Selecting the Right Doctor for You

Marcia H. Hickey Vice President, Strategic Initiatives & Hospital Administrator Hebrew Health Care, Inc.

Many of us have found ourselves in the situation of having to choose a new doctor.  Perhaps there’s been a change in our insurance carrier and we must select from a list of providers approved by the new company.  Other people have relocated and are starting from scratch with a new physician.  Some physicians even retire…how dare they!  Whatever the reason, here are a few items to consider when selecting the right doctor for you:

  • Try to get recommendations from your current physician or specialist, family, friends, and coworkers.  Ask what they like about their doctors.  Check the online rating systems that are available on the internet to see what other people say about their doctor (www.healthgrades.com or www.vitals.com.)

  • Location is important.  How easy is it to get to the office?  Is there plenty of parking?  What about access to the building?  Is it in a safe area?  If you rely on public transportation, is there a stop near the office?  Is there a pharmacy for filling prescriptions and a lab for blood tests nearby?

  • Much of your contact will be with the office staff.  Are they friendly and courteous?  Do they show concern for your needs and well being?  Are they helpful?  Do they explain things clearly?

  • Availability is essential.  What are the office hours?  Do you need evening or weekend appointments?  How long should you expect to wait for a return phone call from the doctor or nurse?  Is there someone you can call when you have medical questions but don’t need to talk to the doctor?  Is this a large practice with multiple physicians and nurse practitioners?  Who provides coverage when your doctor is away?  What hospital does the doctor refer to?  What specialists does the doctor work with?  Who will coordinate your care if you have specialists providing some of your care?

  • Perhaps the most important consideration is how comfortable you are in talking to the doctor.  Is this a person with whom you will be able to have an open and honest discussion of your medical issues?  Can you ask questions easily?  Does the doctor listen carefully to your concerns?  Does the doctor routinely use other means of communication such as email, texting or a website to communicate?

These are just a few tips to get you started selecting a doctor.  You should feel comfortable asking questions and interviewing potential physicians.  It’s your health so take the time to find the right doctor for you.

Pain Relief: Part III

By Henry Schneiderman MD, Vice President for Medical Services and
Physician-in-Chief,  Hebrew Health Care

So, if pain has not been relieved by a thorough trial of full-dose acetaminophen, and one wisely considers the NSAIDs too unsafe, what measures are available:

1) Nonpharmacologic relief: numerous compelling studies demonstrate efficacy of non-medication measures. Warm packs prove very helpful to promote healing, largely by augmenting regional blood flow, and to relieve discomfort”all the more so when muscle spasm exacerbates pain as is the case in a great many musculoskeletal injuries and problems whether they start out with muscle strain or not. Topical cooling can also play a key role, particularly reduction of blood flow relieves swelling. Neither modality is to be abused: burns or frostbite are not in the plan. Package inserts from a popular disposable heating products, Therma-Care, cover the essentials: don’t use on a body part that lacks proper sensation, so that you don’t discover a burn by smelling it, don’t exceed the manufacturer’s recommended duration of application, don’t apply over a sore, don’t use on a part of the body with known impaired blood supply whether arterial or venous.

Therapeutic exercise of muscles that act on a sore joint stabilizes the joint over time and so reduce pain, for instance in ordinary knee arthritis. Crucial elements include professional oversight, which usually means a physical therapist in the loop; and continuing to perform the exercise regularly even after the initial pain has eased. Sometimes a very simple soft brace strap can keep a tendon from slipping out of kilter. Don’t just purchase what looks promising at CVS: consult a professional.

2) Propoxyphene (Darvon; and others): Combinations of this with other medications go by names including Darvon Compound and Darvocet N-100. Avoid these like the plague! For 35 years they have been documented as causing numerous deaths. Many persons swear by them but there are ALWAYS safer and more effective options.

3) Aspirin: Aspirin works wonderfully at preventing and treating heart attacks and strokes; and reduces risk of colon cancer. However, it is an NSAID, so no reader of the prior columns will be surprised to hear that though I have myself swallowed a baby aspirin every morning for more than 20 years for these purposes, I disagree with the manufacturer’s claim that additional doses can be used for pain relief. Aspirin is notorious for causing stomach bleeding. Many patients must not take it at all, including those with prior bleeding problems, active stomach ulcers, low platelet counts, true aspirin allergy, or risk for Reyes syndrome that causes brain damage when flu-like symptoms under age 25 are treated with aspirin.

The only pain that should trigger aspirin is chest pain suggesting a heart attack. In that case you need to be seen in an Emergency Department at once. If you are having such pain and reading this column to figure out what to do:
a. stop reading NOW
b. dial 911 NOW
c. THEN and only then, and only if you are not forbidden aspirin, chew up 4 baby aspirin or one adult-size aspirin, while you wait for the ambulance to get to you.

4) Tramadol (Ultram): This drug was developed to fill a perceived gap between pain that could be relieved by acetaminophen and pain requiring opiates. Like many a compromise, it achieves partial success. Some persons find great relief from tramadol. Others are less satisfied. Concerns about liver toxicity often make doctors reduce the prescribed doses. Tramadol is a niche medicine, very helpful to some but not a panacea. Pain that can’t be controlled on this drug and that is not neuropathic means it is time to consider opiates.

5) Neuropathic pain: Some pain results not from nociception, the body’s discerning tissue injury, but from signal misperception in nerve cells and their connections in the brain. Examples include the pain felt by some diabetics in perfectly healthy limbs, or phantom but absolutely NOT psychogenic pain experienced by an amputee in a limb that is no longer on the body! A substantial fraction of “regular” pain may also embody neuropathic mechanisms. Neuropathic pain is uniquely amenable to some medicines that help the brain powerfully in this condition despite modest or minimal anti-pain effect in ordinary nociceptive pain. The three leading such medicines are gabapentin (Neurontin), duloxitene (Cymbalta) and pregabalin (Lyrica). Each carries a formidable list of potential side effects, the weight gain experienced by many persons who take pregabalin being one sidestepped in the blizzard of television commercials. Each has some other activities such as antidepressant or anti-seizure, but for all, the anti-pain activity is not caused by these other properties. A medicine best known as a pure topical anesthetic also turns out to have anti-neuropathic activity: the LidoDerm patch, a topical lidocaine delivery system. Patients with undiagnosed neuropathic pain are often stunned at how much better they feel, and with how much less fuss, when given the right one(s) of these medicines.

6) Corticosteroids: When inflammation causes pain, clearing out the inflammation can be optimal; the expectation is that the pain will follow. NSAIDs combat pain and inflammation all at once, so if they were not so dangerous, they could be seen as ideal: clear up the cause and the effect all at once.

Some inflammation is best treated by eradicating its source, as when an antifungal medicine obliterates infection that leads to inflammation that makes a toe with athlete’s foot burn. In this setting, an anti-inflammatory approach would not be wise. However, there are conditions wherein prednisone or other corticosteroid medicine whether topical or systemic, makes all the difference. The possible adverse effects are legion, from crinkly skin to heart failure to uncontrolled hypertension to worsening or triggering diabetes, the safest use of these medicines requires a highly attentive and skilled physician or nurse practitioner.

7) Opiates: The very group name is more acceptable to the public than its equally sound scientific synonym, the narcotics.

The prototype of this class of drug is morphine sulfate. The public has an utterly unrealistic view of morphine as something reserved for the end of life”an impression foisted by old movies among other sources of misinformation that we fail to update critically. Morphine is also a superb drug for the middle of life. It not only relieves pain, but also confers two other separate and distinct benefits: relief of anxiety, and relief of breathlessness. Almost nobody requires injection to receive morphine. It is available orally for both immediate-release (MS-IR and other brands) and sustained-release (MS-Contin and other brands). A concentrated form is released to the bloodstream from under the tongue (Roxanol and other brands). This means that anybody who needs a maintenance dose in the middle of the night need not be awakened to swallow it!

Morphine (and its relatives) work well because they fit a pre-existing brain system, the endorphins; they are a lock and key for a means that the brain already possesses to ameliorate suffering. Hence their superior efficacy over all alternatives comes as no surprise.
Addiction concerns about opiates are wildly exaggerated in our society. Persons who have not had substance dependency before, and who receive responsible counsel and prescriptions, are most unlikely to become addicted and to display escalating drug requirements. Most physicians who specialize in pain management agree that we deny helpful drugs which sustain quality of life to too many persons because of inappropriate concern that we will create addicts”something nobody wants to do, of course.

Codeine is a widely used opiate. Many persons regard it as more familiar and less frightening, a kind of “morphine lite”. The trouble is, a substantial minority of the population lacks an enzyme to convert this drug into its active form. These persons get NO BENEFIT from the drug. Of course when a patient protests “The drug is not working, please give more”, the clinician is likely to misinfer drug-seeking and to become judgmental and withholding, rather than simply to change medicine. By the way, codeine is also unique as an anti-cough agent.

Oxycodone is another crucial member of the opiates, whether in its short-acting form or in the long-acting oxycontin that has become notorious because of abuse by persons who use it to get high or to sell for criminal profit. Hydromorphone (Dilaudid) is an opiate often chosen as safest for persons with reduced kidney function, though also useful for any person who needs opiates.

A transdermal opiate patch is called the fentanyl patch (Duragesic and other brands). While a patch sounds highly appealing for the person who “hates pills”:
a. One need take no pill to use concentrated liquid morphine;
b. The patch is far more expensive
c. For persons who are very thin, patches do not work properly
d. The patch works by creating equilibrium between a depot of the drug that forms under the skin, and the bloodstream. This means that pain relief does not occur for a solid 24 hours after the drug is begun or the dose increased”sometimes even longer; equally troublesome, if dose reduction is needed, removing the patch will only lower drug levels in the bloodstream after 24 hours have passed.

Let me educate you more about opiates:

1. The body adapts to use of opiates. All the well-known side effects such as confusion and low BP tend to ease and clear with continued use beyond a few days. The single exception is constipation. So, if you are going to be taking an opiate, make sure you have a laxative, ideally a stimulant such as senna, or something gentler such as polyethylene glycol 3350 (Miralax).

2. No mainstream doctor uses opiates to hasten death, notwithstanding Doctor Kevorkian. These drugs are used safely to reduce discomfort and suffering. Close monitoring of breathing and blood pressure need only be maintained for a short time on starting and with increases. To withhold opiates due to overblown and misrepresented concerns is inexcusable.

3. There is no maximal tolerable dose of opiate. If a pain source is dreadful, dose increases can be done safely, under supervision, so that few or no persons should have to put up with severe pain, or have to be drowsy to avoid intense pain.

4. Chronic pain does not manifest in the same behaviors as does acute pain. We need to be on guard against concluding that a chronic pain is mild or well-controlled just because the face is not drawn, or the person is able to sleep, or the pulse is not racing. We have no laboratory test to quantify pain, nor any perfect physical finding on examination. A basic tenet is to believe the patient, not naively, but emphatically.  On this analogy I will end: I give something to any beggar who asks me; I realize that sometimes I am being conned, and that some are not in need, and that some will go spend the money on crack cocaine. But are we to test for need and veracity so hard that we risk missing a chance, in this short and precious life granted to each of us, to bring a little mercy into the world, to reduce suffering where we can?

Pain Relief Part II

By Henry Schneiderman MD,
Vice President for Medical Services and Physician in Chief, Hebrew Health Care

NSAIDs: This bizarre acronym stands for “non” steroidal anti” inflammatory drugs;” but within those, is limited to those that work by inhibiting an enzyme called cyclo” oxygenase, thus reducing the local concentration of the prostaglandin chemicals that, among a hundred other functions, contribute markedly to inflammation.

Two of the innumerable NSAIDs in wide use are ibuprofen (Motrin) and naproxen (Aleve). I do not prescribe these nor recommend that people use the lower ” strength preparations available over the counter. Why? Because for older persons, the risk of damage to the stomach lining, resulting in internal bleeding ” sometimes enough to require blood transfusion and sometimes even fatal ” is too high, and alternatives exist. I differ from the practice of many other physicians. My outlook derives from published scientific literature and from extensive practice experience ” my own and that of others. At Morning Case Conference in any large teaching hospital, the majority of major gastrointestinal bleeding cases in persons over age 50 results from use of an NSAID.

Many people take NSAIDs with no problem. Unfortunately, prior use without incident does not guarantee future safety. Warning symptoms are inconsistent, so the advice, “let me know if you experience stomach pain and stop the medicine,” does not confer adequate protection.

NSAIDs have at least two other problems: they can temporarily reduce kidney function, most especially in persons whose bodies are low on water; this can lead to dangerously high blood potassium levels. And especially in persons who are taking medicines called beta-blockers, NSAIDs can inhibit medicines that lower the blood pressure, resulting in hypertension and in retention of salt and water. The latter means swollen ankles at a minimum and sometimes worse. Am I merely indulging in, “if you read all the warnings, you’ll never take anything?” Not at all. I recognized that NSAIDs combat pain superbly and effectively reduce the inflammation that often causes or worsens a pain problem. But for the time-seasoned gastrointestinal lining of a person over age 50, the risks mandate, in my judgment, other remedies for pain.

If one does use NSAIDs, lower doses are less dangerous; so is shorter-term use. I dread that an educated lay person takes more than the recommended number of pills or capsules of the non-prescription form to make up the total mg ordinarily prescribed. Worse, if he or she employs this end-run for weeks or more for, say, an arthritic hip, such a person can wind up forced to seek medical attention in the emergency department which despite the great skill of those who practice, there is no elder’s favorite place” after passing out from bleeding into the intestine.

Can’t stomach a second pill…how do I  protect my stomach?

Several medicines are used to reduce the jeopardy to the stomach caused by NSAIDs. These include proton pump inhibitors such as omeprazole (Prilosec) the first “purple pill,” before esomeprazole (Nexium), the histamine receptor blockers such as ranitidine (Zantac) and famotidine (Pepcid), and misoprostol (Cytotec). Some are available, in low strength, over the counter.

The trouble is that they prevent no more than 60% of episodes of NSAID-induced bleeding. That is just not good enough. If one must take and NSAID-I certainly advocate adding such gastric protection. Besides incomplete stomach protection, these drugs have no effect on NSAID threats to kidneys, blood pressure and tendency to retain salt and water.

What about “Selective” NSAIDs?

Great excitement greeted the introduction of the COX-2 selective NSAIDs some years back. These inhibit one or the two cyclo-oxygenases, and thus were designed to combat inflammation, while giving less interference with positive functions of enzyme subtypes do not sort out neatly; empirically, gastrointestinal bleeding still occurs, admittedly less often, but still plenty enough to represent major risk.

Much publicity attended the removal of one such medicine, rofecoxib (Vioxx) from the market, due to concerns about a second adverse effect unfamiliar from the older NSAIDs: a distinct tendency to increase the rate of heart attack; another such agent, Bextra, came off the market soon after. A third selective NSAID or coxib remains, celecoxib (celebrex). The manufacturers are scrambling to vindicate this compound and to derive others that retain benefits without posing threats.

I hate to quit here but we’re out of time and space. The subject of pain is complex enough that it clearly requires a third column, “Relief.”

Pain Relief: Part One

By Henry Schneiderman MD,
Vice President for Medical Services and Physician in Chief, Hebrew Health Care

This is the first in a series of posts, providing medical and wellness advice for the intelligent non-technical reader, who is either elderly himself or herself, or involved in the care of an older person.  These are not intended to replace, and must not be used instead of conversation and consultation with your doctor, who will know particulars of your body and your case that may call for different specific choices for care.

I’ve chosen “pain” for the first in the series, because every person has pain at various points in life. The first issue is always to have a diagnosis that explains the pain. That will dictate whether treating this symptom is a correct and safe first approach, or needs to be combined with other testing or intervention. A knee that has hurt for the last 30 years is likely arthritic and does not usually require new testing unless suddenly worse. By contrast, new acute pressure under the breastbone requires immediate medical attention; simply using pain medicine to ease such chest pain would be a poor choice reminiscent of the old cliche of poor medical practice. “Take two aspirin and call me in the morning.”

Whenever it is possible to alleviate or eliminate a source of pain, that is a preferred course of action: If an arthritic hip hurts whenever one walks, for example, one continues pain medicine to take the edge off, uses exercises from physical to strengthen the muscles that stabilize the joint, and if the situation does not become tolerable, one consults an orthopedic surgeon about whether surgical total hip replacement is indicated.

Two responses to pain make no sense but are extraordinarily common:

1. To limit one’s activity to avoid pain-this sets up a vicious cycle of weakening.
2. To believe that there is a virtue and medical soundness in “toughing it out.”  Living with pain that could be helped does not ennoble anybody. Such a choice sets up consequences including loss of strength and mobility, depression, sleep disturbance, and increased susceptibility to a whole gamut of purely physical ailments.

Acetaminophen (sold as Tylenol among other brands) is a wonderful pain medicine. With it or any other medicine, one has to get AHEAD of pain; catching up with pain is more difficult and more miserable than staying ahead. A great starting regimen is two extra strength caplets, for a total dose of 1000 mg. This is done four times daily; the doses should be as widely spaced as possible, regardless of food in the stomach for instance, first thing on arising, 1:00 p.m., 6:00 p.m. and last thing at bedtime.

Unless you have liver problems or are taking two or more drinks of alcohol a day, this dosage is safe regardless of age, at least for the short-term. At the end of a full week of taking such doses unfailingly ” avoiding the pitfall of skipping a dose because you have felt well, it’s time to ask yourself if your pain has fallen to zero. The scale is “0 is no pain, 1 is the least pain, 10 is the worst pain of your life.” If you are at zero or a low number that is comfortable for you, you can cut back to three times daily and repeat the question a week later.

If on this second follow up, you find that most of the time you are comfortable, you can cut back to twice daily, ideally at a 12 hour spacing, which keeps the blood level of the medicine as constant as possible. This regimen can be kept up as long as needed. It has the further advantage that if you need a booster dose now and then ” for instance, an hour before an exertion that routinely makes a joint ache more ” the total daily dose stays under 3 grams a day for long term safety. If you know in advance that you’ll need the booster, arrange the other doses so that there is at least five hours between any two doses.

If you drink two alcoholic drinks a day or more, or if you have known liver problems, you’ll need to consult your own physician about what it is the maximal safe daily dose over the long term for you. Acetaminophen is very safe when used wisely, but a leading poison when deliberately overdosed: I’d be mortified if any reader of this column accidentally took too much.

Next time, I will share why I do not prescribe Motrin, Advil, Ibuprofen, or Aleve to anybody over the age of 50, even if he or she is on a stomach-protecting medicine; and why I am so set against even the reputedly safer “COX-2 selective” agents such as celecoxib (celebrex) and Bexxtra. I’ll also reveal why I do not recommend aspirin for pain relief, notwithstanding the prominent television ads for this, and notwithstanding how enthusiastically and often I prescribe a single baby aspirin a day for preventing heart attacks, strokes, and perhaps even colon cancer.

I will conclude with the latest deeply encouraging information about morphine, a wonderful pain medicine (by mouth, no more need for injection) not just at the end of life ” the setting we all think about when we hear the word morphine ” but also in the midst of life, and for all kinds of pain including severe arthritis.

As you’ll see, I believe it’s high time for all of us “mature over 50” persons to avoid some widely used medicines. At the same time, we need to grow more comfortable and at ease about a drug that has had undeserved bad press, fear of addiction and of side effects, but that is in fact is a perfect solution much more often that we might think.

The Risks of Pneumonia in Geriatric Patients

Pneumonia is one of the leading causes of death among seniors.

There are two basic types of pneumonia, Community acquired pneumonia and aspiration pneumonia. Community acquired pneumonia is caught from other persons. It occurs among people of all ages living in the general population.

Aspiration pneumonia caused by inhalation of bacteria from the back of the throat, mouth or nose occurs because of an impaired swallow, leading to potential infection. This is common among geriatric patients, especially those who are in institutions, whose immune function and swallowing function are often compromised because of extreme age and preexisting medical conditions such as stroke.

The most common symptom of pneumonia is a cough that persists after five to ten days. Other symptoms can include fever, fatigue, loss of appetite, discomfort in the chest, lungs or upper abdomen, discolored sputum (green or bloody phlegm), and disorientation. “Pneumonia can be difficult to diagnose since x-rays are not always diagnostic,” explains Dr. Ava Pannullo, Medical Director at The Hospital at Hebrew Health Care. “That’s why geriatric doctors rely on clinical changes, either physical, functional or mental in an older patient’s status to signal that something may be wrong.”

Smokers, diabetics, kidney disease sufferers and those exposed to second hand smoke are at greater risk for lung infection because their local immune system is compromised. They are at greater risk for contracting pneumonia than the general population. For this reason Pneumococcal and influenza vaccines should be offered to these populations

The treatment for pneumonia is generally straightforward. Initially, antibiotics are administered to kill the bacteria. Breathing treatments and expectorants are also introduced to open up the airways, loosen phlegm and ultimately cough out the mucus that accompanies pneumonia. The treatment process typically lasts 10 to 14 days. Seniors with pneumonia in just one place in their lungs have a good chance of full recovery. The presence of pneumonia in several parts of the lungs is more severe and makes recovery more difficult. With advancing age the lung tissue becomes less elastic decreasing the lung’s ability to expand and contract. Osteoporosis with resulting deformity and curvature of the spine also affects breathing by impairing lung expansion.

Simple steps for preventing community acquired pneumonia include hand-washing and cleansing of often used surfaces; such as the phone, computer keypads, work surfaces, car dashboards etc. decreasing transmission of bacteria and getting a Pneumococcal vaccine, and an influenza vaccine from your physician. Aspiration pneumonia prevention is tougher and involves changing diet consistency along with teaching different swallowing maneuvers.