine is repulsive and tragic. I am retiring next months. Many of my 20+ year patients are telling me that they cannot find physicians who accept Medicare patients.
Moreover, the preferential payment of "facility fees" (I call it welfare for hospitals) to hospital owned practices has pretty much destroyed physician owned practice. So patients have no choice of practice styles. Before this shift occurred, there were certainly problems with physician practice, but there was never any attempt to identify and build upon what was done well.
Right now, we are facing a "perfect storm" in the demographic bulge of the baby boomers who are now entering their 70s, and the retirement of same age physicians. The current state of US medicine is repulsive and tragic. I am retiring next months. Many of my 20+ year patients are telling me that they cannot find physicians who accept Medicare patients.
27
Thank you for your years of service to mankind.
4
Over-treatment is becoming a universal phenomenon, not particularly about elders, and is more serious in many other countries like China. A lot of it has to do with mind-sets and emotions, in addition to real physiological conditions and medical data. When patients and/or their caregivers are placing blind trust on the “magic power” of modern medical interventions, and when over prescription is, after all, profitable, there is very little motivation for physicians and nurse practitioners to resist the pressure and fight a two-front battle.
The key to gradually solve this problem is education and effective communication.
The key to gradually solve this problem is education and effective communication.
2
Dr. Ezekial Emmanuel concerns. See Paula's ebook interview with him. Kudos to them both.
2
He always has some provocative ideas.
Whether for myself or for my elderly parent, almost every time I suggested a change in treatment the doctor resisted it, even when it was about a medication originally prescribed by a previous doctor. The only way we've been able to make a change when needed was to find another doctor and discuss the change as the reason for the first visit.
3
I think that patients need to take charge of their own health care and adopt the less is more approach to medications. My father lived to 85 and until only a couple of months before he died (complications from a fall due to spinal stenosis) he had taken only one arthritis medication long-term. He did see his gerontologist frequently the last few years, but fortunately that doctor was not quick to prescribe medications for this and that. If he had, my father would have had me to intervene. Many older patients probably need an advocate with their doctors.
3
From this article it is hard to tell how much of this concept of over treating elderly is really supported by scientific studies rather than the impressions of a group of physicians promoting this idea. Fine to raise it as an issue that should be studied, but this article does not compel me to reduce my medications as I get older.
2
Mr. Figdill, several of the highlighted links in the story will take you to abstracts of the studies in question, and to the Choosing Wisely recommendations. You can read them and evaluate the evidence for yourself.
3
I clicked on the NEJ link on targeting HBA1c levels in diabetics. In every part of the article I could see, including the methods, they ONLY speak of the A1c level target and do not even mention the medication and or method used to target A1c levels. Metformin which is relatively safe? Aggressive exercising and diet (probably also safe). Insulin - probably has lots of complications being such a potent hormone with widespread effects? Glyburide - an inexpensive old mainstay that causes weight gain as well as hypoglycemia? I don't know if they controlled for this essential variable (method of treatment), but scientifically the study is not sound without it. It is the specific treatment that matters, not just the HBA1c levels achieved.
1
Yes, older people are over-treated. My father and mother saw their primary care physician every six months. At their ages of 90 and 88, they were sent specialists for a myriad of tests each year, but some of those tests were invasive. My father died from when the colonoscopy he agreed to, tore his intestine. My mother's last mammography resulted in a biopsy of a pea-sized tumor and she then faced 6 weeks of radiation or mastectomy instead of what should have been a wait-and-see approach. She died before she had to endure any of that.
They trusted their primary care doctor, which was good. What was not good was that he sent them to too many specialists.
They trusted their primary care doctor, which was good. What was not good was that he sent them to too many specialists.
17
Except that now that we are in the age of outcome-based incentives, the algorithms don't discriminate by age. So if the 87 year old had a systolic blood pressure of 150, and LDL cholesterol of 105, the primary care doctor will have his/her finances or "quality grading" metrics adversely affected.
While it seems as if this could be an easy problem to solve by adjusting the metrics, they are so poorly designed and done with so little input or revision from front-line practitioners, it is essentially a non-starter.
While it seems as if this could be an easy problem to solve by adjusting the metrics, they are so poorly designed and done with so little input or revision from front-line practitioners, it is essentially a non-starter.
7
As a critical care doctor who also sees some general medicine office patients I couldn't agree more. I always emphasize with the residents I teach that guidelines and goals are just that, and the actual risk and benefits to an individual patient needs to be assessed. In all my patients, but particularly my older ones, I always ask does this medication improve the actual quality of their life and/or does it prevent premature death? If it meets those standards I will consider prescribing it, otherwise I avoid filling up the medicine chest just to make my chart look better.
13
By the time my mother in-law died she was taking over 17 medications, some of which she had begun taking 25 years before her death. At 85, when she became ill, the family became aware of the situation and began to question the doctors as to the relevance of these meds other than to alleviate side effects of meds. No one had an answer because no one wanted an answer. Everyone was making money and she a medicare patient was basically a cash cow. While medications are a lifeline to many, the abuse of prescribing drugs to the elderly is a shame.
My mother in-law was taken off her medications as she entered into hospice care and she was probably the mentally alert and happiest she had been for 25 years. It was a good year for everyone.
It's time the medical profession starts looking beyond dollars and cents and reverts back to the Hippocratic Oath-does anyone remember what that is?
My mother in-law was taken off her medications as she entered into hospice care and she was probably the mentally alert and happiest she had been for 25 years. It was a good year for everyone.
It's time the medical profession starts looking beyond dollars and cents and reverts back to the Hippocratic Oath-does anyone remember what that is?
21
When I took over care for an elderly aunt with dementia, I found she was on 14 different medications. Many of them were to counteract OTHER medications. Some she was put on in the hospital for some temporary condition, and never taken off of!
Some drugs caused diarrhea, so she was put on anti-diarrheal drugs (round the year)....these, of course, caused constipation. So she was put on stool softeners.
She was on allergy meds for allergies she had been diagnosed with years ago and just renewed ad infinitum. Testing showed she no longer had the allergies. Some of the inhalers were VERY expensive! She was going through one a month.
In the end, I (finally) got her off of all her meds, but it was a huge fight. She passed soon after, but from an entirely unrelated cause -- a sepsis infection caused by a urinary tract infection.
When I pointed out to her primary care doctor, that a 93 year old woman with dementia should NOT be taking statins or BP meds (her resting BP was 130/85), I was told "are you trying to kill your aunt? She could have a STROKE!" -- no, better she live to 99 and have full blown dementia in a nursing home.
Some drugs caused diarrhea, so she was put on anti-diarrheal drugs (round the year)....these, of course, caused constipation. So she was put on stool softeners.
She was on allergy meds for allergies she had been diagnosed with years ago and just renewed ad infinitum. Testing showed she no longer had the allergies. Some of the inhalers were VERY expensive! She was going through one a month.
In the end, I (finally) got her off of all her meds, but it was a huge fight. She passed soon after, but from an entirely unrelated cause -- a sepsis infection caused by a urinary tract infection.
When I pointed out to her primary care doctor, that a 93 year old woman with dementia should NOT be taking statins or BP meds (her resting BP was 130/85), I was told "are you trying to kill your aunt? She could have a STROKE!" -- no, better she live to 99 and have full blown dementia in a nursing home.
4
20 years ago in nursing school I learned about (1)the placebo effect, which gets you better without any ac tual intervention, and (2)interactions of medications especially in the elderlly. This is now a surprise?
5
I know a lot of physicians. Most of us spend our days trying to sort through our patients medical, psychological and social problems as best we can. No greed involved. I frequently tell patients that the goal is to do not too much or too little. This applies to diagnostics as well as treatment. The trick is to find that sweet spot. With new evidence, sometimes readjustment is necessary.
7
The focus of this article is on the treatment, possibly the over treatment, of high blood sugar. The column also mentions high blood pressure, and reports that current guidelines suggest this common condition too may be overmedicated: "Blood pressure readings, too, should be allowed to rise as patients age."
This seems to contradict a major study recently described in the Times a couple of months ago, the Sprint study, which found that high blood pressure should in fact be aggressive treated, more so that it is routinely treated today.
http://www.nytimes.com/2015/09/12/health/blood-pressure-study.html
This illustrates how complex medicine and public health are. As new research is done, and experience is accumulated, recommendations are ever shifting, and it's hard for patients and their physicians to know what to do.
This seems to contradict a major study recently described in the Times a couple of months ago, the Sprint study, which found that high blood pressure should in fact be aggressive treated, more so that it is routinely treated today.
http://www.nytimes.com/2015/09/12/health/blood-pressure-study.html
This illustrates how complex medicine and public health are. As new research is done, and experience is accumulated, recommendations are ever shifting, and it's hard for patients and their physicians to know what to do.
4
Very simple, greediness of doctors!
1
Not so simple. They have trained to "cure'' stuff not let it be. that means lots of re-education.
2
Maybe people need to control their blood sugar early on and therefore never get diabetes. Has anyone walked through a shopping mall and seen all the overweight people, children and adults? I know you can lead a horse to water....but come on people. Go visit Boulder one of the healthiest cities in the US and one can dramatically see how people there are not so fat. It is actually incredible the difference. I wonder if Boulder has so many diabetics as the rest of the country. Go take a walk and think about your waist size.
3
You've never heard of Type 1 diabetics? Some people are born w/diabetes (or their pancreas don't manufacture insulin). For them, there is no choice.
In addition, this article is about people who have been diagnosed and treated for diabetes (whether type 1 or type 2 isn't specified) and have kept it under very good control for years.
In addition, this article is about people who have been diagnosed and treated for diabetes (whether type 1 or type 2 isn't specified) and have kept it under very good control for years.
2
While on vacation, I was asked to make a "housecall" on an elderly patient, a family friend, having trouble with his legs, difficulty walking, possibly arthritis in the knees. He and his wife served us tea and cookies while we talked. Apparently, it wasn't arthritis, it was muscle weakness that made it difficult for the old man to get up out of his chair. Just as we were about to leave, the old man pulled out a meticulous notebook containing copies of his medical records, lab reports, and medication list. The records showed he was on a statin drug to lower his cholesterol which was an astounding 110 on his latest lab. This is the lowest cholesterol I have seen in a long time. No doubt this poor old man was suffering from statin induced myopathy and possibly other ill health effects from very low serum cholesterol. A few months later I heard that his doctor was in agreement with stopping the statin drug, after which he improved. Here is a quote from Dr Takata in Clin Interv Aging. 2014; 9: 293–300. "(Our) findings suggest that low Total Cholesterol and low LDL-Cholesterol may be independent predictors of high mortality in the very elderly”. Lowering cholesterol in the elderly frequently causes more harm than good. For more see: http://jeffreydachmd.com/cholesterol-lowering-drugs-for-the-elderly/ jeffrey dach md
11
I know a couple of others who experienced the same thing.
There IS a place for statins, but overall they are over prescribed.
There IS a place for statins, but overall they are over prescribed.
5
Overtreatment and preventable medical errors are the third leading cause of death in the United States, killing 200,000 - 400,000 or more people per year. Doctors are killing more people than terrorists, shooters, plane crashes, police brutality, climate change, and many other causes that gain far more media and policy attention. To save more lives and improve the quality of life of more people, we ought to focus more on curtailing overtreatment and mistreatment by the medical industry. We can help by building public awareness and adopting policies that support patient safety, transparency, rigorous clinical studies, evidence-based practices, and holding providers accountable for quality measured in terms of risk-adjusted outcomes.
For more info:
http://journals.lww.com/journalpatientsafety/fulltext/2013/09000/a_new,_...
http://www.hospitalsafetyscore.org/newsroom/display/hospitalerrors-third...
http://jama.jamanetwork.com/article.aspx?articleid=1104821
http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Hea...
For more info:
http://journals.lww.com/journalpatientsafety/fulltext/2013/09000/a_new,_...
http://www.hospitalsafetyscore.org/newsroom/display/hospitalerrors-third...
http://jama.jamanetwork.com/article.aspx?articleid=1104821
http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Hea...
4
'To save more lives and improve the quality of life of more people, we ought to focus more on curtailing overtreatment and mistreatment by the medical industry'
I would not blame the 'medical industry' totally. It is also the mind set of the 'consumers', i.e., us. Even if I sneeze once, my wife will say, 'why don't you go see the doctor?'. She is probably one of those who does not feel well unless her doctor says she is well.
And I feel so sad that she almost feels so proud that she has now 'won' a permanent blue handicap sticker for her car (the temporary ones were red). Now she feels like she somebody!
I would not blame the 'medical industry' totally. It is also the mind set of the 'consumers', i.e., us. Even if I sneeze once, my wife will say, 'why don't you go see the doctor?'. She is probably one of those who does not feel well unless her doctor says she is well.
And I feel so sad that she almost feels so proud that she has now 'won' a permanent blue handicap sticker for her car (the temporary ones were red). Now she feels like she somebody!
1
I have seen similar behaviors- proud to have the blue handicap sticker. Yet my secretary fought tooth and nail to improve her health so she would not need such a sticker.
1
Having read the book by Dr Richard Bernstein (T1 diabetic for decades) I find it hard to believe the sanguine response to HBA1C above the 5's. Above 140 mg/dl (a little over 6 HbA1c) your body is being destroyed by high blood sugars. Your eyes are affected, your nerves, your ability to properly digest food or fight off infections are all compromised. That number may not be 140, it may be above 100.
I do not know for sure but I wish we all did! Since diabetes is the inability to process carbohydrates properly, why not get off carbs of all kinds including whole grains? That may not help everyone but it could help many get off medications. Without medications/insulin I thought that extremely low bg was very rare. When lowered by diet and exercise, there should not be low blood sugar issues.
My other wish is to have diagnoses done by computer. We have so much computing power these days. I want to be able to put lots of information into a super computer and have it spit out humanity's best guess for what ails me and what I can do about it....if anything.
I think the NYTs articles about thinking like a doctor are interesting and alarming. If you do not hit on the right practitioner at the right time your diagnosis may be totally wrong. If your doctor has no experience with your ailment then she may get it completely wrong. It should not be left up to this kind of chance these days.
I do not know for sure but I wish we all did! Since diabetes is the inability to process carbohydrates properly, why not get off carbs of all kinds including whole grains? That may not help everyone but it could help many get off medications. Without medications/insulin I thought that extremely low bg was very rare. When lowered by diet and exercise, there should not be low blood sugar issues.
My other wish is to have diagnoses done by computer. We have so much computing power these days. I want to be able to put lots of information into a super computer and have it spit out humanity's best guess for what ails me and what I can do about it....if anything.
I think the NYTs articles about thinking like a doctor are interesting and alarming. If you do not hit on the right practitioner at the right time your diagnosis may be totally wrong. If your doctor has no experience with your ailment then she may get it completely wrong. It should not be left up to this kind of chance these days.
5
At 58 I aim to never be on chronic medication. My health care professionals are always baffled when I tell them I'm not taking anything.
14
They why go to the doctor?
3
lI'm 83 next Sunday and have the same experience of surprise from nurses and doctors when I say that I'm not taking any medication. My answer: I exercise six hours weekly, eat well, control my weight and have a positive attitude with mutual caring and loving from my wife and two daughters. I see my internist once a year
5
Follow the money. Doctors learn about drugs from the company "pushers". These are the well dressed drug company employees who come around telling the doctors how wonderful and useful their drugs are. The used to give out gifts too, but I think those are illegal now. (Incidentally, they frequently park in spaces for the handicapped because as they told me, their case is very heavy.)
Doctors are at a loss when it comes to older patients because naturally the drug company isn't going to tell them to prescribe less. The other real danger is that older kidneys don't always filter the drugs as fast so overdoses are more common among the elderly. I read a report that most people over 55 take 5 prescription drugs. It is shocking to me that the medical professionals are lead into unnecessary and dangerous treatments because that is what they learned years ago and refuse to follow new guidelines.
Doctors are at a loss when it comes to older patients because naturally the drug company isn't going to tell them to prescribe less. The other real danger is that older kidneys don't always filter the drugs as fast so overdoses are more common among the elderly. I read a report that most people over 55 take 5 prescription drugs. It is shocking to me that the medical professionals are lead into unnecessary and dangerous treatments because that is what they learned years ago and refuse to follow new guidelines.
11
I'm old, but you are out of date. Twenty years ago your comments about drug salesman would have been right on, not so much anymore.
4
I practice primary care internal med and I am forever trying to minimize meds with my elderly patients with the goal of "first, do no harm." I engage my patients through discussion and follow-up re-assurance which has worked well. I agree with several other comments that we have a societal culture of wanting more and more to be done in our aging population, especially at the end of life. We need a cultural shift to say it is okay and, perhaps, better in many cases to do less.
52
.......... and Dr. Ezekial Emanuel concurs.
See article elsewhere in today's NYTimes.
My new healthcare mantra replaces the, "Don't just stand there, do something" with the newer, "Don't just do something, stand there".
"Primum non nocere".
See article elsewhere in today's NYTimes.
My new healthcare mantra replaces the, "Don't just stand there, do something" with the newer, "Don't just do something, stand there".
"Primum non nocere".
11
The following is from paragraph three of this article:
"They sent this fictional case study to primary-care professionals at Veterans Affairs medical centers across the country and asked a series of questions about the man’s treatment."
This is about a study of nearly 600 doctors in the VA system, across the country. The participants were NOT physicians in private or hospital practice - they were VA doctors.
Assuming one can extrapolate the results of this study onto about 600 doctors in private practice, then, it seems the lesson for us is this: all of us, young, middle aged, senior citizens, need to learn as much as possible about our own health care needs, so we can engage our doctors in meaningful discussions about options available, and treatment choices we make.
Adult children of elderly parents - if our parents are not able to be knowledgeable about their own health care, and are unable to ask important questions of their doctors, then, someone needs to do so on behalf of the parent, or, risk the parent getting lost and shuffled around in the hell that is Old People Health Care Land.
The patient-doctor relationship should be a partnership. Doctor is the expert who educates patient about his/her medical condition, and advises what all the options are, regardless of cost. Patient, in consultation with this doctor, makes the final decision.
"They sent this fictional case study to primary-care professionals at Veterans Affairs medical centers across the country and asked a series of questions about the man’s treatment."
This is about a study of nearly 600 doctors in the VA system, across the country. The participants were NOT physicians in private or hospital practice - they were VA doctors.
Assuming one can extrapolate the results of this study onto about 600 doctors in private practice, then, it seems the lesson for us is this: all of us, young, middle aged, senior citizens, need to learn as much as possible about our own health care needs, so we can engage our doctors in meaningful discussions about options available, and treatment choices we make.
Adult children of elderly parents - if our parents are not able to be knowledgeable about their own health care, and are unable to ask important questions of their doctors, then, someone needs to do so on behalf of the parent, or, risk the parent getting lost and shuffled around in the hell that is Old People Health Care Land.
The patient-doctor relationship should be a partnership. Doctor is the expert who educates patient about his/her medical condition, and advises what all the options are, regardless of cost. Patient, in consultation with this doctor, makes the final decision.
9
Think, most of the nearly 600 respondents were physicians at VA medical centers, but the group also included some nurse-practitioners and physician assistants.
2
Some patients are afraid that if they don't comply with their physician's wishes, the physician will terminate care. It happens. Elderly people can be particularly concerned about this, but it can be true of anyone. Where I live, health care providers may terminate care of patients who miss an appointment w/out providing so many hours of notice prior to that appointment. Regardless of how much that practice/provider may over book and their patients may wait.
Your comment also assumes that a physician has the time and will take the time to talk with his/her patients. If the physician is an employee of a hospital or clinic chain, he/she may effetively have quotas for how many patients/he/she is expected to see in a day. That doesn't leave much time for "discussion." The last time I saw a health care provider, she spent more time entering data into the examination room's computer then she did talking to or examining me. She's an employee of a hospital/clinic chain that has an almost complete monopoly of health care providers in the county I live in, and the county adjacent. This is the second system this chain has installed--and I suspect at least 6 years of chartnotes were lost in the transition, although I doubt if the provider will admit it.
Consolidation of health care providers in the US (happening) as well as health insurers won't lead to better health care at more reasonable prices, but the opposite.
Your comment also assumes that a physician has the time and will take the time to talk with his/her patients. If the physician is an employee of a hospital or clinic chain, he/she may effetively have quotas for how many patients/he/she is expected to see in a day. That doesn't leave much time for "discussion." The last time I saw a health care provider, she spent more time entering data into the examination room's computer then she did talking to or examining me. She's an employee of a hospital/clinic chain that has an almost complete monopoly of health care providers in the county I live in, and the county adjacent. This is the second system this chain has installed--and I suspect at least 6 years of chartnotes were lost in the transition, although I doubt if the provider will admit it.
Consolidation of health care providers in the US (happening) as well as health insurers won't lead to better health care at more reasonable prices, but the opposite.
3
My doctor tells me that I am a 'borderline diabetic', but he is not aggressive about it and has not prescribed any drugs, urging me to 'watch it'. In the beginning, he had asked me to check my blood sugar three times daily - which I did for a few weeks and then completely gave it up. I figured that checking blood sugar using the glucometer was more stressful than the actual disease.
On every visit for the last few years, he has been urging me to get a colonoscopy and I am yet to have one. My argument is that I am not a meat-and-potato eater - I eat a lot of vegetables everyday - and I am fortunate enough to have a regular bowel movement. Just because I immigrated to the US does not mean that I will get colon cancer.
I know I am taking some risks but I am quite happy about it. After all, someone once told him that almost all of us will die some day, and I believe him.
On every visit for the last few years, he has been urging me to get a colonoscopy and I am yet to have one. My argument is that I am not a meat-and-potato eater - I eat a lot of vegetables everyday - and I am fortunate enough to have a regular bowel movement. Just because I immigrated to the US does not mean that I will get colon cancer.
I know I am taking some risks but I am quite happy about it. After all, someone once told him that almost all of us will die some day, and I believe him.
14
I disagree about the colonoscopy unless you are over 75. I am the healthiest person I know. Exercising daily, perfect diet and weight for 30 years. I was shocked when I had 2 adenomas at 52 with a routine colonoscopy. Doc said it was probably genetic. Now at 65 I look 45, am still in perfect health, no meds, and have never had cancer, so there you go. There is a always a small cancer risk even with those of us who do EVERYTHING right. Sorry to burst your bubble but glad I had it done.
9
So ....... we're all "borderline".
2
Ummm. You have an opportunity to adjust your lifestyle so you do not end up with diabetes which is a life altering disease with potential dire consequences such as leg amputations and blindness. I agree that it is your life but do you really understand what the risk of diabetes is? Or are you burying your head in the sand of denial?
I'll throw in the dangers of anti-anxiety drugs too. I've been poisoned by Xanax! Taken it for many years and am, just now, learning the dangers of this class of drug when taken regularly. I am trapped. Very hard to quit. Check out benzobuddies.org.
8
Many patients at this age have middle-age offspring that demand all tests, all procedures; they often insist their elderly parents or grandparents should be submitted to as many tests and procedures as if they were 45 or 55 years old.
Not addressed here is the innapropriate use of aspirin for primary prevention in the elderly.
Not addressed here is the innapropriate use of aspirin for primary prevention in the elderly.
10
The real indication for a colonoscopy, mammogram or whatever is a source that will pay for it. Most knee jerk screens are worthless and should go the way of the routine physical examination. They do nothing other than keep rapacious hospital corporations afloat. Worse they may trigger high morbidity treatments of niggling conditions.
20
......... and one might find "incidentalomas".
7
I find this talk of relaxing standards for diabetic control for seniors infuriating. I worked very hard to get my HA1-c down to normal levels of approximately 5.5% and was rewarded for my efforts by having Medicare decide I didn't need the insulin I require to live. My poor pharmacist was never paid for 9 months supply he sold to me at rock bottom prices, only 10% above his cost of goods sold.
Since then I have been hounded by M.D.s who think I am lying when I report that I have never had any low blood sugar. Is this the reward a responsible adult should reap for doing an excellent job on the blood sugar control? Well, it is the latest FAD and when all these seniors live longer than expected and start developing serious complications, you health professionals can be very happy, as your billings will surely increase. I deeply distrust all of you.
Since then I have been hounded by M.D.s who think I am lying when I report that I have never had any low blood sugar. Is this the reward a responsible adult should reap for doing an excellent job on the blood sugar control? Well, it is the latest FAD and when all these seniors live longer than expected and start developing serious complications, you health professionals can be very happy, as your billings will surely increase. I deeply distrust all of you.
7
I am confused by your comment. Why do you think you still need insulin?
4
I am diabetes 1 I do not create any insulin at all. I achieved my 5.5 level with rigorous testing and injecting as much as 180 units of insulin a day. When Medicare decided my insulin was not needed, they were threatening my life.
Thanks. I understand now.
The article fails to note that for the years about 1995 til about 2010 that insurance companies put metrics in place to reward monetarily doctors who had their diabetics' a1c values under 7, and punish those who had too many patients with a1c values above 7, based on a study that came out in the mid 1990s. This metric was applied to all diabetic patients even if they were extremely ill, terminally ill,or elderly.
I worked for a major PPO in CT that had this system in place. The PPO did not remove that metric until at least 3 years after the first data started coming out about avoiding over treatment of blood glucose in the elderly.
That means your doctor was being rewarded for bad care ,punished for providing good care , during that time interval. I know, I lived through it, my emails about it to the CEO went unheeded.I drew a line in the sand ethically and tried to do the right thing, but I did not see those financial"withholds"returned to me.
The NYT should do an expose' article about the current system of quality of care metrics in place and how little they actually tell us about true quality of care, they are just there to try to let insurers find ways to withhold reimbursement for care.
I worked for a major PPO in CT that had this system in place. The PPO did not remove that metric until at least 3 years after the first data started coming out about avoiding over treatment of blood glucose in the elderly.
That means your doctor was being rewarded for bad care ,punished for providing good care , during that time interval. I know, I lived through it, my emails about it to the CEO went unheeded.I drew a line in the sand ethically and tried to do the right thing, but I did not see those financial"withholds"returned to me.
The NYT should do an expose' article about the current system of quality of care metrics in place and how little they actually tell us about true quality of care, they are just there to try to let insurers find ways to withhold reimbursement for care.
32
Quality metrics should measure impact on the outcomes that matter to consumers:
1. reduced pain
2. increased ability/functioning
3. delayed mortality
If a provider's service does not achieve at least one of these consumer-determined goals better than placebo, then it is wasteful at best and harmful or lethal at worst.
There is a great need for more rigorous and meaningful quality measurement programs in healthcare.
1. reduced pain
2. increased ability/functioning
3. delayed mortality
If a provider's service does not achieve at least one of these consumer-determined goals better than placebo, then it is wasteful at best and harmful or lethal at worst.
There is a great need for more rigorous and meaningful quality measurement programs in healthcare.
1
Natasha, the issue with that approach is:
1. Pain is subjective, difficult to quantify and we are the grips of an opioid epidemic worsened by the 'pain as vital sign' movement.
2. Agreed with this, though again it is incredibly subjective and as people age or progress in a progressive illness they will experience decrease ability and functioning.
3. Mortality is a reality
Doctors cannot reverse the aging process and patients must take a large share of the responsibility and understand that 40-50-60-70 years of not taking care of your body is not reversible by a physician.
1. Pain is subjective, difficult to quantify and we are the grips of an opioid epidemic worsened by the 'pain as vital sign' movement.
2. Agreed with this, though again it is incredibly subjective and as people age or progress in a progressive illness they will experience decrease ability and functioning.
3. Mortality is a reality
Doctors cannot reverse the aging process and patients must take a large share of the responsibility and understand that 40-50-60-70 years of not taking care of your body is not reversible by a physician.
1
My 90-year-old mother was recently hospitalized after a suspected seizure--we couldn't wake her up. Turns out she'd had numerous seizures, but we had only seen the aftermath. In the ICU she had another one, so we were sure. (An MRI showed no sign of stroke but it was possible a stroke was hidden, hence the incertitude.) The heart specialist said she was fine. We later learned from a nurse that she had a 4cm+ aortic aneurism. The heart specialist didn't consider it important in an old lady who seemed to have dementia (she doesn't have dementia, but post-seizure she wasn't very clear). The neurologist said she could go straight back to the nursing home, and was shocked to learn she had been living in an apartment, doing research via the Internet, and that she walked fine with a walker. My siblings and I were dismayed at the extent to which an older person, inhabitually badly coiffed and disoriented, is taken for a near-vegetable. This happened in the Midwest USA, BTW.
As for diabetics, my father was one. The problem with letting blood sugar go up a little is that it might go down a lot. And that is scary.
As for diabetics, my father was one. The problem with letting blood sugar go up a little is that it might go down a lot. And that is scary.
15
You bring up an important point when a parent sees new physicians when the parent has a medical crisis. These Drs need to know what the patient was like prior to the crisis.
11
Take good care of yourself and get those required tests and flu, shingles, pneumonia, and hepatitis shots. If you do not take care of yourself no one else will.
12
its time the media starts talking about 80 year olds and stop thinking 70 year olds are elderly. most will probably make it to 85.
at 65 i could do 60 pushups and i have never been too strong.
at 65 i could do 60 pushups and i have never been too strong.
11
....... some people grow up with the belief system that is their responsibility to take care of themselves, some expect their physicians to do it for them.
1
Doctors certainly recommend overtreatment but patients and their family also too often want 'everything' done even in the most elderly, disabled or terminal patients. We as a society are addicted to 'doing somethng' especially if Medicare pays for it. Hopefully with the aging of the Baby Boomers, there will less will become more in a sensible, natural way.
11
Apart from the number of medications prescribed for the older person, which tends to be outrageously high, physicians seem to have forgotten, if they ever knew, that dosages of all medications in the elderly must be adjusted downward. "Start low and go slow" is the mantra of geriatricians, beginning with an almost homeopathic dose and gradually increasing until effect is established. Why?
Because as we age our kidneys, livers etc. can't handle drugs as well as they did when we were younger so that it takes less of a medication to have an effect. Most elders are chronically overdosed because of this fact. By the time the second dosage is ingeates, much of the first is still in the system.Too many physicians seem to have forgotten their basic physiology and know too little of the aging body.
Because as we age our kidneys, livers etc. can't handle drugs as well as they did when we were younger so that it takes less of a medication to have an effect. Most elders are chronically overdosed because of this fact. By the time the second dosage is ingeates, much of the first is still in the system.Too many physicians seem to have forgotten their basic physiology and know too little of the aging body.
23
My mother in law suffered from dementia, high blood pressure and arthritis. The medications she took carried increased risk of ulcer, and she ended up with one. It went undiagnosed, even as she became ill with low potassium and other problems. Most were directly related to medication side effects.
These should have been obvious with better attention, better geriatric care. She suffered, couldn't really advocate for herself, couldn't help us advocate for her. Her treatment accelerated her admission to a nursing home rather than delaying it.
Geriatrics is like pediatrics, in that the patient may not be wholly able to speak for himself, and medications and treatments act differently on the unhealthy aging. We need more people well versed in how to care - not medicate, care - for the elderly.
These should have been obvious with better attention, better geriatric care. She suffered, couldn't really advocate for herself, couldn't help us advocate for her. Her treatment accelerated her admission to a nursing home rather than delaying it.
Geriatrics is like pediatrics, in that the patient may not be wholly able to speak for himself, and medications and treatments act differently on the unhealthy aging. We need more people well versed in how to care - not medicate, care - for the elderly.
20
As a man of 71 years, I read articles talking about overtreatment of the elderly population, many of whom have serious medical conditions.
I am in relatively good health with only atrial fibrillation(managed) and prostatic hypertrophy(managed). I have maintained my weight for the last 40 years and exercise regularly.
I find physicians typically spend much time and effort to find something else wrong or send me to a specialist who can(and will) do so.
It would be refreshing to see physicians start to realize that all seniors do not need, or want, radical intervention. Keep up the flow of this type of reasoning.
I am in relatively good health with only atrial fibrillation(managed) and prostatic hypertrophy(managed). I have maintained my weight for the last 40 years and exercise regularly.
I find physicians typically spend much time and effort to find something else wrong or send me to a specialist who can(and will) do so.
It would be refreshing to see physicians start to realize that all seniors do not need, or want, radical intervention. Keep up the flow of this type of reasoning.
38
I have the final word as to the meds I will take. I don't even mind changing doctors who don't take me seriously and say they won't treat a non-compliant patient, but I program computers for a living and they can't. I'm the only one to decide how well I will live for as long as I last.
12
Brava Fredda .......... I feel the same.
Why shouldn't we be the ultimate decision makers for ourselves ?
Why shouldn't we be the ultimate decision makers for ourselves ?
2
It's DYI medicine vs. mechanized medicine in large hospital and physician networks in which the practices are paid by formula based on capitation. The patient's well-being is at the bottom of the food chain. The large predators at the top - pharma, hospitals (especially the for-profit chains), specialty practices, insurers - make huge profits at the expense of patients. The only thing that protects us patients is the ability to sue. So-called tort reform will be the bullet in the back of the head.
14
Well, hospitals & health insurance corporations are businesses.
Their ultimate responsibility is return on investment to shareholders.
If they don't fulfill that responsibility, their shareholders will seek greener pastures & they will soon be out of business.
Their ultimate responsibility is return on investment to shareholders.
If they don't fulfill that responsibility, their shareholders will seek greener pastures & they will soon be out of business.
1
My take from the article is:
The importance of having a doctor who is current on medical thinking and research and who has the time and desire to listen to patients.
And the metrics for effective patient care need to be carefully developed.
The importance of having a doctor who is current on medical thinking and research and who has the time and desire to listen to patients.
And the metrics for effective patient care need to be carefully developed.
16
Dream on----all these worthy goals you state are the opposite of what is currently happening in patient care.
1
........ and @ age 75, my responsibility for my own healthcare benefits from reading current articles on a website such as, uptodate.com
It's a team effort ya' know.
Monitoring one's own LFT's & GFR's helps one respond with informed consent (or not), to suggestions for additional meds.
I am very fond of my PCP (physician).
She is my "consult", like my attorney, & I go to her for questions I can't answer myself.
It's a team effort ya' know.
Monitoring one's own LFT's & GFR's helps one respond with informed consent (or not), to suggestions for additional meds.
I am very fond of my PCP (physician).
She is my "consult", like my attorney, & I go to her for questions I can't answer myself.
I'm not diabetic but my husband and best friend both are so I've made it my business to understand the disease. I have seen first hand the physical and behavioral effects of low blood glucose levels. Until it gets very high, high the effects of high blood glucose are more insidious. (Way too high and you die.) Either condition clouds a person's sense of judgment.
What is glossed over in the article and all of the comments so far is an explanation that the HbA1c is measure of how much glucose is attached to a person's blood hemoglobin and is an average of months of blood glucose levels, over weighted to the most recent months. As an average, it may look decent - I hesitate to cite a number but maybe 6 to 8 - but could mask blood glucose levels at points in time that could have varied from the 60's to the 300's or higher at points of time on a glucometer (around 90 is normal for a non-diabetic). Either of those point in time readings would have been dangerous, the 60 an immediate danger of fainting, etc. and the 300, if at all frequent, of chronic tissue damage to eyes, organs and extremities.
Many diabetics (my husband but not my best friend who is insulin dependent) are not doing daily glucometer blood tests but are relying solely on HbA1c tests. Many doctors are relying solely on the HbA1c because they can't reliably tell whether glucometer readings were taken after fasting or gorging. They aren't a great substitute for point in time blood glucose monitoring.
What is glossed over in the article and all of the comments so far is an explanation that the HbA1c is measure of how much glucose is attached to a person's blood hemoglobin and is an average of months of blood glucose levels, over weighted to the most recent months. As an average, it may look decent - I hesitate to cite a number but maybe 6 to 8 - but could mask blood glucose levels at points in time that could have varied from the 60's to the 300's or higher at points of time on a glucometer (around 90 is normal for a non-diabetic). Either of those point in time readings would have been dangerous, the 60 an immediate danger of fainting, etc. and the 300, if at all frequent, of chronic tissue damage to eyes, organs and extremities.
Many diabetics (my husband but not my best friend who is insulin dependent) are not doing daily glucometer blood tests but are relying solely on HbA1c tests. Many doctors are relying solely on the HbA1c because they can't reliably tell whether glucometer readings were taken after fasting or gorging. They aren't a great substitute for point in time blood glucose monitoring.
12
And I've been told A1C is the "gold standard," even to the exclusion of regular glucometer readings. I'm confused.
1
tornadoxy, as carol mentioned, the A1c is an average across the last three months. It does not replace daily readings because it can still return acceptable levels even if there were spikes one way or the other at any given time during that same period.
1
Makes you wonder if an underlying reason is to treat less and pay less. Old people are a treasure. This is an unfortunate byproduct of our current health care payment system. Death by insurance company.
12
I personally disagree with your comment. I have seen too many elderly patients subjected to treatment that they will never recover from because they do not have the physical nor emotional strength. However just because one is older does not mean they should not receive care. The care needs to be appropriate. Benefit versus risk. Most Americans just do not seem to understand that concept.
13
It may be there is more than one factor. Eager potential heirs not the least among them.
1
Please, it is the opposite, see my other comment ,please.
There is a saying in medicine - "Don't just do something, stand there." which encourages the physician to take a step back before adding another medication or ordering a test or procedure and consider the alternative, which is to allow things to unfold on their own, understand, and sometimes take advantage of the natural history of the disease. Time and the natural evolution of a disease process is sometimes the physician's and the patient's best friend.
36
I like many of these commenters, were born of the so called silent generation. Like current and futre genrations we experience lots of change. I coined this era we are experiencing, and experience in medicne, is the advent of preventable care. The current crop of practicing physcians seemed trained in preventative medicine. The model is not complicated. Constant doctors visits, constant testing to find something they can then treat, to prevent issues down the road. Example if your treated for high BP you will typically see your GP every 3 months. Often a complete CBC is run and that in turn usually will detect some parameters out of range. Then you have to go back in a few months to re test . Often you get a referral and the big issue for the elderly is they can end up treated by three or four doctors, who more often only share paperwork or downloaded digital test, no one on one. My parents were of the greatest generation and lived into their nineties, with almost no doctor patient interaction until the end. Their long living relatives often into their late nineties even two over 100 died at home of who knows what. Diet for me growing up would be met with horror comments. Typical German, lots of pork, bacon, with only vegetables we grew or game I shot and provided. Makes me always wonder. Guess it was genetic an area that doen't seem to get much research money.
24
Are you kidding me? Why are you going every 3 months to your doctor because of high BP? Is it not under control or what? Why the CBC? Something is unclear here.
2
anon, not sure what's unclear about this, but consistently high BP and/or blood glucose requires closer monitoring until they can be brought under consistent control, whether it be through a change in diet alone and/or addition of medication(s).
Unless a situation is dire in the extreme, my GP's approach (as is probably true of others) is generally to first attempt the most conservative course of treatment. Labs every two to three months initially is the only way to track if the treatment not only achieves the desired result, but continues to do so consistently without any adverse effect. This frequency allows for timely, necessary adjustments in either the dosage of the current medication(s) or a change of medication(s) entirely. Once lab results and follow-up indicate the condition is properly controlled, all things remaining the same, they can then be scheduled at greater intervals.
Unless a situation is dire in the extreme, my GP's approach (as is probably true of others) is generally to first attempt the most conservative course of treatment. Labs every two to three months initially is the only way to track if the treatment not only achieves the desired result, but continues to do so consistently without any adverse effect. This frequency allows for timely, necessary adjustments in either the dosage of the current medication(s) or a change of medication(s) entirely. Once lab results and follow-up indicate the condition is properly controlled, all things remaining the same, they can then be scheduled at greater intervals.
1
I understand if the high BP or glucose is not under control and the diet or med are not working as planned. However, that is not what the original comment stated. I was left with the impression that was the routine for this posters high BP which I still do not understand.
1
We (my doctor and me) are working on titrating an essential drug for me to prevent complications of a condition that could include sudden death. For the third time in two weeks my doctor has called me outside office hours to adjust dosage based on late lab results. Today, Saturday, the call was 7:30 AM. This is only one of the outstanding benefits of having this physician who consults with me and expects me to research her advice before taking it. What a difference from my mother (and much of her generation) wherein patients were completely scientifically illiterate (no internet) and who ultimately died from medical interventions over which they exercised *no* control.
Much of what will be published in response to this column will be stories of "outliers' - people who anecdotally are on the extreme edge of the central research - and I'm one on the positive side of that truism.
Much of what will be published in response to this column will be stories of "outliers' - people who anecdotally are on the extreme edge of the central research - and I'm one on the positive side of that truism.
13
I just experienced the need to work with my doctor, to try and eliminate a recently added BP med, making up a cocktail of 3 popular prescribed bp meds. We got to that juncture by my following and recording my bp with a relaible home monitor. I determined as I aged, doctors typically practice what they were taught in med school. With all the studies published with regularity about changes in care, new parameters etc., to me seems clear, doctors follow the one size fits all routine. BMI, BP, Gluscose levels etc. Lots of my friends and family members complain of the side effects of blood presuure meds, driving down BP in the 120/80 range. Big issue is, doctors are always in a hurry, and usually take one reading, in a white coat hypertension environment, and fill out a prescription. Two of my relatives have fallen and one suffers fatigue. Doctors do co-operate, but many seniors never bring up issues. I found urologist follow old guidleines for PSA testing as example. Gastro and GP's order colonoscopies on a 5 or 10 year cycle . Difficult for we patients as heart attack and stroke have dropped, as has colon cancer. If you not always being poked and tested how could they find problems?
2
Well, more testing might discover more "incidentalomas" which might increase the "revenue stream" for some entity in the healthcare chain.
4
I'm looking forward to the future time- if I live that long- when we will all be able to quickly take our own blood, do in-home analysis with special programs, a little equipment, and our own computers, and basically be our own nurse-practitioner. It will happen someday. Then who do you hit with the malpractice law suit?
3
I am baffled by why anyone would want to do in home analysis? Geez how often are people going to have their blood drawn? Typically it is once a year or more like every 3 to 5 years for most.
This is undoubtedly the future of medical technology. Be your own nurse/doctor, etc. As in so many areas of life, technology will eliminate all the middlemen. Be your own contractor/professor/banker/broker/lawyer/tax return preparer etc. Of course, there will be much fewer actual workplace "jobs" for this self-monitoring class.
3
anon, as I mentioned in response to your other comment about a 2-3 month frequency of blood labs, it entirely depends any conditions, new or existing, and their severity.
Read the "Last Well Person" by Dr. Nortin Hadler... brings up many of these over treatment issues, especially considering the outcomes are often feeble. When I look around it's clear that medicine and health are gigantic businesses and the consumer really needs to be self informed. Not an easy thing, even in this day and age of information. I'd also recommend reading anything by Dr. John Ioannidis (Stanford School of Medicine) some great insight into why so much medical research is flawed, and why we need to be judicial in what we perform. Sadly, doing nothing doesn't make much money...
11
Americans are overdiagnosed and overtreated for many conditions, and that harms us all. Overtreatment and overdiagnosis are primary reasons why the US has the highest per capita health care costs in the country but the lowest health outcomes in the developed world. We would be far better off physically, emotionally and financially if doctors followed the key principle of medical ethics, "First do no harm."
39
Each patient should decide how much medical treatment he or she wants.
The decisions will depend on the whole set of medical problems present.
Then we might consider our preferred combination of methods of dying.
http://www.tc.umn.edu/~parkx032/ELMO.html
The decisions will depend on the whole set of medical problems present.
Then we might consider our preferred combination of methods of dying.
http://www.tc.umn.edu/~parkx032/ELMO.html
3
Elderly people frequently present to the ER with grocery bags full of bottles of medications, prescribed by multiple physicians who may or may not know what other medications an individual is taking. We refer to this as polypharmacy. Beyond the questionable benefit that some of these drugs provide these people, side effects, drug-drug interactions, the very different way that drugs are metabolized in the elderly, not to mention how difficult it is to keep track of multiple medications makes this practice another hazard in these folks lives, while not necessarily improving their quality of life. The big winners here are pharmaceutical companies. Medication regimes should be simplified, taking into account quality of life less than " goals " measured in numbers such as A1c, cholesterol and blood pressure. A good life is not measured in how long you live but how well you live.
27
You are right except for the part about them bringing their meds to the ER with them, more often they say,can't you just get the list from the pharmacy, but the pharmacy is closed...
2
"He had lost weight with age, however, so Dr. Sussman suggested he stop insulin shots and begin taking the diabetes drug metformin, which comes in pill form.".... Really ??? Strange article.
I am not elderly but my GP recently advised me the same regarding the slightly relaxed standards for the A1c due to the risks of hypoglycemia, not referring to my own profile as I've never experienced it, but as a change of philosophy and practice in general.
I do agree that in some in our senior population are being subjected to too much treatment. While working in an assisted living facility, for example, I knew a very sweet, tiny and frail lady in her 90s who often mention in conversation that she had stomach issues. It wasn't in the form of complaints and she never mentioned or exhibited any signs of pain or discomfort.
Sadly, her doctor subjected her to routine colonoscopies - every six months. I wasn't in a position with any authority to give any input or to question it, but it became evident that made no sense to do it at all let alone so frequently.
I had a hard time conceiving of how he justified to himself the need to continually putting her through that, and was always worried that the preparation for the procedure, taxing as it can be in general, could be even more physically stressing for someone of her age and frail nature.
I do agree that in some in our senior population are being subjected to too much treatment. While working in an assisted living facility, for example, I knew a very sweet, tiny and frail lady in her 90s who often mention in conversation that she had stomach issues. It wasn't in the form of complaints and she never mentioned or exhibited any signs of pain or discomfort.
Sadly, her doctor subjected her to routine colonoscopies - every six months. I wasn't in a position with any authority to give any input or to question it, but it became evident that made no sense to do it at all let alone so frequently.
I had a hard time conceiving of how he justified to himself the need to continually putting her through that, and was always worried that the preparation for the procedure, taxing as it can be in general, could be even more physically stressing for someone of her age and frail nature.
55
Colonoscopies every 6 months doesn't make sense for any age, unless perhaps they were continually plucking out large numbers of polyps each time (would be surprising, since they don't usually grow so quickly).
3
My late mother had diabetes. She was treated by this fresh young doctors who gave her aggressive treatment and gave her high potency medicines i guess. The result was her sugar got so low that she lost consciousness and later on she also had paralysis.I guess the older one gets the organ's ability to take heavy medicines decreases.
8
I'm wIth taopraxis. I avoid the doctor whenever possible for the very reasons cited in this piece. It's good to be validated by an informative article like this!
15
When one of my older diabetic patients' A1c comes back at, say, 5.9%, I usually DO de-intensify their medication regimen, to avoid hypoglycemia -- although certain medications, such as metformin, carry a lower risk of hypoglycemia than, say, insulin. Same with blood pressure. If BP is hovering around the lower range of what is considered "normal", I look at the whole picture of the patient and see if it makes sense to remove a medication or lower the dose of a medication. Often it does.
It is not quite true to say, "a 7.5 or 8 percent blood glucose level (measured as HbA1c, an average of several recent readings) produces the same benefits as very low glucose". No expert is claiming that an A1c of 7.5% produces the same benefits as, say, an A1c of 5.5% (not sure how the author defines "very low glucose", so I picked an A1c that would be great in a young person). Instead, the *risks* of maintaining an A1c of 5.5% -- or even 6.5%, the standard cutoff for diabetes diagnosis -- outweigh the potential *benefits*. It isn't worth it to risk hypoglycemia, fatigue, dizziness, etc. just to maintain a lower A1c. This is especially true in patients with life expectancies in the 5 to 10 year range, as they won't live long enough to reap all the cumulative benefits of a lower A1c, but they *will* have dangerous side effects.
Recommendations by the American Geriatrics Society and the American Diabetes Association are here: http://www.ndei.org/ADA-AGS-diabetes-older-adults-2012.aspx
It is not quite true to say, "a 7.5 or 8 percent blood glucose level (measured as HbA1c, an average of several recent readings) produces the same benefits as very low glucose". No expert is claiming that an A1c of 7.5% produces the same benefits as, say, an A1c of 5.5% (not sure how the author defines "very low glucose", so I picked an A1c that would be great in a young person). Instead, the *risks* of maintaining an A1c of 5.5% -- or even 6.5%, the standard cutoff for diabetes diagnosis -- outweigh the potential *benefits*. It isn't worth it to risk hypoglycemia, fatigue, dizziness, etc. just to maintain a lower A1c. This is especially true in patients with life expectancies in the 5 to 10 year range, as they won't live long enough to reap all the cumulative benefits of a lower A1c, but they *will* have dangerous side effects.
Recommendations by the American Geriatrics Society and the American Diabetes Association are here: http://www.ndei.org/ADA-AGS-diabetes-older-adults-2012.aspx
32
This physician is, wisely, pointing out overtreatment vs. undertreatment is not determined by the glycohemoglobin A1c number; it is determined by hypoglycemia, medications used, and effect on quality of life. It's complicated. It takes time. Even the writer of this article did not understand the central problem.
The terminology in this piece is all screwed up. The % measurements cited are not measurements of glucose, but measurements of the % of hemoglobin to which a glucose molecule has become attached, so called Hgb A1C. It reflects the average level of glucose over time but it really is very different from glucose and using it to decide on lightening up on diabetes treatment could lead to mistakes.
8
You are absolutely correct that the terminology is wrong and that a 6.5% A1c represents the percentage of molecules of Hemoglobin A to which a molecule of glucose has become attached. It does not represent the "percentage of glucose", and I hope the author corrects the post. However, an algorithm has been developed that converts A1c to an average blood glucose level over the last 3 months, and in that sense, A1c does tell us what the person's glucose has been. The A1c does enable us to make decisions about adjusting a diabetes regimen; not sure why you think it would lead to mistakes. I do also look at the patient's fasting glucose level, as that also tells part of the story.
5
I noticed this too. Another example of sloppy journalism. Although I agree with the sense of the article.
3
As an 'older adult' with several co-morbidities and a threshold of 'age & mechanical failure' its trying to break the cycle of being referred to yet another clinical specialist by one's GP. Where have the 'General Physicians' gone? Someone who can review the 'battlefield'. Presumably once one becomes a Physician its best to specialise to maximise 'commercial' benefits by obtaining referrals. The pendulum needs to be pushed backwards in order to accomodate the generalist.
30
The problem is that as there has been a huge increase in medical information, it is almost impossible for an internist or family practice doctor to keep abreast of the latest guidelines for managing numerous medical issues: the recommendations are constantly being updated. In addition, there is pressure to see many patients rapidly (in part to decrease health care costs) and increasing requirements for documentation. The internist likely does not have time and an adequate knowledge base to manage all the issues. So they manage what they are comfortable managing, when they have time, and refer the rest on to specialists. And it is an imperfect system. As a neurologist, I not infrequently see patients for chronic back pain without any attempt at basic conservative management by the primary care physicians ( garden variety low back pain is not clearly a neurological issue) and other times I see generalists trying to manage neurological problems that are clearly beyond their area of expertise.
13
Richard, an experienced FP can handle 90 % of the problems they see, but with current insurance , do not have the time to address them.
I would see a typical patient who would come in with DM, HBP, and hyperlipid. for a recheck, and OBTWwould want to discuss depression , have me check out a skin lesion, and check out a pain.
I would check out all of those things, and could do it in 45 min - hr. Perhaps I would have to order tests, or a prescription, or maybe not; maybe they would need a referral to a specialist, but maybe I saved them the trip to a specialist . If so, I have just evaluated 6 medical issues in one appt that could have been referred to 5 different specialists if they were seeing just a gatekeeper. My copay would be $25, whereas to see 5 specialists would be $40x5=200 out of pocket to the patient, not to mention the time and effort and gas mileage.
The insurer wins because they do not have to pay 5 specialists consultation fees, which could add up to $1500 or more.
Yet the insurer only pays in the range of 150 to 180 for such a visit. The overhead in a typical office is at least 200 to 300 (even $400) per hour, so I have now lost money by being a thorough provider.
What works in primary care these days is seeing many patients, each for a few minutes , at 100 a visit. Anyone who needs anything gets referred out.
I left primary care because this setup was only getting worse over time.
Where are the articles on this ?
I would see a typical patient who would come in with DM, HBP, and hyperlipid. for a recheck, and OBTWwould want to discuss depression , have me check out a skin lesion, and check out a pain.
I would check out all of those things, and could do it in 45 min - hr. Perhaps I would have to order tests, or a prescription, or maybe not; maybe they would need a referral to a specialist, but maybe I saved them the trip to a specialist . If so, I have just evaluated 6 medical issues in one appt that could have been referred to 5 different specialists if they were seeing just a gatekeeper. My copay would be $25, whereas to see 5 specialists would be $40x5=200 out of pocket to the patient, not to mention the time and effort and gas mileage.
The insurer wins because they do not have to pay 5 specialists consultation fees, which could add up to $1500 or more.
Yet the insurer only pays in the range of 150 to 180 for such a visit. The overhead in a typical office is at least 200 to 300 (even $400) per hour, so I have now lost money by being a thorough provider.
What works in primary care these days is seeing many patients, each for a few minutes , at 100 a visit. Anyone who needs anything gets referred out.
I left primary care because this setup was only getting worse over time.
Where are the articles on this ?
57
So 65% of the doctors are prescribing treatment based on doctor risk rather than patient risk. Great.
78
A lot of the medical profession is floundering when it comes to elder medical care. Medicine needs many more well trained gerontologists and palliative medicine specialists. Otherwise, too many aging adults will be the victim of too much, too little or inappropriate treatments for symptoms related to advancing age.
71
Like everybody else on Planet Earth, doctors are rational beings that respond primarily to incentives and to their own needs. We all know there is less motivation to be a GP or gerontologist.
5
Until compensation for 'cognitive' practice approaches that for 'procedural' practice there will remain a perverse incentive for physicians entering practice to avoid specialties where time must be spent talking with patients (internal medicine, gerontology, pediatrics) in favor of gastroenterology, ophthalmology, plastic surgery, etc. where payment is by-the-procedure.
6
Baby Boomers are just now entering the Senior Citizen bracket. So it won't be long before MD's will realize the money to be made specializing in elder medical care.
1
I feel that we live in a world of medical insanity, and if we are ok with it, we are insane too
Anatomy and physiology don't change much over millions of years, and yet we delude ourselves into believing that any new study is a "truth", to be worshiped and practiced until another "truth" comes along, This is particularly pernicious when the "evidence based" gurus impose new "guidelines" for practicing physicians.
The "protocols" and "algorythms" have become unstoppable monsters> in the hospital where I work, as soon as the word 'stroke' is whispered, the cascade of tests starts and does not stop even when there is evidence that it was not a 'stroke'. When the word "meningitis" is suggested, regardless of whether the patient has bacterial meningitis or not, triple antibiotics are started (just in case). Elderly patients who feel dizzy on multiple anti-hypertensive medications (but the blood pressure is "normal" >110/60) get a major work up for ischemia, when their dizziness in probably iatrogenic.
And now we start to see that we have a problem?
Anatomy and physiology don't change much over millions of years, and yet we delude ourselves into believing that any new study is a "truth", to be worshiped and practiced until another "truth" comes along, This is particularly pernicious when the "evidence based" gurus impose new "guidelines" for practicing physicians.
The "protocols" and "algorythms" have become unstoppable monsters> in the hospital where I work, as soon as the word 'stroke' is whispered, the cascade of tests starts and does not stop even when there is evidence that it was not a 'stroke'. When the word "meningitis" is suggested, regardless of whether the patient has bacterial meningitis or not, triple antibiotics are started (just in case). Elderly patients who feel dizzy on multiple anti-hypertensive medications (but the blood pressure is "normal" >110/60) get a major work up for ischemia, when their dizziness in probably iatrogenic.
And now we start to see that we have a problem?
55
So as with other things, sometimes less is more.
Too bad it's so confusing for everyone to figure out though. We only have one body in this life, so can we please just stick to what works? Let's ask experienced practitioners....maybe they have a clue.
Too bad it's so confusing for everyone to figure out though. We only have one body in this life, so can we please just stick to what works? Let's ask experienced practitioners....maybe they have a clue.
5
It is trivially easy for me to recall examples from my own family of people who were undertreated or overtreated:
My late father-in-law suffered a sudden onset of extreme fatigue, stomach pain, loss of appetite, low grade fever, and elevated white cells.
Doctor gave him an SSRI and a referral to a psychiatrist for a week later and went on vacation.
After intervening and getting him to a hospital, we discovered he had gastric cancer and was on the verge of bleeding to death.
My sister, in her fifties, developed breathing problems...long story short, we found she was taking multiple, interacting medications at questionable doses prescribed by multiple non-communicating physicians. Happy ending this time...removed some drugs from the picture and she recovered.
As for me, I'm retired and my medical care is free, supposedly, but you cannot tell by me because I haven't been to a doctor in years and I do not intend to see one unless I'm bleeding, running a high fever or something of a similar nature. Seriously, folks, medicine is not risk-free...
My late father-in-law suffered a sudden onset of extreme fatigue, stomach pain, loss of appetite, low grade fever, and elevated white cells.
Doctor gave him an SSRI and a referral to a psychiatrist for a week later and went on vacation.
After intervening and getting him to a hospital, we discovered he had gastric cancer and was on the verge of bleeding to death.
My sister, in her fifties, developed breathing problems...long story short, we found she was taking multiple, interacting medications at questionable doses prescribed by multiple non-communicating physicians. Happy ending this time...removed some drugs from the picture and she recovered.
As for me, I'm retired and my medical care is free, supposedly, but you cannot tell by me because I haven't been to a doctor in years and I do not intend to see one unless I'm bleeding, running a high fever or something of a similar nature. Seriously, folks, medicine is not risk-free...
111
I suspect your father-in-law did not have a consistent relationship and long history with a single physician who would have known his new symptoms were unusual for him and ordered appropriate treatment not think he was depressed. You may be heading down the same dangerous path. Get a checkup and some baseline testing done. Many serious conditions have no symptoms until it is too late to treat. When you do feel sick, they will know you and have history (an essential part of medical treatment) to compare with your new status. It is worth a couple hours of your time to live well not just long.
5
When I was a child in the 1950s one had to be almost dead before going to the doctor. Now you go in for something and are automatically scheduled for another visit in 3 months. I never go back unless the problem hasn't gone away. I see no benefit in regular visits unless something is really going to be done. Just a "how are you doing" isn't worth my time or the doctor's
10
1. In many healthcare systems, practitioners are graded on how many patients with hypertension or diabetes have measurements in the high range without adjustment for age.
2. Everyone is bombarded by advertisements to "ask your doctor" about various new drugs to control these conditions just as the doctors are bombarded by advertisements and drug company sponsored educational programs to use these drugs.
3. Even 75 year olds may anticipate 20 years more life, and they want those years to be maximally healthy.
2. Everyone is bombarded by advertisements to "ask your doctor" about various new drugs to control these conditions just as the doctors are bombarded by advertisements and drug company sponsored educational programs to use these drugs.
3. Even 75 year olds may anticipate 20 years more life, and they want those years to be maximally healthy.
9
Run away from the drugs advertised on TV. They're advertising to you because they can't convince the doctors or their price is astronomical. I can hardly stand to watch the network news any more. Amazing how it takes them longer to say how their med can kill you than the benefits of taking it.
7
We need to go back to the time when prescription drugs weren't allowed to advertise on TV.
I watch the commercials featuring beautiful scenes with smiling happy people while the announcers drone on listing all the side effects of the drug. It sounds like the side effects are worse than the illness the drug is supposed to treat.
I watch the commercials featuring beautiful scenes with smiling happy people while the announcers drone on listing all the side effects of the drug. It sounds like the side effects are worse than the illness the drug is supposed to treat.
17
Broadcasters would fight that because these drugs are the only revenue stream left for the evening news, which only the old folks watch any more. Once you're past about 50 only Mylanta and Depends are interested in you, for advertising purposes.
This makes sense. I knew this a long time ago when I was talking to an insurance executive about my long-term care disability plan. He said that an hba1c of 8 was acceptable to the insurance company for patients in their 60s and above. When I cited the 7 hba1c of my doctor, he said not to worry. The insurance guidelines are determined by exhaustive actuarial studies on mortality and they won't lose money by following the guidelines. The difference seems to be that insurance companies are concerned with mortality or else they lose money.
20
Great point. Insurance companies can play a valuable role in protecting consumers from overzealous, defensive, ignorant, and/or greedy physicians whose interventions often cause more harm than good.
1
At 72 I had cardiac bypass surgery. Is was put on beta blocker and statin. No one looked to see if I really needed it. Since I have expertise in medicine I decided, considering the side effects I was suffering, to do an experiment. I went off the beta blocker and my blood pressure after a few weeks was 115/75.
After six weeks off the statin my lipid profile was 'low risk'. Now no meds, no muscle pain, huge improvement in cognitive function and much better sleep.
After six weeks off the statin my lipid profile was 'low risk'. Now no meds, no muscle pain, huge improvement in cognitive function and much better sleep.
93
I think you are not understanding the purpose of those two meds. Beta blockers are given mainly to lower your heart rate so that your heart doesn't work as hard and statins are given to remodel the plaque you have...which you do. You have coronary artery disease and if you think that is going away because you had bypass you are sadly mistaken. The plaque will continue to grow without the statin and you may be back in that operating room at some point or worse...stroke. Don't even think about stopping the aspirin.
4
I stopped the statins years ago and now I can think straight and no longer have to deal with muscle pain-- as far as I'm concerned statins are a form of poison. I am 73 years old, I've lived a full and rewarding life. Representative Grayson was right, but now his assessment is expanded to healthcare in general not just the to the ravenously greedy and hypocritical Republicans, for seniors US healthcare translates to "die and die quickly."
4
Are you a doctor? You shouldn't practice without seeing the patient first.
1
Geez, I'm not a medical professional, and even I knew this! Just because I read a lot in the culture of medicine, preventive health, etc. There's a very firm culture in place of doing things certain ways. It's NOT a profession that is very evidence-based, although it wants to claim that. Whenever you deal with the medical world, you have to realize that there's a good chance you're NOT getting accurate info and well-reasoned treatment plans, so you have to do a lot of your own homework. You can really be seriously harmed if you don't. Unfortunately, many people are not able to do that or not inclined to. I hope I never get infirm enough to affect my thinking abilities to the point where I can't do my own homework. But I would think that if there are official new guidelines out there saying that things should be less tightly managed, doctors wouldn't be vulnerable to lawsuits because they followed them. Wouldn't they be vulnerable if someone ended up with problems after they DIDN'T follow them?
19
I agree 100% with you, the last few years I have read a ton of literature (not nutball websites) and I had no idea that the "evidence" was either not there, or extremely weak. Who knew?!
4
Having just gone through a year of dying with my mother, I can say that I observed my mother as afraid to raise the question of adjusting any of her meds. I took the initiative to do so and her Dr. agreed to do so. Senior patients are absolutely bombarded with drugs and "therapies" that often don't make one bit of difference in their quality of life at the end--but makes a big difference to the health care center's bottom line. I am getting 40-50 page "bills" of services rendered to my mother-- occupational therapy--at age 95- for tying her shoes--but she wasn't supposed to bend over...speech therapy--but the drugs she was on made her throat so dry speech therapy was useless. Over-treatment is an understatement. Fear of legal action on the part of the physician is ridiculous. We should sue for all the useless "treatment" that was shoved on my mother. And when I went to stop one of the therapies she asked me not to--she didn't want to make any of the nurses mad. I assured her that would not be the case.
Something to also "get" is the more of these costly "therapies" are prescribed, the more attention the patient gets. Everyone wants and needs attention. It's a terrible cycle. It is a disgrace. No wonder her physician couldn't look me in the eye when I asked about the need for these treatments. Nothing was going to change- quality of life was not going to get better. And now she's gone.
Something to also "get" is the more of these costly "therapies" are prescribed, the more attention the patient gets. Everyone wants and needs attention. It's a terrible cycle. It is a disgrace. No wonder her physician couldn't look me in the eye when I asked about the need for these treatments. Nothing was going to change- quality of life was not going to get better. And now she's gone.
159
I think it is a great idea to sue for the obvious useless treatments put upon your Mom. The NYTimes had some very good articles about such excessive treatments forced on the elderly when they were nearing death. Holding doctors and institutions accountable for excessive unnecessary treatments would be a very good way to empower patients and families.
6
This is a complicated problem but to pretend this is just a "physician issue" and we should "sue for over treatment" is simply irresponsible. We live in the most anxious culture in the world, and patients and family members frequently request and request and request treatment. It is much harder than you think to say no (usually a GP is fired if she/he does). It is easier to do than to not do. Frequently reimbursement is tied to health goals that are insanely aggressive for seniors. GPs are overwhelmed by all of the demands they face, and this can lead to over treatment. We demand specialty care, and specialists frequently over treat having little knowledge of the overall picture. Is it any wonder GPs are tired, sad, frustrated, and retiring in droves? We (America) are afraid of dying, sadly, and every little ache can lead to an office visit. Our culture is partly to blame. Beating up on GPs will not solve the problem, and it IS a serious and terrible problem.
23
RollerFlan - I agree with you and profoundly apologize for my reactive insensitive potentially harmful post. I am embarrassed and really regret what I said. My letter is not representative of how I think or who I am. Your post is very well written and thoroughly covers the real issues here and terrible position compassionate and ethical good physicians are in, as well as the confusion and fear patients find themselves in dealing with our crazy healthcare system. I am really glad you wrote what you did.
2
Completely agree about glucose control in the elderly. However when I have told my patients or families about this I get the response that you don't care about the elderly or you just think I am too old to treat and you want to let me die. Quite the opposite. I want them to have a good quality of life, avoid some really bad problems (falling) and not spend their assets on things they don't need.
I recently urged a good friend who is 78 y/o not to undergo a colonoscopy. His response was that he might live to 100 and did not want to worry about cancer. How does one respond to that emotional response when the person wants to ignore the science. Very difficult problem.
I recently urged a good friend who is 78 y/o not to undergo a colonoscopy. His response was that he might live to 100 and did not want to worry about cancer. How does one respond to that emotional response when the person wants to ignore the science. Very difficult problem.
86
Your only response is to present the odds of living to 100 or finding and treating colon cancer after a colonoscopy (along with the life-degrading consequences of surgery, chemo, etc.). Most people do not have a good grasp of probabilities, risks, and likely outcomes of procedures and have not come to grips with their own mortality. But everyone has the right to be wrong.
6
There can be such a hysterical response to prolong life and deny that death will eventually come. If you're not paying for it, why would you care if your medical bills for over treatment ran into the tens of thousands and more for little discernible benefit, but very discernible loss of benefit for other areas of societal investment...
3
Mr. Figdill, the United States Preventive Services Task Force, after assessing many studies, recommends that routine colon cancer screening in asymptomatic people stop at 75.
6
I wonder what country this guy is talking about "we are more scared of failing to do something than doing too much". ??? All I get are endless useless taxpayer fraud funded appointments big deal. It means nothing to go to an office just to have a doctor shrug his/her shoulders or worse if you are finally lucky enough to get to a specialist it turns out since they don't get paid they just waste your time going to them to be told whatever insurance we have doesn't cover the correct treatment. So why even make the appointment? Because that's how the money is made. Why else is it impossible still after 18 months of trying I'm still unable to file a complaint with Medicaid since they refuse to give out genuine addresses that work. Our system is designed to fail because that's where the money is at.
Don't get me started on the above the law nurse practitioners.
Don't get me started on the above the law nurse practitioners.
5
Don't get you started about NPs? What's wrong with NPs... Please enlighten me.
4
If I'm paying for and the insurance is paying for a doctor I want to see a doctor. If I'm being treated by a NP the charge should reflect that.
4
During his ultimate hospitalization, the senior residence he lived in refused to take him back -- he needed more 'monitoring' than they could provide -- and he was placed in a nursing home. Within weeks, he was a shell of his former self, suffering the dramatic cognitive and functional decline that occurs to so many in nursing homes (and perhaps exacerbated by the impact of his frequent hypoglycemic events, although that's conjecture). He died after a few months in the nursing home.
I can't get past the thought that if he had been allowed to deintensify his treatment, he'd be alive and well today, albeit spilling sugar into his urine. I'd rather have that sweet man around, even if his urine is too sweet.