Monthly Archives: October 2013

Why To Exercise Today: Study Finds Fitness May Protect Against Harm Of Sitting

Exercise per se may not protect us from sitting-related disease, but being fitter may. (Paul Haeberlin/Flickr)

Exercise per se may not protect us from sitting-related disease, but being fitter may. (Paul Haeberlin/Flickr)

“Be fit to sit is the answer!” the press release from the American College of Sports Medicine tells us.

And it’s an answer I must say I like very much. Because, as someone who likes to work out but also to sit most of the day, I did not like earlier studies suggesting that exercise cannot offset the mounting evidence that prolonged sitting is bad for us.

See, for example, this Daily Mail headline, with its emphatic upper case: “Exercising regularly WON’T offset the risk of sitting for long periods of time: An hour of activity a day isn’t enough to stave off heart disease, diabetes and cancer, study finds.”

But the research machine rolls on, and now a new Norwegian study in the journal Medicine & Science in Sports & Exercise adds another piece to the puzzle: It suggests that in fact, exercise per se may not protect us from sitting-related disease, but being fitter may.

In other words, it may not be enough to get plenty of physical activity if it’s so gentle it doesn’t affect your fitness; but if it’s moderate or vigorous enough — like interval training — to raise your fitness level, it may in fact protect you.

Researcher Javaid Nauman summarized the study and its findings in an email. The message, Nauman says, is that “people who sit for long periods of time need to exercise and improve their fitness. This is done by completing aerobic exercise at a moderate intensity or higher. Physical activity that has no effect on fitness will do little to protect against the harms of sitting.”

Prolonged sedentary time is associated with cardiovascular risk factors independent of physical activity. Whether a high level of cardiorespiratory fitness can modify the deleterious health consequences related to high sedentary time is not known.

We conducted a cross-sectional study of 12,274 men and 14,209 women (≥20 years) without known cardiovascular disease. Each hour increase in sedentary time was associated with 5% and 4% greater likelihood of having a cardiovascular risk factor clustering independent of physical activity in men and women, respectively. And more than seven hours of sitting per day increased the risk of cardiovascular risk factor clustering by 35%. Continue reading

Opinion: In Simulation Era, Your Doc’s First Try At A Procedure Should Not Be On You

A mannequin for practicing open heart surgery at the Boston Children’s Hospital’s recently unveiled simulation center. Called “Surgical Sam,” it has a life-sized “heart” that accurately mimics the beating motions of a healthy or abnormal human heart. (Jesse Costa/WBUR)

A mannequin for practicing open-heart surgery at the Boston Children’s Hospital’s recently unveiled simulation center. Called “Surgical Sam,” it has a life-sized “heart” that accurately mimics the beating motions of a healthy or abnormal human heart. (Jesse Costa/WBUR)

Most doctors never forget the paralyzing terror of their first invasive procedure.

Dr. Charles Pozner, of Boston’s Brigham and Women’s Hospital, recalls the first time he placed a central line, which involves sticking an eight-inch-long needle into a patient’s jugular vein to place an intravenous line. He had never even seen it done before, but a chief resident offered him the opportunity after a long day working together.

“When I was a medical student, the last thing you wanted to say when someone offered a procedure to you was ‘no.’ You wanted to learn, to be part of the team,” Pozner told me. The chief resident walked him through it without mishap, but “it was an unsafe thing for the patient, and an unsafe thing for me, because I was potentially harming the patient,” he said.

Twenty years later, in 2013, I went through a similar process. I watched a colleague place a central line during my first week as an intern. A couple of days later, I placed my first one, as my senior resident supervised. Thankfully, everything went fine. But that doesn’t mean I’m comfortable with the idea of wielding eight-inch-long needles after only watching someone do a procedure once.

“See one, do one, teach one” is the ancient medical adage for this: that after doctors in training have seen one procedure or operation, they’re qualified to do the next one. It has been the model for teaching physicians for generations.

But in the age of robotic surgery and simulation medicine, is this concept really acceptable anymore?

The short answer is no. Clearly, doctors in training should practice on computers and simulated patients, not real ones. Particularly when, according to a study out this week, medical errors are the No. 3 cause of death nationwide.

The longer answer is more complicated. No one openly defends the concept in medical journals — in fact, experts talk about “see one, practice many, do one.” But the “see one, do one, teach one” culture still persists in hospitals around the country, and it remains routine for physicians in training to practice their first procedure on real patients. (As a patient, what can you do about it? See the tips below.)

“Would you fly on an airplane if they say, ‘We’ll drop the price of our tickets but our pilots will opt out of flight simulation?'”

– Dr. Antonio Gargiulo

But that is changing, as more hospitals and medical schools invest in high-tech simulation centers like the $12 million center unveiled by Boston Children’s Hospital this week.

Dr. Pozner, who is medical director of the Brigham’s STRATUS Center for Medical Simulation, says that in time, medical simulation will mean the death of “see one, do one, teach one.”

The Pilot Analogy

Consider pilots. Chesley “Sully” Sullenberger, the pilot who remarkably landed his plane on the Hudson River, is often mentioned in the medical literature on simulation, as are his hundreds of hours practicing simulated emergencies. If Dr. Atul Gawande famously brought the pilot’s checklist to surgery, simulation proponents think more pilot-style simulation should be brought to medicine.

“It’s called procedural memory,” Dr. Pozner said.

And studies show that simulation works in medicine. One small study trained doctors in robotic surgery, showing that they could reach expert level proficiency by the time they operated on their first real patient.

“The main advantage of this tool is you can get technically perfect before you even touch a patient,” said Dr. Antonio Gargiulo, medical director of the Center for Robotic Surgery at Brigham and Women’s Hospital. Continue reading

Narrating Medicine: Let’s Talk Bedpans, And Why Doctors Should Get Good With Them

As a doctor myself, writes Dr. Anna Reisman, I was embarrassed that I didn’t know how to help a patient with a bedpan. (Michaelwalk/Wikimedia Commons)

As a doctor myself, writes Dr. Anna Reisman, I was embarrassed that I didn’t know how to help a patient with a bedpan. (Michaelwalk/Wikimedia Commons)

I was visiting my friend in the hospital and she had to pee. Walking to the bathroom was not an option: She’d been told not to get out of bed, she felt weak and lightheaded, and she was attached to an IV and a monitor.

She pressed the call button and stated her problem. A voice: They’d let her nurse know. A few minutes later, I stuck my head outside the curtain and scanned the empty hallway, feeling guilty that all I could do was share her frustration.

Then someone pulled open the curtain and smiled in at us. “I need the bedpan, we’ve already called twice,” my friend said. The woman in scrubs, who turned out to be one of the doctors, said she’d take care of it. My friend and I sighed with relief.

But the doctor slipped back out. Taking care of it meant finding someone who knew how to do it. When she returned a couple of minutes later and saw that still nobody had showed up, the good doctor offered to do it herself. She fetched a bedpan and awkwardly slid the pink plastic container under my friend, the whole time apologizing that she didn’t know which end was up.

The current U.S. nursing shortage includes licensed practical nurses and certified nursing assistants, the people who usually manage bedpans. And so hospitalized patients feeling the urge to urinate may have to wait longer than is possible.

If you’re thinking this is a minor issue, think again: Holding one’s urine can set a patient up for a urinary tract infection; the physical discomfort can be a stress on an already sick body, driving up blood pressure and pulse; and waiting with a bursting bladder is a mental stress, too.

As a doctor myself, I was embarrassed that I didn’t know how to help. I didn’t learn bedpan basics in medical school.

The alternative isn’t any better: Consider the shame and discomfort of lying in cold, wet sheets until someone can change them, plus the serious health risks that include skin breakdown and infection. For patients who already have pressure sores, these complications can be life-threatening.

As a doctor myself, I was embarrassed that I didn’t know how to help. I didn’t learn bedpan basics in medical school, or at any other time during my training. I would guess that most doctors, like me, would rather volunteer to hunt for someone else to do this than just getting the job done.

No, it isn’t rocket science to place a bedpan, but it’s easy to bumble by making a mess, leaving the patient in an uncomfortable position, exposing and embarrassing, and so on. Continue reading

Harvard Study: Shopping For Health Care Fails To Lower Costs

A new study is bad news for the push for health care shopping. (Caden Crawford/Flickr)

A new study is bad news for the push for health care shopping. (Caden Crawford/Flickr)

I hate it when there’s more bad news about the health care costs that are devouring our family, municipal and national budgets. (Latest number: $3 trillion, or 17.5 percent of America’s GDP.)

But here it is: A Harvard study just out in JAMA finds that when health care consumers use price-comparison tools, they don’t end up spending less. In fact, they may even spend a bit more, perhaps because they think higher prices mean better quality.

So much for the idea that if you just let people shop for cheaper care, prices will surely go down.

The study’s senior author, Dr. Ateev Mehrotra of Harvard Medical School, says the findings do not mean that health care price transparency mandates — which have passed here in Massachusetts and more than half of states overall — are a bad idea. Rather, he says, the message is that “It isn’t that easy just to fix this problem.”

About the study: It looks at nearly 150,000 employees at two big companies that gave their workers access to an online health care shopping tool, and compares them to nearly 300,000 status-quo employees. It found that among the employees who got the tool, outpatient spending on average went up a couple of hundred dollars, from $2,021 to $2,233.

The control group’s spending also went up slightly, but among the workers with the shopping tool, spending went up a bit more: by an average of $59 for outpatient care, including $18 out of pocket.

“Some of it is benefits design. …[And] we should also recognize that not everything in health care is shoppable.”

– Dr. Ateev Mehrotra

“Not A Panacea For High Health Care Costs,” says the headline of an accompanying editorial in JAMA. No kidding. Surely no one expected price transparency to solve our $3 trillion problem, but still, these results are also surely disappointing to anyone who hoped health care shopping might at least make a dent.

Or perhaps it will, someday. I spoke with Dr. Mehrotra, an expert on consumerism in health care, about what the results mean. Our conversation, lightly edited:

How would you sum up what you found?

There’s a lot of enthusiasm in the health care system about increasing price transparency, to both help patients become better consumers and to decrease health care spending. And unfortunately, in our results, we do not find that providing price transparency decreases health care spending.

I think there’s been this general idea that, ‘Oh, all we need to do is give people high deductibles, give them prices, and magic will happen, and people will start switching their providers to lower-cost providers.’ And one main message from this is that this should temper that enthusiasm, and it’s more complicated than that.

I don’t think it’s that patients think shopping for care is a bad idea. People generally realize that prices in health care are high and they should switch. But there are other factors that are playing a role.

Dr. Ateev Mehrotra (Courtesy)

Dr. Ateev Mehrotra (Courtesy)

Some of it is benefits design. We have these really complicated health care benefits designs that people really struggle to master, and under our current benefit design you might go to such a website and say, ‘Oh, I’m thinking of having my knee operated on and I’ll pay the same amount at every hospital, so it doesn’t matter.’ And a lot of the surgeries were for things that were relatively higher cost and therefore it didn’t matter. So that’s an issue.

And also, a lot of health care is emergent: When you’re having a heart attack and you’re in an ambulance, you’re not going to say, ‘Oh, let me see where it’s cheaper for me to go for care.’ So we should also recognize that not everything in health care is shoppable. Continue reading

Sudders, Bharel Discuss Release Of 2015 Opioid Death Numbers

There is still no sign that Massachusetts’ opioid epidemic is slowing.

New numbers released Monday show that 1,379 people died from unintentional opioid overdoses in the state in 2015. And that number is expected to top 1,500 once all death investigations are complete.

The data also show that more than half of the deaths last year involved the potent painkiller Fentanyl, which is sometimes mixed with heroin.

Health and Human Services Secretary Marylou Sudders and Department of Public Health Commissioner Monica Bharel joined WBUR’s All Things Considered to discuss the crisis.

The numbers the state released provide real-time information, they told us. Bharel also said the data help officials understand who is most affected by the opioid epidemic.

Related:

Mass. Opioid Crisis Continued To Worsen In 2015

Exacerbated by the potent painkiller fentanyl, the opioid crisis in Massachusetts continued to worsen in 2015, with more people dying of overdoses, according to the latest quarterly snapshot from the state Department of Public Health.

There were 1,379 confirmed opioid-related overdose deaths in Massachusetts last year, an 8 percent increase over the number of confirmed deaths in 2014 (1,282). More alarming still, the 2014 figure represents a 41 percent increase over the number of overdose deaths in 2013 (911). Continue reading

Earlier:

Some Doctors Say Focus Of Opioid Addiction Treatment Must Shift From Medication To Long-Term Recovery

While most say medication-assisted treatment for opioid addiction improves patient outcomes, some doctors are questioning seeking a cure from the same industry they say caused the problem. Pictured here, OxyContin, an opioid, is seen in a pharmacy in 2013. (Toby Talbot/AP/File)

While most say medication-assisted treatment for opioid addiction improves patient outcomes, some doctors are questioning seeking a cure from the same industry they say caused the problem. Pictured here, OxyContin, an opioid, is seen in a pharmacy in 2013. (Toby Talbot/AP/File)

While addiction treatment providers are increasingly recommending that medication be used to help wean people off opioids, some doctors are concerned there is now too much of a focus on medication and not enough on the harder work of long-term recovery from substance use disorder.

During the annual American Society of Addiction Medicine conference in Baltimore last month, a frequently heard statistic was that every 20 minutes someone in the U.S. dies from an opioid overdose.

“Imagine if we had someone in America dying from terrorism every 20 minutes,” Vermont Gov. Peter Shumlin said. “You wouldn’t have to just take your shoes off at the airport, you’d have to take everything off.”

Shumlin became a leading political voice on the opioid epidemic after dedicating his 2014 state of the state address to the problem in Vermont. Shumlin told the 1,800 people at the Baltimore conference that the nation needs their help to reduce the 250 million prescriptions written for opioid painkillers every year.

Continue reading

Senate Votes To Increase Smoking Age To 21 In Mass.

The Massachusetts Senate voted to raise the minimum age to buy tobacco products from 18 to 21. Signs like this one may need to change if the legislation makes it to the governor's desk. (Joe Difazio for WBUR)

The Massachusetts Senate voted to raise the minimum age to buy tobacco products from 18 to 21. Signs like this one may need to change if the legislation makes it to the governor’s desk. (Joe Difazio for WBUR)

The Massachusetts Senate voted 32 to 2 on Thursday to raise the state’s tobacco purchasing age from 18 to 21, passing legislation that supporters said would cut down youth tobacco use and nicotine addiction.

The bill, compiled by the Joint Committee on Public Health based on several separate pieces of legislation, also bans pharmacies and health care institutions from selling tobacco products and prohibits the use of electronic cigarettes in places where smoking is already banned.

“This bill is also very meaningful to me,” said Sen. Cynthia Creem, a Newton Democrat. “I started to smoke when I was under 21 and I was a teenager, and it was easy. It was the thing to do, and I did smoke…I wish that I was not able to smoke, and that I was older and understood the risks.”

Continue reading

Related:

Weight Gain, Heart Disease, Back Pain: Longer Car Commutes May Harm Your Health

The worsening traffic in Boston -- or any metropolitan area -- does not just cost drivers time. It may also cost them health. Here's early afternoon bumper-to-bumper traffic on 93 in Milton (Jesse Costa/WBUR)

The worsening traffic in Boston — or any metropolitan area — does not just cost drivers time. It may also cost them health. Here’s early afternoon bumper-to-bumper traffic on 93 in Milton (Jesse Costa/WBUR)

Four years ago, Barbara Huntress-Rather got a great job, as director of quality improvement for a health care company that serves fragile seniors. Just one problem: She lived in Lawrence, and the new job was in Lynn.

“The first day I drove to work and said, ‘Oh, Lord, what have I done?’ ” she recalls. “After having a short commute for quite a few years, I hadn’t done the commute before in rush hour traffic and I was absolutely stunned at how long it took — it was over an hour.”

A harrowing hour, or more, hunched at the wheel, watching out constantly for aggressive or distracted drivers. In the months that followed, the effects on her health were dramatic: “I gained back 40 pounds that I had lost, developed low back pain and high blood pressure,” she says.

Huntress-Rather didn’t immediately blame her commute; she blamed herself for eating too much and feeling too tired to exercise. But she hit a turning point when her nurse practitioner told her she’d need blood pressure medication.

“I had always prided myself in being in good physical shape and meditating and doing all the things that would keep me from having high blood pressure,” she says. “And I immediately made the connection between not working out, spending endless hours in the car and feeling totally stressed most of the time. I was either commuting or worrying about commuting.”

Barbara Huntress-Rather found that her long commute led to weight gain, high blood pressure and back pain. She aims to retire soon and get her good health back. (Jesse Costa/WBUR)

Barbara Huntress-Rather found that her long commute led to weight gain, high blood pressure and back pain. She plans to retire earlier than she would have otherwise and get her good health back. (Jesse Costa/WBUR)

Huntress-Rather is practically a textbook case of what longer car commutes can do to bodies and minds. The evidence has been mounting in study after study in recent years, adding up to strong reason to believe that the worsening traffic in Boston — or any metropolitan area — does not just cost drivers time. It may also cost them health.

Let’s begin with the No. 1 killer of Americans: heart disease. Continue reading

Related:

Buffets One Day, Vomiting The Next — Life With A Rare GI Disease

Melissa Adams Van Houten was diagnosed with a rare GI disorder in 2014. (Courtesy)

Melissa Adams Van Houten was diagnosed with a rare GI disorder in 2014. (Courtesy)

I am going to share some pretty personal information. Not a big deal to some of you, I am sure, but to me, it is huge. I am not the kind of person who does this — or at least I did not used to be. But things have changed.

In February of 2014, I spent a week in the hospital and was eventually diagnosed with gastroparesis, a disorder that slows or stops food from moving from the stomach to the small intestine.

I am guessing most people have never heard of this; I know I had not, prior to being diagnosed.

A Life-Altering Day

My life changed in ways I could not have imagined — overnight.

One day, I was able to eat at buffets, and the next day, I was unable to tolerate all foods and liquids. I was hospitalized with severe pain and vomiting, put through a battery of tests (including one particularly terrible one where they forced a tube down my nose and pumped my stomach). Eventually, I was diagnosed, but was given only a brief explanation of my illness and its treatment before I was sent home.

For the next few weeks, I was on a liquids-only diet, and was told that I had to gradually work my way up to soft foods and (eventually) solids. I am able to eat some soft foods, these days, in tiny amounts, but it is becoming clear to me that I will likely never again be able to eat “normal” foods in “normal” amounts.

Thinking About Food — Always

At first, I told myself that I would not let this stupid disease define or control me — it simply would not be the center of my life. But as time passed, I began to see how foolish this was. Every single day, every second of every day, I think about food. I see it; I smell it; I cook it and feed it to the other members of my household; but I cannot have it myself. Continue reading