From Bleak House to My House: A Second Look at Vitamin D

This morning, I noticed that UK news was alight with stories about how the UK National Health Service and NICE are recommending daily vitamin D. In the UK, they are giving out low-dose vitamin D like chocolate at drugstores, groceries, and at your PCP. So it gave me pause after my last post.

First, I wondered: is it really that much more bleak in the UK that the evidence-based authorities are pushing vitamin D so aggressively with certain high-risk groups? Then I thought: did the University of Wisconsin study on postmenopausal women that I wrote about really pan vitamin D supplements? Could the researchers have done better in informing the public. I doubt the public got the story clearly.

I reached Deborah Grady, MD,Professor and Associate Dean of Clinical and Translational Research, at University of California San Francisco,  today, who wrote a companion short commentary in JAMA Internal Medicine on the University of Wisconsin study. I asked her for clarification on the UK/US points of view. She responded: “I don’t think that there is much argument about low-dose vitamin D. [400 IUs per day] of vitamin D is safe, pretty cheap, and might be helpful. The argument is really around much higher doses.”

Meanwhile, today’s US papers were less favorable on vitamin D, referencing  the JAMA Internal Medicine paper.. I asked BMJ’s Richard Lehman for his take on this. He responded: “I have some vitamin D on my desk and I take it occasionally. That’s what they call a British compromise.” That’s an unfamiliar term for me, but a UK-trained doc explained it to me this way: “it’s a political compromise that gives everyone a little bit of what they want and holds the peace for a very long time, but offers no real solution.”

I have spent most of today diving through arcane medical stories that probably could have been more useful for readers.  Perhaps it is unrealistic to hope that vitamin D advice could be as clearcut as the bulleted list from NICE below.

According to NICE (National Institute for Health and Care Excellence), the listed groups below are high-risk groups for vitamin D deficiency and it is these groups that UK public health authorities are reaching out to with enhanced vitamin D access:

  • All pregnant and breastfeeding women, particularly teenagers and young women
  • Infants and children under 5 years
  • People over 65
  • People who have low or no exposure to the sun. For example, those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods
  • People who have darker skin, for example, people of African, African–Caribbean and South Asian origin.

All this input and I haven’t been away from my desk all day. I mean zero time outside, in the sun. It’s just about sundown. Perhaps it’s tantamount to living in the UK. I suppose I should try to change that – although I am not sure how.


Seeing Your Doctor for Prevention,
Treating On Your Own: A Report from the Field

First off, let me be clear: what I report below I am not recommending. My first obligation is to my readers. Also, I am grateful to Brooke Binkowski, a stellar journalist-friend, who spontaneously emailed me this story this morning. It arrived in my inbox amid a heated social-media discussion about who the real villains are in the failure to vaccinate. Also, why is it we can’t reach them. Are they the rich and entitled, the libertarians, the natural, organic folk, or who?

Sometimes, you hear a story and it makes you want to use it while it’s hot. This is a gem of a story, but it’s not really about vaccines very much. If you like it, you might want to follow Brooke at @brooklynmarie. She has a lot of great stories up her sleeve.

Here’s what Brooke wrote:

Because of who I am and where I live, I collect old hippies, you know, I feed them, talk to them, hang out with them… one of them stopped by yesterday, he’s about 70, an ex-drug runner, never has taken care of his health, has diabetes, and has had major heart surgery last year (I went to see him in the hospital.)

Anyway I said: “How have you been? He said, “Oh, I’ve been fine. I ran into complications recently, did something to my pinky toe, so I cut it off.” I said, “I’m sorry – you had it cut off?” He said “No, I cut it off myself, just nipped it off with a pair of pliers, wanna see?” (of course I did, I am one of those people)

So he’s showing it to me, it’s healing nicely, etc, and I say to him, well what happened? He said: “I’m diabetic, it was getting gangrenous, just wasn’t feeling it, so… also I decided to go off my heart meds, they were making me feel like crap.” So this guy, the ex-drug runner who cuts off his own toes and now lives out in a boat on the marina. He has a daughter. Guess what?  He got her vaccinated.

Man holds pliers to his toe. This is a likeness,  This toe is healthy and was left alone.

Man holds pliers to his toe. This is a likeness, not the toe or the man in the story.This toe is healthy and was left alone.

Cardiovascular Care and the Bush Effect

Pres Bush at NIH

It’s too soon to tell whether former President George W. Bush’s stent to open his coronary artery will change how Americans receive cardiovascular care, but I certainly have my worries. If the argument to aggressively search for cardiac disease in asymptomatic people wins out, I see my healthcare premiums rising precipitously and continuing in that direction. It’s not just the premiums either, but putting healthy people into this perennial-patient or at-risk status for no good reason.

I don’t want to live in a world where we speak of how elevated each of our risk status is for cardiovascular disease, a stroke, or heart attack, as if it is a badge of courage. I learned recently that I have only a 4% risk of having a heart attack or stroke in the next ten years, apparently strong enough for my primary care physician to recommend a statin to lower my risk even further.

A month ago, I went for a routine physical at my primary care physician’s office. I got recommended immunizations, but there were aspects of the visit that troubled me. Once you are in a gown sitting at the exam table, you are fair game for consenting to a procedure right there, on the spot. How stupid I was not to pull out my smartphone to check whether a test was warranted. My doctor had moved from an academic medical center to open a new group practice.

Cardiovascular Testing Flourishing

I got hornswoggled into a carotid ultrasound test. The test evaluates blockages in your neck. What led to this test was my admission after persistent questioning (I am really well) that I very occasionally feel dizzy. Suddenly, the specter of a looming stroke was in the cards, perhaps a blockage in my neck. My blood pressure was 120/80 in both arms. When I asked the technician performing the test why it was being done, she said: “to prevent a stroke.” Now who would want to have a disabling stroke? It was a compelling argument on the surface.

Other contributing factors that were too daunting to address was the fact that a cardiologist sat in the office and owned the equipment. Who needs a fight with my doctor over whether the test is warranted and might be motivated by a conflict of interest? At another physician practice, on a rainy day, I once was offered a stress EKG, because: “He’s got the time. He had some cancellations because of the rain today.” The rationale: it was a few months after my mother died. I had occasional pounding in my chest.

Had I pulled out my smartphone and looked at the American Board of Internal Medicine Foundation Choosing Wisely site or a handful of other sites either time, I would have immediately learned that a carotid ultrasound test or stress EKG was unwarranted. I recommend readers bookmark this site and challenge their doctors before undergoing tests like these. It is a valuable reference. I should have known better. (Note: at press time, the link on the website was broken. It will be inserted as soon as ABIM Foundation fixes it.)

With my insurance, I only got stuck with a relatively small copay, but what would happen if everyone who walked in the door was seen unwittingly as a candidate for this procedure, stress EKGs, and more? Make no mistake about it, it’s happening. You tolerate it, fellow Americans, you are going to have to pay for it. Don’t be surprised if your premiums go up and if healthcare costs wipe you out. I may not pay for this kind of test this year, but it won’t be long before the economists make sure Americans fork out for these tests.

Oddly enough, when I returned home, in my mailbox, I found a glossy, oversize postcard from a teaching hospital touting its cardiovascular disease prevention program. They are popping up everywhere, offering a potpourri of risk assessment for heart attacks, strokes, and vascular disease, risk factor identification, treatment programs to reduce risk factors, secondary prevention, and screening before starting sports and exercise programs.

I don’t think that Bush was needed to propel overuse of cardiovascular procedures further over the top. It has been well on its way, but Bush’s stent underscores the trend. In this blog, in many posts, I have pointed to the numerous ways overuse is hazardous for your health, financial wellbeing, and more. It will be up to those concerned with overuse to devise new strategies to stop this train. Right now, it seems unstoppable.

















Confused About What Health Reform Has to Offer:
Sept. 23rd Marks One Year with New Patient Protections

Obama signs the Patient Protection and Accountability Act, 2010

You may not love every single bit of health reform coming down the pike, but make no mistake about it: new patient protections that went into effect one year ago had their one-year anniversary Sept. 23. I think health reform, as enacted by the Patient Protection and Accountability Care Act (AKA “PPACA”), is a milestone for patients.

PPACA has a universal mandate, meaning that every American must have health insurance. If you’ve followed this issue, challenges to the law have been filed, but it is too early to tell how things will end.

I like the concept of a universal mandate and coverage because it brings us closer to everyone sharing the risk and financial cost of health care for all. Sure, I’d rather see something like single payer, but politically, I doubt that would fly at this moment. I admit that I am biased in favor of health reform and I did plenty of writing for a living that clarified health reform. So continue reading with that in mind.
PPACA Measures Enacted  Sept. 23, 2010

New patient protections that went into effect on Friday are good news. In comparison with where we were before, or where the right could move this issue, the public should applaud these changes. Consider these changes that went into effect on Friday:
1.    Insurers can no longer impose caps on essential benefits like hospital stays.
2.    Health plans cannot drop you when you get sick.
3.    Recommended preventive care, such as screening mammograms, colonoscopies, and vaccinations no longer require copays, coinsurance, or deductibles in all new insurance plans.
4.    Your health plan is more restricted in enforcing annual spending caps, but they will be completely eliminated by 2014.
5.    Individuals with Medicare Part D coverage get a $250 rebate, and 50% of the doughnut hole will be eliminated in 2011. By 2020, the doughnut hole will be eliminated.
6.    Prior authorization for emergency care and denial of out-of-network emergency care has been eliminated.
7.    Women can go directly to their ob/gyns without referrals.
8.    Lifetime limits on most policies are eliminated.
9.    An appeals process at health plans must be in place.

10. Dependents can remain on the parents’coverage until age 26.

My discussion of the law is far from comprehensive. There is plenty more.

It’s easy to feel blue when we hear potential nominees for President sit silently while a mob suggests an uninsured 31-year-old man die.

So I am taking a moment to pause so that we can remind ourselves what new patient protections health reform offers. If you have more to add, please put them up in comments and tweet them. Here’s a nice graphic of what becomes effective, when. Bookmark it, show it to skeptics. Challenges to health reform are often scary.

Preventing Falls in Hotel Bathtubs

I wouldn’t have considered posting this, except that I am in the WordCount Blogathon and don’t want to miss a day. I fell in a hotel bathtub in a “boutique luxury” hotel this morning, arrive late to a meeting, and then traveled back home by train. I am pretty badly bruised and home from my trip.

I am going to think twice about staying in “boutique”AKA “old” hotel in the future. Apparently, they don’t have to have a sturdy rail to hang on to. In many states, you only need to have a rail if the hotel is newly built. There was no such thing in or near this bathtub. A mat, which I used other days, was not close to the bathtub so I didn’t remember to put it down when I entered the shower. Not that a mat is the best protection.

In medicine, we’d call this an “adverse event” or an “avoidable error.” I am not going to sue, but I kind of wish sites like Travel Zoo, Expedia, and Priceline tabulated accidents at hotels. The reviews don’t leave space for that and people are getting older everywhere.

Can we change things so that hotel bathtubs are not hazardous? At any rate, like I said, I wouldn’t have put this up, except it shook me up and I am too tired to write much more of a post tonight. I think there should be more stringent requirements for bathroom safety in hotels everywhere.

I’ll be back to normal programming tomorrow. Good night all!