THE "F" WORD

I think that fibromyalgia is a diagnosis that is used too freely by both physicians and patients. It is often used when no other etiology for a person's symptoms of fatigue with diffuse aches and pains can be found after a physical exam is performed and laboratory studies are obtained.

The purpose of a diagnosis is several fold. For the doctor, it defines an array of effective treatments and anticipated outcomes. For the patient, it provides reassurance that they have a known, definable condition with predictable long term expectations.

The problem arises for a doctor when a diagnosis is assigned to a patient prematurely or incorrectly. The problem arises for a patient when a diagnosis is misconstrued, resulting in unwarranted feelings of helplessness and hopelessness.

Not so long ago, many patients were given a diagnosis of hypoglycemia or chronic Epstein-Barr virus infection to explain a constellation of vague symptoms that did not appear to have any clear medical explanation. These diagnoses allowed the doctor to have an explanation to the give the patient for their condition and avoid the need for additional studies or referrals. The patient could be told that they just have to live with it as there were no effective treatments.

The diagnosis allowed the patient to be assured that no dire, life-threatening condition existed. Although no treatment would help, a variety of symptoms could now be safely ignored whenever the patient's particular condition flared up.

The diagnosis that serves this function now is fibromyalgia. While there is no confirmatory blood test or x-ray that can establish this condition with certainty, there exists a defined list of symptoms and subjective exam findings to support it. More often than not, the diagnosis is loosely and frequently applied.

My professional opinion is that a patient with this condition has an abnormally low pain threshold. Everybody has aches and pains daily. Most people are either too busy to notice them or they minimize those that they do notice and accept that they occur without allowing them to limit their activities or become the focus of their lives. Oftentimes the fibromyalgia patient will obsess over every minor symptom.

I believe that people with fibromyalgia have true symptoms and real pain. I do not believe that a physician is doing those patients any favors by enabling them to view themselves as disabled or invalids because of the condition. I have seen many patients on disability and on chronic narcotics because of fibromyalgia.

A patient is better served by having a doctor treat the symptoms of this condition with medications that are safe to use long-term such as anti-depressants, sleep-aids, muscle relaxers, and non-addictive pain medications. The doctor needs to encourage the patient to try and live a fully-functional life and not support the patient's erroneous belief that their condition should dominate their day to day existence.

Some patients with fibromyalgia will doctor shop and prescription shop in a futile attempt to become symptom free. The doctor needs to make it very clear to the patient that the above scenario is not realistic. Rather the emphasis should be on safe, long-term symptom control to allow the patient to participate in as much work and recreational activity as is feasible.

If the patient, and especially their doctor, sows a future of misery and limitations, that is what is learned and that is what is reaped. The power of positive (and realistic) thinking is important and genuine.

CAVEAT EMPTOR

I think people should think long and hard about how important their health is to them before deciding to order medications from Canada or over the Internet. Saving a little (or sometimes even a lot) can be very costly.

Now I understand, as should all primary care physicians, that the cost of prescriptions can impose an extreme financial burden on a patient. But I also understand that proper medications can improve life's quality and prolong its length.

Unfortunately, some doctors just assume a patient has insurance coverage for medications and so prescribe without concern for cost. A physician should always inquire about a patient's ability to afford an expensive medicine before prescribing it.

For almost all medical conditions there are several different drugs that can be used for treatment. The choice should be based on effectiveness, side effects, and cost. A doctor is not doing the patients any favors by prescribing the most marvelous medicine in the world if it is unaffordable by them.

If a patient has good prescription insurance coverage, or is independently wealthy, a doctor has it made. Any medication can be used. The challenge comes when the choices are limited.

The cash paying patient obviously has limitations on what is affordable. The patient with insurance who has a high deductible or very restrictive formulary might have very similar if not identical limitations. Options for these individuals include samples, generics, pharmacy discounted medications, and patient assistance programs.

My office, thanks to the generosity of some pharmaceutical companies, is often able to provide the patient with samples of medications, often for months at a time. The advantage includes no cost to the patient while the disadvantages include inconvenience in the patient having to call and come by the office monthly or more often to pick up the medicine. The medicine might need to be changed depending on sample selection which might require additional office visits or lab studies.

Generic drugs are an attractive choice for many patients without insurance and required by formulary rules for many with insurance. The pharmacies like them since the profit margin is often greater from a generic prescription than from a brand name one.

All medications eventually become generic as the patents expire and so these are always older agents. They may require several doses a day and require more frequent monitoring for a higher rate of side effects, as well as not be as beneficial in treating certain diseases as compared to newer, branded drugs.

A few medications for blood thinning, thyroid troubles and heart problems should not be given generically since the amount of active drug in one generic may be a little higher than in the branded medication but a little lower in a different generic. You may receive a different company's generic pill every month. This can result in too much fluctuation in a medicine that needs to be kept in a narrow therapeutic range to be safe and effective.

Within the past year, starting with Wal-Mart, some pharmacies have been offering certain generic medications for free or for a very low set price. While this clearly benefits the patient, I suspect it also benefits the store as people will tend to shop and buy other products while waiting for their prescriptions to be filled. The lists tend to be fairly inclusive by including several options for many common conditions like infections, diabetes, and hypertension.

Most pharmaceutical companies offer a patient assistance program for people that require a particular branded drug but do not have insurance to cover it or cannot afford it. This should be a last resort as the paperwork required is usually quite burdensome to both the patient and the doctor. The patient is required to send in proof of income and the doctor is required to complete pages of information and repeat the process up to every three months depending on the particular company.

People who choose to try to save money by ordering medication through Canadian pharmacies or over the Internet are making a mistake and their doctor should not condone or assist them in this endeavor. The reason for the price disparity in the cost of the same branded medication in different countries is muti-factorial and will not be delved into in this particular essay. The cost savings does not justify the risks involved for either the patient or the physician.

It is still illegal for a patient to directly receive prescriptions from foreign countries in the United States. You may not agree with this, but not agreeing with the law does not justify breaking it in this case. Your doctor is also breaking the law if he assists you in this endeavor. I suspect the medications received from reputable Canadian mail-in pharmacies are probably genuine and safe.

It is a crapshoot when you get medications from elsewhere outside this country or over the Internet. There are countless examples of counterfeit branded medications being sold for everything from erectile dysfunction to cancer chemotherapy. Contrary to the popular dictum of the worst medication a doctor can give a patient is one that cannot be afforded, the really worst medication a doctor can give a patient is one that is different from what is prescribed.

The doctor must be sure a patient can afford the prescribed medications. The patient must be sure the doctor is aware if a particular medication is unaffordable. Only then can the above listed measures be utilized effectively to provide the optimal health care for an individual. Only then can both parties avoid illegal activities and be sure that the medication being prescribed is the medication being taken.

DOCTOR KNOWS BEST

I think a little bit of knowledge can be a dangerous thing, especially when it involves your health. In days of yore, the only readily available health information was from your family doctor. Today, there is a cesspool of health information easily accessible.

Information can be accurate or inaccurate. It can be appropriately or inappropriately applied. Good information taken out of context can be just as harmful as bad information.

The best source of information for health care information is your family doctor. Other reliable sources include websites from respectable organizations such as the American Academy of Family Physicians.

Poor sources of information that may not be accurate can include well meaning family and friends, disreputable web sites, as well as ads placed in newspapers or on television by lawyers. Information from these sources should either be ignored or viewed with a very jaundiced eye.

Medicine is increasingly complex and what might have been true in the past might not be true in the present. I will often see older patients who request a penicillin shot to cure their infection. This is what always worked when they were a kid I am told. Unfortunately, most bacteria have developed resistance to this antibiotic and unless they have strep throat or syphilis, penicillin isn't likely to get the job done.

One can find a web site to support any crackpot medical idea. They often quote so-called "professionals" with questionable credentials and have dubious testimonials. They usually attempt to dupe the reader into purchasing a cure-all snake oil product or self-help book.

Lawyer sponsored ads attempt to scare anybody that has been on a particular medication to call even if there are no past or current health problems related to that drug. They obviously have a tremendous financial interest in convincing you that had, are having, or might someday have a significant health problem from just being on a certain medication regardless of how briefly that it was used. It is interesting to note which T.V. shows tend to run these ads (Jerry Springer, et. al.).

Poor sources of information that are accurate can include the Physicians' Desk Reference (PDR), the pharmacy's handout that is provided with your prescription, the television, and newspaper health advice columns.

The PDR is a book that functions best as a c.y.a. vehicle for pharmaceutical companies. It does have useful information, but this is a needle amidst a haystack of useless information. Among other things, it lists every side effect ever reported by anyone taking the drug during the trial phases. This does not mean that the drug caused the side effect. Thus you might find insomnia listed as a side effect of sleeping pills and headache as a side effect of migraine medicines.

The pharmacy provides a written handout that consolidates the information from the P.D.R. and translates it into lay language for the patient. It is almost always from a software program purchased from a national vendor and is intended to be a c.y.a. vehicle for the pharmacist. It also contains useful information, but this is not distinguished from the useless information. A medicine might be listed as causing contradictory side effects like drowsiness and sleeplessness.

Unfortunately, the patients that are the most likely to obsessively read the handout and look up the drug in the P.D.R. are the same folks who are very suggestible. It is well known that medical and nursing students often become convinced that they have the various diseases that they are currently studying.

The television reports a sensationalized version of health care news. This news is often reported before the information can undergo a peer review process in which other doctors analyze the study and data to determine its relevance and validity. You will have heard the information as soon as or before your doctor has making it very difficult for him to know how that new information can best be applied to individual patients.

The syndicated columnist is attempting to diagnose patients by information that is presented to the writer. This is precarious at best since there is no exam, no review of tests, and no ability to ask for additional information. Because of these factors, the columnist offers several possibilities and then almost invariably advises the patient to see a specialist.

A plethora of sources are available for health care information with widely differing quality and pertinence. But there is no substitute for your family physician when it comes to receiving personalized, accurate, and useful health related information.

HEY LOLLY, LOLLY

I think that having your doctor treat you over the phone for a new medical problem is very problematic. It is even more worrisome if the doctor you are dealing with is a physician who is covering for your regular doctor.

There are many reasons that patients try to get diagnosed and treated over the phone. There are also many reasons that your physician may choose to treat you over the phone. Seldom are these good reasons.

A patient might not want to take the time to come in for an office visit or the doctor might not have an appointment available when the patient needs to be seen. To me, a primary care doctor has a duty to see a patient who needs evaluated regardless of how full the schedule might be.

Problems might arise outside of the doctor's office hours. To me, a patient who is evaluated over the phone for a new problem should either be triaged to see a doctor soon (through the E.R., an urgent care or at their own doctor's office) or be advised to try an over the counter product and seek face to face medical attention if the symptoms worsen or do not resolve. Unfortunately, some patients have been known to intentionally wait to call until after hours in an attempt to get treated over the phone and avoid an office visit.

A patient and/or doctor might be trying to avoid the expense of an office visit. With some health insurance plans (i.e. HMOs), the doctor gets a set amount of money every month for each patient whether or not they are seen in the office. This creates an inherent conflict of interest in that the doctor makes more money by treating a sick HMO patient over the phone and reserving appointment slots for those who pay for each visit.

I don't blame the patient for trying to get medical advice over the phone. Locally it seems to be a readily accepted practice of both doctors and patients. The patient feels they are getting all the benefits of an office visit, evaluation and treatment, with none of the downside, time and expense. The doctor should be the one that knows better.

It is well documented in the medical literature that patients' ability to accurately self-diagnose their ailment is very poor. So, for example when a woman calls and states that she has a yeast infection or a urinary tract infection, she is more often than not, incorrect. While gas pain is could be just indigestion, sometimes it is a heart attack and while a fever and stiff neck could be strep throat, it is also sometimes meningitis.

A proper diagnosis is often difficult even during an office visit. It is often impossible to do over the phone. These misdiagnoses may just be a nuisance and involve inappropriate and ineffective treatment, or it could result in a catastrophic delay in a proper hands-on evaluation by a physician with potentially life saving timely treatment.

An incorrect phone diagnosis of an acute illness is an avoidable and indefensible liability. A patient and physician might benefit when things go right, but when things go wrong, only the lawyers benefit.

THE LONG AND WINDING ROAD

I think that Josh Estelle, of the Pfenninger insurance agency, and Kim Cronk, of the County council, should be congratulated. They came up with an idea to increase the health care options for city and county employees while decreasing total health care costs.

The city and county are self-insured. In simplified terms, this means that the more health care expenses the employees incur, the more the city and county (i.e. the taxpayers) must pay. As the eighth and fifth largest employers respectively, this amounts to a large sum of money.

A significant expense involves emergency room visits. Unfortunately, after 5 p.m. (or earlier depending on the doctor) during the week and not at all on weekends, the employees' physicians are not available to see patients. So, while a medical problem may not be a life or limb threatening emergency, it may be a condition that could become one if not appropriately treated for 2 or 3 days.

After-hours or on weekends, phone advise from your doctor may be helpful, but it does not take the place of a hands-on evaluation from a physician. Previously, the employee's only option locally was to go the emergency room and have the city or county (i.e. taxpayer) pay a large bill or to come to the Spiceland Pike Medical Center.

The problem with the latter choice was the requirement to pay up front and the patient might not get reimbursed from their insurance company. Many people would rather wait for long periods in the emergency room for care that can be provided more efficiently and inexpensively in a doctor's office if it means no immediate expense and the co-pay for the E.R. visit will be about the same as the cost of an office visit. The taxpayer's cost however will be vastly different.

Mr. Estelle and Mr. Cronk were both aware, as are the regular readers of my compositions, that for a variety of reasons, I am loathe to join any health insurance plan. But, their idea addressed my concerns about charging different people different amounts for the same service, loss of autonomy in medical decision making and administrative hassles.

As of 4-15-07 the Spiceland Pike Medical Center now will see patients with city and county health insurance and charge only the co-pay at the time of service. My understanding is that the co-pay will be less than the employees have to pay at any other doctor's office.

This was made possible because I am allowed to keep my already low fee schedule intact and not have to arbitrarily provide a percent discount. My charges sans discount are lower than those "discounted" prices of other providers so the city and county save money.

Another key component was the elimination of my loss of medical decision making autonomy. I refer to specialists and for additional testing as I, and not some insurance pencil pusher, sees fit.

The last selling point to me was the lack of administrative hassles. I can bill the insurance company and receive reimbursement quickly and efficiently and can therefore keep my prices the same due to not incurring any additional overhead expense. My contract with the insurance company is one page. For comparison the one I was offered from another insurance company recently was over 40 pages and did not even include a fee schedule, as per the norm.

This agreement benefits all those involved. Patients have more options, the county and city (taxpayers) save money, the emergency department can devote its resources to true emergencies, and I have the opportunity to help more people while maintaining my ability to practice medicine without compromising my autonomy.

Of note, I do not know why other insurance companies do not do likewise. I suppose it's because they do not want the hassle of changing the status quo for a single doctor. It would be nice if those purchasing the policies were thought of first and provided with more choices as it would not cost the insurance companies any extra money.

I did offer this same proposition to the local hospital when I first opened. The administration at that time would not discuss this unless I joined their health network which I was not about to do. There is no good reason that the self-insured local county owned hospital, as the third largest employer in Henry County, shouldn't try and save taxpayer dollars by entering into a similar agreement with myself for the benefit of its employees and the taxpayers.