Four national retailers were blasted by the New York state attorney general’s office with demands to remove their popular store bands of dietary supplements from their shelves. Tests were run and the results showed that roughly four out of five products contained none of the herbs listed on the labels. Some contained little more than fillers like rice, powdered garlic, and ingredients that could be dangerous to people with allergies.

Wal-Mart, GNC, Target and Walgreens were accused of selling herbal supplements that did not contain herbs. That constitutes fraud. Unlike prescription drugs, the government does not regulate the safety and sale of supplements such as Ginkgo Biloba, St. John’s Wort, Ginseng, Echinacea, and others, because they are classified as food products, not medicines. Not that I have total faith in the FDA’s regulation of pharmaceutical drugs—I don’t, especially regarding generic medications imported from India and other countries.

Over half of the U.S. population takes dietary supplements, according to the CDC. You have to wonder how many people had allergic reactions or developed side effects from  the non-disclosed ingredients in the fraudulent products in New York. How many may have occurred and went unreported? 

According to Slate, many people think that because herbs are “natural” and sold legally that they must be safe and effective. Maybe that’s why so many of us blindly trust herbal supplements. It’s a bit mind-boggling that we do since no one really knows what’s in any of them. There is a general mistrust of the FDA and pharmaceutical drugs but not about the quality of ingredients in dietary supplements, at least with the general public. Not too long ago I had a conversation with a woman in a health food store who protested when I mentioned that the supplements she was devoted to were not regulated in any credible way. She said, “I hope they are never regulated.”

There seems to be an ingrained loyalty and trust in these dietary supplements, and with over half of our population taking them, there must be a reason. Is it because these products are readily available to anyone and we are not dependent on physicians to use them? We rely on doctors for prescription medications and that’s not without seeing us in person and performing an exam and evaluation.

Is it because we want to heal ourselves? We can visit any GNC or Walgreens to buy remedies that promise weight loss, increased mental alertness, increased libido, and a good night’s sleep. Could it be that innately we know our bodies best and need some control over treatment for what ails us?

It’s a bit baffling that we have placed so much trust in companies like GNC, for example, whose products labeled Ginkgo Biloba only contained rice, asparagus and spruce—as in the tree.

At Target, products labeled St. John’s Wort and Valerian Root tested negative for herbs listed on the labels. The list goes on.

Where this gets dangerous is when products contain ingredients that people might be highly allergic to or could cause harm in other ways. According to the research published in the Journal of the American Medical Association in October of 2014, researchers found anabolic steroids in 85 percent of body building and sports enhancement supplements. This gets downright scary.

Does having access to supplements that promise cures make us feel more in control of our health? Are we seeking to heal ourselves because we don’t trust doctors or can’t afford to see them? Why put blind faith in a product we know zero about?

I support self-healing whenever possible. I believe in patient empowerment. I also have faith in certain alternative treatments. But don’t consumers deserve to know what’s in supplements taken by over half of the population?

I’ve seen alternative medicine practitioners myself, such as acupuncturists and chiropractors. When I had a severe, lower abdominal pain condition lasting 16 months that no physician could diagnose or treat, I turned to them. I drank smelly teas, ingested capsules containing powdered ingredients with names I could not pronounce–all in hopes that the debilitating pain would subside. Nothing helped.

With all good intentions these practitioners tried to alleviate my pain with their herbs and supplements. Of course that wasn’t possible (something we didn’t know at the time) because what I had was a muscle tear in my C-section site with nerve involvement and an inguinal hernia with a nerve passing through the hole. A hernia specialist/surgeon fixed that and I’ve been pain free for 3 ½ years.

It’s frightening to look back on an acupuncturist I saw back then, one who was recommended by a physician at a highly respected medical school. After taking the supplements he gave me, I developed allergic reactions such as itchy ears, swollen glands, and sinus problems. I understood then that no herbal supplement was regulated. But I took them anyway because I was desperate, needed hope, had to believe the practitioner who recommended them.

Like anyone else, I fell for the promise.

We do need regulation on dietary supplements. Not just to protect consumers from swindlers making false claims but to protect our health, especially for those who have life-threatening allergies.

If you’re wondering about your own dietary supplements and if they are viable, you might check The U.S. Pharmacopeial Convention (USP), a scientific nonprofit organization that sets standards for the identity, strength, quality and purity of medicines, food ingredients and dietary supplements. See link here http://www.usp.org/dietary-supplements/overview You might also try ConsumerLab.com see link here  https://www.consumerlab.com I don’t claim any responsibility for the information from these two organizations. 

I welcome your comments.

For further information, please see The Take-Charge Patient.

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With the New Year, many of us have an eye on new beginnings, from weight loss and increased exercise to work productivity strategies. Maybe you’re even thinking about how to take better care of yourself.

One important self-care strategy is related to your healthcare. 2015 is the year patients and their advocates/caregivers can do their part to increase the quality of care, maximize the time with doctors and nurses, and increase their chances of accurate diagnoses and safe medical encounters.

Healthcare is becoming even more complex with the implementation of the Affordable Care Act and many providers have even less time to spend with patients. This means that if we want higher quality care, we must be proactive and partner with our providers. If we actively participate in care, discuss treatment options with our doctors and nurses, and share in decisions, we are more likely to experience  successful, pleasant and safe medical encounters. 

 10 strategies to help you in the coming year.

1. Get organized. Gather copies of of pertinent medical records such as MRI, CT scan, blood test results, and any surgery or procedure reports. Put them in a health file at home. This allows you to retrieve a test when you need it, and not depend on a busy doctor’s office or facility to forward your records. Get copies of your records for yourself so you are in control.

2. Understand your health insurance plan. No one likes surprise medical bills so ask questions about what your plan covers, the amount of your deductible, if there is co-insurance and what that percentage is and when it applies, and which medications your plan covers. There have been a number of changes in health insurance and you might not be aware of them. Call your health plan’s customer service number and ask questions.

3. Prepare a list of questions before you see a doctor or nurse. If you prepare ahead of time, this allows you to think about what you want out of the medical encounter. Write down questions or input them into your smart phone. We’ve all experienced forgetting questions and later calling our medical provider to retrieve information. Document what your doctor or nurse explains so you can refer to the information later. It can be stressful seeing a provider and stress interferes with cognitive function, namely memory.

4. Do your part for an accurate diagnosis. Diagnoses that are wrong, missed or delayed are believed to affect 10 to 20 percent of cases. If you are seeking a diagnosis from your doctor, create a symptom diary ahead of time. Track your symptoms on a daily basis. List the following:

-Where on or in your body your symptoms are located.

-When they started and if there was a physical event before or at the time symptoms developed.

-Note what makes them worse or better (such as exercise or eating a meal), when they occur or if constant.

-Document pain (list pain on scale of 1-10, 10 being the worst) and when it occurs.

-Note what you think might be causing your symptoms.

Share this information with your provider. The more information you offer, the more likely you’ll receive an accurate diagnosis.

5. Do your part to prevent medication errors. According to the Institute of Medicine, 1.5 million people are harmed by medication errors every year. Create a list of your current medications and their dosages, over-the-counter medications, herbs and supplements, and allergies to medications. Bring this with you to each medical encounter.

6. Ask questions. If you don’t understand something that is explained to you by a medical provider, ask for clarification. This does not imply that you aren’t smart. It implies that you want to understand. Medical information can be complex.

7. Do your research. Find out as much as you can about a medication, proposed diagnosis or treatment plan. This is important so you are informed.

-Ask your doctor for information.

-Research on credible websites.

-Ask questions of other patients who have the same diagnosis or treatment. Online patient communities can be helpful.

-Go to your local library for information. Ask the librarian or medical librarian for assistance.

8. Get a second opinion. If you question a diagnosis, if surgery is recommended, or if you have a serious illness, get a second opinion from a qualified specialist who is board-certified and affiliated with a respected medical school.

9. Use your pharmacist. If you have unanswered questions about your medications or are having difficulty managing them, make an appointment with your pharmacist and ask for help.

10. Bring a loved one with you to a doctor’s appointment. Ask this person to document answers to your questions so you can refer to it later. If a loved one accompanies you, you’ll feel less nervous about asking questions.

Let’s make 2015 the year of the safe patient!

Happy New Year! Best wishes for a safe and prosperous 2015.

Martine

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80 percent of prescriptions in the U.S. are for generic medications. Generics are supposed to be less expensive alternatives to brand name drugs. However, prices for certain generics are rapidly increasing. 50 percent of generic medications increased in price in the last year and 10 percent more than doubled in cost during the same time period. Among them are thyroid replacement hormone, doxycycline, digoxin and other heart medications, tetracycline, albuterol (pill form), and certain medications for blood pressure and high cholesterol.  

I thought generics were supposed to offer a lower-cost alternative to brand name medications. Pharmacists are reporting seeing generics priced similarly to the brand name of the same medication.

Something is wrong here. Apparently Vermont Senator Bernie Sanders and Maryland’s Elijah Cummings were concerned enough to investigate why generic drug prices are soaring. A hearing of the Senate Subcommittee on Primary Health and Aging was called to probe for answers and incite action last Thursday.

In addition, many brand name medications for asthma, COPD, diabetes, as well as heart medications, cancer treatments, hormones and nasal sprays, will no longer be covered by health insurance plans in 2015. Brand name medications are cost prohibitive. Now, certain generics are too, and patients are being forced by health insurance companies to accept less expensive alternatives to the medications their doctors have prescribed or not take them at all.  

This is not what our medical providers want. Doctors are handicapped enough already by health insurance denials. Even pre-authorizations for prescription medications are now often turned down.

Take my husband, Jamie, who was given samples of Celebrex for pain. When those ran out, he tried to fill the prescription for the same drug. Our health insurance company, HealthNet, turned that down even after a pre-authorization was done by his doctor’s office. He was offered Meloxicam instead, which is not nearly as effective as Celebrex in reducing his pain. He limps along.

Our pharmacist explained that until Jamie has tried two more alternative prescription anti-inflammatories, that HealthNet will not approve Celebrex. The generic for Celebrex is not yet available. Our pharmacist also said that even when the generic is available (in December of this year) that it might be almost as expensive as the brand. That could mean that HealthNet will not approve that either.

Unless your health plan’s drug formulary covers your medication, you might be out of luck. A drug formulary is a list of prescription drugs, both generic and brand, that are preferred by your health plan.

If you’re shopping for health plans now during open Open Enrollment (November 15, 2014-February 2015) you might ask if the medications you take regularly are covered. No one wants to be surprised by an unexpected medical cost.

Tips to Help You

1. When shopping for health insurance plans, ask if your regular medications are covered by the plan.

2. Mail order pharmacies tend to be less expensive than retail pharmacies. 90-day prescriptions tend to be less expensive than monthly refills. 

3. Some pharmacies will give you discounts on certain medications. Ask your pharmacist.

4. Ask your medical provider for samples. This is only useful for time-limited treatment. All samples are brand name medications.

5. Consider asking your doctor for a higher dosage of your medication and split it in half. However, there is controversy around this tip. For example: you are supposed to take a 10mg tab. Ask for a 20mg tab. Check with your doctor and pharmacist before splitting pills. It’s only safe for certain types of tablets. 

6. Drug manufacturers will sometimes offer discounts for brand medications. Go to the medication name website and type in discount. For example: Daytrana.com/savings. There will be an explanation of the discount you can receive and under what conditions.

7. There are discount prescription programs to help offset the cost of your medications if you can’t afford them, such as Rx Assist  and Needy Meds

8. Ask your pharmacist for help with reducing the cost of your medication.

 

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Guest blog by Beth Boynton, RN, MS

Before trying to answer this question I need to differentiate between my use of the terms ‘consumer’ and ‘patient’.  I’d like to use the term ‘consumer’ to include all of us who may receive health care service and ‘patient’ to include those who are actively being treated at any given moment.  The need to make this distinction will become clearer as we consider the topic.

It seems obvious that collaboration between healthcare professionals, consumers, and patients is our best hope for fixing problems like making care safer, kinder, and more cost-effective. Yet in order for this to happen, healthcare professionals must try to understand what patients need and want in terms of their care so that we can provide the best care, patients should speak up as best they can to tell us, and consumers need to understand as much as they can about how our healthcare system works (or doesn’t work) so that efforts to change will be based on solid ground.  

While patient-centered care is an approach that is helping gear clinicians to listen to, respect, and empower patients, I wonder how we might reach out to consumers to invite them to learn more about the work that nurses, doctors, and other healthcare professionals do, how it affects us, and consider how they might be supportive. Empathy for healthcare providers seems important in the pursuit of collaborative care and the dismantling of the old ‘us and them’ paradigm.  

Yet, there is a big caveat to this and it presents a paradox that leads me to write and hopefully inspire discussion about it. When consumers are patients it is the job of healthcare professionals to take care of them.  Not the other way around.  There is an inherent dependency involved in the relationship and it does not seem right for nurses and doctors to expect patients and families to be empathic about their challenges when patients are sick and/or vulnerable.  On the other hand, not making room for empathy may interfere with truth finding and problem-solving that we could be working on together.  

For example, healthcare employers often tell nurses via customer service training that they should never tell patients that the organization is short-staffed.  Nurses are running around from urgent task to urgent task.  Patients and families have reasonable requests and sometimes urgent needs that go unattended for too long. Instead of providing more staff there are memos to discourage overtime and care providers are given critical evaluations for lack of time management skills. Workarounds are never openly advised, but there is not enough time or staff to do things properly. Shortcuts become taboo to talk about, common, and unsafe. It is frustrating, sometimes extremely frustrating and I don’t know any colleagues who feel good about making patients wait for pain medication, leaving work for the next shift, or forgetting to give a critical antibiotic.  

I have two thoughts about this conundrum.  One is that patients and consumers deserve to know the truth.  This way they are empowered to help or get their care elsewhere. In fact, I’ve often thought that organizations facing budget constraints should work with a consumer group to come up with a plan of how family members,  volunteers, and even administrative leaders might help during a nurse staffing shortage. Nurse Assistant training is only 6-8 weeks and could be a prerequisite for working in a hospital or nursing home.  That way there would always be help available and things that get delayed would not include patient care. Alternatively, hospitals and nursing homes could just be honest. “We welcome you and there is a bed, but you should probably bring someone with you to help the nurses and nurse assistants because we had someone call in sick for duty.”

The other thought is that at some point consumers should know how such conditions affect the people they are entrusting their care to and the health care systems they depend on. Burnout, substance abuse, and even suicide are tragic and interrelated problems that healthcare professionals face. And maybe empathizing with the frustrated nurse or doctor isn’t appropriate when being cared for, but maybe simple efforts such as getting to know neighborhood nurses and doctors on a deeper level would help. Conversations outside the clinical environment between consumers and healthcare professionals that help discover emotional or physical stressors may create doors for authentic and co-creative problem solving might help.  

I don’t have an exact answer to this question about empathy, but I do believe that we all deserve and maybe even need it. Honesty should be a priority and seeking answers will somehow help us to move forward toward a collaborative vision of healthcare that is safer and more compassionate. What thoughts do you have?

Beth Boynton RN, MS is a national speaker, consultant, and the author of “Confident Voices:  The Nurses’ Guide to Improving Communication and Creating Positive Workplaces”.  She specializes in communication, collaboration, & emotional intelligence for healthcare professionals and organizations and is trained in the Professor Watson Curriculum for Medical Improv through Northwestern University Feinberg School of Medicine. Her video, “Interruption Awareness:  A Nursing Minute for Patient Safety” and blog, “Confident Voices in Healthcare” have drawn audiences from all over the world.  She is currently writing a core text on communication for nursing students with F.A. Davis Publishing Co which is tentatively scheduled for publication in the Spring of 2015.  Her complete CV is online. 

 

 

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As an avid reader of physicians’ memoirs, I dove into Sandeep Jauhar’s, Doctored: The Disillusionment of an American Physician, prepared for an unveiling of our dysfunctional health care system. I half expected to fall into a story about a physician who pursues his passion for practicing medicine in the face of overwhelming odds and surfaces as the victor. That isn’t what Doctored is about. It’s value lies in the author’s ability to let readers see behind the curtain of a physician’s life and pursuit of a profession that isn’t what it once was. Although not hopeful for physicians and patients alike, Doctored is a moving and well-written memoir that showcases the author’s struggle to practice medicine while confronting a number of personal and ethical challenges.

Because I’ve interviewed so many physicians for my books, The Take-Charge Patient and Critical Conditions, I understood the author’s exasperation with the time-crunch with patients, low reimbursements from health insurance, frustrations with health insurance denials, and massive amounts of paperwork. I’ve heard the same from almost all of the doctors I’ve spoken to.

As a cardiologist at a teaching hospital outside of Queens, Sandeep Jauhar struggles to earn an income to support a wife and growing family. He deals with unscrupulous doctors who over-test for profit and in the name of defensive medicine. He is a physician trying to do the right thing by his patients but at the same time earn enough money to put food on the table. Unlike many of his cohorts who take it for granted that prescribing unnecessary tests for unsuspecting patients is the only way to increase their incomes, Jauhar questions his journey as a cardiologist, challenges the idea of using patients to bilk health insurance companies.

However, Jauhar does in fact join the peccant group of physicians who compromise their integrity to make more money. What saves him from being an unlikeable narrator is his conscience, his discomfort with selling out.

Jauhar casts a dark shadow on many physicians, calling our attention to ulterior motives to boost referrals, another word for kickbacks from other doctors. He writes, “Referrals are also a way for cash-strapped doctors to generate business.” Giving an example of three physicians who all agree to call one another when an issue with a patient arises that is outside the scope of their expertise, he offers a clear picture of the dirty referral process. “It’s hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor.”

Ever wonder about your doctor’s referral to a specialist? Read this book and you’ll find out information to consider.  

Jauhar is certainly caught in a bind, not unlike many other doctors who go into medicine because they want to care for patients, only to discover they can’t manage financially unless they make other choices. In conflict with the business of medicine, Jauhar reveals the underbelly of the physician population. He takes on work for cardiologists who perform needless stress tests for young patients, echocardiograms, and more.

His family pressures him to socialize with other doctors in effort to snare referrals. Jauhar is judged for resisting the doctor parties that lead to financial rewards, for not wanting to use tried and true strategies for manipulating others for gain. Contrary to his integrity, he does it anyway.

Throughout Doctored we are privy to interesting patient stories to illustrate ethical challenges faced by Jauhar. There are morality tales in the cardiac wing of the hospital, in treating end-of life patients whose families want them to survive no matter what, in sending patients to specialist after specialist in effort to find an accurate diagnosis for what ails them.  

Jauhar’s doubts bleed into the competency of other physicians and their ability to accurately diagnose. His own father suffered with chronic headaches. After a slew of prescribed drugs, from muscle relaxers and antidepressants to prednisone, his father then submitted to a battery of tests requiring a hospital stay. Those tests turned up very little in the way of a diagnosis. His father was seen by an array of specialists but “no one could tell him what was wrong.” Even when his father’s doctor did show up to see him in the hospital, Jauhar writes, “she spent no more than a couple of minutes with my father then rushed off.”

All of us patients can relate to that.

Jauhar’s father eventually stopped the medications on his own and after two weeks the headaches disappeared. So much for modern medicine.

When Jauhar’s wife, Sonia, was pregnant with their second child, the chief of obstetrics at Cleveland Clinic performed a fetal ultrasound. They were told the baby was a girl. That opinion turned out to be wrong. They were having a boy, a fact conveyed by a Rastafarian man on a beach in Anguilla where Jauhar and his wife had vacationed previous to the ultrasound. The significance of this portrayal is greater than one might think. It sheds light on a deeper premise in the book—that even the best doctors can be wrong, and someone with no medical training can get it right.

Jauhar laments diagnostic workup of the past and explains that diagnosis used to be based on observation and physical exam of the patient. He points out that these tools appear to be obsolete today and states that doctors are so uncomfortable with uncertainty that they rely on tests and numbers. The obvious is overlooked, not just because of physician over-confidence but because of fear of missing something that might result in being sued for malpractice.

Using his own misdiagnosis of a patient as an example of how physicians mistakenly come to erroneous conclusions, Jauhar describes a patient, an intern, who sees him for chest pain. He shows us how easily misdiagnosis comes into play by his own diagnostic error. This patient did not have pericarditis as Jauhar thought, but a heart attack. Jauhar missed it, causing the patient to suffer through the night with extreme pain. After discovering his faulty diagnosis, he even acted in ways that some doctors might when first learning of their own misdiagnoses–he initially blamed everybody else.

Jauhar writes, “Most doctors are afraid to take responsibility for medical errors.” However, he does eventually do the right thing. This is where we align with him, feel empathy toward an imperfect human being. He admits his mistake to his patient and says, “I thought you had pericarditis. I was obviously wrong. I’m sorry.”

Assuming the patient would not want to be treated by him again, Jauhar asks if he’d been given a referral to another cardiologist. The patient insisted on sticking with him as his doctor. And the point is clear that it is the apology, the relationship between doctor and patient, which increases patient loyalty and reduces potential malice when a medical error occurs.

Most patients have been treated like objects at one point or another so many will relate to Jauhar’s description of patients dismissed by doctors who just don’t care. He recounts a conversation with a nurse about the assumption that most patients are unwilling to ask questions and divulge personal information to doctors, something they do with nurses. When asked why, the nurse responded with, “Because they have a relationship with me.”

Bingo.

Jauhar consistently alludes to the lack of time for the doctor-patient relationship, something that is still considered a cornerstone of quality care, even the heart of care. He draws the conclusion that it is the time pressure that contributes to medical errors and the lack of physician and patient satisfaction.

Doctored isn’t a comfortable read, but a compelling one. I found myself not wanting to continue reading at times, overwhelmed by the road blocks doctors and patients face today. There were times when I felt slimed by the horror stories about deceptive physicians, wondering just how much of the same I’d been subjected to as a patient with a chronic pain condition lasting 16 months when I received 10 misdiagnoses from 11 physicians.

Jauhar does offer a few solutions to overuse of health care and to dwindling time with patients. I won’t go into all of them, but I’m happy to report that better-informed patients are one of the more potent solutions that Jauhar recommends. “If patients are more involved in medical decision-making, there would be more restraints on doctors’ behavior, thus decreasing unnecessary testing.”

Not exactly the reason I was hoping for but active participation on the part of the patient is crucial to increasing quality of care and safety.

 

 

 

 

 

 

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