HMOs, Antibiotics and the Philosophy of Caring
Dr. Marc answers readers' question every other week. To send a query, click here.
Dear Dr. Marc,
In the UK, if you go to the doctor with a minor infection, you are quite likely to be sent home with the advice to rest up and drink plenty of fluids. In the US, it still seems to be the case that you are likely to be prescribed an antibiotic, almost by reflex. Given the concerns of developing resistance to antibiotics, are practices changing in the US? If not, why not?
There does seem to be a mutual tendency on the part of both patients and doctors here in the United States to shovel antibiotics at minor respiratory infections. This may be due in part to the presence of atypical bacteria, as well as the perception (real or otherwise) that the pills make a difference. Certainly you are correct that overuse of antibiotics can breed resistant strains.
Perhaps the difference between the US and the UK can be accounted for by the tendency that still exists here to buy into the "American dream." Here we like to believe that our products are magic elixirs, almost like a gift the doctor is dispensing to the patient for coming to see him. Each new shiny pill is the latest and greatest. We can be cured of our minor ailments, made better and perhaps stay young longer, all by taking a little tiny pill. Perhaps In the UK many patients are less expectant, and therefore more realistic.
Dear Dr. Marc,
I'm turning 50 next month and the issue of colonoscopy has come up. How important is it for everyone to take that test? Additionally, what are your opinions about the camera pill version?
New York City
Generally, this column is not a forum for straight medical questions. But I am a practicing internist, and further, I have experienced a colonoscopy, at age 46. Also, some might say that this question is, in fact, a political one, in that one of the reasons for recommending colonoscopy for everyone over 50, some people might argue, is to generate income for doctors and colonoscope makers.
I don't buy that. We live in a society with a preponderance of colonic disease, including cancer. This may well have to do with the American diet, but until we change something, scrutinizing the colon for those with a family history of polyps or cancer is a wise idea. For everyone else, much data suggest that 50 is a good place to start, with repeat studies at least every five to ten years. I don't think the virtual colonoscopy done by CT scan is equivalent; it is promising, but studies don't support it sufficiently...yet. Further, the prep for the virtual is almost the same, and, as my patients tell me, the prep is the most difficult part. Having experienced both the prep and the colonoscopy, I think fear and anticipation are far worse than either the prep or the procedure itself. I recommend this procedure; it is a rare chance to see close-up exactly what we, our food, and our environment are doing to our innards.
Dear Dr. Marc,
My early years were spent in India. I often (with my siblings) would go along with my grandmother (an obstetrician and general practioner) on the day she provided free services at a public clinic. My mother was a nurse who would assist her. In those days all doctors had to provide a certain number of hours per month of free service in order for them to maintain their license to practice. So there were times when the poorest person would receive services from the best physician in town. Of course, this did not guarantee that everyone received great healthcare. The lines were long, but I know some really destitute families received very good services, as fate would have it. I once suggested such "free" service from doctors for a senior clinic (which, as a director of a Community Action Agency, I managed to open--despite the local medical association opposition). This is a peventive-care effort by early detection by a gerontologist RN. Why play golf all day on Wednesday, I asked--why not a couple of hours of service? When it suits our government, even people who do not have insurance seem to get the best care possible--at taxpayer cost. What comes to mind is the medical care we provided President Boris Yeltsin. I wonder what his HMO, if he had one, would've suggested. I enjoy your comments.
Rock Island, IL
Of course I appreciate the sentiments here. Many doctors, myself included, end up giving a certain amount of charity care even now--not necessarily as a public service, but more from a philosophy of caring. It is hard for me--and others--to discharge patients from my practice even when they can no longer afford insurance or afford to pay me. Your notion of formalizing this could be good for the image that physicians present, though I doubt most would go for it these days, largely because of the current regulatory and punitive climate regarding doctors. As far as insurance companies go, some try to put on a philanthropic face, but most of us aren't falling for it. Thanks for a refreshing reminder of a time when things were more straightforward, at least when it came to healthcare.
Dear Dr. Marc,
Can you explain how HMOs really work? What do those of us with HMO plans need to look out for when it comes to advocating for our own care?
KUMASI JAY GWYNNE
They sign you up to a contract where you have to go through them to get things paid for, but they can decide at any time to not cover something your doctor says you need, leaving you (and your doctor) in the lurch. The best way to try to protect yourself as an HMO client is to have a physician you can trust. I know that seems easy to say, but here's how it works: A physician and his or her staff can guide you through and around the necessary paperwork, make sure you get the appropriate tests and treatments, look for loopholes to protect you and provide you with samples and alternatives when HMOs won't approve your treatments. The alternative is to save money for a rainy day to pay out of pocket for treatments denied you, though I suspect that if enough of that occurs there will be the kind of revolution against HMOs that I and others long for.
Dear Dr. Marc,
My question relates to the ways that pharmacies are now selling patient information to drug companies.
I work for a moderately large company with offices in several locations. We employ about 500 people. My office is in Ohio, and my healthcare benefits coordinator works in Virginia. All my correspondence is by phone or e-mail.
I would like her to ask our insurance and mail-order pharmacy provider to state what their policy is regarding the selling of personally identifiable information to drug companies or to anyone else.
Do you have any suggestions as to how I should specifically word my request? Hopefully, as more people become aware of this situation, publicity and pressure on corporations from employees may affect policy changes. I also intend to ask my local Cleveland-area pharmacy chain as to their policy.
I suggest that you ask her politely and forthrightly. I don't think any specific wording should be required. I have a feeling they'll reveal their policy to you. And, without doing the homework, I'd also be very surprised if the info you're interested in isn't part of public-domain information that you are legally entitled to review.
Dear Dr. Marc,
Reading your column, I came across two letters related to microwaves and cell phones. I was disappointed to find that basic misconceptions were not addressed and that unscientific answers were given.
The reader letter states: "I thought microwaves, like the sun's ultraviolet radiation, have a frequency high enough to be capable of smashing into our DNA and knocking molecules out of place, leading to mutations with the potential of being carcinogenic."
Microwaves do not have a frequency high enough to break the bonds of DNA, the known mechanism by which electromagnetic radiation causes cancer. Microwaves can, however, be absorbed by molecules leading to heating, just the way a microwave oven works. Of course, ovens use frequencies that maximize absorption (heating), and cell phones use frequencies that minimize absorption. The minor heating of tissue could conceivably cause cancer, but it's a different subject from the sun's ultraviolet radiation.
Another reader asks about whether microwaves destroy nutrients. You tell him that "hitting food with microwaves certainly can't be good for it." This is just unfounded prejudice. Precautions are taken to avoid the release of microwaves in ovens for the same reason you don't want to put your head in a conventional oven--you don't want to be cooked. A microwave oven will of course cook you much faster, hence the need for significant precaution.
As to the actual question of nutrients, the microwave may in fact be advantageous compared with the common alternatives. The microwaves themselves are too low-energy to make chemical changes, and only contribute heat. Boiling can remove nutrients that are water-soluble by leaving them behind in the water. Using a microwave, you aren't leaving anything behind. Frying or sauteing adds fat, of course.
Not all technology is bad. You certainly seem to approve of the web. And it might be pointed out that without the judicious use of radiation we wouldn't know about patients' tumors until they were dead of them.
This is an elegantly stated position. You are right to point out that I overlooked the scientific inaccuracy of the previous questioner and focused instead on the food being microwaved. This was not a glib answer. I clearly stated my position that the food being microwaved was the issue, not the microwave oven itself. I, in fact, believe that the lifestyle of reheating is not the healthiest. I own a microwave myself, but on the best days I eat only freshly prepared food and do not have a chance to use it.
I also agree that other forms of heating food may deplete it of basic nutrients much more than microwaving. And we should not fear microwaves just because they are part of the "new technology." As a practicing physician, I am well aware of the positive effects of modern radiographic techniques; however, I don't believe the original discussion of microwave ovens included the slightest attempt to knock technology. Finally, I continue to believe that it is not necessary to assert that microwaving food is safe, when it is more accurate to say that the long-term affects haven't been studied, in part because these studies would be so difficult to perform (I doubt we'll find a microwave company to finance them).